My mom has mild dementia and daily living skills are declining. Who has to determine home care/assisted living needs so insurance will cover them?

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Mild dementia. And recently had thyroid removed. Takes several medications and needs reminders to drink water. Cannot clean her own clothes.

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Does she have long term care insurance? That is the only type of coverage that pays for aides in the home or assisted living facilities. (If not and if she has financial resources, she would be private pay.) Each long term care policy establishes the rules for 'when it pays'. Let us know what type of insurance you refer to.
What insurance sources are you thinking will pay for caregivers?
For LTC insurance it’s as geewiz wrote.

If it’s the government, Medicare (federal) benefits tend to be tied into limited period of time services after a hospitalization (Medicare Part A paid for) whether in a facility or in home.
For Medicaid (joint federal & state programs), it’s going to depend on what your state has in place. States are required to pay for skilled nursing care but eligibility (medical & financial) are determined by each state as each state administers its Medicaid uniquely. Some states do not pay for any AL at all ever. Some pay for AL through waiver programs which tend to very narrow eligibility coupled with waiting lists (its one of the reasons why you read AL have a couple of years of private pay before Medicaid kicks in).

For VAs Aid and Attendance, va too has medical and financial eligibility.

Most caregiving in the US is done by family and family does for free out of a sense familial duty. If your parent has resources (SS, savings), they can pay you to caregive. If you go this route you do need to get a caregiver contract done by an elder law atty that will be totally Medicaid compliant so if in the future they apply to Medicaid there’s no eligibility or gifting issues. 

Most Medication management in & of itself does not need skilled nursing care as an aide or other non skilled worker can distribute Rx’s or prompt mom to drinking water. 
The medical eligibility for NH level care is really getting tightened up by the states as Medicaid costs for older / elder population is busting state budgets. 
If you mean nursing home placement, that usually happens after a hospitalization and the person’s PCP usually orders it. How it is paid for is related to your mother’s assets.

Otherwise no insurance plan I know of, commercial or Medicare, will pay for aides or other CG’s to come into the home & provide care.
Maybe it’s getting near time for your mom to need 24/7 care in a nursing home? If that’s in your future begin to read about Medicaid coverage for NH so you can review your mother’s financial resources in the event she needs to apply.

Hiring CG’s on your own to care for mother at home doesn’t need a MD order and isn’t paid for by insurance, in general. Families pay out of pocket.
Good luck!
If your mother has long-term care insurance, contact one of the large, national home care agencies. They can process her long-term care insurance claim. We did that for my relative. We used Amada and they got the claim approved in only 3 weeks.

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