ALTCS Application Packet

Before proceeding with the
ALTCS application…
Determine if the applicant needs the assistance of an Elder Law attorney to proceed
with the ALTCS application by answering the following questions:
YES
NO
Is the applicant single, having gross income over $2,199 each month?
Is the applicant single, having more than $2,000 in assets?
Is the applicant married, having more than $23,844 in assets?
Does the applicant’s assets include any of the following: Trust, Life Insurance, Annuities, Long Term
Care Insurance, Interests in Real Property (including a residence), Time Shares, Promissory Notes, Loan
Agreements, Personally Held Stocks/Bonds, Multiple Vehicles, Business Property, and/or a Life Care
Contract?
Has the applicant or the applicant’s spouse gifted or transferred any cash, bank accounts, real property,
or personal property (i.e. something other than typical birthday and holiday presents) to another person
or entity within the last 60 months? (This would include placing another person's name on any accounts
and/or property.)
If the applicant has enough income and assets to currently pay for his/her care needs, is the applicant, due
to a chronic, long-term illness, going to be paying for long-term care longer than a period of two months
with private funds?
Does the applicant need a guardian, conservator, or fiduciary to assist with the application?
Has the applicant recently been diagnosed with a chronic illness and is needing to financially plan for
future medical needs?
Does the applicant want to legally protect assets for a spouse and/or children?
If YES was checked on one or more of the above questions, it is in the best interest of the
applicant to meet with an Elder Law attorney BEFORE applying for benefits.
Have questions concerning ALTCS eligibility? Call 1-800-243-1160 and ask
to speak with an Elder Care Social Worker for a FREE benefits analysis.
JacksonWhite, P.C. | www.arizonaseniorlaw.com
2015 ALTCS Application Packet
ALTCS Information Packet
Table of Contents
» Form DE-828: Filing an Application for the Long Term Care System (ALTCS)
» Form DE-101: Request for Application for AHCCCS
Long Term Care Services
» ALTCS Medical Eligibility Pre-Admission Screening (PAS)
» ALTCS Financial Eligibility Fact Sheet
» ALTCS Program Contractors
» ALTCS Office Locator
WARNING: Some documents following this page are needed for application to the
Arizona Long-Term Care System (ALTCS). We strongly encourage you to speak with
the Elder Law department at JacksonWhite BEFORE proceeding with the application
process yourself. Incorrectly filing for the ALTCS program, either too soon or too late,
can cause unnecessary ineligibility. Call 1-800-243-1160 today to speak with a
JacksonWhite Social Worker.
JacksonWhite, P.C. | www.arizonaseniorlaw.com
2015 ALTCS Application Packet
JacksonWhite, P.C. | www.arizonaseniorlaw.com
2015 ALTCS Application Packet
JacksonWhite, P.C. | www.arizonaseniorlaw.com
2015 ALTCS Application Packet
ALTCS Medical Eligibility
Pre-Admission Screening (PAS)
General Information
The purpose of the Pre-Admission Screening (PAS) is to identify whether or not applications meet criteria
for Title XIX or Medicaid-funded long-term care services (ALTCS). To receive federal Medicaid funds for an
individual, AHCCCS must demonstrate that the applicant has a medical need for these services and is at risk
of institutionalization. This means that the applicant is in need of long term care at a level of comparable to
that provided by a nursing facility, but which is below that of an acute care setting (hospitalization or intense
rehabilitation) and above that of a supervisory/ personal care setting (intermittent outpatient medical intervention
or benevolent oversight.)
An individual who meets ALTCS criteria for Title XIX eligibility will present a combination of the following needs
and impairments:
• Requires nursing care by or under supervision of a nurse on a daily basis
• Requires regular medical monitoring
• Exhibits impaired cognitive functioning
• Exhibits impaired self care with activities of daily living
• Exhibits impaired continence
• Displays psychosocial deficits
The PAS tool is the instrument used to determine whether or not an individual is medically eligible for ALTCS. It
is completed by an assessor who may be a social worker or a registered nurse. In certain instances a nurse/social
worker team may assess the individual. The assessment is a face-to-face interview with the applicant and other
informants.
The PAS consists of several sections:
1. Intake information
2. Demographic information
3. Functional information and assessment
4. Medical information and assessment
In order to be eligible for ALTCS services, an individual must be determined to be at risk of institutionalization.
PAS screening is designed to determine whether or not the applicant is at risk by examining the individual’s recent
functional and medical condition. This may be achieved by asking questions of the applicant and significant others,
reviewing available records, and observing the applicant’s behavior during the PAS interview.
All the functional and medical assessment criteria are taken into account in the development of a numerical score
which is determined to meet or not to meet the baseline criteria. A level of care is determined based on the score
and individual PAS items. If either the score or the level of care is determined to be questionable or inappropriate
by the PAS team, an evaluation can be made by the ALTCS physician consultant. This physician review may
override the numerical score if appropriate.
JacksonWhite, P.C. | www.arizonaseniorlaw.com
2015 ALTCS Application Packet
ALTCS Medical Eligibility
Pre-Admission Screening (PAS) - continued
Functional Assessment
The functional portion of the screening focuses on the following areas:
1. Activities of Daily Living (ADLs)
• Mobility - purposeful movement within the applicant’s residence
• Transfer - the ability to move between two surfaces, i.e. bed, wheelchair, chair
• Bathing - washing, rinsing, drying body parts, transfer in/out of tub
• Grooming - tending to appearance of hair, teeth, face, hands, nails
• Dressing - Putting on and removing articles of clothing
• Eating - putting food and fluids into system
• Toileting - managing elimination of urine and feces
2. Continence
3. Vision
4. Orientation to person, place and time
5. Behavior patterns such as wandering, aggression, self-injurious, suicidal, or disruptive
Medical Assessment
The medical portion of the screening focuses on the following areas:
• Medical condition:
-Determines an applicant’s medical conditions whether acute, chronic or recurring
-Determine if these conditions impact ADLs
-Determine if medical or nursing treatments are required
• Services and treatment - identifies all services and treatments an applicant receives or needs
JacksonWhite, P.C. | www.arizonaseniorlaw.com
2015 ALTCS Application Packet
ALTCS Financial Eligibility Fact Sheet
Effective January 1, 2015
ALTCS monthly income$2,199
Resources for individual$2,000
Plus burial$1,500
Resources for community spouse CSRD MAXIMUM
$119,220
Resource for community spouse MINIMUM$23,844
Monthly Maintenance Needs Allowance MAXIMUM $2,981
Monthly Maintenance Needs Allowance MINIMUM $1,967
ALTCS Program Contractors
Maricopa County
AHCCCS
Acute Care
Maricopa Health Plan
Mercy Care Plan
ALTCS
ALTCS-DDD
Div. of Dev. Disabilities
ALTCS-EPD
Elderly Physically Disabled
ALTCS-IHS
Indian Health Services
GOVERNMENT
AGENCY
PROGRAM
CONTRACTORS
HEALTH
INSURANCE
Department of Economic
Security
Mercy Care Plan
Gila River Indian
Community
Phoenix Health Plan
Arizona Physician, IPA
Health Choice of AZ
Care 1st Arizona
Bridgeway Health
University Family Care
What is a program
contractor?
The state contracts with
insurance companies, also known
as program contractors, who
coordinate services through
providers in the community.
JacksonWhite, P.C. | www.arizonaseniorlaw.com
Bridgeway Health Solution
UnitedHealthcare
Community Plan
Hopi Tribe
Pascua Yaqui Tribe
Navajo Nation
San Carlos Apache Tribe
Insurance Provider
Tohono O'Odham Nation
White Mountain Apache
Tribe
2015 ALTCS Application Packet
ALTCS Office Locator
Note: ALTCS applications are shipped to the ALTCS office that is NEAREST to patient's residence.
CASA GRANDE OFFICE
500 N. Florence St.
Casa Grande, AZ 85222
Tel: (520) 421- 1500
Fax: (520) 836-6828
PHOENIX OFFICE
801 E. Jefferson Street, MD 1600
Phoenix, AZ 85034
Ph:602-417-6600
FAX:602-253-6385
CHINLE OFFICE
Tseyi Shopping Center, Hwy. 191
P.O. Box 1942
Chinle, AZ 86503
Ph:928-674-5439
FAX:877-660-1450
Toll Free:1-888-800-3804
PRESCOTT OFFICE
Note: Prescott ALTCS staff are sharing space at the DES office.
1519 W. Gurley Street, #11
Prescott, AZ 86305
Ph:928-778-3968
FAX:877-666-5269
Toll Free:1-888-778-5600
COTTONWOOD OFFICE
1 N. Main Street
Cottonwood, AZ 86326
Ph:928-634-8101
FAX:877-666-5208
SHOWLOW OFFICE
580 E. Old Linden Road, Suite 3
Show Low, AZ 85901
Ph:928-537-1515
FAX:877-666-5286
Toll Free:1-877-537-1515
FLAGSTAFF OFFICE
2717 North Fourth Street, Suite 130
Flagstaff, AZ 86004
Ph:928-527-4104
FAX:877-663-5213
Toll Free:1-800-540-5042
GLOBE/MIAMI OFFICE
Cobre Valle Plaza
2250 Highway 60, Suite H
Miami, AZ 85539-9700
Ph:928-425-3165
FAX:877-666-5219
Toll Free:1-888-425-3165
KINGMAN OFFICE
519 E. Beale Street, Suite 130
Kingman, AZ 86401
Ph:928-753-2828
FAX:877-667-5239
Toll Free:1-888-300-8348
LAKE HAVASU OFFICE
2160 N. McCulloch Blvd., Suite 105
Lake Havasu City, AZ 86403
Ph:928-453-5100
FAX:877-664-5264
Toll Free:1-800-654-2076
JacksonWhite, P.C. | www.arizonaseniorlaw.com
SIERRA VISTA OFFICE
NOTE: Sierra Vista ALTCS staff are sharing space at the DES office.
Street Address:
2981 E. Tacoma, Sierra Vista
Mailing address:
1010 N. Finance Center, Suite 201, Tucson, AZ 85710
Ph:520-205-8600
FAX:1-800-824-2656
TUCSON OFFICE
1010 N. Finance Center Drive, Suite 201
Tucson, AZ 85710
Ph:520-205-8600
FAX:877-666-5353
Toll Free:1-800-824-2656
VALLEY OFFICE
801 E. Jefferson Street, MD 800
Phoenix, AZ 85034
Ph:602-417-6000 or 602-417-6400
FAX:602-253-4871
YUMA OFFICE
3850 W. 16th Street, Suite A
Yuma, AZ 85364
Ph:928-782-0776
FAX:877-666-5382
2015 ALTCS Application Packet