Choosing a nursing home is one of the hardest decisions families face. Whether you’re trying to find care for an aging parent, a spouse, or exploring your own long-term care options, it’s important to understand exactly what qualifies someone for nursing home admission. The decision often comes at a moment of crisis after a hospital stay, a fall, or a diagnosis that makes living independently unsafe. But understanding the eligibility requirements can help you feel more confident and informed when the time comes.
This guide explains how medical, cognitive, and financial factors determine eligibility and outlines the steps you can take if you or a loved one may need this level of care.
Who Needs a Nursing Home?
Nursing homes, also called skilled nursing facilities, are designed for individuals who require 24-hour supervision, regular medical treatment, or help with basic daily activities that they can no longer manage on their own. This level of care is more intensive than what is provided in assisted living or in-home care.
People who qualify typically fall into one or more of the following categories:
- They have serious or chronic medical conditions.
- Common examples include advanced heart disease, stroke, late-stage diabetes complications, chronic respiratory illnesses (like COPD), Parkinson’s disease, and other debilitating diagnoses. These conditions require daily oversight by licensed nursing staff or other skilled professionals.
- They need help with most or all activities of daily living (ADLs).
- This refers to essential self-care tasks such as bathing, dressing, eating, using the restroom, managing medications, and safely moving around the home. If someone struggles with three or more of these tasks consistently, they may meet eligibility for nursing home care.
- They have moderate to severe cognitive impairment.
- Dementia, Alzheimer’s disease, and other neurological conditions can cause memory loss, confusion, disorientation, wandering, or risky behavior. In these cases, nursing homes provide a secure and structured environment to ensure safety and quality of life.
- They require ongoing rehab or skilled nursing after a hospitalization.
- Many seniors are admitted to a nursing home temporarily after a surgery, serious illness, or injury. In these situations, nursing homes offer post-acute care and rehabilitation services like physical therapy, wound care, and IV medications.
- Their needs exceed what can be safely managed at home or in assisted living.
- Sometimes, family caregivers reach a point where providing adequate care is no longer feasible. Nursing homes step in when 24/7 supervision or complex medical services are necessary.
In many cases, a nursing home is considered a “last resort” option not because it’s undesirable, but because it provides a level of care that other environments simply cannot match. If your loved one’s condition has become too difficult to manage safely at home, or if their health is declining rapidly, it may be time to explore nursing home eligibility.
The Admission Assessment: Medical and Functional Criteria
Before someone is admitted to a nursing home, they must undergo an official assessment to determine whether this level of care is appropriate. This is not a quick or casual decision it’s based on clearly defined medical, cognitive, and functional needs, often documented through multiple forms and evaluations.
While specific procedures vary by state, here are the main areas considered:
1. Medical Need
A licensed physician must confirm that the individual has medical conditions that cannot be managed safely or effectively at home. These conditions might require continuous nursing care, access to skilled rehabilitation, or monitoring by trained medical staff. The physician will document diagnoses, current treatments, prescribed medications, and the frequency of care needed. Chronic illnesses, frequent hospitalizations, and significant physical decline often factor heavily in this determination.
2. Activities of Daily Living (ADLs)
The individual’s ability to perform essential everyday tasks is a key part of the assessment. Evaluators will review how independently the person can:
- Eat and prepare food
- Bathe and maintain hygiene
- Dress themselves appropriately
- Use the restroom or manage incontinence
- Transfer (e.g., get in and out of bed or a chair)
- Take medications correctly and consistently
If a person is dependent on help for three or more ADLs, it strongly suggests that a nursing home level of care is needed. In many states, ADL limitations alone especially when paired with chronic medical needs can qualify someone for admission.
3. Cognitive and Behavioral Status
Memory and behavior are critical aspects of the eligibility assessment. Professionals look at the person’s:
- Memory function and ability to recall information
- Judgment and problem-solving ability
- Risk of wandering or self-harm
- History of aggressive or inappropriate behavior
- Ability to follow directions or participate in a care plan
Cognitive impairments like Alzheimer’s disease, advanced dementia, or psychiatric conditions that interfere with safety and self-care can qualify someone even if their physical health is relatively stable.
4. State-Specific Tools
Each state has a mandated evaluation process, often tied to Medicaid eligibility. Examples include:
- New York’s PRI (Patient Review Instrument), which measures functional ability, medical needs, and prognosis.
- Florida’s Form 3008, which includes input from both healthcare providers and case managers.
Other states use similar instruments developed by their Medicaid programs or Departments of Health. These tools assess the “level of care” needed and help determine whether the person meets criteria for admission to a skilled nursing facility.
It’s important to note that being medically eligible doesn’t automatically guarantee admission availability of beds, facility policies, and payer source (like Medicaid or private pay) can all influence final acceptance.
Families are encouraged to speak with a hospital discharge planner, social worker, or case manager who is familiar with state-specific requirements. They can help navigate the paperwork and ensure the correct forms are submitted on time.
Families exploring care options may also benefit from reviewing this helpful article: Questions to Ask Nursing Homes Before Making a Decision.
Required Documents for Nursing Home Admission
Once a facility has determined a prospective resident is medically and functionally eligible, the admissions process continues with documentation. Having the required paperwork ready ahead of time can significantly streamline this step.
Here are the common documents most nursing homes require:
- Physician’s order for nursing home care: This is an official form that certifies the medical necessity of nursing home-level services.
- Comprehensive medical history: Including current diagnoses, past surgeries, and treatment plans.
- Medication and treatment orders: A full list of current prescriptions and any special care instructions.
- Insurance information: Documentation related to Medicare, Medicaid, long-term care insurance, or private health coverage.
- Legal authority paperwork: Power of attorney (POA), guardianship documentation, or conservatorship if applicable.
- Advance directives: Living wills, Do Not Resuscitate (DNR) orders, or other medical decision documents.
- Financial documentation: Required for Medicaid applications or to determine private pay capacity.
Tip: Ask the nursing home for a complete admissions checklist to ensure nothing gets overlooked. Some facilities provide this in advance or during an initial consultation.
Financial Qualifications: Who Pays for Nursing Home Care?
The financial side of nursing home care often catches families off guard. According to seniorliving.org costs can exceed $9,000 per month, depending on location and level of care needed. That’s why understanding your payment options and qualifying factors is so important.
Medicare
Medicare helps cover short-term skilled nursing care (up to 100 days) following a hospital stay of at least three days. Coverage is limited to rehabilitation and post-acute recovery not ongoing custodial care.
Use the Medicare Nursing Home Compare tool to find and compare facilities.
Medicaid
Medicaid is the largest payer of long-term nursing home care in the U.S. To qualify into a medicaid nursing home, individuals must:
- Meet income and asset limits (which vary by state).
- Be medically eligible for nursing home-level care.
States apply a five-year look-back rule to review financial transactions and ensure assets weren’t transferred inappropriately. Violations can result in a penalty period during which Medicaid won’t pay for care.
Navigating Medicaid can be complex. Consider consulting an elder law attorney (you can check the National Association of Elder Law Attorneys) or Medicaid planner.
Private Pay
If someone doesn’t qualify for Medicaid and lacks long-term care insurance, they’ll need to pay out of pocket. Some families explore options like:
- Home equity lines of credit.
- Life settlements (selling a life insurance policy for cash).
- Long-term care insurance payouts.
Are you concerned about a nursing home taking your house? Do not be. Nursing homes cannot take a person’s home or require them to sell it to pay for care. If you need help paying for care, or your loved one is concerned about affording nursing home care, a life settlement may be an option. You could sell an existing life insurance policy for a lump sum of cash to help cover expenses.
See how much your policy could be worth.
Life Settlements and Viatical Settlements: Funding Options for Long-Term Care
If paying for care out-of-pocket isn’t possible, many seniors turn to life settlements or viatical settlements for financial relief.
- Life Settlement: A life settlement allows a policyholder to sell their life insurance policy for a lump sum cash payout. The amount is typically more than the policy’s surrender value but less than the death benefit. These funds can be used to cover nursing home costs or other healthcare expenses.
- Viatical Settlement: A viatical settlement is similar to a life settlement, this option is available to individuals with a terminal or chronic illness. Because of the health condition, these settlements may offer higher payouts. The proceeds are often tax-free.
Both options are regulated financial transactions that can unlock much-needed funds for qualified individuals. If your loved one is considering a nursing home and owns a life insurance policy they no longer need, learn more about life settlements here.
Emergency Admissions: What If Someone Needs Help Now?
If a loved one suddenly can’t return home safely due to a fall, hospitalization, or caregiver burnout, you may be able to request emergency placement in a nursing home. These situations require fast action, and understanding the process can help you move quickly.
Hospital Coordination
If the individual is currently in a hospital, start by speaking with the discharge planner, social worker, or case manager. Hospitals often coordinate directly with skilled nursing facilities and can help expedite placement. They’ll also handle much of the paperwork needed to get things moving.
Temporary Admission and Delayed Assessments
Many states allow a delayed nursing home assessment in emergency situations. For example, Texas permits admission before a formal level-of-care evaluation, as long as the assessment is completed within 7 to 14 days of entry. Other states offer similar flexibility. This helps ensure the person gets safe care right away while eligibility is finalized.
Contact Local Aging Resources
If your loved one is not in the hospital but still requires urgent care, contact your local Area Agency on Aging (AAA) for support. They can provide referrals to nursing homes, explain emergency placement options, and connect you with Medicaid waiver programs if applicable.
Use the Eldercare Locator to find your local AAA (Area Agency on Aging).
Can You Place Someone in a Nursing Home Against Their Will?
In general, adults with full mental capacity cannot be placed in a nursing home against their will. Everyone has the right to make their own healthcare and housing decisions unless they have been deemed legally incapacitated.
Cognitive Impairment and Legal Intervention
If a loved one has Alzheimer’s disease, dementia, or another condition that limits their ability to make safe choices, and they refuse needed care, legal steps may be required. These include:
- Power of Attorney (POA): If already established, a medical POA can authorize someone to make healthcare decisions on behalf of the individual.
- Guardianship or Conservatorship: If no POA exists, families may need to petition the court for legal authority to manage care decisions. This involves medical evaluations, court filings, and judicial review.
This is a serious process that removes some personal freedoms. It should only be used when safety is at risk and no less restrictive options are available. An elder law attorney can help guide families through the legal requirements.
Alternatives if a Person Doesn’t Qualify
Not everyone will meet the requirements for nursing home care, and in some cases, it may not be the best fit. Fortunately, there are several other senior care options available based on the individual’s needs and level of independence:
Assisted Living
Ideal for seniors who need help with daily tasks but don’t require 24/7 medical care. These facilities offer meals, housekeeping, assistance with medications, and social activities in a residential setting.
In-Home Care
For those who prefer to remain at home, professional caregivers can provide part-time or full-time support with ADLs, medications, and companionship. Home health agencies also offer skilled nursing care and therapy services at home.
Adult Day Programs
These community-based centers provide daytime supervision, meals, and activities for seniors while allowing caregivers to work or take a break. It’s a great option for those with moderate cognitive issues or mobility challenges.
Short-Term Rehab or Respite Care
Some facilities offer temporary stays for recovery after surgery or illness. Respite care also allows family caregivers a break while ensuring their loved one is well cared for.
Final Thoughts
Navigating nursing home eligibility can be complex, but you’re not alone. Focus on your loved one’s needs both medical and personal and gather the right documents early. If you’re unsure where to start, talk to a healthcare provider, elder law attorney, or local aging services office.
With the right information and support, you can make a decision that protects your loved one’s safety, dignity, and quality of life.
Need Help Paying for Care?
If you’re concerned about the cost of long-term care, a life settlement may help. You could sell a life insurance policy you no longer need and use the funds to pay for nursing home expenses. See how much your policy could be worth with our free estimate calculator today.
