ALTCS "The Whole Enchilada!"

The ALTCS Application Process.

“ALTCS The Whole Enchilada!”

Contributed by: Steve Dabbs, CMP™
Certified Medicaid Planner™

ALTCS (pronounced “All-Texs”) is the acronym for Arizona’s Long-Term Care System. This is Arizona’s Medicaid program for long-term care.

Funding for ALTCS is shared by the federal government, the State of Arizona, and Arizona county governments. The Arizona Health Care Cost Containment System (AHCCCS) administers the ALTCS program, which was founded in 1982 to cover the health care costs of low-income people.

AHCCCS must follow the laws and rules under federal law CFR Title 42. Under Title 42, each state is allowed to provide more benefits than what is required

ALTCS the Whole Enchilada
ALTCS "The Whole Enchilada!"

under federal law. It cannot give fewer services or impose more stringent restrictions. In other words, the state must follow the minimum standards set by the federal government.

ALTCS can offer additional benefits to Arizona residents, but it cannot offer less than the minimum benefits under federal law.

These differences in state laws can be confusing. Often family members who live in a different state from their loved one will be mistaken about ALTCS because they reside in a state that more benefits or options than does the state in which their loved one resides. One example is the  HCBS or the Home and Community Based Services Waiver Program.

These interstate variations in benefits, services, and even qualification requirements often lead people to believe that they don’t qualify for help when in fact, they do.

 

ALTCS ELIGIBILTY QUALIFICATION REQUIREMENTS

The ALTCS qualification requirements are divided into two parts, these are;

1: Medical and the need for long-term care services and,
2: Financial requirements.

Note, you can be qualified for medical coverage but still not be eligible for long-term care services. Meaning you could be eligible for AHCCCS Medical Benefits and not have a high enough medical need (nursing level) to qualify for long-term care benefits.  Or you may be medically qualified but not be financially eligible.

THE MEDICAL ELIGIBILITY AND QUALIFICATION REQUIREMENTS

The medical assessor, a registered nurse or social worker, uses a 60-point scoring process to determine an applicant’s eligibility. Qualifying applicants must be at a nursing facility level of care. The assessment process is called a Pre-Admission Screening (PAS).  

The PAS takes about an hour. Because of COVID-19 precautions, the PAS is now being conducted over the phone rather than in person. 

The PAS Assessor is required to do the following:

  1. Interview the applicant.
    B. Obtain medical information from the applicant’s caregivers and personal representative. A family member can be involved with this process.
    C. Obtain medical records for verification of major medical conditions on all cases and pertinent medical documentation on cases requiring physician review.
    D. Provide information on the ALTCS program to the applicant and/or the applicant’s representative.
    E. Provide information about possible alternative services to applicants who may not be ALTCS eligible. Like VA Benefits.  
    F. Determine whether a case requires physician review; if so, prepare and send the case for review.

During the assessment, the applicant is asked a series of questions based on his or her condition and need for long-term care services. These questions pertain to: 

The Applicant’s ability to perform their Activities of Daily Living or ADL’s

  1. Mobility: the ability to walk without assistance
  2. Transferring: the ability to get up out of bed or chair without assistance 
  3. Bathing: the ability to wash oneself themselves with hands-on assistance
  4. Dressing: dressing and undressing with physical assistance
  5. Eating: The ability to feed oneself safely or with supervision if there is a choking risk
  6. Toileting: the ability to get on and off the toilet, help cleaning, and hygiene

Conditions that Will increase the PAS Score:

Cognitive Impairment,  A diagnosis of Dementia by a Neurologist, is worth 20 of the 60 points needed to qualify.

Incontinence problems: The inability to control bladder and bowel function. Like cognitive impairment, incontinence also scores high. 

 

Orientation Questions

  • Day of the week, month, and year
  • Time of day
  • Current location
  • Home address
  • City and state

Behavioral Issues

  • Wandering 
  • Self-injury
  • Disruptiveness
  • Aggression
  • Resistiveness

Communication/Sensory issues

  • Hearing impairment 
  • Communication: Difficulty finding words
  • Vision: Not correctable with glasses

 

 

FINANCIAL QUALIFICATION REQUIREMENTS 

The ALTCS financial qualification requirements are relatively straightforward and broken down into income and assets.

The income and asset limits are the same for both single or married applicants. ALTCS Applicants are referred to and treated as “Customers” by AHCCCS. 

Assets are countable versus non-countable assets; countable assets are:

Countable Assets:

  • Bank checking,
  • Savings accounts,
  • Stocks, bonds, mutual funds,
  • Retirement accounts 401k’s and IRA,
  • Life insurance (cash value),
  • Cash on hand,
  • Investments and
  • Real Property and/or land other than the primary residence.

 

Non-Countable Assets:

  • The primary residence up to the equity maximum
  • Vehicle,
  • Burial plots
  • Funeral Trust (Pre-Paid Funeral Trusts)
  • Assets used to purchase a Medicaid Compliant Annuity
  • Personal Property ( wedding rings)
  • Household effect
  • Term life insurance policies
  • Up to $1,500 on Cash Value in a life insurance policy

ASSET LIMITS

In 1988, Congress passed the Spousal Improvement Act to prevent a healthy spouse from being left without sufficient Income or resources when his or her spouse needs long-term care.


Because of the Spousal Impoverishment Standards, the financial limits and allowances vary dramatically for married applicants compared to a single applicant.

Congress set minimum limits on Income and total assets to protect the at-home or well-spouse.  Here are the 2021 figures:

Minimum Community Spouse Resource Allowance:     $26,076.00
Maximum Community Spouse Resource Allowance:  $130,380.00

Arizona is a 50% state, meaning that to have the full $130,380 in countable assets, a married couple would have to have double that to $260,760. This allows the community spouse to keep the $130,380 in their name; at the same time, the ALTCS applicant is over-resourced by $128,380  ($130,380 minus the $2000 Individual Resource Allowance = $128,380.00).

Here’s where it is important that you consult with a Certified Medicaid Planner™.  A CMP™ Professional will assist with an asset conversion plan or spend-down plan to preserve the assets. This type of planning can be very complicated and should not be done without professional help. 

ALTCS INCOME LIMITS

The 2021 gross monthly income cap for a single person is $2,382.00, which means that your application will be denied without an “Income Only Trust” in place. (See Income-Only Trust and calculating married couples cap below.)

ALTCS allows a customer to have a monthly “Individual Needs Allowance,” which is $119.10 per month.  This money can be spent in any way that the customer on ALTCS wishes.

For a married couple, the cap is $4,764.  This can be confusing because even though the marital income cap is $4,764, the community spouse can have unlimited Income. So, let’s say that the healthy or non-institutional spouse’s Income is $5000 per month and the Income of the spouse applying for ALTCS is $2,000.

The applicant’s Income qualifies and there is no need for an Income-Only Trust, even though the total household income is $7,000, above the $4,764. The Income of the person applying for ALTCS is below the income cap. 

I’ve seen on many websites that don’t clearly explain this, leaving many people to believe that their Income is too high to qualify. Not all websites mention the “Income- Only Trust” and how this trust document solves the income problem and allows an applicant to qualify.

If you need an Income-Only Trust, see here

Income Minimums and Maximums:  To make this even more confusing, the Community Spouse is allowed a minimum income up to the maximum with additional allowances. Here are the income limits:

Minimum Monthly Maintenance Needs Allowance:   $2,155.00
Maximum Monthly Maintenance Needs Allowance: $3,259.00

Shelter Standard Allowance: $647,00
Standard Utility Allowance:   $295.00

Married Couple Income Case Study #1:  Bob has dementia. After a recent fall, he had to go to the hospital and then to a rehab facility to recover. While at the rehab facility, the staff told Bob’s wife Mary that Bob would not be safe at home and that he would need to be placed in a senior care community or group home.

Mary knew that the average care home is over $4,500 per month and wonders how to pay for Bob’s care. She looks into ALTCS but worries that ALTCS would take all Bob’s Income.

Bob’s monthly social security and pension income is $2,500. Mary’s social security is only $600 per month, for a total household income of $3,100 per month.

Because the Minimum Monthly Maintenance Needs Allowance is $2,155 per month, and along with the Shelter Allowance of $647.00 and Standard Utility Allowance of $295.00 per month,   Mary is entitled to most of Bob’s Income of $2,980.90. This is the total income minus his “Personal Needs Allowance” of $199.10, ( $3,100 – $119.10=  $2,980.90)

Actual Income Caps 

The actual income cap is this if a person’s Income exceeds the cost of care in an assisted living facility, group home, or nursing facility.

To complicate the matter, the community spouse or at-home spouse can have an unlimited income! Converting countable assets to non-countable Income paid to the community spouse is a common spend-down strategy used by a Certified Medicaid Planner™. See ALTCS Secrets

Here a Medicaid Compliant Annuity (MCA) is purchased with otherwise countable assets like bank savings or IRA funds. The Income from the MCA is then paid to the well spouse and is not countable.  Then the Income can be accumulated by the well spouse and not count as a countable asset. 

Sounds too good to be true, right? 

Married Couple Income Case Study #2:  As in Case Study #1, Bob’s social security and pension income is $2,500, and Mary’s social security is only $600 per month, making the total household income $3,100 per month. 

However,  Bob and Mary have $120,000 in assets over the allowable limit and must spend them down to qualify. Rather than spend the $120,000 on care and wait to apply for ALTCS, they purchase a Medicaid Compliant Annuity.  The annuity turns the $120,000 from a countable asset to non-countable Income of over $20,000 per month for six months. 

So, Mary’s Income goes from $600 per month to over $20,600 for six months. Then in the seventh month the Income is treated as in case study #1. 

This preserves the $120,000 and allows Mary to keep most of the Income. 

ALTCS Benefits

What is covered by ALTCS?

  • Doctor visits
  • Emergency Care
  • Hospital Services
  • Immunizations
  • Lab and E-rays
  • Physical Exams
  • Specialist Medicaid Care
  • Surgery Services
  • Transportation to doctor
  • Behavioral Health
    See Manual for Complete list

ALTCS – Home and Community Bases Services – HCBS 

The HCBS program pays for various options for senior living like the cost of room and board and care in an assisted-living community or assisted-living group care home.
What many don’t know is that ALTCS also allows the customer to remain at home and receive both home care and home health care services. They even allow the spouse or another family member to be a paid caregiver.
The ALTCS Application and ALTCS Qualification process are the same as that of nursing home care or in a senior living assisted living community or group care home. Either way, the customer must be both financially and medically qualified.
The difference lies in the way Income is handled. Watch the video “ALTCS – Home Care Benefits – Stay in your home and receive home care paid by ALTCS.”

The ALTCS Application Process and How do you apply for ALTCS?

The ALTCS Application Process

ALTCS denies nearly 80% of the applications. Think about it:  80% of all ALTCS applications are denied!

Here I’m going to explain why, and what you can do to improve your chances of being approved. 

But first, let me answer this question; “Why should you consider hiring a Certified Medicaid Planner  to help you through the ALTCS Application Process?”

The cost of care in an assisted living facility (ALF)  averages $150 per day. Group care homes are about $110 per day or about 30% less than that of apartment-style communities.  These rates are just the basic 1 and 2 levels of care.  In 2020, a nursing home’s average daily rate was $240! 

So each day that you do not qualify it is costing you at least $110 to $240. A Certified Medicaid Planner takes the stress away so you can focus on the care of your loved one.  The fee you pay to a Certified Medicaid Planner, is allowed by ALTCS and is part of any spend-down. So hiring a CMP is actually at no cost to you or your loved one. 

Generally, if you are medically qualified, meaning that your level of care is high enough to have your ALTCS application approved, your required care levels are more like levels 3 or 4. Someone only needing level 1 or level 2 care would not qualify medically for the ALTCS program.  In other words, the price just went up and so did the reason to hire a CMP.

To the Do-It-Yourselfers; I’m someone who prefers to do things myself whenever possible. But I also know when this isn’t cost-effective.  I put a value on my time and if hiring someone to do something will save me time, money and aggravation, then that’s what I . All of us have seen something we’ve liked, and thought that making it ourselves would be less expensive than buying it, until we add up the cost of the materials, labor and time.

The ALTCS application process is no different. I would venture to say that the DIY has a lot to do with why 80% of claims are denied.

If you decide to do this on your own and are denied because of your inexperience, keep in mind that each day you are not approved is costing you as much as $240! 

Generally, applicants who are medically qualified for  ALTCS will require their care levels to be closer to 3 or 4. Those who need only level 1 or 2 care would not qualify medically for ALTCS.  

“Why should you hire a professional to help you with the ALTCS Application?”
Here’s why. Each day that goes by and you are in an assisted living community or group care home costs you money, from $120 to $240 per day.
Yes, the average fee for a Certified Medicaid Planner professional is $3500, which is about the cost of a month of care. The CMP will help you through the process so that the claim is approved the first time the ALTCS application is submitted. This means that in effect, the net cost of a CMP’s services is zero.
In addition, the cost to hire a professional Certified Medicaid Planner can be part of your spend-down need to qualify. As I often say, “You’re going to have to spend down your assets to qualify for ALTCS anyway, so you might just as well hire a professional to help you through the application process.”

What if your denied? What is your next move. 
Again this is where you may want to hire a professional to help you. Remember each day that you are not approve cost you money!

It is not uncommon for case workers at ALTCS adjudicate claims incorrectly. 
I recently was contacted by a spouse of the person that had been denied.

When he called and said the told him they denied him for having excess resources. I asked to see the denial letter and when reading it I learned that the ALTCS financial case work adjudicated the claim as a single individual rather than a married couple..  So anything over the $2000 maximum would cause a denial.  I was able to correct that with a simple phone call.

I have many stories like that one so be sure you understand the rules and why they are denied.

 




CMP- Certified Medicaid Planner

The ALTCS Application Process

The ALTCS Application Process has two parts: medical and financial. You can be medically qualified but be denied financially, and you can be financially qualified yet be denied medically.

This is hard to understand, particularly for someone with $2000 or less in total assets, and has been diagnosed with dementia but can perform all ADLs. If I’ve heard this once I’ve heard it a thousand times: “What do you mean my father won’t qualify? What are we going to do? He can’t live on his own because he has dementia!”  Having dementia by itself will not qualify a person medically for ALTCS.

Nor does having less than  $2000 in assets and needing a full nursing level of care. 

This often happens when someone has had a fall or stoke and has been transferred to a rehab facility. A well-meaning social worker will call ALTCS and start a claim. However, this is one of the top reasons for denial by ALTCS. Here are the others:

  • The ALTCS Application process imposes  strict 15-day deadlines to respond to a request by the ALTCS financial caseworker. If you don’t provide the information in that time, the claim will be denied.

Think about everything else that you are dealing with at this time. You probably aren’t even aware of the information that will be required. Much less be able to get it or try to direct a family member to gather the information in the time allotted. 

How can you prevent this from happening? 

Ask the social worker not to open the case for you until you or a loved one can consult with a Certified Medicaid Planner or ALTCS Planner.

Over the asset limits:  With a single person and the person applying for ALTCS,  this is fairly straightforward.  The most someone can have in countable assets is $2000. Anyone with more than that amount will be denied!

 

Let me circle back to #1.
* How does the social worker know how much money is in all of an applicant’s financial accounts?
* How does the social worker know if an annuity has been annuitized and has no underlying cash value? Is it only going to count as Income? How does the social worker know if the annuity should be transferred to a Medicaid Compliant Annuity?

*How does the social worker know that an applicant owns two cars, not one that is exempt, because it was purchased for a grandchild, but the applicant’s name is on the title?
*How does a social worker know that an applicant has a time share in Mexico or Scottsdale?
*How does a social worker know the details of an applicant’s financial situation?
*Here a great one: How does the social worker know how to prevent the State of Arizona from placing a lien on an applicant’s home and taking it after the applicant’s death? 

A CMP can answer the questions that a social worker cannot.

 

ALTCS Application ApprovalA CMP will be sure that the entire ALTCS application is ready for approval before it is submitted to ALTC.  

ALTCS Application click on button below

How do you apply for ALTCS?  – What you need to have ready. 

Items to gather and have ready. 

♦ ____ Copy of Driver’s License, State ID, or any other government-issued photo identification, both front and back.
Please also include a copy of the patient’s social security card, both front, and back

♦ ____ Copy of the patient’s birth certificate (if possible to recover not required)

♦ ____ Copy of all medical insurance cards, both front, and back, including Medicare and any other private insurer. Please also include current year statements from each insurer verifying the premiums paid

♦ ____ Copy of Marriage certificate 

♦ ____ Current year statements from all income sources. These may include the patient’s social security award letter, pension statements, VA award letters, etc.. 

♦ ____ Current statement from the patient’s nursing home or care facility. Please also include the the date the patient first moved to the facility or its long‐term care unit 

♦ ____ Copy of the deposit made to the patient’s nursing home

♦ ____ Past 30 days of statements are required for application submission. The State will make a

request for the remaining months post-submission if they have a question on any transaction.

♦ ____ Bank Statements for otherwise eligible month CMP will advise month needed. 

♦ ____ Copy of the title for any vehicles owned or partially owned by the patient

♦ ____ Copy of the most recent vehicle insurance statement for each vehicle

♦ ____ Copy of deeds for any real estate owned or partially owned by the patient. Please also include a current property valuation for each piece of real estate and a copy of the current year’s property taxes . 

♦ ____ Copy of any pre‐paid funeral policies, life insurance policies, and long‐term care insurance policies the patient may have.

♦ ____ Copy of any current utility bills the patient is responsible for.

What is the Income-Only Trust a.k.a Miller Trust?

Think of the income-only trust as a  funnel with spouts on its side as well as the bottom. 

The ALTCS applicant’s Income is assigned, or poured, into the Income-Only (or Miller) Trust. Income that is transferred to the Trust can be used only for the applicant’s allowable expenses, which include:

  • The  Monthly Personal Needs Allowance, for things like haircuts, toiletries, personal items, entertainment, and church contributions
  • Any Medicare, Medicare Supplement Premiums, and dental insurance premiums
  • Medical expenses that are not covered by ALTCS or Medicare

If a recipient is married, the healthy spouse might be able to use the additional Income, known as the Community Spouse Resource Allowance, for living expenses. 

The balance of the Income flows from the bottom of the funnel and is used to share the cost of the care home or community.

And now Income is no longer a bar to approval.

How do you get an Income-Only Trust? 
legal document preparer can prepare an Income-Only Trust. 

 

Gifting assets to qualify for ALTCS is not illegal!

When you call the ALTCS main office and ask, “My mother has $23,000, and I know that the maximum resource allowance for an individual is  $2000. Can she just give me $21,000 to bring her below the $2000, so she will qualify?” 

The ALTCS Financial Eligibility Worker will say, “That will cause a penalty!”  The word “penalty” implies that this is illegal; it isn’t. ‘

So what is the penalty?

The penalty is just a period of ineligibility. Someone who makes a gift of assets will still be eligible for ALTCS benefits. But because of the gift, services will not start right away.

Use this information carefully. Although gifting assets to qualify for ALTCS is not illegal, when done hastily or with the wrong recipient, it can be a disaster!

This case was referred to me. Mary, a single woman, meets the medical qualification requirements but had about $74,000 in total assets, placing her $72,000 over the limit.

If she calls the ALTCS office and asks what she should do to qualify for ALTCS benefits, the financial caseworker will say, “She’ll have to spend down her assets.” See the rest of the story here…. ALTCS Secrets #5. 

Just be sure you are working with an advisor who has a complete understanding of how the gifting penalty works.   

Seek the advice of a Certified Medicaid Planner

Also see here Certified Medicaid Planner, CMP

Post-ALTCS Qualification Information

So your ALTCS approved now what? 

During the APPLICATION process you where required to choose a plan provider

ALTCS Information and Community Resources

Arizona Care Alliance “A”
Please provide information on:

Due to Covid-19, protecting both you and our current residents of the Assisted Living Care Communities and Group Homes is our highest priority. Therefore an appointment for a tour is required. We will notify the home that you would like a tour, and one of our resource partners will contact you to arrange a time and answer your questions.

Thank You!
Arizona Care Alliance