If you or a senior loved one needs help paying for long term senior care in Arizona, it may make sense to apply for coverage under the Arizona Long Term Care System, known by its acronym ALTCS. ALTCS, which is administered by the Arizona Health Care Cost Containment System (AHCCCS), is Arizona’s Medicaid-funded statewide program designed to help provide coverage for Arizona seniors to receive care either at home or in a community setting. The ALTCS application can sometimes require filling out several forms and collecting a lot of information related to your or your senior loved one’s health status and finances, and so it’s important to stay organized and make sure you’re on top of all the required information. It’s also helpful to work with a local Arizona elder law attorney or other professional with experience with ALTCS applications such as an Arizona financial planner. 

To learn more about all the forms required to start your ALTCS long term care application see our explainer below.

ALTCS Overview

Before going through all the forms required to start an application for ALTCS coverage it’s helpful to first start with a brief overview of what ATLCS is, who ALTCS helps, and what ALTCS covers. ALTCS provides long term care coverage to eligible Arizona seniors age 65 or older either at the seniors’ home or in a community-based setting such as an assisted living or nursing home facility. In order to qualify for coverage under ALTCS an Arizona senior must meet both financial and health-based criteria, which focus at a high level on whether the applicant requires financial assistance to pay for senior care and whether the applicant has a medical need for long term care. 

The ALTCS application process has several steps, including completing the relevant application documents, providing supporting documentation related to the applicant’s financial and medical conditions, and an interview with a medical professional to assess the applicant’s need for care. While many Arizona seniors will apply for ALTCS themselves, it’s important to remember that another individual can submit the application on the senior’s behalf if they have trouble or would like the assistance navigating the ALTCS application process. 

ALTCS Application Forms

You can begin your ALTCS application by either calling or visiting your local ALTCS office, or submitting the DE-101 form (explained in more detail below). To learn more about each form involved in the ALTCS application process, check out the ALTCS website here (or the AHCCCS Document Archive here)  or read about each form below. 

DE-828 Filing an Application for ALTCS

Link to form. While the DE-828 form is not a formal part of the ALTCS application process, it’s a great place for ALTCS applicants to start because it provides general information about ALTCS, including information about financial and non-financial eligibility requirements, how to apply for ALTCS coverage, and the different types of services that are covered by ALTCS. In addition to this helpful application information, the DE-828 form also provides useful contact information for getting in touch with ALTCS or your Benefits and Eligibility Specialist should you have any questions about the ALTCS program that arent answered by the form. Because of all the helpful information contained in this form, we always suggest that ALTCS applicants start by reviewing the DE-828 before starting their ALTCS application.

DE-101 Request for Application for ALTCS

Link to form. The main form required to begin your ALTCS application is the DE-101 Request for Application for ALTCS. In order to start an application for ALTCS an applicant may either call ALTCS toll-free at 888-621-6880, visit their local ALTCS Office in person, or submit a completed DE-101. You may notice that Included in the above link to the ALTCS DE-101 form is the DE-202 Authorization to Disclose Protected Information to AHCCCS (described in more detail below). While the DE-202 is not strictly required to start the ALTCS application process, ALTCS suggests submitting this form along with your DE-101 Request for Application together as providing all of this information upfront can help expedite the application process. 

The DE-101 can be filled out by either the senior applicant or their chosen authorized representative if they want someone else to fill out the application on their behalf. This form focuses on the senior ALTCS applicant’s biographical information (including their health history) and their current living situation. The DE-101 form also requests the applicant, or their authorized representative, to mark down their availability as the applicant or their authorized representative is required to complete an interview with ALTCS staff as part of the application process.

DE-202 Authorization to Disclose Protected Health Information to AHCCCS

Link to form. As discussed above, the DE-202 Authorization to Disclose Protected Health Information to AHCCCS is the form that an applicant (or their authorized representative) signs allowing their healthcare providers to disclose their health-related information to AHCCCS in order to determine whether they are eligible for ALTCS coverage. ALTCS suggests filing this form at the same time as the DE-101 as it can expedite the application process if ALTCS already has all the authorizations they need to get your senior loved one’s healthcare information and confirm they are eligible. One thing to keep in mind is that the senior ALTCS applicant is always free to revoke this grant of authorization simply by contacting AHCCCS either on the phone or in writing.

DE-112 Authorized Representative Form

Link to form. The DE-112 Authorized Representative Form lets a senior applicant choose another individual to complete the ALTCS application on their behalf. It’s important to keep in mind that in order to help your senior loved one apply for ALTCS you do not need to be their power of attorney, but if you aren’t the power of attorney you do need to make sure you complete and file the DE-112 Authorized Representative Form. An authorized representative is empowered, among other things, to sign and complete the ALTCS application on the senior applicant’s behalf as well as to give ALTCS any requested supporting documentation or personal information required for the senior’s application. The Authorized Representative Form also imposes several restrictions on the authorized representative, including the duty to keep the applicant’s information confidential as well as to update AHCCCS if the customer has any life events that may change their ALTCS eligibility, such as a increase or decrease in income or a change of address. 

Spanish Language ALTCS Forms

A final, very helpful thing to keep in mind is that AHCCCS also provides all of the above application forms in Spanish. If you or a loved one are interested in applying for ALTCS coverage but are more comfortable with Spanish language documents, make sure to check out all the translated versions of the ALTCS application forms that AHCCCS has to offer.

To learn more about how Sunbound can help make paying for senior living and senior care more affordable for you or your senior loved one, send us an email at info@sunboundhomes.com or request more information on Sunbound. Sunbound is the best way to pay for senior living and senior care, and we’re on a mission to make senior living and senior care more affordable for everyone.