Understanding the Requirements to Go Into a Nursing Home

Oct 23, 2025 4 min read •

Senior Living elder care Healthcare Planning

According to the Centers for Medicare & Medicaid Services (CMS), nursing homes must meet specific federal and state requirements for care and safety. To determine eligibility for long-term care, it's crucial to understand what are the requirements to go into a nursing home, which involve a combination of medical, functional, and financial criteria.

Quick Summary

Nursing home admission requires meeting medical necessity, assessed functional ability, and financial qualifications, which vary by state. This process includes a physician's order, a functional assessment focusing on Activities of Daily Living (ADLs), and evaluation of assets and income for payment options like Medicaid or private pay.

Key Points

Medical necessity is required: A physician must certify that an individual requires a skilled level of care that cannot be safely managed at home.
Functional ability is assessed: Eligibility is determined by an assessment of the individual's capacity to perform Activities of Daily Living (ADLs), such as bathing, dressing, and eating.
Financial requirements vary: Payment options include private pay, Medicare (for limited skilled care), Medicaid (for long-term care for those with low income/assets), and long-term care insurance.
Cognitive and behavioral factors are considered: Impairments from conditions like dementia and associated behavioral issues are key factors for admission.
State-specific criteria must be met: While federal guidelines exist, each state sets its own specific requirements for nursing home-level care.
Proper documentation is essential: A physician's order, medical history, state forms, and financial paperwork are all necessary for admission.
The admissions process can be complex: It involves medical evaluations, financial assessments, paperwork, and touring facilities to find the right fit.
Medicare does not cover long-term custodial care: It is a common misconception that Medicare pays for ongoing nursing home stays; it only covers short-term, skilled nursing services.

Navigating the Primary Admission Criteria

Deciding to move into a nursing home is a significant step that involves a thorough assessment of a person's needs. The specific requirements can differ from state to state, but all admissions are based on three fundamental areas: medical necessity, functional ability, and financial resources. These criteria ensure that a nursing home is the most appropriate and safest care setting for the individual.

Medical Necessity: When Is Skilled Care Required?

A physician's order is a cornerstone of nursing home admission. This order, much like a prescription, certifies that the patient requires a level of skilled nursing care that cannot be safely or adequately provided in a less intensive setting, such as a private home or assisted living facility. This skilled care is often needed for chronic or acute conditions that necessitate continuous medical supervision and specialized treatment. Examples of medical needs that can trigger eligibility include:

Daily injections or medication management
Complex wound care, like daily dressings
Use of medical equipment such as ventilators or catheters
Ongoing monitoring for chronic illnesses like diabetes or heart disease
Rehabilitation services following a surgery, stroke, or other health crisis
Specialized memory care for advanced dementia or Alzheimer's

Functional Ability: The Role of Activities of Daily Living (ADLs)

A functional assessment evaluates a person's ability to perform routine activities, known as Activities of Daily Living (ADLs). The inability to perform several ADLs independently is a common indicator for needing nursing home-level care. This assessment, often conducted by a physician or state-appointed agency, considers the individual's physical and cognitive status. The level of required assistance is a critical factor.

Here is a list of common ADLs and how they relate to nursing home requirements:

Bathing and personal hygiene: Requiring substantial assistance with washing, grooming, and dental care.
Dressing: Needing help putting on and taking off clothes.
Toileting: Requiring assistance with using the toilet.
Transferring: Needing help moving from a bed to a chair or wheelchair.
Eating: Needing assistance with feeding oneself due to physical or cognitive issues.
Continence: Managing bowel and bladder control.

Cognitive and Behavioral Factors

For individuals with cognitive impairments like dementia or conditions that cause behavioral issues, a nursing home may be necessary to ensure safety and provide specialized care. These facilities can offer a secure environment and staff trained to manage the specific challenges associated with cognitive decline. Unpredictable behavior, wandering, or severe disorientation are key indicators that round-the-clock supervision may be necessary.

Financial Requirements for Nursing Home Admission

Paying for nursing home care is a major consideration, with options including private pay, Medicare, Medicaid, and long-term care insurance. Facilities will conduct a financial assessment to determine how the costs will be covered.


Payment Method	Coverage Scope	Eligibility Overview
Private Pay	Covers all nursing home costs, including room and board.	Requires personal savings and income to cover the full cost. Often used before other funding sources are exhausted.
Medicare	Limited to skilled nursing care and rehabilitation for a maximum of 100 days, following a qualifying hospital stay.	Must meet specific medical necessity criteria and have a qualifying three-day hospital stay. Does not cover long-term custodial care.
Medicaid	Can cover long-term custodial care, including room and board, for those with limited income and assets.	Requires a person to meet strict state-specific income and asset limits. Often requires a "spend-down" of assets to qualify.
Long-Term Care Insurance	Benefits vary based on the policy but can cover a wide range of long-term care services.	Eligibility depends on the policy's specific triggers, such as needing assistance with ADLs.

The Application and Admissions Process

Once a person has been assessed and is deemed a candidate for nursing home care, the admissions process involves several key steps and requires compiling specific documentation:

Obtain Physician's Orders: A doctor must write an order for admission and provide a treatment plan, including medications and therapies.
Gather Paperwork: Collect medical history, physical examination results, insurance information (Medicare, Medicaid, etc.), and legal documents like Power of Attorney and advance directives.
Complete State-Specific Forms: Every state has a certification form to confirm the resident meets the state's nursing home criteria.
Undergo Health Screenings: Facilities typically require proof of recent vaccinations and a negative tuberculosis test.
Tour and Select a Facility: Visit several facilities to compare quality of care, services, and amenities. It's important to choose a facility that is Medicare and/or Medicaid certified if relying on those programs for payment.

Conclusion

Entry into a nursing home is a multi-faceted process guided by medical necessity, functional limitations, and financial resources. While the specifics can vary by state, the core evaluation focuses on whether an individual needs the round-the-clock skilled care that these facilities provide. A thorough assessment and clear understanding of the financial implications are crucial steps for ensuring the right care is found. Consulting with healthcare professionals and potentially an elder law attorney can provide invaluable guidance throughout this complex transition. The National Council on Aging (NCOA) is a valuable resource for further information on paying for and choosing a nursing home.

Frequently Asked Questions

Medicare covers limited, short-term skilled nursing care and rehabilitation, typically for up to 100 days following a qualifying hospital stay. Medicaid, in contrast, can cover long-term custodial care for individuals who meet specific state-level income and asset requirements.

ADLs are basic self-care tasks that include bathing, dressing, eating, transferring (moving from bed to chair), toileting, and maintaining continence. The inability to perform these tasks is a key factor in determining the need for nursing home care.

Yes, a physician's order is required for admission. The doctor must assess the individual and certify that they need a skilled level of care that can only be provided in a nursing home setting.

For individuals with severe cognitive impairments like dementia or Alzheimer's, a nursing home with a dedicated memory care unit may be necessary. Staff are specially trained to handle the behavioral challenges and safety concerns associated with these conditions.

A 'spend-down' is the process of reducing one's countable assets to a level that meets a state's Medicaid eligibility requirements. This is often necessary for those with assets above the state's limit who need to qualify for Medicaid to cover long-term care costs.

No, not all nursing homes accept Medicaid, although many do. For those who plan to use Medicaid, it is essential to research and confirm that a facility is Medicaid-certified and accepts new Medicaid residents.

You will need several documents, including the physician's order, medical history, recent test results (like for tuberculosis), and financial paperwork related to Medicare, Medicaid, or other insurance.

The 'lookback period' is a five-year period before a Medicaid application during which any transfers of assets for less than fair market value are reviewed. These transfers can trigger a penalty period of ineligibility for Medicaid coverage.

References

Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.