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There are three types of organizations that serve as ALTCS program contractors:
NOTE Program contractors for EPD customers are determined by the customer’s county of fiscal responsibility (see MA1104B). However, customers that have a Dual Eligible Special Needs Plan (DSNP) with Medicare will be automatically moved to the EPD Program Contractor that is aligned with their Medicare DSNP.
The Department of Economic Security (DES/DDD); and
American Indian contractors.
The effective date of enrollment is determined by the customer’s AHCCCS status on the date of approval.
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If the customer is... |
Then ALTCS enrollment and capitation... |
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Enrolled with an AHCCCS Complete Care (ACC) plan at the time of approval |
Begins on the date ALTCS approval the ALTCS approval is processed. The customer is disenrolled from the AHCCCS Complete Care (ACC) plan the day before. Exception: If the effective date of ALTCS eligibility is before the date the customer was enrolled with a health plan, the prior period begins on the first day of the ALTCS application (or the first eligible month) and ends on the day before the health plan enrollment began. Enrolled with an AHCCCS Complete Care (ACC) plan at Time of Approval Example |
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Not enrolled with an AHCCCS health plan |
Is retroactive to the effective date of eligibility (prior period coverage). Not Enrolled with an AHCCCS Complete Care (ACC) plan Example The customer may also have unpaid medical bills from services received in the three months prior to the month of application (Prior Quarter) on a Fee-For-Service basis if determined to be eligible for ALTCS during the months in which the medical services were received. |
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Enrolled with a Dual Eligible Special Needs Plan (DSNP) |
Customers that are enrolled in an EPD Program Contractor plan need to have their enrollment aligned to their Dual Eligible Special Needs Plan (DSNP) with Medicare. This is known as Exclusively Aligned Enrollment (EAE). The customer will be automatically moved to the EPD Program Contractor that is aligned with their Medicare DSNP. |
After enrollment occurs:
The program contractor gives the customer written information about their organization.
The customer chooses the doctor he or she prefers as a primary care physician (PCP) from the program contractor’s list of participating physicians. If the customer does not choose a PCP, one is assigned. The primary care physician coordinates care and acts as a gatekeeper. If the customer’s current doctor is a member of the program contractor’s network, the customer does not need to change doctors.
A case manager assigned by the program contractor contacts the customer and the customer’s representative soon after enrollment to establish a service plan that best meets the customer’s needs. Input from the customer and the customer’s family is encouraged.
The customer receives an ID card in the mail from the program contractor that includes the name and phone number of the program contractor. The customer presents this ID card whenever medical services are requested or provided (ex., doctor’s offices, hospitals, labs and pharmacies).
NOTE DDD members receive their ID cards from DDD. American Indian Health Plan (AIHP) members receive their ID cards from AHCCCS.
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Term |
Definition |
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Program Contractor |
Program contractors are responsible for:
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County of Fiscal Responsibility |
The Arizona county that is responsible for paying the State’s funding match for the customer’s ALTCS Service Package. NOTE The county of physical presence (where customer physically resides) and the county of fiscal responsibility may be the same or different counties. |
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Dual Eligible Special Needs Plan (DSNP) |
A type of Medicare Advantage (Part C) plan designed for persons who are eligible for both Medicare and Medicaid. |
This requirement applies to the following program:
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Program |
Legal Authorities |
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ALTCS |
42 CFR 422.107 ARS 36-2933 AAC R9-28-412 through R9-28-417 |