Level of Care Determination Michigan

The Clinical Gate to Every Michigan Long-Term Care Program

Before your parent can receive Medicaid-funded nursing home care, MI Choice Waiver services, PACE enrollment, or MI Coordinated Health (MICH) benefits, they must pass a clinical assessment called the Michigan Nursing Facility Level of Care Determination — the LOCD.

The LOCD is not a financial test. It evaluates whether your parent's physical, cognitive, and behavioral needs are severe enough to require the level of care that a nursing facility provides. Meeting this clinical threshold is required even if your parent will receive care at home through a waiver program rather than in a facility.

The Eight Doors

The LOCD uses a structured tool with eight clinical domains, each called a "door." Your parent needs to qualify through only one door to pass the assessment. A licensed health professional — a registered nurse, social worker, or physician — conducts the evaluation face-to-face.

Door 1: Activities of Daily Living (ADLs). Evaluates physical dependence in the most basic self-care tasks: bed mobility, transfers (moving from bed to chair), toilet use, and eating. The assessment uses a standardized scale — your parent must demonstrate significant dependence in at least one late-loss ADL.

Door 2: Cognitive Performance. Uses the Cognitive Performance Scale to measure short-term memory, daily decision-making ability, and the capacity to communicate needs. Moderate to severe cognitive impairment — such as Alzheimer's disease or vascular dementia — typically qualifies through this door.

Door 3: Physician Involvement. Measures medical instability. Your parent qualifies if they have required at least one physician visit and four physician order changes (or two visits and two order changes) within the 14-day period before the assessment. This door captures acute medical conditions that require frequent clinical intervention.

Door 4: Treatments and Conditions. Identifies high-acuity clinical needs: stage 3 or 4 pressure ulcers, intravenous medications or feedings, ventilator dependence, tracheostomy care, or end-stage care needs.

Door 5: Skilled Rehabilitative Therapies. Applies when the patient is receiving ongoing physical, occupational, or speech therapy at a skilled level — meaning the therapy requires the clinical judgment and supervision of a licensed therapist.

Door 6: Behavioral Issues. Covers cognitive or behavioral challenges that create safety risks: hallucinations, delusions, wandering, verbal or physical aggression, or consistent resistance to essential personal care.

Door 7: Service Dependency. Applies to individuals who have been receiving waiver or nursing facility care for at least one continuous year and would experience clinical decline if that care were discontinued. This door protects existing program participants during annual reassessments.

Door 8: Frailty. A catch-all for individuals who do not clearly qualify through Doors 1–7 but present a combination of chronic health conditions that collectively create a nursing-facility-level risk. Chronic obstructive pulmonary disease combined with diabetes and limited mobility, for instance, might qualify through this door even though no single condition alone would.

Look-Back Periods

The assessment is not a snapshot of your parent's worst day. Each door uses a specific look-back window:

• Doors 1, 2, 5, and 6: 7-day look-back
• Doors 3 and 4: 14-day look-back
• Door 7: 12-month continuous service history
• Door 8: Overall clinical trajectory

Timing the assessment matters. If your parent had a particularly difficult week — a fall, an infection, a behavioral episode — the 7-day window for Doors 1 and 2 captures that deterioration. An assessment conducted during a stable period may miss the daily reality of caregiving.

Who Conducts the LOCD and Where the Data Goes

The assessment is conducted by a licensed health professional — typically a registered nurse and social worker working together. For MI Choice Waiver applicants, the regional waiver agency or Area Agency on Aging coordinates the assessment. For nursing facility admissions, the facility itself conducts the evaluation.

Once completed, the LOCD must be entered into the Community Health Automated Medicaid Processing System (CHAMPS) via MiLogin within 14 calendar days. This is the state's electronic system for processing Medicaid eligibility — the LOCD records the clinical eligibility determination, while separate financial eligibility and program-enrollment steps still apply.

What Happens If the Assessment Fails: Door 0

A "Door 0" result means the LOCD tool found your parent does not meet any of the eight clinical thresholds. The assessor must issue an adverse action notice explaining the determination.

You have three business days from the date of that notice to request a Secondary Review from MPRO (IMPROve Health), the state's clinical review contractor. The secondary review evaluates documentation across all eight doors — not just the one that initially failed. The provider must upload supporting clinical records into CHAMPS within one business day, and MPRO is required to render a decision within two business days after that.

If MPRO upholds the Door 0 finding, you can file a formal administrative hearing request with the Michigan Office of Administrative Hearings and Rules (MOAHR) using Form DCH-0092 within 90 days. If your parent is currently receiving Medicaid-funded services and appeals the termination within program timelines, Medicaid must continue paying for those services throughout the hearing process.

Preparing for the Assessment

Document your parent's daily reality before the evaluation. Keep a log of ADL needs (how many times they need help transferring, toileting, eating), behavioral incidents, physician visits, and medication changes. Share this log with the assessor — the formal evaluation captures only what is observed or documented during the look-back window, and a well-prepared caregiver log fills gaps that the medical record may not reflect.

The Hospital-to-Home in Michigan guide includes a pre-assessment preparation worksheet and a step-by-step walkthrough of the MPRO secondary review and MOAHR hearing process.

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