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These are situations where changes or inconsistent information may be an indicator of possible fraud and abuse.
The customer applies on January 15th. The customer and the spouse are married and live together with their 5-year-old son. The husband’s income makes the household over income. The application is denied on January 20th. The customer reapplies on January 31st and reports the husband is no longer in the home.
On the initial application filed March 2020, the customers are married with one child. On the renewal application in March 2021, the customer reports they are recently separated and are not living together. They now have a second child together. On the renewal application in March 2022, the customer reports they are still separated and are not living together. They now have a third child together. This may be an indicator they are living together.
On the March 19th application, the customer states she is pregnant with 1 unborn child. She is denied for over income. She reapplies on April 1st and states she is pregnant with 2 unborn children. She is again denied for being over income. On April 10th she reapplies and says she is now pregnant with 3 unborn children. The customer may be increasing the household size to get her income below the income limit.
A) In August, the self-employed customer provided his tax return as proof of his income. The application is denied on August 15th for being over income. In September, he reapplies and is reporting a drastic change in his current income. This may be an attempt to under report or hide income.
B) The self-employed customer provided his tax return as proof of his income. The document shows gross income in the amount of $109,000.00. The adjusted gross income amount is $9,000.00. The customer may be over inflating the deductions to reduce his income or there are deductions being counted by the IRS that are not counted for Medicaid.
In 2023, the customer reported using his savings account and credit cards to pay his living expenses. He also reported the same information on the 2024 renewal application. On the 2025 renewal application he is still reporting the use of credit cards and savings to pay his expenses.
A) The customer was initially applied in 2010 at 7 years old. His Initial PAS summary noted that he was on the Autism Spectrum, had Developmental Delays, but was dependent with daily activities with "set up" assistance. He was able to communicate, has no aggression or disruptive behavior, but would "verbally self-harm" by "saying" he would hit himself. He scored a 42.25 on his PAS.
AHCCCS OIG received a referral that his caregiver had submitted claims for services not rendered and there was a possibility of the customer living in another country; indicating that he may no longer be eligible for ALTCS. No reassessments were completed in 15 years. When the customer was reassessed in 2025, at the age of 21, he was scored 22.4 and no longer eligible for ALTCS.
B) The customer was initially assessed in 2015 and approved as she was left partially paralyzed after suffering a stroke in 2014. Other medical conditions were also noted. She was approved with a score of 67.50. The OIG received a referral indicating her financial and medical situation may have changed. It was also alleged her caretaker was more of a housekeeper/maid and not actually providing services. A home visit was conducted. The investigators found her fully ambulatory without any walking aides or slurred speech. The AHCCCS OIG requested a reassessment, 9 years after her initial approval. She scored a 43 and was placed on Transitional coverage.
A parent answers questions for their young child's PAS Assessment and the PAS scores below the eligible threshold. The parent reapplies a few weeks later, and changes a number of their previous responses, contradicting what was reported on the prior PAS. There are no new medical evaluations or records supporting these changes. The parent does not provide a reasonable cause for the reported changes. The parent may be altering their report meet the eligibility threshold.