May 2011, Volume 14, Number 2
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How to Help With an ALTCS Denial
Chances are pretty good that you have at least one resident, client, or patient that has recently received an ALTCS denial. After all, given that the denial rate for the ALTCS benefit hovers right around 70 percent, applicants actually stand a greater chance of denial than they do of approval, particularly if they did nothing to prepare themselves for the ALTCS application. Nevertheless, even individuals who have been denied ALTCS have options, and as a health care provider, you are uniquely situated to help individuals sort through these options so they may ultimately qualify for the benefit they need.
Option one: Request an eligibility hearing
ALTCS applicants can receive a fair and impartial review of an ALTCS denial by requesting an eligibility hearing within 45 days from the denial. The appeal process begins with a pre-hearing discussion, at which applicants can speak with an eligibility worker about the reason for the denial. If the pre-hearing discussion does not resolve the issue, the next step is the eligibility hearing itself, which takes place at the Office of Administrative Hearings in front of an Administrative Law Judge. ALTCS applicants can arm themselves with every possible advantage by having an attorney represent them at the hearing, although nothing prevents applicants from advocating on their own behalf.
If you determine that a resident, client or patient might have received an ALTCS denial in error, you can suggest the possibility of pursuing an eligibility hearing. Individuals can request a hearing by submitting an official request for a hearing, the form for which is found on the back of the ALTCS Notice of Action. Alternatively, the patient can submit a written request containing his or her name, a specific request for a hearing on the denial, and the reason for which he or she believes the denial was made in error.
One thing to keep in mind as you consider this option with individuals is that the ALTCS program has very strict eligibility requirements. Most denials are not the result of eligibility worker error, but are the result of applicants genuinely not meeting the eligibility requirements. Individuals should probably determine whether the eligibility hearing might in fact bring a favorable outcome before they pursue this option. A benefits screening with JacksonWhite Elder Law can help determine their appeal rights, as well as the validity of the denial issue, before they proceed with the appeal process.
Option two: ALTCS planning
A second option that is available to a person who has recently been denied ALTCS is to consult with an Elder Law attorney about ALTCS planning. As you know, the ALTCS benefit is only available to applicants who meet specific income and resource requirements. Even those who do not presently meet these requirements, however, might well qualify for the benefit after some planning. With a specific plan, the individual could get on track to qualify for the benefit with as little delay as possible.
There is almost always planning that can help an individual prepare for the ALTCS application. Ideally, individuals and families will think about planning before they apply for the benefit the first time, but they can also prepare after they have received an ALTCS denial. Importantly, however, it is not the ALTCS eligibility worker’s role to help your patient qualify for the benefit. Rather, eligibility workers stick to determining eligibility and Elder Law attorneys offer counsel on ALTCS planning that can actually facilitate eligibility. By working with JacksonWhite to prepare for a reapplication, those you serve might be able to overcome an ALTCS denial.
Working together to help those you know qualify for ALTCS
As a health care provider, you want to provide your patients, residents and clients with the highest quality of care, but you also want to ensure compensation for your services. Many times, the only way to obtain compensation for your services is through the ALTCS program. It can be frustrating when your patients do not qualify for a benefit that will afford them the opportunity to receive the care they absolutely need. If a patient at your facility or someone in your care has recently been denied ALTCS, we can help by evaluating their situation and preparing with them a plan to qualify for the benefit.
Because the best way to overcome an ALTCS denial is to avoid the denial to begin with, we also work with many facilities to help their applicants qualify for the ALTCS benefit on the first application. Many ALTCS applicants could establish a seamless transition between payer sources, which brings benefits to patients and health care providers alike, by simply planning in advance. Of course, this seamless transition is best accomplished by exercising foresight, and by relying on experience with ALTCS rules and requirements. By consulting with us early in the process, you can relieve this burden from your social workers, while at the same time help patients at your facility qualify for the ALTCS benefit on their first application.
Whether your resident or patient has recently received a denial for the ALTCS benefit or you are hoping to help them avoid an ALTCS denial in the first place, ALTCS planning is a must. The sooner that you start considering these issues with patients at your facility, the more likely you are to facilitate a smooth transition between payer sources. The Elder Law department at JacksonWhite is available for consultations and as an information source to help in this process however we can.
AHCCCS Announces ALTCS Contracts
On May 5th, the Arizona Health Care Cost Containment System (AHCCCS) announced that nine contracts had been awarded to three successful managed care companies. Those managed care companies will provide services to Arizonans enrolled in the Arizona Long Term Care System (ALTCS) program. The contracts were awarded for up to five years, beginning on October 1, 2011.
Currently, more than twenty-five thousand Arizona residents are enrolled in the ALTCS program, which serves individuals who are low income, at risk of institutionalization and either elderly (age 65 and over), blind, or disabled. ALTCS members also receive medical care under the long term care program, including doctor’s office visits, hospitalization, prescriptions, lab work, and behavioral health services. ALTCS has been viewed as a national model for its success in supporting over 70 percent of its members in the home or in community-based residential facilities rather than placing members in more costly nursing home settings.
A total of nine managed care companies submitted offers to serve either a portion or all of the State’s ALTCS population, resulting in a competitive process that drives down program costs. Contracts were awarded to the identified companies in the following regions of the State:
Maricopa County – Bridgeway Health Solutions, Evercare Select and Mercy Care Plan
Pima/Santa Cruz Counties – Evercare Select
Cochise/Graham/Greenlee Counties – Bridgeway Health Solutions
Yuma/La Paz Counties – Evercare Select
Mohave/Coconino/Apache/Navajo Counties – Evercare Select
Yavapai County – Evercare Select
Pinal/Gila Counties – Bridgeway Health Solutions
Just recently, SCAN was approved to have a “capped” contract, meaning they are allowed to keep all members as of October 1, 2011. After that date SCAN will not be able to secure new members.
Alzheimer’s & the Law: Protecting Yourself and Your Family Now Available in Digital or Hard Copy Versions
The new Alzheimer’s & the Law guides have arrived and are ready to be given as a resource to clients, families, patients and residents. This guide covers a variety of topics from paying for long-term care to advance directives to the types of long-term care facilities. Request digital or hard copy versions of the guide here.
A special thank you to our sponsors: Synergy Homecare, ABRiO Care, Cypress Home Care Solutions, Homewatch Caregivers, Grace Hospice, Home Helpers Direct Link, Aunt Barb’s Home Placement, Palm Valley Rehabilitation and Care Center, Hospice of the Pines, Accent Care, Hospice Inspiris, Canyon Valley Memory Care Residence, Lake View Terrace Memory Care Residence, Heartfelt Care, Geriatric Resources and New Hope Hospice. Without their support, this guide and the moni given to the Alzheimer’s Association wouldn’t be possible!
From the blog…
The Elder Law Department at JacksonWhite is committed to making sure we blog regularly on a broad spectrum of Elder Law related topics. Subscribe to get a weekly email of the most popular topics from that week or join us on Facebook to be notified when a new blog is posted.
Standards for drafting wills and Arizona conservatorships
May 25, 2011 – Guardianship Blog
Arizona state probate laws: Anti-lapse
May 24, 2011 – Probate Blog
Trusts might not help long-term care eligibility
May 24, 2011 – ALTCS Blog
When you might need an Arizona special needs attorney’s help
May 20, 2011 – Special Needs Trust Blog
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