MEDICAID/ARIZONA LONG
TERM CARE SYSTEM
Since 1982, Arizona has participated in the Medicaid program
through the operation of the Arizona Health Care Cost Containment
System ("AHCCCS") under a federal waiver allowing payment of
federal Medicaid dollars into our homegrown version of a managed
care program. In 1987, the state legislature added long term
care services to the AHCCCS program by establishing the Arizona
Long Term Care System ("ALTCS") for Medicaid-eligible persons who
are elderly (over age 65), or physically or developmentally
disabled. As a result, ALTCS is a separate division of
AHCCCS, operating under Medicaid long term care rules.
Although the names are different, it is correct to say that ALTCS
is Medicaid.
Benefits available under the ALTCS program range from home care
services and assisted living to care rendered in an adult foster
care home or skilled nursing facility. Because ALTCS is a
needs-based program, a person must be both medically and
financially "needy" before long term care services are
rendered.
Medical eligibility is determined by a
pre-admission screening ("PAS") conducted by a nurse and/or social
worker. The screening consists of both a functional and
medical assessment. Different screening tools are used to
assess medical eligibility of the elderly, or physically or
developmentally disabled. The primary consideration is the
individual's ability to perform his or her activities of daily
living ("ADL"), such as mobility, transferring, toileting,
dressing, feeding, bathing and grooming. The individual's
diagnosis, sensory function, orientation, emotional/cognitive
behavior and necessary medical services and treatments are also
considered. The overall purpose of the PAS is to determine
whether the individual is at risk for institutional
placement.
Financial eligibility consists of both income and
resource requirements, which vary depending on whether the person
who is applying for benefits is single or married. The
following provides basic information concerning such
requirements.
I.
Income Requirements effective 2012:
A. Single
person: limited to $2,094.00 per month.
B. Married
person: The applicant can meet the income eligibility
requirement if:
1. The total income
of both spouses does not exceed $4,188.00 per month;
2. The total income
received by the applicant under his name as well as half of the
income received in both names does not exceed $2,094.00 per month
or;
3. The total income
received by the applicant under his name does not exceed
$2,094.00.
C. If a single
applicant's income exceeds the monthly income amount, but is under
$6,481.94 per month if they live in Maricopa, Pima, or Pinal
county, $5,688.34 a month if they live in any other county, an
"income-only" trust can be established which will still allow the
individual to qualify. In any other county of residence in
Arizona the limit is $5,688.34 for the income received in the
individual's name plus ½ of the joint income or $12,963.88 in
combined income for both spouses.
II.
Resource Requirements:
A. Single
person: The applicant cannot have more than $2,000.00
in countable resources to qualify for ALTCS. (An applicant
who is disabled and under age 65 may become eligible under certain
conditions by the establishment of a trust even if countable
resources exceed $2,000.00).
B. Married
person: The applicant's spouse may retain half of the
total countable resources of both spouses, except that
the half retained cannot exceed the maximum of $113,640.00 and the
spouse may keep a minimum of $22,278.00 even if half is less than
$22,278.00. In addition to the half that the spouse retains,
the applicant is still permitted to retain $2,000.00 in
resources. Under most circumstances, if both spouses in a
marriage are applicants then each is limited to $2,000.00 in
resources.
C. Single and
Married persons: Certain resources are considered
excluded and therefore may be retained in addition to the countable
resources. In general, these resources include the
following:
1. The primary
residence, if the applicant and/or his spouse have an ownership
interest in the property and the applicant states it's his or her
intent to return home, or if a spouse or dependent relative is
living in the home. Note, a primary residence held in trust
is countable for ALTCS purposes.
2. An
automobile.
3. A burial fund of
$1,500.00 for each spouse set up in a bank account and labeled as
such, or as part of a prepaid burial plan. If the burial plan is
funded by the irrevocable assignment of proceeds of a life
insurance or annuity policy, there is no value limit to the plan as
long as the proceeds assigned do not exceed the fair market value
of the burial plan.
4. Burial plots for
the applicant and spouse and members of immediate family of an
unlimited value. The burial plot exclusion includes the cost
of the headstone, casket, niche, burial container, opening and
closing the grave and perpetual care.
5. Household goods
and personal effects.
6. The combined
cash value of all life insurance policies insuring any one
individual with a combined face value that does not exceed
$1,500.00.
7. All
funds in an account designated as a Uniform Transfer to Minors Act
("UTMA") account. Any funds withdrawn from the account as
cash or used for food, clothing or shelter are considered as a
resource in the month following the month of withdrawal if
retained. The value of the account is considered as a
resource in the month following the month in which the child's
21st birthday occurs.
8. The assets
of a trust created for the benefit of a disabled person under the
age of 65 with his or conservator, or court, and if the trust
contains a provision whereby AHCCCS is reimbursed the cost of
services rendered to the individual, which is the capitated rate,
at the time of his or her death. her resources if the trust is
established by a parent, grandparent, guardian or or conservator,
or court, and if the trust contains a provision whereby AHCCCS is
reimbursed the cost of services rendered to the individual, which
is the capitated rate, at the time of his or her death.
III.
Transfers:
The Deficit Reduction Act ("DRA") of 2005, changes the Medicaid
rules regarding transfers or gifts. Any transfers or gifts
made to someone other than a spouse or in the case of transfers to
or from a trust within 60 months prior to application must be
disclosed to ALTCS. ALTCS then calculates a period of
ineligibility by dividing the total amount transferred by the
average monthly cost of care in the county as determined by ALTCS,
which is currently $6,481.94 in Maricopa, Pima, or Pinal counties,
and $5,688.34 in all other Arizona counties. The resulting
figure is the number of months of ineligibility. Fractions
are not rounded down. Multiple transfers or gifts
may be aggregated at the discretion of the State. The period
of ineligibility runs from the date of application assuming
the applicant would otherwise be eligible, i.e., would meet medical
criteria and otherwise meet the financial requirements at that
time.
For transfers or gifts made prior to enactment of the DRA, which
was February 8, 2006, the "old" rules apply. The disclosure
requirement is 36 rather than 60 months, with the exception that
the 60 month rule applies to transfers to/from trusts. ALTCS
then calculates a period of ineligibility by dividing the total
amount transferred by the average monthly cost of care. The
resulting figure is the number of months of ineligibility, with
fractions being rounded down. The period of ineligibility
runs from the date of transfer, with the first month being the
month in which the transfer was made. If a transfer is made
within a period of ineligibility resulting from a prior transfer,
then the amount of the recent transfer is added to the prior
transfer, and the ineligibility period runs from the date of the
first transfer. Transfers or gifts totaling less than the
average cost of care as determined by ALTCS do not result in the
imposition of a period of ineligibility. In addition,
transfers or gifts made prior to 36 months before applying for
ALTCS benefits will not result in the imposition of a period of
ineligibility, unless the transfer was made from a revocable trust
or, in most cases to an irrevocable trust, in which case the "look
back period" is 60 months as it is now for all transfers or
gifts.
Under the previous as well as current law, certain transfers do not
result in a period of ineligibility. Any gift made prior to
the 60 months before applying for ALTCS benefits will not result in
the imposition of a period of ineligibility. Transfers to a
spouse and transfers of an excluded resource other than a home,
also do not result in the imposition of a period of
ineligibility. There are also other limited instances in
which transfers do not result in a period of ineligibility, such as
transfers to/from a spouse, transfers to a disabled child or to a
trust for a disabled child's benefit, transfers to a disabled under
age 65 trust which is described above.
IV.
Share of cost:
A. Single
person: Once the applicant qualifies for Arizona Long
Term Care and is receiving services, he may have to pay a share of
the cost of his care on a monthly basis. He/she will only be
permitted to keep a small spending allowance, currently $101.10 per
month. In addition he or she is able to deduct non-covered
medical expenses including the cost of Medicare and other insurance
premiums.
B. Married
person: Once a married person qualifies for Arizona
Long Term Care he or she is entitled to the $104.70 per month
spending allowance plus enough income to cover his or her
non-covered medical expenses, including insurance premiums.
In addition, the spouse is entitled to a minimum of $1,839.00 per
month, plus a standard utility allowance of $341.00 per month plus
the monthly mortgage or rent amount and monthly property taxes and
insurance minus $552.00. The resulting total cannot exceed
$2,841.00 per month. If the spouse does not have enough of
his or her own income to cover this amount, then he or she is
entitled to receive enough money out of the applicant's income to
make up the difference.
The rest of the applicant's income must be paid to
ALTCS for the share of cost. Share of cost is never assessed
against the spouse's income. A share of cost will not be
assessed at all if the applicant receives services in
the home, unless perhaps, if an income only trust has been
established.
V.
TEFRA Liens and Estate Recovery:
Effective September of 2004,
ALTCS is permitted to place a lien on an individual's home property
regardless of form of ownership, that is, whether owned as a joint
tenant, life estate, or beneficiary deed, under the following
conditions:
1 If the individual is
over the age of 55;
2 If the individual is
permanently "institutionalized," that is, the individual has
continually resided in a hospital or nursing facility for 90
consecutive days;
3 If none of the
following individuals are residing in the home: a spouse, child
under the age of 21, child who is blind or disabled, or sibling who
has an equity interest in the home and who was residing in the home
for at least 1 year immediately before the date of the individual's
"institutionalization."
According to the lien regulations, ALTCS will be required to send
the individual notice of intent to file a lien at least 30 days
prior, which delineates the right to request a fair hearing among
other things. If a lien is filed, ALTCS may only recover the
lien upon sale or transfer, and is prohibited from doing so if the
individual is survived by a spouse, child under the age of 21,
blind or disabled child, sibling who currently resides in the home
under the circumstances described above, or a child resided in the
home for at least 2 years immediately before the date of
"institutionalization:" and who provided care that enabled the
individual to reside at home rather than in an
"institution."
If a person has received services through the ALTCS program after
the age of 55, then AHCCCS will also have a claim to recover the
cost of services rendered to that individual during his or her
lifetime against assets subject to probate. Note that ALTCS
will only recover against the probate estate as defined by Arizona
law and will not recover against joint tenancy property, life
insurance proceeds or designated beneficiaries on pension plans or
IRA's. ALTCS will not implement estate recovery if the spouse
survives the ALTCS recipient or if there is a disabled
child. See ALTCS booklet DE-810 for more specific
information.
NOTE: This is a
basic general outline only and the numbers are subject
to change. The numbers are effective as of 01/01/2012.
3200 North Central Avenue
. Phoenix . Arizona