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Long-Term Care: Medicaid (AHCCCS) and ALTCS Eligibility

In order to qualify for Arizona Long-Term Care System assistance, an individual must meet three separate tests: Medical Eligibility, Income Eligibility and Resource Eligibility.

More: Frazer Ryan's Long-Term Care Legal Services and Related Articles

 

Video
Qualifying for Medicaid to Pay for Long-Term Care

 

By Marsha Goodman

MEDICAL ELIGIBILITY

Many families focus on financial qualifications for the Arizona Long Term Care System (ALTCS) but are not aware that there are also very strict medical requirements. In order to meet the medical criteria, the individual need the level of care comparable to what would be received in a nursing facility, even if the person does not currently reside in that kind of facility, or does not intend to after qualifying for ALTCS benefits.

The determination of whether someone is medically eligible is made through a pre-admission screening (PAS) conducted by an ALTCS caseworker. Someone who needs only supervisory or personal care, such as that received by intermittent outpatient medical visits, or “standby assistance” with bathing or grooming will not meet this requirement. Instead, the individual must demonstrate that he or she has a non-psychiatric functional and/or medical condition that substantially interferes with the individual's ability to perform the activities of daily living. For example, the individual:

  • requires nursing care by or is under the supervision of a nurse on a daily basis;

  • requires regular medical monitoring;

  • has impaired cognitive functioning which was determined, by a neurologist, to be caused by a physical condition such as Alzheimer’s Disease, and not by a mental or behavioral health condition such as depression or bipolar disorder; or

  • is unable to perform at least two activities of daily living, such as bathing, grooming, eating or toileting, without the hands-on assistance of another person.

A different set of criteria is used for individuals who were developmentally disabled before the age of 19.

While most states require out-of-home placement to qualify for Medicaid, in Arizona those services may include home and community-based services (HCBS), which, as the name implies, can be delivered at home or in a facility such as a group home, memory care or assisted living facility, as long as the facility has a contract with at least one of the three program contractors that administer ALTCS benefits. In 2017, the three contractors authorized to administer benefits to eligible individuals in Maricopa County are the Mercy Care Plan, United Health Care Plan, and Bridgeway Health Solutions Plan.

Upon enrollment in the ALTCS program, individuals are allowed to select the plan that best suits their needs. Each program contractor provides the same services, but each may work with different nursing homes, assisted living facilities, specialists, doctors, dentists, hospitals, etc. An eligible individual should check with his or her facility or provider to determine which contractor to select. For more information, visit the AHCCCS website.

INCOME ELIGIBILITY

In order to be eligible for ALTCS benefits, the applicant’s monthly income must be less than a specified income cap, which is 300% of the Federal Poverty Rate. For 2017, the income cap is $2,205. If an applicant is married, ALTCS uses the “name on the check” rule, which adds together the gross income from all sources of the applicant only, but does not consider the income of the spouse. If the applicant’s gross income exceeds the income cap, ALTCS will add together the gross income of both spouses and divide that total by 2. If that figure is less than the income cap, the applicant will qualify, even if his or her individual income exceeds the cap.

It is important to remember that ALTCS counts the gross income, which means that they add back the deduction taken for the Medicare Part B premium from Social Security income, or the deductions for health insurance premiums or tax withholdings from a private pension.

If the individual fails both tests, an income-only trust may be utilized.

RESOURCE ELIGIBILITY

In Arizona, the value of countable resources that can be owned by the ALTCS applicant cannot exceed $2,000. If an applicant is married, the resources owned by both spouses are combined when making the eligibility determination. However, the community (non-applicant) spouse is allowed to keep half of the couple’s countable resources up to a maximum amount, and no less than a federally set minimum. In 2017, the minimum is $24,180.00, and the maximum amount is $120,900.

One vehicle and the applicant’s and/or spouse’s personal and household goods are not counted as resources. The primary residence titled in the name of the applicant and/or spouse is generally not counted as a resource, but equity value in excess of $560,000.00 would be counted. Certain income-producing property and the principal value of a specific type of annuity is also not counted, although the income that is generated is counted as income.