Medicaid Functional Assessment in PA

The functional eligibility assessment is the single appointment that determines whether your loved one qualifies for Medicaid-funded home care in Pennsylvania — and if they do, how many hours of care they’ll receive. Everything hinges on this visit, and most families walk into it without knowing what’s about to happen or how to prepare. That’s a problem, because how your loved one’s needs are documented during this assessment shapes their care plan for months or years to come.

Here’s what the assessment involves, what the assessor is looking for, and how to make sure the result reflects your loved one’s actual situation

What the Assessment Is

The functional eligibility assessment is an in-home evaluation conducted by a trained assessor— typically arranged through your loved one’s Managed Care Organization (MCO) or the local Area Agency on Aging. In Philadelphia, the Philadelphia Corporation for Aging (PCA) often coordinates these assessments in conjunction with the MCO.

The purpose is to determine whether your loved one meets the nursing-facility level of care required for home and community-based services under Community HealthChoices. In plain language: the assessment asks whether your loved one’s daily needs are significant enough that, without adequate help at home, a nursing home would be the realistic alternative.

If they meet the threshold, the assessment also establishes the baseline for the care plan — what services are needed, how many hours are justified, and what level of support is appropriate.

What the Assessor Evaluates

The assessor goes through a structured evaluation of your loved one’s ability to perform daily activities. Each category is observed, discussed, and scored based on how much help is needed.

Activities of Daily Living (ADLs) are the core of the assessment. These include bathing — can your loved one bathe or shower safely without help? Do they need assistance getting in and out of the tub, washing certain areas, or managing water temperature? Dressing — can they select appropriate clothing, put it on, fasten buttons and zippers, and manage shoes? Eating — can they feed themselves, or do they need help cutting food, managing utensils, or being reminded to eat? Toileting — can they get to and use the bathroom independently, manage clothing, and clean themselves? Transferring — can they get in and out of bed, stand from a seated position, and move between surfaces safely? Mobility — can they walk through the home, navigate stairs, and move between rooms without risk of falling?

Instrumental Activities of Daily Living (IADLs) are also assessed. These include medication management — can your loved one organize and take their medications correctly without reminders or supervision? Meal preparation — can they plan and cook a safe, nutritious meal? Housekeeping — can they maintain a safe living environment? Laundry — can they wash, dry, and manage their clothing? Shopping — can they obtain groceries and essential supplies? Transportation — can they get to medical appointments and other necessary destinations?

The assessor also evaluates cognitive function (memory, decision-making, orientation), behavioral patterns (wandering, agitation, resistance to care), and the home environment itself (safety hazards, accessibility, whether the physical space supports home-based care).

How the Scoring Works

Each activity category receives a score based on the level of assistance required — from fully independent to fully dependent. The combined scores across all categories produce an overall picture of your loved one’s functional status.

There isn’t a single magic number that guarantees eligibility. The assessment looks at the full picture: how many areas of daily life require help, how intensive that help needs to be, and whether the combination of needs rises to a level that would otherwise require institutional care.

In practice, most individuals who need regular hands-on help with two or more ADLs —particularly bathing, toileting, transferring, or eating — will likely meet the nursing-facility level of care threshold. But the specifics matter, and how the needs are described and documented during the assessment directly affects the outcome.

How to Prepare

Preparation makes a real difference. Families who walk into the assessment ready tend to get more accurate results than families who wing it.

Describe the bad days, not the good ones. This is the single most important piece of advice. Ifyour mother can dress herself on a good morning but needs help three out of five days, theassessment should reflect the three. Caregiving needs aren’t determined by peak performance —they’re determined by what happens when things don’t go well. If you paint too rosy a picture,the authorization will reflect that picture instead of the reality.

Don’t coach your loved one to perform. Many older adults instinctively try to appear more capable when a stranger is evaluating them. They’ll insist they can manage the stairs when they haven’t used them in months. They’ll claim they cook their own meals when the family has been preparing every one. This isn’t dishonesty — it’s pride and habit. But it undercuts the assessment. Gently explain to your loved one beforehand that this visit is about getting them the help they need, and that being honest about their limitations is the best thing they can do for themselves.

Have documentation available. Medical records, hospital discharge summaries, a list of current medications, and notes from doctors describing functional limitations all strengthen the assessment. The assessor can observe your loved one for an hour — documentation fills in the rest of the story.

Be present during the assessment. As the family member who provides daily care, you have firsthand knowledge that the assessor doesn’t. You know how many times your father has fallen in the last six months. You know that your mother forgets her blood pressure medication unless someone physically hands it to her. You know that bathing takes 45 minutes and requires constant supervision. Speak up during the assessment — the assessor relies on caregiver input as much as direct observation.

Mention overnight and weekend needs. Assessments sometimes focus on weekday daytime activities because that’s when the visit occurs. If your loved one needs help at night (toileting, repositioning, managing anxiety or confusion) or has different needs on weekends, make sure those are documented.

What Happens After the Assessment

If your loved one meets the nursing-facility level of care, the MCO uses the assessment results to develop a care plan. The care plan specifies which services are authorized (personal care, homemaker services, respite, etc.) and how many hours per week or month are approved.

This is the moment to request Participant-Directed Services if you want a family member to be the paid caregiver. The care plan and the PDS request happen in the same care planning conversation with the service coordinator.

If your loved one does not meet the threshold, you have the right to appeal. Request the determination in writing, review the scores, and if you believe the assessment didn’t capture the full picture, file a grievance with the MCO or request a Fair Hearing through the Department of Human Services. Providing additional medical documentation and a detailed description of daily needs can strengthen the appeal.

CareChoice Helps Families Prepare

The functional assessment isn’t a test you can study for, but it is an evaluation you can prepare for. CareChoice helps Philadelphia families understand what the assessment covers, how to present their loved one’s needs accurately, and what to do if the result doesn’t match reality.

Getting this right the first time means the right services, the right hours, and the right support for your family from day one.

Talk to CareChoice →Contact our Philadelphia team