How Do You Get Into a Medicaid Nursing Home?

Why is getting a Medicaid-eligible loved one into a nursing home so complicated?

Although many residents ultimately use Medicaid to pay for long-term nursing home care, admission isn’t straightforward. Facilities often require proof of payment before accepting a new resident, yet in many states Medicaid won’t finalize eligibility until after admission. Add limited “Medicaid beds,” complex eligibility rules, and multi-layered nursing home regulations—and the process can take months.

The Medicaid Paradox: Most nursing homes won’t accept a resident without a guaranteed payer, and in many states, Medicaid will not approve the applicant until after the person is admitted.

Families can still navigate this successfully by choosing the right route, understanding required screenings, and timing the Medicaid application carefully. If you’re unsure about eligibility, consider taking a quick prescreen and/or consulting a Medicaid planner.

What preadmission screenings will your loved one need?

What is PASRR—and why does it matter?

The Preadmission Screening and Resident Review (PASRR) is a federal requirement to identify serious mental illness (SMI) or intellectual disability (ID) needs and determine the least restrictive, appropriate setting. It helps ensure persons who could be served at home or in the community aren’t placed unnecessarily in a nursing facility.

How is “nursing facility level of care” (NFLOC) determined?

Separate from PASRR (sometimes combined by states), the NFLOC review confirms that the person meets your state’s medical/functional criteria for nursing home care. Your state Medicaid agency or the facility can guide you through the local process.

Which path should you take to gain admission?

Before choosing, consider: Do they have Medicare? Are they already on Medicaid? Is short-term cash available? Do local homes accept Medicaid Pending? Will you need to spend down? How urgent is admission?

1) Could a “Medicaid Pending” admission work for you?

How it works: Find a facility that accepts Medicaid Pending residents, move in, apply for Medicaid, and the facility holds billing until the application is decided.

• Step 1: Build a list of nearby facilities that accept Medicaid (ask specifically about Pending).
• Step 2: Call admissions to confirm they accept Medicaid Pending without a guarantor.
• Step 3: Ask if a Medicaid bed is available; if not, join the waitlist (join several, if possible).
• Step 4: Apply for Medicaid only if you’re confident of approval—or work with a planner first. If denied, eviction risk is high unless you appeal or begin private pay.

What are the drawbacks?

• Few facilities accept Medicaid Pending without a financial guarantor.
• Average quality ratings can be lower (with exceptions).
• If Medicaid is denied and no appeal is filed, immediate discharge is likely unless private pay begins.

2) Can you enter via Medicare—and transition to Medicaid?

When this fits: Your loved one still has available Medicare Part A skilled nursing days and meets the criteria (3-day qualifying inpatient stay, admitted to SNF within 30 days, daily skilled need, MD order, Medicare-certified facility). Enter on Medicare, then apply for Medicaid as coverage ends.

What are the drawbacks?

• The 100-day Medicare window can be tight for compiling a complete Medicaid application.
• Facilities may push for a payment guarantor if Medicaid is later denied.

3) Should you private pay during “spend-down” and then switch to Medicaid?

How it works: If countable assets exceed your state’s Medicaid limit, pay privately for care (or spend on permitted items) until assets fall below the limit. Choose a facility that accepts Medicaid so you can switch payers when eligible.

What are the drawbacks?

• Out-of-pocket costs can be significant if not carefully planned.
• You must time the Medicaid application correctly to avoid an early denial for “excess” assets.

4) Could the family privately pay during spend-down—with a planned refund?

How it works: Family pays the facility while the resident applies for Medicaid. In some states, Retroactive Medicaid (up to three months prior to application) may reimburse the facility, which then refunds the family. Get any refund agreement in writing and request retroactivity on the application (if not automatic in your state).

What are the drawbacks?

• If the Medicaid application is denied or retroactivity isn’t approved, the family may not be refunded.
• Because risks are higher, many families work with a Medicaid planner on this path.

How do you start—no matter which path you choose?

1. Verify likely eligibility: Use a quick screen or consult a Medicaid planner to confirm financial/medical eligibility and strategy.
2. Build your facility list: Identify nursing homes in your area that accept Medicaid—and specifically ask about Medicaid Pending and bed availability.
3. Get a physician referral: Ask your loved one’s doctor for a nursing home referral and help coordinating PASRR/NFLOC steps.

What else should families keep in mind during the process?

• Documentation is everything: Early collection of financial statements, deeds, insurance, ID, and medical notes will speed the application.
• Admission ≠ approval: “Likely eligible” is not the same as “approved.” Time your application carefully.
• Ask about bed types: Facilities may have limited “Medicaid beds.” Get on multiple waitlists where possible.
• Appeal if needed: If Medicaid denies or a facility moves to discharge, timely appeals can protect placement while reviewed.