Overview of Arizona Long Term Care System
The Arizona Long Term Care System (ALTCS) is an AZ Medicaid Program through which long-term care services and supports are provided for elderly, blind and disabled residents who require the level of care provided in a nursing home. While nursing facility care is an available benefit, a variety of home and community based services (HCBS) are also available to prevent and / or delay nursing home admissions. These include adult day care, home delivered meals, personal care assistance, personal emergency response systems, and respite care.
In addition to long-term care, ALTCS program participants receive medical and behavioral health benefits via a single Medicaid (AHCCCS) health plan provided by a managed care organization (MCO). A MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. ALTCS program participants have several long-term care managed care health plans from which to choose.
There are two options for participant directed care for program participants who reside in their own home. These options, Agency with Choice (AWC) and Self Directed Attendant Care (SDAC), allow them flexibility in regards to who provides them with personal care assistance and homemaker services. This means that rather than be assigned one of the MCO’s network of licensed care providers to receive services, a program participant can hire their own “direct care worker” (caregiver).
With SDAC, the program participant takes on all employer responsibilities, and hires, trains, manages, and can even fire, their own caregiver. A financial management services agency handles the financial aspects of employment responsibilities, such as tax withholding and caregiver payments. With AWC, the program participant and the provider agency share employer responsibilities. The program participant can select, supervise, and dismiss their own caregiver, but the provider agency is ultimately responsible for hiring and firing the caregiver. While relatives, including adult children can be hired, it is thought that spouses can only be hired by going through a provider agency.
ALTCS program participants can reside in a variety of settings. This includes one’s home, the home of a loved one, an adult foster care home, an assisted living facility, or a nursing home.
The ALTCS Program is an entitlement program. This means meeting eligibility requirements equates to immediate receipt of program benefits. Put differently, the program does not limit the number of participant enrollment slots and there is not a waitlist for program participation.
Arizona’s Medicaid Program is called the Arizona Health Care Cost Containment System (AHCCCS) and operates under a 1115 Demonstration Waiver. The Arizona Long Term Care System (ALTCS) is an AHCCCS Program. While ALTCS covers state residents who are developmentally or intellectually disabled, the part of the program that covers those who are elderly or physically disabled is sometimes abbreviated as ALTCS-EPD.
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For-Service” or “Managed Care”. Under Fee-For-Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.
Benefits of Arizona Long Term Care System
In addition to medical benefits, such as doctor’s appointments, laboratory services, x-rays, and hospitalization, dental, and behavioral health benefits, a variety of home and community based services are available via ALTCS. An individual care plan will determine which services and supports a program participant will receive. Potential HCBS are as follows.
– Adult Day Health Care
– Attendant Care – supervision, personal care assistance, and homemaker services
– Case Management
– Community Transition Services – to assist with transitioning from a nursing to community living
– Durable Medical Equipment / Medical Supplies
– Home Delivered Meals
– Home Health Care – home health aides, nursing services, therapies
– Home Modifications – for safety and accessibility (i.e., grab bars, wheelchair ramps, and widening doorways)
– Homemaker Services – assistance with housecleaning, laundry, shopping for groceries, preparing meals, etc.
– Hospice Care
– Nursing Facility Care
– Personal Care Services – assistance with daily living activities (i.e., bathing, dressing, eating, and mobility)
– Personal Emergency Response Systems (PERS)
– Respite Care – in-home and out-of-home short-term care to alleviate a primary caregiver
– Therapies – occupational, physical, speech, and respiratory
– Transportation – non-emergency, but medically necessary
While program participants can reside in an adult foster care home or an assisted living residence, ALTCS does not cover the cost of room and board.
Eligibility Requirements for Arizona Long Term Care System
The ALTCS Program is for Arizona residents who are elderly (65+ years old), blind, or disabled. Additional financial and medical eligibility criteria is below.
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. There is a minimum income allowance, set at $2,177.50 / month (effective July 2021 – June 2022), which is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,259.50 / month (effective January 2021 – December 2021), and is dependent on the non-applicant spouse’s shelter and utility costs. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished.
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $4,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance. In AZ, it is also called a community spouse resource deduction.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.
The home is often the highest valued asset an Arizona Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, AZ Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– The applicant has a minor or disabled child living in the home.
To learn more about the potential of Medicaid taking the home, click here.
Medical Criteria: Functional Need
An applicant must require a nursing facility level of care (NFLOC). For the ALTCS Program, the tool used to make this determination is the Pre-Admission Screening (PAS). A need for assistance with the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, bathing, grooming, dressing) is one area of consideration. Cognitive deficits, which are common in persons with Alzheimer’s Disease or a related dementia, are also taken into account. A diagnosis of dementia, such as Alzheimer’s disease, in and of itself does not mean one will meet a NFLOC.
Qualifying When Over the Limits
limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
When persons have income over the limits, Miller Trusts, also called a qualified income trust can help. Specific to Arizona, they are also called income-only trusts. “Excess” income is deposited into the trust, no longer counting as income.
When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets on medical bills, household furnishings and appliances, or even a vacation. Another option, although it must be implemented well in advance of the need for Medicaid-funded long-term care, is the Long Term Care Partnership Program. Not only does it allow some assets to be exempt from Medicaid’s asset limit, but it also protects them from Medicaid’s estate recovery program. There are many other options when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Arizona to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be executed years prior to the need for long-term care. However, there are some workarounds, such as the Modern Half a Loaf Strategy, and AZ Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.
How to Apply for Arizona Long Term Care System
Before You Apply
Having income and / or assets over the Arizona Medicaid Prior to applying for the ALTCS Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.
Persons can apply for the ALTCS Program via their local ALTCS office. The location of the ALTCS offices can be found here, or alternatively, persons can call the toll-free number for ALTCS at 1-888-621-6880 to apply. Another option is to fill out the Request for Application For Arizona Long Term Care System (ALTCS) and fax, email, mail, or drop it off at one’s local ALTCS office. Relevant information is on page 4 of the application. Once financial eligibility has been determined, an in-person functional needs assessment will be scheduled.
Additional information about the Arizona Long Term Care System Program can be found here. Persons can also call ALTCS at 1-888-621-6880 or contact their local ALTCS office. The Arizona Health Care Cost Containment System administers the Arizona Long Term Care System Program.
Approval Process & Timing
The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.