What Is the Functional Eligibility Assessment for Adult Day Care in PA?

To qualify for adult day care through Pennsylvania’s Community HealthChoices Medicaid program, your loved one must pass a functional eligibility assessment — a structured evaluation that determines whether they meet the standard for long-term services and supports (LTSS). Many families are uncertain about this process, what it actually measures, and how to approach it. This post explains it plainly. 

What Is the Functional Eligibility Assessment? 

The LTSS Needs Assessment is conducted by a Pennsylvania Department of Human Services assessor, typically in the person’s home. It evaluates the individual’s ability to perform activities of daily living (ADLs) — bathing, dressing, eating, toileting, transferring, and mobility — as well as instrumental activities of daily living (IADLs) such as managing medications, preparing meals, managing finances, and getting around in the community. 

The goal of the assessment is to determine whether the person meets the clinical threshold for what Pennsylvania defines as ‘nursing facility level of care.’ This does not mean they need to move to a nursing facility — it means their care needs are significant enough to qualify for LTSS services, including adult day care. 

What ‘Nursing Facility Level of Care’ Actually Means 

This phrase is often the biggest source of confusion for families. It sounds extreme — it isn’t. Many people who meet this standard are currently living at home with family support, managing with help from a relative or home care worker, and fully capable of participating in a community-based program like adult day care. 

The standard is about the type and level of care needs the person has, not about where they currently live or whether they are in crisis. A person who needs hands-on assistance with bathing, dressing, and medication management may meet the nursing facility level of care standard while still living at home and functioning well in a supported environment. 

How to Prepare for the LTSS Assessment 

1. Don’t minimize. The assessor’s job is to see the real picture. Help your loved one be themselves during the assessment — do not dress up their abilities or assist with tasks they normally struggle with. 
2. Document specific incidents. Before the assessment, write down examples of recent challenges: falls, medication errors, wandering, confusion about time or place, inability to complete meals or personal care independently. 
3. Be present for the assessment if possible. A family member or caregiver who can provide collateral history is invaluable. The assessor may ask you to describe what assistance is needed on a typical day. 
4. Be specific about supervision needs, not just physical assistance. If your loved one can physically walk to the bathroom but cannot initiate the process without prompting, that supervision requirement matters. 
5. Request a copy of the assessment findings. If you disagree with the outcome, you have the right to request a review. 

 What We See in Practice 

The families who struggle most with the LTSS assessment are often those who have been providing excellent care at home — they’ve built a support system that compensates for their loved one’s limitations so effectively that it can look, during a 90-minute assessment, like the person is more independent than they actually are. The assessment is trying to measure capacity without support. Help the assessor understand what the person’s day looks like without the family’s compensatory help, not with it. 

 What Happens After the Assessment 

If the assessment determines that your loved one meets the nursing facility level of care standard, the next step is choosing a CHC MCO and working with a Service Coordinator to build a care plan. If the determination is that the person does not meet the standard, you can request a review or explore other funding options including OPTIONS funding through the Area Agency on Aging. 

For the full enrollment walkthrough, see: How to Enroll Your Parent in Adult Day Care Through Community HealthChoices. For information about which Medicaid plans cover adult day care in Montgomery County, see: Which Medicaid Plans Cover Adult Day Care in Montgomery County, PA?. 

Frequently Asked Questions 

 Ready to Learn More? 

Schedule a free tour of SarahCare Adult Day Center in Jenkintown. 

Call us: 215-999-1200 or contact us here.