Pennsylvania's Department of Human Services uses this two-page evaluation to decide whether a Medical Assistance applicant medically needs nursing facility, ICF or home and community-based care. A licensed physician records vital signs, ICD-coded diagnoses, care needs, orders, prognosis and a recommended level of care. A department designee such as Aging Well then reviews it and marks the applicant medically eligible or not, and the original goes to the county assistance office.
A licensed physician completes items 1 to 20C and signs; a physician in training (MT or OT) may not sign. The applicant, or a legal guardian or responsible party, signs the release in item 10, and Aging Well or another department designee completes items 21 and 22.
Check New or Updated at the top. Enter the MA recipient number, the applicant's name (last, first, middle initial), Social Security number, birthdate, age and sex, the attending physician and the physician license number. The instructions call items 1 to 7 self-explanatory but single out item 8: it takes the physician's license number, not the Medical Assistance number.
Item 9 records where the evaluation took place by code: 01 hospital, 02 nursing facility, 03 personal care or domiciliary care, 04 own house or apartment, or 05 other, which you must specify. Item 10 is the applicant's authorization to release medical information to the county assistance office and DHS for Title XIX inpatient care, home and community-based services and any shelter deduction. The applicant signs if able; otherwise a legal guardian or responsible party signs.
Record height, weight, blood pressure, temperature, pulse rate and cardiac rhythm. In the medical summary, include the medical information you consider important for the level-of-care determination, and list the patient's known allergies here, because the form has no separate allergy box. This narrative is what explains the level of care you recommend in item 20A.
Item 13 asks how much help the patient would need to leave the building in an emergency: independently, with minimal assistance or with total assistance. Item 14 asks whether the patient can administer their own medications: self, under supervision, or no. The instructions frame item 14 as whether the patient is capable of being trained to self-administer medications.
Enter the ICD codes in the blocks and write each diagnosis by name in the space beside its block. List the primary (principal) diagnosis first, then secondary, then tertiary. These diagnoses need to support the medications and treatments you order in item 17, since the instructions require every medication to have a diagnosis supporting its use.
Check each category that applies: physical, speech, occupational or inhalation therapy, special dressings, irrigations, special skin care, parenteral fluids, suctioning, or other (the instructions give mental health and case management as examples). In item 17, write orders for medications, treatment, rehabilitative and restorative services, therapies, diet, activities, social services and special procedures for health and safety. Orders should meet the needs checked in item 16.
Check only one prognosis (stable, improving or deteriorating) and only one rehabilitation potential (good, limited or poor), both based on the patient's current medical condition. The instructions say the rehabilitation potential in item 19 should be consistent with the prognosis in item 18, so review the pair together before signing.
In 20A, recommend one level of care: Nursing Facility Clinically Eligible, Personal Care Home, ICF/ID, ICF/ORC, inpatient psychiatric care, or other (write it in). Complete 20B only for an NFCE patient who will be served in a nursing facility: indicate whether the patient may eventually return home or be discharged and, if yes, within 180 days or over 180 days. In 20C, print your name, add a telephone number, then sign and date.
Leave these blank. Medical and other professional staff of the Medicaid agency or its designee, such as Aging Well, review the evaluation, record whether the applicant is medically eligible, add comments on a separate sheet if needed, and sign with their title and date. This review is how the department certifies medical eligibility for services.
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MA-51 Medical Evaluation - Plan of Care
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Sources for this guide
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Only a licensed physician. The instructions state that a physician in training, meaning a Medical Doctor in Training (MT) or an Osteopathic Doctor in Training (OT), may not sign it. The physician prints their name, adds a telephone number, signs and dates item 20C, and enters their license number in item 8.
There is no fixed expiration date. The instructions say the MA 51 is valid as long as it reflects the applicant's current conditions. If the patient's condition changes, complete a new evaluation and check 'Updated' at the top so the reviewer knows it replaces the earlier one.
Item 20A offers Nursing Facility Clinically Eligible (services at home or in a nursing facility), Personal Care Home, ICF/ID, ICF/ORC, inpatient psychiatric care, and Other, which you write in. Check only one. The instruction page defines each level, for example NFCE care can be provided in the community through home and community-based services or in a nursing facility.
No. The physician recommends a level of care. Items 21 and 22 are completed by Aging Well, the appropriate Department of Human Services program office or another department designee, who reviews the evaluation, marks the applicant medically eligible or not, and signs. The county assistance office then determines overall eligibility.