ALTCS (Arizona Long Term Care System)
What You Need to Know (but certainly not all there is to know...)
ALTCS is a complicated system and can be a confusing process. Make sure you reach out to your local ALTCS office for assistance when applying for assistance.
7 out of 10 applicants are denied for ALTCS the first time they apply. With non-financial, financial, and medical reasons for denial, there is an obvious need for someone to take those applicants by the hand and help them understand why, work with them on options to prevent a denial, and help them through the process of becoming eligible.
ALTCS Medical Eligibility
The eligibility is getting tougher. For example, it used to be that a dementia diagnosis in the chart was sufficient. Now, it must be documented by a neurologist. If you have a diagnosis of dementia or Alzheimer’s disease, make sure you schedule a follow through on their visit to a neurologist. This is worth 20 of the 60 points needed to qualify!!
ALTCS only needs the following records: the most recent history and physical, physician progress notes for a year, documented list of medical conditions and diagnoses, prescription and OTC (over-the-counter) list, hospital or SNF (Skilled Nursing Facility) discharge summaries from the past 6 months, and if residing in assisted living, the most recent monthly or quarterly needs assessment.
Remember to request records in advance to prevent delays in processing. These can be provided to ALTCS before the actual medical assessment.
If you are receiving care at home from a family member, encourage them to begin journaling the services they are providing (date of service, time started, time ended, what service was performed). This will help show ALTCS how often the care is needed. A Caregiver Agreement can also be generated for family members providing care.
To be approved for the program, the applicant must reside in an ALTCS approvable setting. Approvable settings include home receiving or intending to receive services, or a skilled nursing facility (SNF) or an assisted living home (ALH) or assisted living facility (ALF) with an AHCCCS provider ID number.
Many consumers are surprised that home care is a covered service. BUT the maximum number of hours one can receive is 40 hours per week. ALTCS does not pay retroactively for home-based care even if the application was approved retroactively. This is generally the same for ALH/ALFs. Family members can become the paid caregiver if an approved ALTCS home care provider hires them and they meet hiring requirements.
If the applicant moves during the ALTCS application process, ALTCS must know about the move (date of move, name, address, and phone number of the facility). ALTCS cannot approve the applicant under he/she is in an appropriate ALTCS setting. If he/she has a hospital stay and must go to a rehab center thereafter, please do not allow the hospital to discharge the applicant to a non-ALTCS approved rehab. If you do, ALTCS can approve the case, BUT ALTCS will not pay any unpaid bills for that rehab.
If you wish to move the applicant to an assisted living facility/home, please make sure this home already has an ALTCS provider ID number. If this facility/home does not, ALTCS WILL NOT approve benefits in that facility/home.
Financial Eligibility - Key Points
Assets (resources) include, but are not limited to, financial accounts at any institution, life insurance, annuities, investments, property, and vehicles. Countable assets do not have an “exclusion” reason. The asset or “resource” limit for single individuals is $2,000. The asset or “resource” limit for married couples is $26,720; however, some married couples can keep more. The maximum a married couple may be eligible to keep is $125,600.
Married couples need to have their spousal share determined as soon as they are eligible to have it determined. When is that? When the first person needs 30+ days of institutionalization (i.e. nursing home care or hospital/nursing home care or a combination of them). OR 30+ days of home-based or assisted living care. Note: ALTCS makes this determination on HCBS and assistive living. They must determine if the care prevented institutionalization for it to count. This is called a Resource Assessment.
Life insurance with a $1,5000 face value or less is typically excluded. Policies over $1,500 are counted and many have to be surrendered BUT that is NOT the only option.
Home property in Arizona valued less that $572,000 is typically excluded; however, i the property is in a TRUST OR over that value, it becomes a countable asset. Although removing it from the trust will gain excludability, it does not fix their estate planning issues.
Consumers need to understand that their Estate Recovery for ALTCS members. It used to be that this applied to folks over 55 only; however, effective May 6, 2018, there is no longer an age related to this. Estate Recovery applies to ALL applicants. Estate Recovery means the State will go after the estate to recover the costs incurred to care for that member. Some exemptions and waivers to apply:
* Surviving spouse, surviving children under age 21, or surviving child who is blind or disabled
* Heirs who own business in that property*, heirs who reside in the residence and have for the past year and who do not own another residence
* A vehicle is typically excluded; however, it must be in use for the customer’s benefit or for the spouse
It’s important to disclose gifts. Many people are fearful of doing this. ALTCS needs to know about these so they can determine if the transfers or gifts are compensated or uncompensated. Compensated transfers DO NOT affect eligibility. Uncompensated transfer can result in periods of ineligibility. Transfer do no result in a “denial” of benefits. Instead, if the ALTCS member meets all requirements and has a transfer, ALTCS imposes a penalty period.
Some transfer may be excluded and some penalty periods can be waived.
* There is not a penalty if you receive something of equal value for the item that you transferred
* There is not penalty for transfer to a spouse or disabled child
Example: Mrs. Williams change the title to her home and gave it to her daughter. The private pay rate in the county in which she lives in $5,000. The home was worth $150,000. Her daughter did not give her anything for the home. $150,000 divided by $5,000 = 30 months of ineligibility for full long term care services.
Income limit for a single person is $2,250 per month. Income limit for married couples is $4,500 per month. Couple have two income tests - first as a couple; then the applicant's income as a single person.
For more information, on the internet go to: https://azahcccs.gov/resources/guidesmanualspolicies/eligibilitypolicy/eligibilitypolicymanual/index.html
Applicants who fail the test can use a Miller Trust (aka: Income-Only trust) to qualify. There are five major steps to completing this kind of trust:
* Create the trust with the specific requirements as dictated by law;
* Sign and notarize the trust;
* Create a bank account titled to the trust;
* Deposit income received into the trust bank account; and
* Make disbursement according to the Trust’s rules.
* Many people think you need an attorney to do this. Many times, a long-term care planner or legal document preparer can assist with setting this up for a reasonable fee.
Other Health Insurance
Medigap or Medicare Supplement Insurance. This is health insurance which core the “gap” between what Medicare covers (typically 80%) and what it doesn’t (typically 20%); it also help pay deductibles (depending on the plan). This type of insurance almost always has a premium that the customer pays (sometimes retiree plans pay for this). The best time to enroll in this plan is when you turn 65 because you are guaranteed issue during that time.
ALTCS members DO NOT have to give up this coverage. For members residing in facilities, ALTCS allows the premium as a deduction from their cost of case. Because ALTCS is the payer of last resort, all medical bills go through Medicare and any Medicare Supplement before any bills get paid by AHCCCS/ALTCS. This coverage gives people the MOST CHOICE and depending on the plan, this type of Medicare insurance typically has the MOST COVERAGE.
Medicare Advantage Insurance
These are private health insurance plans that combine Medicare coverage ito one plan and whose members must see providers within that plan. Some plans have premiums and some area zero-premium plans Member pay co-pays for their care and plan limits. Compared to Medicare only, this is a great option to limit maximum out-of-pocket exposure.
ALTCS members DO NOT have to give up the plan they are already on if they are happy with their providers, BUT they need to understand that if their current providers are NOT also ALTCS contracted providers, then ALTCS WILL NOT cover the unpaid portions of those bills. IF they go to providers that are contracted with both their current plan AND ALTCS, then some of their out-of-pocket costs will be covered.
ALTCS members (and acute care AHCCCS members, too) may be eligible for extra benefits after approval by enrolling in a Dual Special Needs Plan - one that coordinates with their ALTCS program contractor (Mercy Care Plan, Banner University, or UnitedHealthCare).
The program contractor’s each have their own Dual Special Needs Plan and they are assertive in their attempts to get ALTCS members to switch. Many plans have a zero dollar premium. Many have additional benefits like a health products catalog for OTC items, dental coverage, vision, hearing, some have chiropractic care, etc.
ALTCS applicants must apply for all potential benefits. If the applicant has ever worked for federal, state, city, or county government OR for an employer with a pension plan, they need to check into those potential benefits. By asking these questions, many have found large amounts of extra assistance.
If the applicant is a Veteran or widow of a Veteran who served during wartime, ALTCS requires they apply for benefits. Now, does that mean he/she has to submit a perfected application with the intent to be approved? No, they can choose to do a basic application instead.
Can people be on ALTCS and VA benefits? YES!! Is it always a good idea? No. Sometimes it can be a headache to manage the funds because the VA is not good at stopping or reducing benefits when they should or could.
It is important for families to make the best decisions for their loved ones. Many promote VA services as a way to fund care and use VA planners to do so. Not everyone gets to stay home or in assisted living during their whole life, and if they need skilled care, the planning it takes to get VA eligible can sometimes negatively impact ALTCS eligibility. Some VA planners are not familiar with ALTCS guidelines and if they use irrevocable trusts or annuities to qualify their Veteran or widow for benefits, this can have long-term negative consequences to their ALTCS application. Utilizing a skilled planned who is familiar with both of these alternatives is the best option for families who are questioning which direction to go.
ALTCS is supposed to make a decision in 45 days. They RARELY meet that timeframe. Many people do not realize that they can file an appeal when the case goes over the due date. As long as you’ve provided everything they’ve asked for, you can file the appeal about a week after the 45th day.
Average processing times have recently been around 55-60 days.
You don’t have to do this alone. Understanding the pitfalls of applying for government programs, getting denied for coverage and not understanding why, or even being sold a product that does not serve you are some of the many issues that arise.
Please contact your local ALTCS office for additional information. Call 888-621-6880, or write to 801 E. Jefferson Street, MD 3900, Phoenix, Arizona 85034.