Arizona Medicaid (AHCCCS/ALTCS) Application Packet

Arizona Medicaid (AHCCCS / ALTCS) Application Packet

Part I — Applicant and Household Information

Applicant (Vulnerable Adult / Senior):

Community Spouse (if married and not both applying):

Authorized Representative / POA:

Part II — Program Selection

☐ ALTCS — Elderly & Physical Disability (E/PD) — applicant is age 65+ or determined disabled, AND requires a nursing-facility level of care (Pre-Admission Screening, "PAS").
☐ ALTCS — Developmentally Disabled (DD) through DDD.
☐ AHCCCS Health-only / SSI-MAO — applicant does NOT need nursing-facility level of care.
☐ Medicare Savings Program (QMB/SLMB/QI) — premium and cost-sharing assistance only.

Care setting requested:

☐ Skilled nursing facility ☐ Home and Community Based Services (HCBS) waiver ☐ Assisted living facility ☐ Adult foster care

Part III — 2025/2026 ALTCS Financial Eligibility (Verify Current Year)

A. Income Limit (Single Applicant)

B. Asset Limit

C. Home Equity

D. Other Exempt (Non-Countable) Assets

☐ One automobile (any value if used for transportation of applicant or spouse)
☐ Household goods and personal effects
☐ Irrevocable burial plan / burial plot / $1,500 burial fund
☐ Term life insurance (no cash value)
☐ Whole-life insurance with face value ≤ $1,500
☐ Medicaid-compliant immediate annuity (irrevocable, non-assignable, actuarially sound, AHCCCS named remainder beneficiary)
☐ Special needs trust (d)(4)(A) or pooled trust (d)(4)(C) for disabled person under 65

Part IV — 60-Month Look-Back and Transfer Penalty

ALTCS reviews all uncompensated transfers made within 60 months (5 years) before the application date. 42 U.S.C. § 1396p(c); A.A.C. R9-28-409.

A. Penalty Divisor (2025/2026 — Verify Current AHCCCS Notice)

Penalty period (months) = uncompensated transfer amount ÷ applicable divisor. The penalty period begins the date the applicant is otherwise eligible and applying for ALTCS, not the date of transfer.

B. Transfer Disclosure (Required)

For EACH transfer, gift, sale below fair market value, addition or removal of joint owner, trust funding, or unusual withdrawal during the 60-month look-back, complete:

C. Recognized Exceptions to Transfer Penalty

☐ Transfer to spouse or for sole benefit of spouse
☐ Transfer to disabled child (any age) or trust solely for disabled child
☐ Transfer of home to child caregiver who lived with applicant ≥ 2 years and provided care preventing institutionalization
☐ Transfer of home to sibling with equity interest who resided for ≥ 1 year before institutionalization
☐ Transfer made exclusively for purpose other than qualifying for Medicaid
☐ Return of transferred asset (full cure)

Part V — Verification Documents Checklist

☐ Photo ID / driver's license / state ID
☐ Social Security card (applicant and spouse)
☐ Birth certificate / proof of age
☐ Proof of Arizona residency (utility bill, lease, voter registration)
☐ Proof of citizenship or qualified non-citizen status
☐ Marriage certificate / death certificate of prior spouse / divorce decree
☐ Medicare card (Parts A, B, D) and supplemental insurance cards
☐ Other health insurance / long-term care insurance policy
☐ Bank statements — ALL accounts (checking, savings, CDs, money market) for 60 months before application
☐ Most recent statements for retirement accounts (IRA, 401(k), 403(b), pension)
☐ Investment / brokerage statements (60 months)
☐ Annuity contracts, structured settlement documents
☐ Life insurance policies — face page and most recent cash-value statement
☐ Real property — deeds, current tax assessment, mortgage statement, equity loan
☐ Vehicle titles / registrations
☐ Prepaid burial / funeral / cemetery contracts (showing irrevocability)
☐ Trust instruments (revocable, irrevocable, special needs, Miller Trust)
☐ Tax returns (last 5 years) and W-2s/1099s
☐ Pension award letter; SSA benefit verification ("Proof of Income" letter)
☐ VA award letter (if applicable)
☐ Court orders (guardianship, conservatorship, divorce, QDRO)
☐ Power of attorney / health-care POA
☐ Bills/invoices supporting any large bank withdrawals during look-back

Part VI — Qualified Income Trust ("Miller Trust") — If Income > $2,901/month

☐ QIT established and signed before [__/__/____]
☐ Separate non-interest-bearing or interest-bearing trust account opened at [______________________] Bank
☐ AHCCCS named as residual beneficiary up to total medical assistance paid
☐ Monthly funding instructions in place (direct deposit redirect or monthly transfer)
☐ Trustee: [________________________________]

Part VII — Estate Recovery Disclosure (42 U.S.C. § 1396p(b); A.R.S. § 36-2935)

I/we acknowledge that, after the recipient's death (and after the death of any surviving spouse, minor child, or disabled child), AHCCCS may seek recovery against the recipient's estate for the cost of long-term care services received at age 55 or older, including HCBS, nursing facility, and related medical/prescription services. Recovery may be deferred or waived for hardship.

Acknowledged by: ____________________________ Date: [__/__/____]

Part VIII — Application Filing

A. How to File

B. Application Date and Retroactive Coverage

ALTCS coverage may begin up to 3 months retroactive from the month of application if the applicant was otherwise eligible. The application date is the date AHCCCS receives a signed application identifying the applicant.

Application signed and submitted: [__/__/____] Method: ☐ Online ☐ In person ☐ Mail ☐ Fax

C. Pre-Admission Screening (PAS)

A registered nurse or social worker from ALTCS must conduct an in-person PAS to confirm the applicant requires a nursing-facility level of care. Schedule PAS at: [__/__/____] Time: [____]

Part IX — Signatures and Authorizations

I declare under penalty of perjury under the laws of the State of Arizona that the information provided in this application and all supporting documents is true, correct, and complete. I understand that knowingly providing false information may be prosecuted as a Class 6 felony under A.R.S. § 13-2310 and may result in denial, recoupment, and loss of benefits.

Applicant: ____________________________ Date: [__/__/____]

Community spouse: ____________________________ Date: [__/__/____]

Authorized representative: ____________________________ Date: [__/__/____]

I authorize AHCCCS, DES, and the local ALTCS office to obtain records and verify information from financial institutions, employers, the IRS, the Social Security Administration, the Veterans Administration, and any health-care provider necessary to determine eligibility. This authorization is valid for the application and any redetermination.

Signature: ____________________________ Date: [__/__/____]

Sources and References

• AHCCCS Eligibility Policy Manual: https://www.azahcccs.gov/shared/MedicalPolicyManual/
• ALTCS Program Overview (DES): https://des.az.gov/services/aging-and-adult/long-term-care
• AHCCCS ALTCS Transfer Policies (DE-818): https://www.azahcccs.gov/Members/Downloads/Publications/DE-818_english.pdf
• A.R.S. Title 36, Chapter 29 (AHCCCS): https://www.azleg.gov/arsDetail/?title=36
• A.A.C. R9-28 (ALTCS rules): https://apps.azsos.gov/public_services/Title_09/9-28.pdf
• 42 U.S.C. § 1396p (federal Medicaid transfers/look-back): https://www.law.cornell.edu/uscode/text/42/1396p
• Health-e-Arizona Plus (online application): https://www.healthearizonaplus.gov
• Arizona Long Term Care Ombudsman (DES): https://des.az.gov/LTCOP