Program Manual Section ALTCS MA508

The customer is a community spouse living at home.

On July 8th, the customer enters a nursing facility. She is discharged on August 28th and returns home. Community spouse rules apply for both July and August since she was living in the community for at least one day in each of those months.

The customer is admitted to the nursing facility again on September 11th and does not return home until December 21st. Community spouse rules apply for September since she was living in the community for at least one day in that month. Community spouse rules do not apply for October and November because the customer was not living in the community for at least one day in either month. Community spouse policy applies again in December because she returned home during the month.

Program Manual Section ALTCS MA524B

A customer applied for Medical Assistance on July 5, 2021. The customer’s current noncitizen status is Lawful Permanent Resident (LPR). He was granted LPR status on November 12, 2019. The customer provides information that he originally entered the U.S. as a Parolee. Documentation in the file from a prior application shows he was granted Parolee status on April 4, 2015. Since the customer was granted the Parolee status more than five years in the past, he has met the 5-year waiting period and can qualify for full AHCCCS MA.

A customer applied for Medical Assistance on May 4, 2021. She is currently a Lawful Permanent Resident (LPR) and says she adjusted to that status from Battered Noncitizen. She provides the following documents:

LPR card showing a grant date of June 3, 2018;

Approval of self-petition under the Violence Against Women Act (VAWA) with an approval date of September 15, 2017; AND

A notice of "prima facie" approval of a pending self-petition under the Violence Against Women Act (VAWA) dated January 25, 2016.

The SAVE response confirms the current LPR status and grant date. However, her earliest qualified status began on January 25, 2016, with the prima facie approval under VAWA. This date is used to determine the customer has had a qualified noncitizen status for more than five years and can qualify for full AHCCCS MA.

Programs Manual Section Caretaker Relative Pregnant Women Child Adult KidsCare MA602D

These examples are divided into five groups based on taxpayer or tax dependent status and age:

Taxpayer Budget Group

Tax Dependent Under Age 19 Budget Group

Tax Dependent Age 19 or Older Budget Group

Not a Taxpayer or Tax Dependent (under age 19) Budget Group

Not a Taxpayer or Tax Dependent (age 19 or older) Budget Group

Each section includes budget group examples only for the person in the scenario that meets the rules for that section. The location of any examples for other people in the scenario is listed at the end of the scenario.

The customers are married but recently separated and are not living together. They have two children. The son is 15 years old and lives with his father. The daughter is 8 years old and lives with her mother. The customers plan to file a joint tax return for the current year and claim both children as tax dependents. (See Example #4 for the son’s and daughter’s budget groups)

The Budget Group for… Includes… Father Self Mother (joint filer) Son (his tax dependent) Daughter (his tax dependent) Mother Self Father (joint filer) Son (her tax dependent) Daughter (her tax dependent)

The customer and the spouse are married and live together with their 5-year old son. They plan to file separate tax returns this year. The spouse will claim the son as a tax dependent. (See Example #9 for the son’s budget group)

The Budget Group for… Includes… Customer Self Spouse (living in the same home) Spouse Self Spouse (living in the same home) Son (her tax dependent)

The customer is divorced and lives alone. He plans to file a tax return for the current year and will claim his 12-year old son as a tax dependent as allowed by the divorce decree. The son lives with his mother in Colorado..

The Budget Group for… Includes… Customer Self Son (his tax dependent)

The customers are married but recently separated and are not living together. They have two children. The son is 15 years old and lives with his father. The daughter is 8 years old and lives with her mother. The customers plan to file a joint tax return for the current year and claim both children as tax dependents. (See Example #1 for the parents’ budget groups)

The Budget Group for… Includes… Son Self Father (taxpayer claiming him) Mother (taxpayer claiming him) Daughter (other tax dependent claimed by taxpayers) Daughter Self Father (taxpayer claiming her) Mother (taxpayer claiming her) Son (other tax dependent claimed by taxpayers)

The customer lives with her 2-year old son and her 8-year old nephew. She plans to file a return for the current year and will claim both her son and her nephew as a tax dependent. The customer is only applying for her son. Her nephew already has coverage through the ALTCS program.

The Budget Group for… Includes… Customer's son Self Customer’s mother (taxpayer claiming him) Mother’s nephew (other tax dependent claimed by taxpayer)

The customer, her 20-year old daughter and the daughter’s 1-year old son live together. The customer plans to file a tax return for the current year and will claim her daughter as a tax dependent. The daughter’s son will be claimed by his father who lives in another state. (See Example #8 for the daughter’s son’s budget group)

The Budget Group for… Includes… Daughter Self Daughter's mother (taxpayer claiming her)

The following provide examples of budget groups for people who are not taxpayers, are not claimed as a tax dependent, or ARE claimed as tax dependents but meet an exception from using tax dependent rules.

The customer, age 17, lives with his mother, his step-father, his 21-year old brother, and the brother’s 2-year old daughter. No one in the home plans to file a tax return for the current year, and no one is claimed as a tax dependent by someone else.

The Budget Group for… Includes… Customer Self Customer’s mother Customer’s step-father

The customer, her 20-year old daughter and the daughter’s 1-year old son live together. The customer plans to file a tax return for the current year and will claim her daughter as a tax dependent. The daughter’s son will be claimed by his father who lives in another state. (See Example #6 for the daughter’s budget group)

The Budget Group for… Includes… Son Self Son's mother

The customers are married and live together with their 5-year old son. They plan to file separate tax returns this year. The mother will claim the son as a tax dependent. (See Example #2 for the parents’ budget groups)

The Budget Group for… Includes… Son Self Mother Father

The customer lives with her 5-year old granddaughter. The customer plans to file a tax return for the current year and will claim the granddaughter as a dependent.

The Budget Group for… Includes… Granddaughter Self

The customer and his partner are both over 19 years old and are not married. They live together along with the partner’s 12-year old son. No one plans to file a tax return for the current year, nor will they be claimed as dependents by someone else.

The Budget Group for… Includes… Son Self Mother Self Mother's son

The customer is 63 years old and lives with her adult daughter. The adult daughter plans to file a tax return for the current year and will claim the customer as a dependent.

The Budget Group for… Includes… Customer Self

The customer is pregnant and lives with her daughter.

The Budget Group for… Includes… Customer Self Daughter Unborn Child Customer's daughter Self Mother

Programs Manual Section Caretaker Relative Pregnant Women Child Adult KidsCare MA602D

Member completes and application online stating she files head of household and claims her 2 children. While working her case, the Benefits and Eligibility Specialist discovers the children’s father (not in the home) has also submitted an application and reports claiming the 2 children. This would require further verification to determine who is actually claiming the children for tax purposes.

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Program Manual Section All programs MA603

On January 3 rd , the customer receives his regular VA pension check of $290.00. On January 15 th , he gets another check for $290.00 with a letter saying that his January check was delayed due to a computer error. The customer realizes that the second check was sent by accident and plans to return it.

The second payment is not returned until early April. The customer explains that he was not able to return it sooner due to illness. The return of the second $290.00 check is verified and the reason for the delay is noted in the file.

Program Manual Section All programs MA603

The customer is unable to pay his car payment. His sister pays the monthly loan payment for him directly to the lender. The payment is not income to the customer.

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Program Manual Section All programs MA604B

The customer has a flat rate long-term care insurance policy. It pays $50.00 a day for each day that he is in a nursing facility. The payments are made monthly.

The customer has signed a form that authorizes the insurance company to make the payments directly to the nursing facility. However, he can have the payments sent to himself instead at any time.

The insurance payments are revocably assigned, so they are considered constructively received. The payments are counted as income to the customer, just as if they were sent to him instead of the nursing facility.

The customer has a disability insurance policy that pays $2,500 per month. The insurance payment is being paid to the customer's spouse. The customer can have the payments paid to him at any time.

The disability insurance payments are revocably assigned, so they are considered constructively received. The payments are count as income to the customer, not the spouse.

The customer purchased an irrevocable annuity in 2012 that pays $1,500 per month. Payments are currently being paid to the customer's son. According to the annuity contract, the customer may change who receives payments from the annuity at any time.

The annuity payments are revocably assigned, so they are considered constructively received. The payments are counted as income to the customer. Payments made to the customer's son during the transfer look-back period must be reviewed as potential transfers ( MA902A ).

Program Manual Section ALTCS MA604.B

The customer has a flat rate insurance policy. It pays $50.00 a day for each day that he is in a nursing home. The payments are made monthly.

The customer irrevocably assigns these monthly insurance payments to the nursing home beginning in the month of November. He cannot change the assignment or get the ongoing payments back.

Any payments the customer got before November are counted as income in the month he got them. Starting in November, the payments are not counted as income. However, if the customer is applying for or getting ALTCS, the assignment of the insurance payments is as a transfer.

Program Manual Section ALTCS only MA604.B

The customer is an ALTCS customer. She irrevocably assigns her pension payments for January and February of this year to her adult child.

Since only two months of the pension payments were assigned, the payments are considered constructively received for ALTCS. The payments for January and February are counted as income for the customer just as if she had actually received them.

Program Manual Section ALTCS Only MA604.B

The customer is an ALTCS recipient with a Long-Term Care (LTC) flat rate insurance policy that would be making payments, but the customer has not submitted the insurance claim. The payments are considered constructively received for ALTCS purposes. The payments are considered income just as if the customer had received them.

Program Manual Section ALTCS SSI-MAO MSP FTW MA604.E

The customer applies in November. He is working and paid weekly. The customer gets five weekly checks in November. The total income from the five checks received in November is more than the income limit. In December and for the next few months, the customer will receive four weekly checks. The total income from the four checks he normally gets is less than the income limit.

The customer will be denied in November for excess income, and approved for December and ongoing. The worker uses the customer’s pay schedule to figure out the next month he will get five checks and sets an alert for the month before to review his case.

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Program Manual Section ALTCS SSI-MAO MSP FTW MA604.E

The customer applies in November. He is working and is paid every other week. The customer gets three bi-weekly checks in November. The total income from the three checks received in November is more than the income limit. In December and for the next few months, the customer will get two bi-weekly checks. The total income from the two checks he normally gets is less than the income limit.

The customer will be denied in November for excess income, and approved for December and ongoing. The worker uses the customer’s pay schedule to figure out the next month he will get three checks and sets an alert for the month before to review his case.

Programs Manual Section Adult Caretaker Relative Child Pregnant Woman KidsCare MA604F.1

The customer applies in October. He is employed under a contract with a local bank to revise their human resources policy. The contract runs from September 1 st through March 31 st of the following year. He is paid $2000 monthly for a total of $14,000.

He was paid $2000 in September, and has not been paid yet for October.

The monthly equivalent is calculated by taking the income he will get under the contract from the month he applied through September of the following year.

He will get $2000 per month for the months of October through March for a total of $12,000. This amount is divided by 12 to get the monthly equivalent of $1000.

Programs Manual Section Adult Caretaker Relative Child Pregnant Woman KidsCare MA604F.1

The customer applies in March. She is employed under a contract with the school district as a teacher’s aide. She has received a contract for the last two years and expects to get a contract for the next school year too.

The contract covers the school year from August 23 rd through May 23 rd . The customer will be paid bi-weekly, and the total contract amount is $24,600.

The monthly equivalent is calculated by taking the anticipated income from the month she applied through February of the following year.

Programs Manual Section Adult Caretaker Relative Child Pregnant Woman KidsCare MA604F.2

The customer has worked at the Honey Baked Ham store every holiday season (from October 1 through December 31) for the last 4 years. On her application, she says that she will be working there again this year.

AZ DOR shows income from this employer only in the 4th quarter of each of the last 4 years. She has earned an average of $1,200 each year from this seasonal job and expects to make the same amount this year.

The expected annual income of $1,200 is divided by 12 months to get the monthly equivalent of $100 per month.

Program Manual Section All programs MA604B

The customer reports receiving a raise in pay from $9.00 per hour to $9.50 per hour, however they have not yet received any paystubs with the new pay rate. The customer’s normal hours are 30 hours per week, paid bi-weekly, both of which are not expected to change. To forecast the new pay amounts:

(Normal bi-weekly hours of 30 hours per week) x (2) = 60 hours per pay period

(60 hours) x (new pay rate of $9.50 per hour) = new anticipated pay of $570 per pay period

Program Manual Section All programs MA604G

The customer reports that their new work hours will vary between 10 and 20 hours per week. Their pay rate is $8.25 per hour and that will not change. To forecast the new pay amounts:

Add the range of hours to get the average weekly hours: (10 + 20) = 30. Divide by 2 = 15 (Expected averaged weekly hours).

Multiply by 2 to get the average hours per pay period. (15 x 2) = 30 (Expected averaged bi-weekly hours).

Multiply by the pay rate to get the new expected bi-weekly pay rate (30 x 8.25) = $247.50

The customer reports that their new work hours will vary between 20 and 25 hours per week. Their pay rate is $8.25 per hour and that will not change. To forecast the new pay amounts:

Add the range of hours to get the average weekly hours: (20 + 25) = 45. Divide by 2 = 22.5 (Expected averaged weekly hours).

Multiply by 2.15 to get the average hours per pay period (22.5 x 2.15) = 48.37 (Expected average semi-monthly hours)

Multiply by the pay rate to get the new expected semi-monthly pay rate (48.37 x 8.25) = $399.05

Program Manual Section All programs MA604G

The customer reports that she gets paid weekly, works on call, and that zero pays are not unusual. She provided 4 weekly paychecks, 1 of which is a zero pay. The gross pay for each of the checks were (check 1 = $300.00, check 2 = $290.00, check 3 = $0.00, and check 4 = $310.00). To determine the monthly amount to budget for a MAGI program:

Add all of the pay amounts for the income period ($300 + $290 + $310) = $900

Divide by the amount of total number of pay periods including the zero pay period ($900 divided by 4) = $225

Multiply by 4.3 because she is paid weekly ($225 x 4.3) = $967.50 (average monthly amount including the zero pay)

Program Manual Section All programs MA604E

The customer does not get their full Social Security payment in the amount of $1,200 per month because an overpayment is being recovered in the amount of $121.00 monthly. At the time of the overpayment, the customer was not receiving AHCCCS benefits. The customer’s full gross amount of $1,200.00 is countable income.

The customer is entitled to a full monthly Social Security payment in the amount of $1,600.00. The customer only gets $1,360.00 per month because an overpayment of $240.00 is being recovered monthly. The customer was receiving AHCCCS benefits during the overpayment. The overpayment was factored into eligibility determinations during that period. The $240.00 is excluded from the customer’s countable income.

Program Manual Section All programs MA604G

The customer takes on an extra shift that is outside of her normal work hours. She reports that this is recurring, and happens every other week. The customer is paid weekly, and she provided 4 weekly paychecks. The gross pay for each of the checks were:

check 1 = $300.00

check 2 = $450.00

check 3 = $300.00

check 4 = $450.00

To determine the monthly amount to budget for a MAGI program:

Add all the pay amounts for the income period ($300 + $450 + $300 + $450) = $1,500

Divide by the amount of total number of pay periods ($1,500 divided by 4) = $375

Multiply by 4.3 because she is paid weekly ($375 x 4.3) = $1,612.50 (average monthly amount including the bonus)

The customer is asked to take on an extra shift for a co-worker who has called out sick. She reports that this is an unusual circumstance. The customer is paid weekly, and she provided 4 weekly paychecks. A call to the employer verifies that the customer normally works 30-35 hours per week and the additional hours worked in week 3 were unusual. The hours and gross pays provided were:

check 1 = 32 hours $480

check 2 = 30 hours $450

check 3 = 40 hours $600

check 4 = 34 hours $510

To determine the monthly amount to budget for a MAGI program:

Add all the pay amounts for the income period that are included in the normal range of hours verified by the employer, not using the usual pay ($480 + $450 + $510) = $1,440

Divide by the amount of total number of checks used ($1,440 divided by 3) = $480

Multiply by 4.3 because she is paid weekly ($480 x 4.3) = $2,064 (average monthly amount excluding the unusual pay)

The customer receives a one-time bonus. She reports that this is unusual, and the employer verified that this was a one-time occurrence. The customer is paid weekly, and she provided 4 weekly paychecks. The gross pay for each of the checks were:

check 1 = $600.00

check 2 = $625.00

check 3 = $1,300.00 (Includes the $700 Bonus)

check 4 = $600.00

To determine the monthly amount to budget for a MAGI program:

Add all the pay amounts for the income period subtracting the bonus amount ($600 + $625 + $600 + 600) = $2,425.00

Divide by the amount of total number of pay periods ($2,425 divided by 4) = $606.25

Multiply by 4.3 because she is paid weekly ($606.25 x 4.3) = $2,606.88 (average monthly amount excluding the bonus)

The customer reports that she had a special project at her work and worked an extra seven hours during her last four checks, but this is unusual and will not continue. A call to the employer confirms that she will no longer work the extra hours and her normal pay is 33 hours a week at $15 an hour. She is paid weekly and provided a copy of her last four checks. The gross pay for each of the checks were:

check 1 = $600.00

check 2 = $600.00

check 3 = $600.00

check 4 = $600.00

Because all checks can’t be used to determine the ongoing income, use the statement from the employer to project income for future months. To determine the monthly amount to budget for a MAGI program:

Multiply the number of normal hours by the hourly pay (33 x $15) = $495.

Multiply by 4.3 because she is paid weekly ($495 x 4.3) = $2,128.50

Programs Manual Section All programs, except ALTCS MA605.1

The customer is 40 years old. He is a single person applying for MA in January 2014. The customer lists income of $1,150 per month from his job on the application. The state hub shows average monthly income of $1,220 from the job. No other income is found by the state and federal hubs.

Under the Adult Group, the income limit for a budget group of one person is $1,274 per month. Since both sources of information show that his income is below the limit, the customer qualifies for MA no matter which source is used. The difference in the two amounts does not affect eligibility, so it is reasonably compatible.

The customer is also 40 years old and a single person applying for MA in January 2014. The customer lists income of $1,150 per month on the application from his job, but the state hub shows average monthly income from this job is $2,150. No other income is found by the state and federal hubs.

Under the Adult Group, the income limit for a budget group of one person is $1,274 per month. Since the customer says his income is low enough to qualify for MA, but the state hub shows his income is too high to qualify, he will need to provide proof of his current monthly income. The difference in the two amounts could affect eligibility, so it is not reasonably compatible.

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Programs Manual Section All programs MA606H

Example Calculation The customer is in a nursing facility and on ALTCS. His spouse lives at home and is applying for SSI MAO. The customer’s gross income is $745 per month. He pays $38.50 for health insurance His personal needs allowance (PNA) is $149.10 His calculated Share of Cost (SOC) is $0 The calculated CSMIA is $895 $745.00 (gross income) -$149.10 (PNA) -$38.50 (insurance premium) =$557.40 (remaining income) Remaining income is less than the CSMIA. So, the allocated income amount is $557.40. The customer is in a nursing facility and on ALTCS. Her spouse lives at home and is applying for MSP. The customer’s gross income is $1,490 per month Her PNA is $149.10 She pays $120.00 for health insurance Her calculated SOC is $983.55 The calculated CSMIA is $245.00 $1,490.00 (total gross income) -$149.10 (PNA) -$120.00 (TPL) -$983.55 (SOC) =$237.35 (remaining income) Remaining income is less than the CSMIA. So, the allocated income amount is $237.35. The customer is in an assisted living home and is on ALTCS. His spouse lives at home and is applying for ALTCS. The customer’s gross income is $4,500 per month His PNA is $2,982.00 He pays $50.00 for TPL Calculated SOC is $0 The calculated CSMIA is $1,062.00 $4,500.00 (total gross income) -$2,982.00 (PNA) -$50.00 (TPL) =$1,468.00 (remaining income) Remaining income is more than the CSMIA. So, the allocated income amount is the full CSMIA amount of $1,062.00.

Programs Manual Section All programs MA606S

The customer is out of work and getting short-term disability insurance payments. The proof provided by the insurer shows that he is entitled to a maximum benefit of $1,250.00 per month. However, he also gets a monthly Social Security Disability payment of $820.00.

The $820.00 from Social Security is deducted from the maximum short-term disability benefit, resulting in an actual disability insurance payment of $430.00. Only the $430.00 actually paid is considered as disability insurance income.

The customer is getting long-term disability benefits of $1,500 per month. The proof provided by the employer shows that the customer’s long-term disability premiums were split between the employer and the customer with each paying half. The employee’s half of the premiums were paid with after-tax income.

Since half of the premium was paid by the employee with after-tax income, half of the $1,500 payment is excluded from counting as income. The other half of the payment is counted since the other half of the premium was paid by the employer.

Programs Manual Section All programs MA606DD

The customer received a quarterly gaming distribution of $2000 in October from the tribe. Since quarterly payments are based on new gaming profit, we will not know the amount of each payment until after the payments have been received. So, the $2000 received in October is used to anticipate the amount of the payment that will be received in the next quarter (January).

NOTE For programs where income is not prorated over the months in the quarter and is counted in full for the month it is received, a quarterly payment may put the person over the income limit. If the gaming income puts the customer over the income limit for January, his AHCCCS Medical Assistance will be stopped from January 1 to January 31. His benefits will be reinstated for February 1st.

Programs Manual Section All programs MA606EE

The customer is a tribal member and has an allotment of trust lands. These lands are leased out for livestock grazing, and the customer gets a semi-annual payment of $4,500 from this lease. The proof received shows that the lands leased are federally-designated trust lands, and the income is not counted when determining the customer’s eligibility.

The customer is a member of a tribe that has federally protected fishing rights.Each year during the spring, he fishes and sells much of the catch. He provides proof from the tribe of his fishing rights, and the income is not counted when determining his eligibility.

The customer is a member of a tribe with federally protected hunting and gathering rights. She creates and sells artworks and crafts from deer and elk antlers, hide and other products from this hunting. She provides proof of her tribal hunting and gathering rights, and the income is not counted when determining her eligibility.

The customer gathers and sells herbs and plants for use in traditional tribal ceremonies. She makes between $200 and $600 per month from this self-employment. She provides a statement about the spiritual and traditional significance of the plants and herbs for tribal ceremonies. The income is not counted when determining the customer’s eligibility.

Programs Manual Section MAGI programs MA606CCC

The customer’s business did not make any profits for the year. The customer gives proof that the business had a loss of $2,400 for the year. The $2,400 is divided by 12 to get the monthly amount of loss. The average monthly loss is $200. This amount is subtracted from the budget group’s countable income when determining income eligibility.

The customer’s business did not make any profits for the year. The customer gives proof that the business had a loss of $1800 for the year. The $1800 is divided by 12 to obtain the monthly amount of loss. The average monthly loss is $150. The income from this business is counted as $0 when determining the budget group’s countable income eligibility for the month.

The customer provided two Schedule C Tax forms as proof of income for the business the customer and spouse share. Both the customer and spouse filed taxes as joint owners of the business. Since both customers run the business, they are co-owners and each filed taxes for their part. Income from the business would be counted for each member when determining the budget group’s countable income.

The customer and her family were part of the Adopt-A-Road program for years while she was in high school. Last year she moved into an apartment with her friends but had trouble finding work. She decided to use her experience as a volunteer and collect cans and other materials she could sell. She does keep regular hours and considers this her job. When she filed taxes, she used Form 1040 and had to attach a Schedule 1 for ‘Other Income’. Even though she did not have a formal business, her self-employment income is countable, and the tax forms may be used as proof.

The customer started a business in early September last year. The customer started making money right away and the businesses income has stayed the same ever since. He and his family applied for Medical Assistance in March of this year. The customer explained that the tax forms are the only proof they could give, but that they expected this income to stay about the same month to month. We would use the customer’s tax forms to calculate his monthly income from the previous year. By dividing the income and expenses claimed on his tax forms by the number of months (September through December) he was in business.

The customer and spouse have a mortgage on their farm. The customer is now applying for ALTCS. They give tax documents for the farm as proof of income. The mortgage payments are entered as an expense on the tax documents. For ALTCS, and other Non-MAGI programs, the interest paid on the mortgage is deducted from the income. Payment of the loan principal is not deducted from the income when determining the budget group’s countable income.

The customer owns and operates a small cafe. The business has a mortgage for the land and the building. The customer applies for Medical Assistance in the Adult program. The customer gives tax forms as proof of income. The mortgage is entered as an expense. For Adult and MAGI programs, the full amount of the expense paid for the mortgage is allowed. Both principal and interest are deducted from the income when determining the budget group’s countable income.

The customer is self-employed. The customer gives taxes for last year as proof of income. When applying, the customer provided a letter explaining that this income is less than last year. The letter says that the income is about the same every month. The customer is asked to provide proof of the last 30 days of income and expenses for the business. This proof will be used when determining her budget group’s countable income for the month.

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Programs Manual Section All programs MA606TT

A pay stub from Arizona State Retirement System (ASRS) shows:

$950 gross monthly income;

$100 of the gross amount is for a health insurance premium supplement; AND

$100 is deducted for a health insurance premium.

$950 (Gross income) - $100 (health insurance premium supplement) = $850.00 countable income.

NOTE For ALTCS, a share of cost deduction would not be allowed for the health insurance because ASRS is paying the entire premium for the customer.

A pay stub from Arizona State Retirement System (ASRS) shows:

$1200 gross monthly income;

$100 of the gross amount is for a health insurance premium supplement; AND

$300 is deducted for a health insurance premium.

$1200 (Gross income) - $100 (health insurance supplement) = $1100.00 countable income.

NOTE For ALTCS, only $200 would be allowed as a share of cost deduction because it is the amount the customer actually pays for the premium.

A pay stub from Arizona State Retirement System (ASRS) shows:

$800 gross monthly income;

$100 of the gross amount is for a health insurance premium supplement; AND

$80 is deducted for a health insurance premium.

$100 (health insurance supplement)-$80 (health insurance premium) = $20 countable from the health insurance supplement. Only an amount up to the premium paid may be deducted from the total income.

$800 (Gross income) + $20 (The amount of the supplement that exceeds the total premium paid) = $820 countable income.

NOTE For ALTCS, a share of cost deduction would not be allowed for the health insurance because ASRS is paying the entire premium for the customer.

Programs Manual Section ALTCS SSI MAO MSP MA606AA

The customer got into a car accident. The injuries caused by the accident made him need nursing home care. The customer’s best friend created a GoFundMe crowdfunding campaign to help pay for the customer’s medical expenses related to the car accident.

Since the customer is not the owner of the GoFundMe campaign, it is not counted as a resource for ALTCS. When the money is given to the customer, it is a gift/contribution and is counted income for non-MAGI Medical Assistance programs.

The customer had a stroke and needed nursing home care. She created a Fundly crowdfunding campaign to help pay for expenses while she is out of work. Since the customer is the owner of the campaign, any money available to her is counted as a resource for ALTCS. All money raised is countable income for non-MAGI Medical Assistance programs.

Programs Manual Section MAGI Programs MA606UUU

The customer has wages reported through a HUB hit. She says she takes care of her father who receives ALTCS services. Her father lives with her. The customer has no other clients. She receives $200 biweekly from the home healthcare agency for taking care of her parent. The $200.00 is a Difficulty of Care payment. It is excluded when determining her eligibility for MAGI programs.

Customer works for a home healthcare agency. The company is paying her to care for two people. She is paid for providing caregiving services two days a week to her son who receives ALTCS services and lives with her. She is also paid for providing caregiving services one day a week to an elderly man who lives in the next town. She receives one check for all the hours she works in the amount of $300.00. Mary provides a statement from the agency saying $100.00 of the total wages is for the person who does not live in her home. The $200.00 received for the care of her son is determined to be a Difficulty of Care payment. The Difficulty of Care payment of $200.00 is excluded when determining her eligibility for MAGI programs. The $100.00 is counted as wages.

The customer provides attendant care to her minor child who is an ALTCS member receiving Division of Developmental Disabilities (DDD) services. The child lives with the customer in the same household. The caregiver agency verifies that the customer is paid as a 1099 Independent Contractor. Although the income is reported as 1099 self-employment income, the payments meet the policy definition of Difficulty of Care. The Difficulty of Care income is excluded when determining eligibility for MAGI programs.

Programs Manual Section MAGI Programs MA606AA

The customer receives $200.00 cash from his family members to cover his monthly expenses. The cash gift is considered a gift income for purposes of eligibility and the ALTCS share of cost.

The customer receives a parsonage allowance from his church to cover housing expenses. The housing allowance is considered contribution income for purposes of eligibility and the ALTCS share of cost.

Programs Manual Section All Programs MA607

The following are examples of when the information provided by the customer is enough proof for expenses exceed income and when the information is questionable or inconsistent and needs more proof.

Example #1 The customer provided proof that child support income recently stopped. This reduced income for the household. The customer does not know how they will meet their living expenses.

The customer’s statement is not questionable or inconsistent. No further proof for expenses exceed income (EEI) is needed for the application but must be reviewed again six months.

Example #2 The customer has no income reported and it is time for their annual renewal. When asked how the customer was meeting basic living expenses, the customer stated they were living off credit cards. The customer’s statement was accepted for proof for the new application. It has now been a year. The customer explained that they moved in with family who is not charging them for shelter costs and food. The customer already reported the move.

The customer’s statement is not questionable or inconsistent. The customer’s statement is acceptable proof that the customer does not have living expenses that exceed income.

Example #1 The customer has no income reported and it is time for their annual renewal. When asked how the customer is meeting basic living expenses, the customer states that they have been living off savings. Additionally, the customer is living with friends and reported expenses of utilities and water. Last year, the customer was asked how much money was in savings. The reported expenses have exceeded the reported savings. The customer did not provide any other explanation.

The customer’s statement is questionable because they would have used all their savings. The customer needs to provide proof of basic living expenses and how the customer is paying the expenses.

Example #2 The customer has no income reported and it is time for their annual renewal. When asked how the customer was meeting basic living expenses, the customer previously stated they were living off credit cards and rent was $500.00. The customer’s statement was accepted for proof at that time. It has now been a year. Further discussion reveals that once a week the customer gives blood to the local blood bank for $50.00. The $50.00 per week is self-employment income.

The customer’s statement is inconsistent. The $200.00 the customer gets does not cover the reported $500.00 rent expense. The customer needs to provide proof of basic living expenses and how the customer is paying the expenses.

Programs Manual Section All programs MA608.B

The customer applies for AHCCCS Medical Assistance on May 23rd. Her earnings history from Social Security shows wages earned through December of the previous year and verifies that she has 36 qualifying quarters. She states that she has earned $4,000 so far since the beginning of the current year.

For the current year, the most quarters for which she can be credited is 2 quarters because May is in the second quarter of the year. The 2 quarters from the current year plus the 36 quarters verified by SSA add up to 38. Since this is less than the 40 quarters needed to be exempt from sponsor deeming, the customer does not have to provide proof of the income earned this year.

NOTE When the fourth quarter of the current year is reached, the customer is potentially eligible for the exemption from sponsor deeming and income for any lag quarters will need to be verified.

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Programs Manual Section Caretaker Relative Pregnant Woman Child Adult KidsCare MA609C

The following examples are for several of the most common types of MAGI deductions:

The customer is employed and has Health Savings Account (HSA) contributions deducted from her paycheck every month. She provided pay stubs verifying the deductions. The amount of the monthly HSA contribution is given as a MAGI deduction.

The customer and his wife both pay spousal support to ex-spouses.

The customer’s spousal support agreement was created in 2017 and has not been modified since then. The spousal support he pays every month is allowed as a MAGI deduction.

The customer’s current wife also pays spousal support, but the agreement was created in February 2019. The spousal support she pays every month is not allowed as a MAGI deduction.

The customer is a full-time teacher and is claiming educator expenses. He provides a copy of his last tax returns confirming the deduction. He also has receipts for the current year showing $312.00 in out-of-pocket expenses for class supplies this year. Only $250.00 of the expenses are allowed as a MAGI deduction. The $250 is divided by 12 to get a monthly amount for the deduction.

The customer and her spouse work and both have pre-tax deductions taken from their pay. The customer provides recent paystubs from their jobs.

She is paid bi-weekly and the paystubs show several deductions from gross pay, which are listed in two separate boxes on the paystub. One box is titled “Pretax deductions”, and the second box is titled “Other Deductions”. The Pretax Deductions box shows deductions for health insurance and retirement totaling $132.00 per pay period. The customer is given a MAGI deduction for $132.00 bi-weekly.

The customer’s spouse is paid weekly. His paychecks also show multiple deductions, but they are all listed together in one box. However, one deduction for $28.00 has an asterisk at the end. At the bottom of the paystub, it explains that deductions with an asterisk are taken pretax. The customer’s spouse is given a MAGI deduction for $28.00 weekly.

The customer is making monthly student loan payments of $250.00. The proof shows that $180.00 of the payment is for the loan principal, and $70.00 is for the loan interest. The $70.00 in interest is given as a MAGI deduction.

The customer is a household of one person with no dependents. He only meets the non-financial requirements for the Adult program. He has counted income of $1,450.00 per month, which is compared to the 2020 income standard for an Adult of $1,415.00. Since the Adult program is the only program that Andrew might qualify for, the MAGI 5% disregard of $54.00 is applied.

After the 5% disregard is applied, the counted income is $1,396.00. The customer qualifies for the Adult program.

In October 2020, a married couple apply for themselves.They have six-year-old twin children who get SSI-Cash and are already receiving AHCCCS MA.

The parents are filing a joint return and claiming the children. Both parents are under age 65 and do not have Medicare. The family’s counted monthly income is $2,373.00. The parents meet the non-financial requirements for two MAGI programs, the Caretaker Relative and the Adult programs.

The budget group size is four people for both parents. The household income of $2,373.00 is first compared to the income limit for the Caretaker Relative program for a family of four, which is $2,315.00. The parents are over the income limit for the Caretaker Relative program. Since they also meet the requirements for the Adult program, the MAGI 5% disregard is not applied to the income test for Caretaker Relative. The household income is then compared to the income limit for the Adult program for a family of four, which is $2,904.00. The household income is under the Adult limit and the parents qualify for the Adult program. The 5% MAGI Disregard is not applied.

The customer is 68 years old and has custody of her three grandchildren. She applies for AHCCCS for herself in June 2020. The children are already on AHCCCS. The customer has counted income of $2,350.00 per month. She will be filing taxes and claiming the three grandchildren as dependents. The customer only meets the non-financial requirements for one MAGI program, the Caretaker Relative Program.

The customer’s MAGI budget group includes all four family members. The customer’s income of $2,350.00 is compared to the Caretaker Relative income limit for a household of 4, which is $2,315.00. Since the Caretaker Relative program is the only program that the customer might qualify for, the MAGI 5% disregard of $110.00 is applied.

After the 5% disregard is applied, the counted income is $2,240.00. The customer qualifies for the Caretaker Relative program.

Program Manual Section All programs MA610

The customer lives with his wife, but they do not meet the community spouse rules. Their two minor children, who are 13 and 15 years old, live with them.

The customer gets Social Security Disability of $1,000 and a disability pension of $500 per month. His wife works full time and earns $4,000 per month.

The two children each get Social Security Survivor’s benefits of $250 per month.

The customer’s eligibility is calculated using the steps below:

Step Action 1 The customer’s monthly income is totaled: $1,000 + $500 = $1,500 2 The total from step 1 is compared to 300% of the FBR. In 2026, 300% FBR = $2,982.00 Because $1,500.00 is less than 300% of the FBR, the customer is income eligible for ALTCS.

Program Manual Section All programs MA610

The Community Spouse Gross Income Test can have two parts: community property rules and name-on-check rules.

The customer lives in a nursing facility and meets the community spouse rules. Her husband lives at home.

The customer gets $1,200.00 Social Security Retirement and $200.00 Arizona State Retirement per month. Her husband gets $1,600.00 Social Security Retirement per month.

First, the gross income test is calculated using community property rules. See the steps below:

Step Action 1 The gross countable unearned income of both spouses are combined: $1,400.00 (customer’s total countable unearned income) + $1,600.00 (spouse’s total countable unearned income) =$3,000.00 total gross countable unearned income 2 The gross countable earned income of both spouses are combined: $0.00 (customer’s total countable earned income) + $0.00 (spouse’s total countable earned) =$ 0.00 total gross countable earned income 3 The combined gross countable unearned income from Step 1 and the combined gross countable earned income from Step 2 are totaled: $3,000.00 (total gross countable unearned income) + $0.00 (total countable earned income) =$3,000.00 total countable income. 4 The total calculated from Step 3 is divided by two: $3,000.00 / 2 = $1,500.00. 5 The result from Step 4 is compared to 300% of the FBR. In 2026, 300% FBR = $2,982.00. Because $1,500.00 is less than $2,982.00, the customer is income eligible for ALTCS using community property rules. NOTE When the result from Step 4 is more than 300% FBR, “name-on-check rules” are applied. See MAE610B.2 below.

The customer lives with his spouse at home and meets the community spouse rules.

He gets monthly income of $800.00 Social Security retirement and $600.00 California State retirement pension. His spouse works full time and earns $5,000.00 a month in wages.

The community property rules are applied first, then the name-on-check rules:

Step Action 1 The gross countable unearned income of both spouses is combined: $1,400.00 (customer’s total countable unearned income) + $0.00 (spouse’s total countable unearned income) =$1,400.00 total gross countable unearned income 2 The gross countable earned income of both spouses is combined: $0.00 (customer’s total countable earned income) + $5,000.00 (spouse’s total countable earned) =$5,000.00 total gross countable earned income 3 The combined gross countable unearned income from Step 1 and the combined gross countable earned income from Step 2 is totaled: $1,400.00 (total gross countable unearned income) + $5,000.00 (total countable earned income) =$6,400.00 total countable income. 4 The total calculated from Step 3 is divided by two: $6,400.00 / 2 = $3,200.00 5 The result from Step 4 is compared to 300% of the FBR. In 2026, 300% FBR = $2,982.00. Since $3,200.00 is greater than $2,982.00, the customer is income ineligible for ALTCS using community property rules. Income eligibility must be determined using name on check rules (continue to step 6 below) 6 The customer’s counted monthly unearned income and earned income is totaled: $1,400.00 (customer’s total countable unearned income) + $0.00 (customer’s earned income) =$1,400.00 total countable income used for the gross income test. 7 The result from Step 6 is compared to 300% of the FBR: Since $1,400.00 is less than $2,982.00 , the customer is eligible for ALTCS using the name on check rules.

Joint Rental Income Example

The customer and spouse are joint owners of a rental property. Their daughter is the agent for the rental property. The monthly rent paid by the renters of the property is $400.00. The $400.00 check paid by the renters is made out to the daughter. Although the check is made out to the daughter, the owners of the income are the customer and the spouse. $200.00 is the customer’s income and $200.00 is the spouse’s income.

Jointly Owned Annuity Example:

The customer and spouse are named as the annuitants on an annuity contract. The $1,000.00 monthly annuity check is made out only in one spouse’s name. Because the customer and spouse are both owners of the annuity, $500.00 is considered the customer’s income and $500.00 is considered the spouse’s income.

Program Manual Section All programs MA610

The customer is not married and lives in a setting where long-term care services cannot be provided.

She gets monthly income of $700.00 Social Security Retirement and a $100.00 VA pension (need-based). She also sells Avon to make extra money and received $80.00 in the budget month from this part time job.

The customer’s eligibility is calculated using the net income test as follows:

Step Action 1 Calculate net unearned income: $700.00 (customer’s total countable unearned income that is not needs based) -$0.00 (1/3 child support deduction is not applicable) =$700.00 (subtotal) -$20.00 (general income deduction) =$680.00 (subtotal) +$100.00 (need-based income) =$780.00 (net unearned income) 2 Calculate net earned income: $80.00 (customer’s total countable earned income). -$0.00 (unused portion of the $20.00 general income deduction) -$65.00 (standard work expense deduction) -$0.00 (IRWE deduction) =$15.00 (subtotal of earned income) -$7.50 (½ subtotal of earned income) -$0.00 (blind work expense deduction) =$7.50 (net earned income) 3 Calculate total net income: $780.00 (net unearned income from Step 1 above) +$7.50 (net earned income from Step 2 above) =$787.50 (subtotal or net income) -$0.00 (no child allocation) =$787.50 (total net income) 4 The result in Step 3 above is compared to 100% of the FBR In 2026, 100% FBR = $994.00. Because $787.50 is less than $994.00, the customer is income eligible for ALTCS using the 100% FBR net test.

The customer and his wife live at home with their two-year-old child. The customer has been on ALTCS six months, when the ALTCS Health Plan notifies the office that he is refusing HCBS. The worker determines ALTCS acute care eligibility using the net test.

The customer gets monthly income of $700.00 Social Security Disability, and his wife works part time and makes $400.00 per month from her job. The child gets $250.00 Social Security Survivor benefits.

The customer’s eligibility is calculated using the net income test as follows:

Step Action 1 Calculate net unearned income: $700.00 (total of the customer’s and the spouse’s counted unearned income) -$0.00 (1/3 child support deduction not applicable) =$700.00 (subtotal) -$20.00 (general income deduction ) =$680.00 (subtotal) +$0.00 (there is no income based on need) =$680.00 (net unearned income) 2 Calculate net earned income: $400.00 (total of the customer’s and the spouse’s counted earned income) -$0.00 (unused portion of the $20.00 general income deduction) -$65.00 (standard work expense deduction) -$0.00 (IRWE deduction) =$335.00 (subtotal of earned income) -$167.50 (½ subtotal of earned income) -$0.00 (blind work expense deduction) =$167.50 (net earned income) 3 Calculate total net income: $680.00 (net unearned income from Step 1 above) +$167.50 (net earned income from Step 2 above) =$847.50 (subtotal of net income) - $142.00 (child allocation amount) =$705.50 (total net income) 4 Compare the result in Step 3 above to $1,491.00 (100% of the FBR for a couple for 2026): Because $705.50 is less than $1,491.00, the customer is income eligible for ALTCS.

The customer is a 2-year-old child with a developmental disability. She lives with her parents and two minor siblings, aged 5 and 8. She has been on ALTCS benefits for seven months when the ALTCS Health Plan reports that the parents are refusing HCBS services for the customer. The worker determines eligibility for ALTCS acute care using the net test.

None of the children get any income. The customer’s father works full-time and makes $4,000.00 per month. Her mother gets a $400.00 pension payment. The customer’s parents are not receiving or applying for SSI or any AHCCCS benefits for themselves.

The customer’s eligibility is calculated using the net income test as follows:

1st Process: Determine Child Allocations Step Action 1 Add the child allocation amounts for each other child in the home other than the customer child (see MA609B.8 ): $497.00 (child allocation for 5-year-old sibling) +$497.00 (child allocation for 8-year-old sibling) = $994.00 (total child allocation) 2nd Process: Deeming Calculation Step Action 2 Subtract the total child allocation from Step 1 from the ineligible parents’ unearned income: $400.00 (total of the ineligible parents’ counted unearned income) - $994.00 (total child allocations from Step 1) = -$594.00 (remaining unused child allocations) NOTE Since the child allocation amount is higher than the unearned income, the remaining unearned income amount to be deemed from the parents is $0. The remaining child allocation is carried over to the net earned income calculation. 3 Calculate ineligible parents’ net unearned income: $0.00 (remaining unearned income amount from Step 2) -$20.00 (general income deduction) = -$20.00 (remaining general income deduction) NOTE Since the general income deduction is higher than the remaining unearned income, the unearned income amount to be deemed from the parents is $0. The remaining general income deduction amount is carried over to the net earned income calculation. 4 Calculate ineligible parents’ net earned income: $4,000.00 (the parent's total earned income) - $0.00 (student earned income deductions) - $594.00 (remaining unused child allocation from Step 2) - $20.00 (remaining unused general income deduction amount) - $65.00 (standard income deduction) - $0.00 (IRWE deduction) = $3,321.00 (subtotal of earned income) - $1,660.50 (½ subtotal of earned income) = $1,660.50 (subtotal of earned income) -$0.00 (blind work expense deduction) = $1,660.50 (total net earned income) 5 Calculate total net income as follows: $0.00 (total net unearned income from Step 3) +$1,660.50 (total net earned income from Step 4) =$1,660.50 (total net income) 6 Calculate the deemed income from the ineligible parents: $1,660.50 (total net income from Step 5) - $1,491.00 (Couple FBR) = $169.50 (amount of deemed income from parents) 3rd Process: Net Income Test Calculation Step Action 7 Calculate the net unearned income: $0.00 (customer child’s own income) + $169.50 (deemed income from parents from Step 6) - $0.00 (1/3 child support deduction – does not apply) - $20.00 (general income deduction) = $149.50 (subtotal unearned income) + $0.00 (no needs based assistance payments) = $149.50 (net unearned income) 8 Calculate the net earned income: $0.00 (customer child’s counted earned income) - $0.00 (student earned income deduction is not applicable) - $0.00 (unused remaining general income deduction from Step 7) - $0.00 (standard work expense deduction) - $0.00 (IRWE deduction) - $0.00 (½ subtotal of earned income) - $0.00 (Blind Work Expenses) = $0.00 (net earned income) 9 Calculate total net income: $149.50 (net unearned income from Step 7) + $0.00 (net earned income from Step 8) - $0.00 (child allocation amount for the customer child’s children) = $149.50 (total net income) 10 Compare the total net income from Step 9 to 100% of the FBR. In 2025, 100% FBR = $994.00. Because $149.50 is less than $994.00, the customer is income eligible for ALTCS using the net test.

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Programs Manual Section SSI MAO MA611

The customer, a 65-year-old single individual, resides with her two adopted children ages 10 and 12. The customer applies for AHCCCS Medical Assistance for herself in January 2026.

The customer receives $1,100.00 for Social Security Retirement per month. She also works part-time to make extra money and received $780.00 in January 2026. The two children do not have any income.

Calculate the customer’s eligibility as follows:

Step Action 1 Calculate net unearned income: $1,100.00 (customer’s total countable unearned income that is not needs based) - $0.00 1/3 child support deduction (not applicable) = $1,100.00 (subtotal) - $20.00 (general income deduction) = $1,080.00 (subtotal) + $0.00 income based on need (not applicable) = $1,080.00 (net unearned income) 2 Calculate net earned income: $780.00 customer’s total countable earned income - $0.00 (unused portion of the $20.00 general income deduction) - $65.00 (standard work expense deduction) - $0.00 (IRWE deduction) = $715.00 (subtotal of earned income) - $357.50 (one-half of the subtotal of earned income) - $0.00 (blind work expense deduction) = $357.50 (net earned income) 3 Calculate total net income: $1,080.00 (net unearned income from Step 1 above) + $357.50 (net earned income from Step 2 above) = $1,437.50 (subtotal of net income) - $994.00 child allocation ($497.00 per child, two children) = $443.50 (total net income) 4 Compare the result in Step 3 above to $994.00 (100% of the FBR for an individual for 2026). Because $443.50 is less than $994.00, the customer is income eligible for AHCCCS Medical Assistance under SSI-MAO using the 100% FBR standard.

The customer is a 70-year-old single individual. The customer applies for AHCCCS Medical Assistance in February 2026.

The customer receives monthly income of $1,050.00 for Social Security retirement. He also works part time and made $125.00 in February 2026 from his job.

The customer’s eligibility is calculated as follows:

Step Action 1 Calculate net unearned income as follows: $1,050.00 customer’s total countable unearned income that is not needs based - $0.00 1/3 child support deduction (not applicable) = $1,050.00 subtotal - $20.00 (general income deduction) = $1,030.00 subtotal + $0.00 income based on need (not applicable) = $1,030.00 net unearned income 2 Calculate net earned income as follows: $125.00 (customer’s total countable earned income) - $0.00 (unused portion of the $20.00 general income deduction) - $65.00 (standard work expense deduction) - $0.00 (IRWE deduction) = $60.00 (subtotal of earned income) - $30.00 (one-half of the subtotal of earned income) - $0.00 (blind work expense deduction) = $30.00 (net earned income) 3 Calculate total net income as follows: $1,030.00 (net unearned income from Step 1 above) + $30.00 (net earned income from Step 2 above) = $1,060.00 subtotal of net income - $ 0.00 child allocation (not applicable) = $1,060.00 (total net income) 4 Compare the result in Step 3 above to $994.00 (100% of the FBR for an individual). Because $1,060.00 is greater than $994.00, the customer is income ineligible for AHCCCS Medical Assistance using the FBR standard. Continue to Step 5 to determine eligibility using the 100% FPL standard. 5 Take the total net income result from Step 3 and add the one-half subtotal of earned income from Step 2 back in: $1,060.00 (total net income from FBR test) + $30.00 (one-half subtotal of earned income) = $1,090.00 (total net income) 6 Compare the result in Step 5 above to $1,330.00 (100% of the FPL for an individual): Because $1,090.00 is less than $1,330.00, the customer is income eligible for SSI-MAO using the FPL standard.

Programs Manual Section SSI MAO MA611

The customer is 70 years old, and lives with his spouse, who is 45 years old. Their 10-year-old daughter lives with them. The customer applies for AHCCCS Medical Assistance for himself in January 2026.

The customer receives a monthly income of $900.00 for Social Security retirement. His spouse works part time and received $1,000.00 in January 2026. Their daughter does not have any income.

The customer’s eligibility is calculated as follows:

Step Action 1 Calculate net unearned income: $900.00 (total of the customer’s and the spouse’s total countable unearned income that is not needs based) - $0.00 1/3 child support deduction (not applicable) = $900.00 subtotal - $20.00 (general income deduction) = $880.00 subtotal + $0.00 income based on need (not applicable) = $880.00 net unearned income 2 Calculate net earned income: $1,000.00 (total of the customer’s and the spouse’s counted earned income) - $0.00 (unused portion of the $20.00 general income deduction) - $65.00 (standard work expense deduction) - $0.00 (IRWE deduction) = $935.00 (subtotal of earned income) - $467.50 (one-half subtotal of earned income) - $0.00 (blind work expense deduction) = $467.50 (net earned income) 3 Calculate total net income: $880.00 (net unearned income from Step 1 above) + $467.50 (net earned income from Step 2 above) = $1347.50 (subtotal of net income) - $497.00 (child allocation) = $850.50 (total net income) 4 Compare the result in Step 3 above to $1,491.00 (100% of the FBR for a couple for 2026): Because $850.50 is less than $1,491.00, the customer is income eligible for SSI-MAO using the 100% FBR standard.

The customer, a 70-year-old man, lives with his 50-year-old wife. The customer applies for AHCCCS Medical Assistance for himself in February 2026.

The customer receives a monthly income of $1,600.00 for Social Security retirement. His spouse has no income.

The customer’s eligibility is calculated using the net income test as follows:

Step Action 1 Calculate net unearned income: $1,600.00 (total of the customer’s and spouse's total countable unearned income that is not needs based) - $0.00 1/3 child support deduction (not applicable) = $1,600.00 (subtotal) - $20.00 (general income deduction) = $1,580.00 (subtotal) + $0.00 income based on need (not applicable) = $1,580.00 (net unearned income) 2 Calculate net earned income: $0.00 (total of the customer’s and the spouse’s counted earned income) - $0.00 (unused portion of the $20.00 general income deduction) - $65.00 (standard work expense deduction) - $0.00 (IRWE deduction) = $0.00 (subtotal of earned income) - $0.00 (one-half subtotal of earned income) - $0.00 (blind work expense deduction) = $0.00 (net earned income) 3 Calculate total net income: $1,580.00 (net unearned income from Step 1 above) + $0.00 (net earned income from Step 2 above) = $1,580.00 (subtotal of net income) - $0.00 child allocation (not applicable) = $1,580.00 (total net income) 4 Compare the result in Step 3 above to $1,491.00 (100% of the FBR for a couple for 2026): Because $1,580.00 is greater than $1,491.00,the customer is ineligible using the 100% FBR standard. Continue to Step 5 to determine SSI Non-Cash eligibility using the 100% FPL standard. 5 Take the total net income result from Step 3 and add the one-half subtotal of earned income from Step 2 above: $1,580.00 (total net income for FBR test) + $0.00 (1/2 subtotal of earned income) = $1,580.00 (total net income) 6 Compare the result in Step 5 above to $1,804.00 (100% of the FPL for a couple): Because $1,580.00 is less than $1,804.00, the customer is eligible for SSI-MAO using the FPL standard for a couple.

Programs Manual Section SSI MAO MA611

The customer is a 10-year-old child who lives with her parents and her two siblings, ages 2 and 5. The customer has been determined by DDSA to have a disability. She is not eligible for SSI because her resources exceed $2,000.00. The customer’s parents apply for AHCCCS Medical Assistance (MA) for her in February 2026.

The customer’s father works full time and received $5,200.00 in February 2026. The customer’s mother receives a monthly pension income of $900.00. None of the three children have any income. The customer’s parents do not receive and are not applying for MA.

The customer’s eligibility is calculated as follows:

1st Process: Determine Child Allocations Step Action 1 Add the child allocation amounts for each child in the home other than the customer child (see MA609B.8 ): $497.00 (child allocation for sibling aged 2) + $497.00 (child allocation for sibling aged 5) = $994.00 (total child allocation) 2nd Process: Deeming Calculation Step Action 2 Subtract the total child allocation from Step 1 from the ineligible parents’ unearned income: $900.00 (total of the ineligible parents’ counted unearned income) - $994.00 (total child allocations from Step 1) = -$94.00 (remaining unused child allocations) NOTE Since the child allocation amount is higher than the unearned income, the remaining unearned income amount to be deemed from the parents is $0. The remaining child allocation is carried over to the net earned income calculation. 3 Calculate ineligible parents’ net unearned income: $0.00 (remaining unearned income amount from Step 2) - $20.00 (general income deduction) = -$20.00 (remaining general income deduction) NOTE Since the general income deduction is higher than the remaining unearned income, the unearned income amount to be deemed from the parents is $0. The remaining general income deduction amount is carried over to the net earned income calculation. 4 Calculate ineligible parents’ net earned income: $5,200.00 (parent’s total earned income) - $0.00 (student earned income deductions) - $94.00 (remaining unused child allocation from Step 2) - $20.00 (remaining unused general income deduction amount) - $65.00 (standard income deduction) - $0.00 (IRWE deduction) = $5,022.00 (subtotal of earned income) - $2,511.00 (1/2 subtotal of earned income) = $2,511.00 (subtotal of earned income) - $0.00 (blind work expense deduction) = $2,511.00 (total net earned income) 5 Calculate total net income as follows: $0.00 (total net unearned income from Step 3) + $2,511.00 (total net earned income from Step 4) = $2,511.00 (total net income) 6 Calculate the deemed income from the ineligible parents: $2,511.00 (total net income from Step 5) - $1,491.00 (100% FBR for a couple for 2026) = $1,020.00 (amount of deemed income from parents) 3rd Process: Net Income Test Calculation Step Action 7 Calculate the net unearned income: $0.00 (customer child’s own income) + $1,020.00 (deemed income from parents from Step 6) - $0.00 (1/3 child support deduction – does not apply) - $20.00 (general income deduction) = $1,000.00 (subtotal unearned income) + $0.00 income based on need (not applicable) = $1,000.00 (net unearned income) 8 Calculate the net earned income: $0.00 (customer child’s counted earned income) - $0.00 student earned income deduction (not applicable) - $0.00 (unused remaining general income deduction from Step 7) - $0.00 (standard work expense deduction) - $0.00 (IRWE deduction) - $0.00 (1/2 subtotal of earned income) - $0.00 (Blind Work Expenses) = $0.00 (net earned income) 9 Calculate total net income: $1,000.00 (net unearned income from Step 7) + $0.00 (net earned income from Step 8) - $0.00 (child allocation amount for the customer child’s children) = $1,000.00 (total net income) 10 Compare the total net income from Step 9 to $994.00 (100% of the FBR for an individual for 2026). Because $1,000.00 is greater than $994.00, the customer is income ineligible using the 100% FBR income standard. Continue to Step 11 to determine if she is eligible using the 100% FPL standard. Net Income Test Using 100% FPL Standard FPL Deeming Calculation Step Action 11 Calculate the deemed income from the parents: $2,511.00 (parents’ total net income from Step 5) + $2,511.00 (one-half subtotal of earned income from Step 4 added back in) = $5,022.00 (subtotal total net income) - $1,840.00 (100% FPL amount for a couple) = $3,218.00 (amount of deemed income from parents) 3rd Process: Net Income Test Calculation Step Action 12 Calculate the net unearned income: $0.00 (customer child’s own income) + $3,218.00 (deemed income from parents from Step 11) - $0.00 1/3 child support deduction (not applicable) - $20.00 (general income deduction) = $3,198.00 (subtotal unearned income) + $0.00 income based on need (not applicable) = $3,198.00 (net unearned income) 13 Calculate the net earned income: $0.00 (customer child’s counted earned income) - $0.00 (student earned income deduction - not applicable) - $0.00 (unused remaining general income deduction from Step 7) - $0.00 (standard work expense deduction) - $0.00 (IRWE deduction) - $0.00 (Blind Work Expenses) = $0.00 (net earned income) 14 Calculate total net income: $3,198.00 (net unearned income from Step 12) + $0.00 (net earned income from Step 13) - $0.00 (child allocation amount for the customer child’s children) = $3,198.00 (total net income) 15 Compare the total net income from Step 14 to $1,330.00 (100% of the FPL for an individual). Because $3,198.00 is greater than $1,330.00, the customer is income ineligible using the 100% FPL income standard.

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Programs Manual Section MSP MA612

The customer has Medicare Part A and Part B. The customer receives Social Security Retirement income of $1,350.00 per month. He also works part time and made $200.00 in February 2026.

The customer’s MSP eligibility is calculated as follows:

Step Action 1 Calculate net unearned income: $1,350.00 (customer’s countable unearned income that is not needs based) - $0.00 (1/3 child support deduction is not applicable) - $20.00 (general income deduction) = $1,330.00 (subtotal) + $0.00 (has no income based on need) = $1,330.00 (net unearned income) 2 Calculate net earned income: $200.00 (customer’s total countable earned income) - $0.00 (unused portion of the $20.00 general income deduction) - $65.00 (standard work expense deduction) - $0.00 (IRWE deduction) = $135.00 (subtotal of earned income) - $67.50 (1/2 subtotal of earned income) - $0.00 (blind work expense deduction) = $67.50 (net earned income) 3 Calculate total net income: $1,330.00 (net unearned income from Step 1 above) + $67.50 (net earned income from Step 2 above) = $1,397.50 (subtotal or net income) - $0.00 (allocation not applicable because the customer has no children) = $1,397.50 (total net income) 4 Compare the result in Step 3 to the MSP for an individual: Because $1,397.50 is between $1,330.01 – $1,596.00 (2026 SLMB FPL Standard), the customer is income eligible for SLMB.

Programs Manual Section MSP MA612

The customer lives with his wife and their 15-year-old daughter. He has Medicare Part A and Part B and applies for Medicare Savings Program benefits for himself in April 2026.

The customer gets $2,000.00 in Social Security Retirement income per month. His wife works and receives $800.00 in April 2026. The customer’s daughter has no income of her own.

The customer’s eligibility is calculated using the net income test as follows:

Step Action 1 Calculate net unearned income: $2,000.00 (customer’s total counted unearned income [$2,000.00] plus the spouse’s counted unearned income [$0.00]) - $ 0.00 (1/3 child support deduction is not applicable) = $2,000.00 (subtotal) - $20.00 (general income deduction) = $1,980.00 (subtotal) + $0.00 (there is no income based on need) = $1,980.00 (net unearned income) 2 Calculate net earned income: $800.00 (customer’s total counted earned income [$0.00] plus the spouse’s counted earned income [$800.00]) - $0.00 (unused portion of the $20.00 general income deduction) - $65.00 ($65.00 work expense deduction) - $0.00 (IRWE deduction is not applicable) = $735.00 (subtotal of earned income) - $367.50 (1/2 subtotal of earned income) - $0.00 (blind work expense deduction is not applicable) = $367.50 (net earned income) 3 Calculate total net income: $1,980.00 (net unearned income from Step 1 above) + $367.50 (net earned income from Step 2 above) = $2,347.50 (subtotal of net income) - $497.00 (2026 child allocation of $497.00 - $0.00 income = $497.00) = $1,850.50 (total net income) 4 Compare the result in Step 3 to the MSP Standards for a couple: Because $1,850.50 is between $1,804.01 – $2,164.00 (2026 SLMB FPL Standard for a couple), the customer is income eligible for SLMB.

Programs Manual Section MSP MA612

The customer is a 15-year-old child. He lives with his parents and two siblings. He has End Stage Renal Disease and receives Medicare Part A and Part B. The customer’s parents apply for Medicare Savings Programs for the customer in February 2026.

The customer’s father works full time and earned $3,500.00 in February 2026. His mother gets $900 per month from Arizona State Retirement. None of the three children have income of their own. The customer’s parents are not getting MA and are not applying for MA for themselves.

The customer’s eligibility is calculated using the net income test as follows:

1st Process: Determine Child Allocations The following steps are used to determine the total amount of the child allocations for the customer’s siblings in the household: Step Action 1 Calculate a child allocation separately for each child of the customer’s parents in the household (excluding the customer child): Sibling 1’s allocation $497.00 (2026 allocation amount) - $0.00 (Sibling 1’s income) = $497.00 (allocation amount for Sibling 1) Sibling 2’s allocation $497.00 (2026 allocation amount) - $0.00 (Sibling 2’s income) = $497.00 (allocation amount for Sibling 2) 2 Combine the individual allocations: $497.00 (Sibling 1’s allocation) + $497.00 (Sibling 2’s allocation) = $994.00 (total allocation) 2nd Process: Deeming Calculation The following steps are used to calculate the amount deemed from the ineligible parent(s) to the customer child: Step Action 3 Calculate remaining unearned income: $900.00 (parents’ unearned income) - $994.00 (child allocation amount from Step 2) = $0.00 NOTE The remaining unused child allocation is carried over to Step 4. 4 Calculated remaining earned income: $3,500.00 (parents’ earned income) - $94.00 (unused child allocation) = $3,406.00 (remaining earned income) 5 Calculate net unearned income of ineligible parent(s): $0.00 (remaining unearned income from Step 3 above) - $20.00 (general deduction) = $0.00 (with -$20.00 unused general deduction) NOTE The remaining unused general deduction is carried over to Step 6. 6 Calculate net earned income of ineligible parent(s): $3,406.00 (remaining earned income from Step 4 above) - $20.00 (unused portion of the $20.00 deduction) - $65.00 ($65.00 work expense deduction) - $0.00 (Impairment Related Work Expense deduction) = $3,321.00 (subtotal earned income) - $1,660.50 (1/2 subtotal of earned income) - $0.00 (Blind Work Expense deduction) = $1,660.50 (net earned income of ineligible parent(s) 7 Calculate total net income of ineligible parent(s): $0.00 (net unearned income of ineligible parent(s) from Step 5 above) + $1,660.50 (net earned income of ineligible parent(s) from Step 6 above) = $1,660.50 (total net income) 8 Determine deemed income from ineligible parent(s): $1,660.50 (total net income from Step 7 above) - $1,804.00 (2026 couple FPL/two parent allocation) = -$143.50 (amount of deemed income) 3rd Process: Net Income Test Calculation The steps below are used to calculate the net income used for eligibility: Step Action 9 Calculate the net unearned income: $0.00 (customer child’s income) + -$143.50 (deemed income of ineligible parents(s) from Step 8) - $0.00 (1/3 child support deduction does not apply) = -$143.50 (subtotal unearned income) - $20.00 ($20.00 general deduction) + $0.00 (no needs based assistance payments) = -$163.50 (net unearned income) 10 Calculate net earned income: $0.00 (total of the customer child’s counted earned income [$0.00]) - $0.00 (unused portion of the $20.00 general income deduction) - $65.00 ($65.00 work expense deduction) - $0.00 (IRWE deduction) = -$65.00 (subtotal of earned income) - $0.00 (1/2 subtotal of earned income) - $0.00 (blind work expense deduction) = -$65.00 (net earned income) 11 Calculate total net income: -$163.50 (net unearned income from Step 9 above) + -$65.00 (net earned income from Step 11 above) = -$228.50 (subtotal of net income) = 0.00 (child allocation amount – customer child does not have dependent children) = -$228.50 (total net income) NOTE Since the total net income is less than zero, use $0.00 to compare to MSP Standards for an individual 12 Compare the result in Step 12 to the MSP Standards for an individual: Because $0.00 is below $1,330.00 (2026 QMB FPL Standard), the customer qualifies for QMB.

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Programs Manual Section ALTCS MA703.E

A customer deposits a $1,000 Social Security check in his checking account. The check includes $200 for the current month and $800 for the four months before. The account already contained $300 in counted funds. The new balance is $1,300 ($500 counted, and $800 excluded retroactive SSA benefits).

The individual withdraws $300. This is considered taken from the counted funds. The remaining $1,000 balance contains the excluded $800, and the remaining $200 of counted funds.

The individual withdraws another $300. $200 is considered taken from the remaining counted funds and $100 from the excluded funds. The balance of $700 is excluded.

The individual deposits $500 from the sale of some furniture, creating a new balance of $1,200. Only $700 of the new balance is excluded.

A customer deposits $200 in excluded funds in a checking account that already contains $300 in non-excluded funds.

The individual withdraws $400. The remaining $100 is excluded.

The individual then deposits $100 in non-excluded funds. Of the resulting $200 balance, $100 is excluded.

he individual next deposits $100 in excludable funds. Of the new $300 balance, $200 is excluded.

Programs Manual Section ALTCS MA703.F

The customer opened a bank account for his nephew and funded it with $5,000. Even though he put the account in the nephew’s name, he still has full control of the account. The resource remains countable to the customer.

A check received by an individual as payment but which is not yet cashed, even six months or more after receipt, is considered constructively received and included in the resource calculation.

The customer irrevocably assigns a $10,000 Certificate of Deposit to his grandchildren. Since the assignment is irrevocable and the CD is no longer available to the customer, the $10,000 assignment is not considered constructively received, but is evaluated as a transfer.

tThe customer assigns a $5,000 savings account to his brother, and the account is now solely in the brother's name. The account cannot be made available solely due to the customer's action. As a result, the savings account cannot be treated as constructively received but instead is evaluated as a transfer.

The customer refuses an inheritance that reverts to another individual named in the will and is no longer available. The resource is no longer considered constructively received, but is evaluated as a transfer.

The customer entered a NF on April 15 th and applied for ALTCS on April 18 th . On April 29 th he paid the NF $5,000. On April 25 th the NF had billed the customer for 16 days in April totaling $2,990 and that payment was due no later than May 5 th .

For April, $2,990 is considered payment of a current bill, but the balance of the payment ($2,010) is an advance payment and is considered a constructively received resource.

Programs Manual Section ALTCS MA703F

The customer has a qualifying long-term care insurance policy. When she enters a nursing home, the policy begins issuing benefits that she uses to pay her nursing home costs.

The customer receives $80,000 in payments from the LTC policy before applying for ALTCS. As a result, $80,000 of her resources will not be counted in determining if she is resource eligible for ALTCS. In addition, $80,000 of any estate she may leave when she dies will be exempt from the Estate Recovery program.

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Programs Manual Section ALTCS MA704C

When asked about any assets held in his name but not listed on the application, the customer states that he holds the title to his son’s car.

The customer provides a written statement explaining why the car is in his name but actually belongs to his son. The customer’s son could not get a loan to buy the car, which he needs to get to work. The customer took out a loan with his credit union and bought the car on his son’s behalf. The son has made all the payments on this loan and has the car in his possession.

The written statement received from the son also confirms the customer’s statement. The car is titled to his father since the loan is in his father’s name. Once the loan is paid off, title to the car will be transferred to the son.

The worker verifies that there are no payments coming from the customer’s account for the car. The customer has proven that he does not have an equitable interest in the car. The son has full equitable ownership. The car is not counted as the customer’s resource in the eligibility determination.

Programs Manual Section ALTCS MA704B MA902B

The customer added her cousin to the title on her property because she wanted it to stay in the family after she dies. The new title shows the customer and her cousin as the joint owners. Since both the customer and her cousin must agree to sell the property, adding the cousin’s name must be evaluated as a 50% transfer.

The customer added his brother to the title on his boat. The new title shows the customer or his brother as the owners. Since this did not change the customer’s ability to sell, transfer, or dispose of the asset, a transfer did not occur. The full value of the boat would be counted as a resource to both the customer and to the brother.

NOTE This example also applies if the title shows “And/Or”.

The customer’s daughter added the customer’s name to her property. The title shows the customer's daughter and the customer as joint owners. Since the customer was added to the property as an owner, 50% of the property value is a resource to the customer.

The customer’s friend added the customer’s name to her property. The title shows the customer's friend or the customer as the owners. Since either the customer or the customer’s friend can sell the property, the full value of the property is a resource to the customer.

NOTE This example also applies if the title shows “And/Or”.

Programs Manual Section ALTCS MA704D

The customer’s account lists both her name and her adult child as her Power of Attorney. The account is funded by the customer. The adult child makes withdrawals for the benefit of the customer. The adult child is acting as a fiduciary for her mother. This bank account is a countable resource to the customer.

The customer’s bank statements show the account is listed in the representative's name only. The representative states all the money in the account belongs to the customer. The bank statements show the customer’s income is the only income going into the account. It also shows only the customer’s expenses are being paid from this account. The account is owned by the representative because the customer’s name is not on the account. The account is not a countable resource to the customer.

The customer owns an out-of-state property. The representative provides a deed showing the property is owned by the customer through their conservator. The deed shows it is the customer’s property and the conservator is acting in a fiduciary manner. The property is a countable resource to the customer.

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Programs Manual Section ALTCS MA705D

The customer has irrevocably assigned ownership of a life insurance policy to a funeral home to fund a burial contract for himself. The equity value of the life insurance policy is $3,000.

The burial contract identifies the purchase of $1,300 of burial space items and $1,700 of burial services. Since the contract is funded by the irrevocable assignment of a life insurance policy it can be totally excluded. $1,300 is excluded as Burial Plot Items and $1,700 is excluded as an Irrevocable Burial Fund.

The customer opened a bank account in 1968 to set aside $400 for her future burial expenses. She has no irrevocable burial arrangement or other burial fund. She applied for AHCCCS benefits in late January. In February, she completes the DE-157 and lists the date she opened the account in 1968 as the date she considered these funds set aside for burial expenses.

The effective date of the exclusion is January. Her account balance in the month of application is $1,000. She receives a burial fund exclusion of $1,000 for the month of January.

The customer applied for ALTCS on November 21 st . He has a revocable burial contract valued at $200. He also has a checking account with a balance of $1,900. At his interview on December 2 nd he reports that on December 1 st he decided to use $1,700 of the money in his checking account to buy a Certificate of Deposit to help cover his burial expenses. He completes the DE-157 and states that December 1 st is the date he set aside the funds for burial.

Since he already has a revocable burial contract worth $200, the available burial fund exclusion is $1,300 ($1,500 - the $200 revocable burial contract). $1,300 of the CD balance is excluded as a designated burial fund beginning with the budget month of December. The remaining $400 is a counted resource.

The customer designated her savings account as her burial fund at her interview on November 8. She has no other burial-related resources.

The opening account balance on November 1st was $1,000. Interest in the amount of $0.33 was posted to the savings account on November 23rd. The burial fund exclusion is $1,000.33 because the interest was paid in the month of designation. The savings account is an excluded burial fund beginning with the budget month of November.

The customer applied in February and has a single revocable burial contract worth $4,500.00 that he purchased two years before. Because the resource includes only burial-related resources, it does not have to be separated to allow the Burial Fund Exclusion.

The contract lists $2,500 in burial services and $2,000 in burial plot item. The full $2,000 for the burial plot items are excluded if separately listed and value given. $1,500 of the contracted burial services is excluded as a burial fund. The remaining $1,000 is a counted resource. Since the funds were designated by title before the application date and do not need to be separated, the exclusions begin with the application month.

The customer applies in May. She has a bank account of $1,200. She states that $500 of the funds in the account is designated for burial, and the remaining $700 is for living expenses. Since the funds designated for burial expenses are kept in the same account as funds that are not related to burial, the $500 cannot be excluded as a burial fund. If customer moves the $500 to a separate account, the exclusion may be given the month the funds are separated.

The customer applied and was approved in May. At the time he applied, he had a bank account for burial expense funds that he designated by title in 2006. The value of the fund in the application month was $2,102. The burial fund exclusion was $1,500 and the remaining $602 is a counted resource. The fund as a whole earns about $0.30 per month, which the customer leaves in the account. All of the interest earned since May is excluded, even though part of it was generated by the original $602 that is counted.

The customer has an excluded burial fund that was valued at $1,485 in April 2009 when the exclusion began. In December of the current year he gets a lump sum payment and is over income. Some of the lump sum payment is not spent, and he customer is over the resource limit in January and February. In March, his resources are again under the limit and his eligibility is no longer suspended. Because his eligibility was suspended and not ended, the value of his excluded burial fund remains unchanged at $1,485 and the interest earned since April 2009 left in the account is also still excluded.

NOTE If the customer had used $50 of the burial fund to buy groceries in December, the exclusion would have ended effective January. The customer would have to re-designate the funds in the account all over again at the current value.

The customer has designated a bank account of $1,000 as a burial fund, and received a Burial Fund Exclusion of $1,000. Two years later, the customer wants to add to her burial account. Even though her burial account balance is now $1,050 due to accumulated interest, she may add up to $500 to the account (the difference between the original designated amount and the maximum of $1,500).

Programs Manual Section ALTCS MA705K

The customer and his wife own a life estate interest in property. The customer is residing in a Nursing Facility and his wife uses the life estate property as her principal place of residence. The value of the life estate is excluded as a Home Property because the customer’s spouse uses the life estate property as her home property.

The customer lived in an apartment for years, until he was placed in a nursing facility. After entering the nursing facility, he used $20,000 of his savings to buy a life estate interest in his son’s home.

Since the customer did not live in the son’s home before he was institutionalized, the life estate is not excluded as home property.

The customer was living in her daughter’s home, but had to enter a nursing facility. After entering the nursing facility, she used $19,000 of her savings to buy a life interest in her daughter’s home.

Even though the customer lived in the home before entering the nursing facility, the life estate is not excluded as home property because she did not have an ownership interest in her daughter’s home before she was institutionalized.

The customer sold his home under an installment contract. The contract has a principal balance of $75,000 as of July 1st. On July 10th the buyer makes a principal payment of $5,000 to the customer.

As of October 31st, the customer has used only $4,000 of the July payment in connection with purchasing of a new home. The unused $1,000 principal payment AND the remaining principle balance of the installment contract ($70,000) are counted as resources effective November 1 st .

A customer’s home property is titled to a revocable trust. The current market value for the property is $309,000. The customer owes $135,500 on the home’s mortgage. $309,000-$135,500= $173,500. The countable equity value for the home property in the trust is $173,500.

Programs Manual Section ALTCS MA705S

The customer and her spouse have a small commercial fishing business. They own a commercial fishing permit granted by the State Commerce Commission, a boat, and fishing tackle. They have been in business since 2002. The Arizona Corporation Commission records show incorporation in 2003. The customer also provided a copy of their most recent business bank statement for proof of income. The bank statement supports the customer’s statement that the property is currently in use. Since this is a valid trade or business, the boat, tackle and permit are all excluded as essential to self-support.

The customer owns a mobile home that he rents out and a small vacant lot that he rents out for event parking. The mobile home has an equity value of $6,100 and produces net annual rental income of $1,000. The vacant lot has an equity value of $4,000 and produces net annual rental income of $120. Each property’s rate of return is calculated separately, as shown below:

Mobile Home – Net annual income of $1,000 divided by $6,100 = 16.3% rate of return. Since the mobile home produces more than a 6% return, $6,000 of its equity value is excluded. The remaining $100 is counted.

Vacant Lot – Net annual income of $120 divided by $4,000 = 3% rate of return. Since the vacant lot produces less than a 6% return, its equity value of $4,000 is counted.

The customer owns an apartment complex with multiple units on the same property. The customer does not actively manage or maintain the property. The apartment complex has a property value of $200,000.

The customer receives $30,000 per year from the apartments. The customer has the following expenses related to the apartment: $2,500 a year in property taxes, and $2,500 a year for insurance.

After expenses are accounted for, the customer’s net income from the apartments is $25,000. Net annual income of $25,000 divided by $200,000 = 12.5% rate of return. The equity value of the property is reduced by $6,000.

Customer owns property with an equity value of $75,000. The customer has an outstanding agreement with a mining company that they may use the property for mining purposes. This mining company pays the customer $6,000 per year. Net annual income of $6,000 divided by $75,000 = 8% rate of return. This property’s equity value is reduced by $6,000.

A farmer has a 4-acre lot 5 miles from his house. He raises 3 cows and a garden every year. He sells two of the cows for $700 each and butchers the remaining cow for personal use. He sells the vegetables once he fills his personal freezers. He makes $1,200 from selling vegetables. The earnings are reviewed as self-employment income. Since this property is used to produce goods or services for the daily needs of the customer, $6,000 is deducted from the equity value of the property.

Programs Manual Section ALTCS MA705X

The customer gives a stock certificate that shows they own 33 shares of Company X. A search of Yahoo Finance for Cryptocurrencies shows the current share price of Company X has a value of $10.50. The resource value is $346.50 (33 shares x $10.50 Share Price).

The customer owns shares of a non-publicly traded stock. The customer gives the stock certificate as proof of ownership. The customer also gives a letter from the accounting department with an estimate of the value of the stock, a detailed explanation of the valuation, and the accounting department managers contact information. The letter from the accounting department is accepted as proof of the resource value.

The customer has a brokerage account. The account statement shows the customers holdings, including the share price and number of shares held. The most recent account statement is accepted as proof of the resource value.

The customer gives an account statement showing they own 40.25 ‘Virtua Coins’ which can be exchanged for US Dollars. The account statement shows the share price, number of shares held, and the value. The most recent account statement is accepted as proof of the resource value.

The customer gives an account statement showing they own an account with multiple digital assets. The customer gives an account statement that shows how much of each currency is owned as proof. Each currency is convertible to USD at various exchange rates. The customer holds 3 different digital assets in the amount of: 26.35 Virtua Coins, 82 Zebra Dollars, and 1032.5 Litle Coins. Each currency is calculated individually using information found on Yahoo Finance for Cryptocurrencies. The account value is then totaled from the resource value of all the currencies held.

Resource 'Currency Amount' x 'Exchange Price per Unit' Resource Value Virtua Coins 26.35 x $10.00 = $263.50 Zebra Dollars 82 x $75.00 = $6,150.00 Litle Coins 1032.5 x $0.32 = $330.40 TOTAL = $6,743.90

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Programs Manual Section ALTCS MA705I

The customer is listed on an account with her daughter. The daughter provided a written statement saying the account belongs to her and she makes all the deposits and withdrawals. Her mother was added to the account in case the daughter needed help during an emergency. The customer provided a written statement saying the account is not hers, her money goes into her own account, and she is removing her name. She provided her bank statement to show where her money is deposited. The daughter provided a recent bank statement showing that the customer’s name has been removed from the account. The checking account is no longer a resource to the customer.

The customer is listed on an account with her daughter. The daughter provided a written statement saying the account belongs to her and she makes all the deposits and withdrawals. No bank statements were provided. The customer did not provide a written statement or proof of where her money is deposited. The checking account is counted as a resource to the customer.

Programs Manual Section ALTCS MA705R

An ALTCS customer has a property agreement with his cousin. The terms of the contract are as follows:

The customer’s cousin must pay $1,300 each month to pay the balance of $150,000 in exchange for the customer’s property.

There is no interest on the amount owed.

The contract does not state that it is non-negotiable.

According to the payment schedule, $125,000 is still owed on the property agreement at the time of application. Since the property agreement does not clearly state that it is non-negotiable, the remaining principal balance of $125,000 is a countable resource to the customer. The $1,300 payments made to the customer are counted as a resource and not counted as income.

An ALTCS customer has a promissory note with her grandson. The terms of the promissory note are as follows:

The customer gave her grandson $50,000 to help him buy his new home.

Her grandson will pay $1,500 each month until the balance is paid.

The agreement clearly states that it is non-negotiable.

The customer’s grandson owes $15,000 on the note at the time of application. Since the note is clearly identified as non-negotiable, it is a transfer. The customer got $35,000 as compensation, so the remaining $15,000 is uncompensated.

In the same month as her application, a customer entered a loan agreement with her friend. The terms of the agreement are as follows:

The customer got $10,000 cash from her friend to help pay for medical costs

The customer will pay $500 a month to her friend until the loan is repaid

The contact does not state that it is non-negotiable.

The $10,000 the customer gets from the loan is not counted as income in the month received. Any amount remaining from the loan is counted as a resource in the month after the month she receives the money. The negotiability of the agreement does not affect treatment when the customer is the borrower.

Programs Manual Section ALTCS MA707

The customer applies for ALTCS in July. The customer is eligible for ALTCS beginning July 1st. The customer is ineligible for August due to receipt of annually received income, but is eligible again in September. The 12-month count begins July 1st and ends on June 30st of the following year. The ineligible month (August) has no effect on the 12-month count.

Programs Manual Section ALTCS MA707

The customer applies for ALTCS on March 3rd. The couple’s CSRD is $32,000. Initial rules are applied and the customer is approved for ALTCS effective March 1st.

In August of the same year, the customer’s wife inherits $30,000 from her sister’s estate. She reports the inheritance and also proves that the other spousal transfers have been completed. The resources in the customer’s name are now $1,500 and his wife has $60,000. Using initial rules, the couple’s combined resources now total $61,500. Since the CSRD is only $32,000 the customer is now over resources under initial rules. However using post-initial rules, the customer’s resources are under the $2,000 limit and he is eligible. The initial period is ended early and the customer remains eligible.

Programs Manual Section ALTCS MA707.4

The standards at MA707.2 are used in the CSRD calculation process.

The calculated CSRA is $30,000, and the spousal share is $15,000.

Spousal share = $15,000 Lesser of $15,000 or $162,660 = $15,000 Greater of $15,000 or $32,532 = $32,532 CSRD = $32,532

The customer qualifies for the minimum CSRD.

The calculated CSRA is $350,000, and the spousal share is $175,000.

Spousal Share = $175,000 Lesser of $175,000 or $162,660 = $162,660 Greater of $162,660 or $32,532 = $162,660 CSRD = $162,660

The customer qualifies for the maximum CSRD.

The calculated CSRA is $96,000, and the spousal share is $48,000.

Spousal share = $48,000 Lesser of $48,000 or $162,660 = $48,000 Greater of $48,000 or $32,532 = $48,000 CSRD = $48,000

The customer qualifies for a CSRD between the minimum and maximum amounts.

The customer entered a nursing facility on March 3, 1999 and applied for ALTCS benefits on August 15, 1999. The FCPI was established as March 1999.

The couple’s countable resources in March 1999 totaled $180,000 and the spousal share was $90,000. The customer qualified for the 1999 maximum CSRD of $81,960. The customer's resources were over the limit and the ALTCS application was denied.

The customer reapplied for ALTCS on February 6, 2026. The $90,000 spousal share determined for the 1999 resource assessment is now compared to the 2026 CSRD limits. Because the maximum CSRD in 2026 is $162,660, the entire spousal share of $90,000 is the new CSRD amount.

The customer requests a resource assessment on July 17. The FCPI is determined to be June of that year. The CSRA is completed and the spousal share is calculated to be $40,000.

On December 5, the customer applies for ALTCS. The customer’s counted resources in December include a $10,000 Certificate of Deposit (CD) that the customer owned and did not report when the CSRD was calculated in June. The CSRD is re-calculated for June and is determined to be $45,000.

Programs Manual Section ALTCS MA707

The customer and his spouse applied for ALTCS on December 6 and are intending to receive HCBS. The customer lived in a nursing facility from April 5 through May 10 of the previous year and his spouse lived in a nursing facility from October 7 through November 12 of the current year. Neither spouse has any earlier periods of institutionalization.

The customer’s FCPI began April of the previous year and his spouse’s FCPI began October of the current year. If a resource assessment is needed, it would be completed as of April for the customer and as of October for his spouse.

Programs Manual Section ALTCS MA707.8

The customer applies for ALTCS on December 5th. The CSRD is calculated to be $30,000. In December, the customer’s counted resources are $22,000, and her husband’s counted resources are $13,000. Resources are determined as follows:

The customer’s resources in December $22,000 The Community Spouse’s resources in December + $13,000 Total counted resources = $35,000 Community Spouse Resource Deduction (CSRD) - $30,000 Total considered resources = $5,000

The total counted resources are more than the resource limit of $2,000, and the customer is not eligible for ALTCS.

The customer’s initial rules period is ending and her eligibility is being redetermined. The couple has completed the spousal transfers, and only a bank account with $700 remains in the customer’s name.

The total counted resources of $700 are less than the resource limit of $2,000, and the customer remains eligible for ALTCS.

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Programs Manual Section ALTCS MA802

The customer owns a revocable trust. She gets $1,200.00 in Social Security income each month, which is direct-deposited into the trust account. In the month that the customer applies for ALTCS, the trustee takes $1,100.00 out of the trust account and gives it to the customer.

The $1,200.00 that went into the trust is higher than the $1,100.00 paid out from the trust. The full $1,200.00 is counted when determining income eligibility and share of cost.

The customer and his wife jointly own a revocable trust. Every month the customer’s $1,500.00 Social Security benefit and his wife’s $300.00 pension payment are direct-deposited to the revocable trust account. The trustee takes $2,000.00 out of the trust account and gives it to the couple. The $2,000.00 paid out from the trust is higher than the $1,800.00 that went into the trust. The $2,000.00 paid out from the trust is counted when determining income eligibility and share of cost.

The customer and her husband jointly own an irrevocable trust. The customer gets $1,200.00 Social Security income per month. The customer’s husband gets $500.00 in military retirement pay. Both the Social Security and the military retirement pay are direct-deposited into the trust account.

In the month that the customer applies for ALTCS, the trustee takes $500.00 out of the trust account to pay the couple’s expenses. The total of all income that went into the trust is higher than the amount paid out. The income assigned to the trust is counted when determining income eligibility and share of cost.

Programs Manual Section ALTCS MA802

The customer created a trust on 8/31/2003. The trust was initially funded with $2,000.00 from the customer, $1,000.00 from the customer's spouse, and $1,000.00 from the customer's brother. No other money was ever added to the trust. The total amount of money in the trust is $4,000.00. The customer and spouse own $3,000.00 between the two of them.

$3,000.00 divided by $4,000.00 equals 0.75. The customer’s ownership percentage in the trust is 75%.

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Programs Manual Section ALTCS MA803E

The customer receives a total of $3,500.00 per month from two pensions. Both pensions are assigned to an income only trust. In 2026, the customer’s share of cost (SOC) is $3,350.90 and his personal needs allowance (PNA) is $149.10.

The trustee pays the SOC from the trust directly to the nursing facility and writes a check to the customer for the PNA. There are no other payments made from the trust.

The SOC payment is not counted as income, but the $149.10 paid to the customer for his personal needs is counted. The customer’s total counted income is $149.10.

The customer receives $2,100.00 from Social Security and $1,000.00 from a pension. Both the Social Security and the pension are assigned to her Income-Only Trust. In 2026, her SOC is $118.00, and her PNA $2,982.00. There are no other payments made from the trust.

The SOC payment is not counted as income, but the $2,982.00 paid to the customer for her personal needs is counted. The customer’s total counted income is $2,982.00.

The customer is an eight-year-old child living at home with his parents. He does not receive any income of his own. In the past he received a large injury settlement, which was put into a Trust for People Under Age 65 with a Disability. The trustee expects to issue the following payments every month:

$15.00 to the customer for spending money;

$100.00 to the grocer for his special food;

$150.00 to medical providers for medical supplies;

$200.00 to the insurance company to insure the specially equipped van, which is owned by the trust; and

$100.00 to the trustee for fees related to administering the trust.

Since only payments for shelter or payments made directly to the customer are counted as income when determining ALTCS eligibility, the customer’s total counted income is $15.00.

The customer lives in a nursing facility and has a trust for a person under age 65 with a disability. The only income source is $680 per month in Social Security benefits. The Social Security income is not assigned to the trust.

The trustee expects to issue two payments each month:

$50.00 paid to the grocery store for special foods for the customer; and

$125.00 paid to the pharmacy for prescriptions, personal care items, and sanitary wipes.

The customer’s total counted income is $680.00 from Social Security.

Programs Manual Section ALTCS MA803E

The customer lives at home and has two sources of income. His Social Security benefit of $2,100.00 is assigned to his Income-Only Trust. His pension of $700.00 is paid directly to him, and is not part of the trust. Both the Social Security and the pension are counted to determine his Share of Cost.

The customer lives in a nursing facility and has a Trust for a Person Under Age 65 with a Disability. The trust funds are in a brokerage account, and earn $300.00 each month in interest.

The customer receives monthly income from an annuity and from her Social Security benefits. The annuity payment is $1,600.00, and is deposited directly into the trust. The Social Security benefit is $2,000.00 per month, and is paid directly to her.

The interest earned by the trust is not counted for eligibility or Share of Cost. The customer’s income from both the annuity and Social Security are counted when determining Share of Cost.

Programs Manual Section ALTCS MA803E

These examples are divided by customer situations. In general, the following information applies to every DE-312:

List ALL 12 months starting with the current month at the time the form is filled out . The row must show the month AND year. For example, “04/2020” or “April 2020” would be acceptable. Writing “April” without the year is not acceptable.

When amounts do not change from month to month, they must be written in the appropriate space for each month. For example, when a customer pays $100.00 per month in legal fees, “100.00” will be in the space for legal fees for all 12 months. Writing “100.00” and drawing an arrow or line through the following months is not acceptable.

When there is income assigned to the trust that is counted in the Share of Cost (SOC) calculation, the SOC must be paid from the trust income.

Focus on the money going into and coming out of the trust: Income that is not assigned to the trust should not appear on this form. Any disbursement that is automatically deducted from income that is not assigned to the trust should not appear on this form.

The customer is applying for ALTCS in June 2020. She has a special treatment trust which requires a completed Special Treatment Trust Anticipated Disbursements Form (DE-312). She has $1,500.00 in countable income that is not assigned to the trust. She lives at home and does not have a share of cost.

The only thing titled to the trust is a financial account with $500,000.00 from a legal settlement.

The customer is requesting the following disbursements:

$100.00 per month in legal fees for the attorney handling the trust

$200.00 per month for personal care services from an AHCCCS-registered provider

$500.00 per month for rent

A one-time disbursement of $750.00 for the purchase of a prepaid burial plan funded by an irrevocable life insurance policy, to be purchased in August 2020

All the requested disbursements are considered allowable disbursements. Since the $500.00 is for shelter, it is counted in the income determination. Her total countable income, including income outside the trust, would be $2,000.00. The other requested disbursements are not counted as income.

The DE-312 should be completed as follows:

Month: Amounts Provided by Benefits and Eligibility Specialist 06/2020 07/2020 08/2020 09/2020 10/2020 11/2020 Income Assigned to the Trust: The ALTCS Share of Cost (SOC): Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees 100.00 100.00 100.00 100.00 100.00 100.00 Medical Insurance: Medical Expenses: 200.00 200.00 200.00 200.00 200.00 200.00 Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* 500.00 500.00 500.00 500.00 500.00 500.00 Pre-Paid Burial Expenses:(See back page) 750.00 Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 800.00 800.00 1550.00 800.00 800.00 800.00

Month: Amounts Provided by Benefits and Eligibility Specialist 12/2020 01/2021 02/2021 03/2021 04/2021 05/2021 Income Assigned to the Trust: The ALTCS Share of Cost (SOC): Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees 100.00 100.00 100.00 100.00 100.00 100.00 Medical Insurance: Medical Expenses: 200.00 200.00 200.00 200.00 200.00 200.00 Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* 500.00 500.00 500.00 500.00 500.00 500.00 Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 800.00 800.00 800.00 800.00 800.00 800.00

The customer is applying for ALTCS in March 2020. He has a special treatment trust which requires a completed Special Treatment Trust Anticipated Disbursements Form (DE-312).

The customer:

Lives in an assisted living home;

Gets $1,000.00 per month in Social Security income and $2,000.00 per month from a pension; and

Pays $144.60 for Medicare Part B and $200.00 per month for other health insurance.

If he is approved for ALTCS, his SOC before the Medicare Buy-in occurs will be $306.40 . His SOC after the Medicare buy-in will be $451.00 .

His Social Security income is assigned to the trust. The trust is also funded with a financial account with $20,000.00.

The customer is requesting the following disbursements:

$75.00 per month in legal fees for the attorney handling the trust

$144.60 for Medicare Part B

$200.00 per month for his health insurance

$200.00 per month for his visits to the chiropractor that is not covered by insurance

All the requested disbursements are considered allowable disbursements. None of the requested disbursements are counted as income. Since the customer has a SOC and the income assigned to the trust is counted for the SOC determination, the SOC must be paid from the trust income.

The DE-312 should be completed as follows:

Month: Amounts Provided by Benefits and Eligibility Specialist 03/2020 04/2020 05/2020 06/2020 07/2020 08/2020 Income Assigned to the Trust: 1000.00 1000.00 1000.00 1000.00 1000.00 1000.00 The ALTCS Share of Cost (SOC): 306.40 306.40 306.40 306.40 451.00 451.00 451.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees 75.00 75.00 75.00 75.00 75.00 75.00 Medical Insurance: 344.60 344.60 344.60 200.00 200.00 200.00 Medical Expenses: 200.00 200.00 200.00 200.00 200.00 200.00 Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 926.00 926.00 926.00 926.00 926.00 926.00

Month: Amounts Provided by Benefits and Eligibility Specialist 9/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 1000.00 1000.00 1000.00 1000.00 1000.00 1000.00 The ALTCS Share of Cost (SOC): 451.00 451.00 451.00 451.00 451.00 451.00 451.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees 75.00 75.00 75.00 75.00 75.00 75.00 Medical Insurance: 200.00 200.00 200.00 200.00 200.00 200.00 Medical Expenses: 200.00 200.00 200.00 200.00 200.00 200.00 Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 926.00 926.00 926.00 926.00 926.00 926.00

Programs Manual Section ALTCS MA803E

These examples are divided by customer situations. In general, the following information applies to every DE-313:

List ALL 12 months starting with the current month at the time the form is filled out . The row must show the month AND year. For example, 04/2020; or April 2020, would be acceptable. Writing “April” without the year is not acceptable.

When amounts do not change from month to month, they must be written in the appropriate space for each month. For example, when a customer pays $100.00 per month in health insurance, “100.00” will be in the space for health insurance for all 12 months. Writing “100.00” and drawing an arrow or line through the following months is not acceptable.

The amount of total disbursements should not be greater than the amount of income assigned to the trust.

When there is income assigned to the trust that is counted in the Share of Cost (SOC) calculation, the SOC must be paid from the trust income.

Focus on the money going into and coming out of the trust: Income that is not assigned to the trust should not appear on this form. Any disbursement that is automatically deducted from income that is not assigned to the trust should not appear on this form.

The customer is applying for ALTCS in March 2020. He has an income-only trust.

The customer:

Lives in an assisted living home;

Gets $1,000.00 per month in Social Security income and $2,000.00 per month from a pension. Both incomes are assigned to the income-only trust; and

Pays $144.60 for Medicare Part B and $200.00 per month for other health insurance.

If he is approved for ALTCS, his SOC before the Medicare Buy-in occurs will be $306.40 . His SOC after the Medicare buy-in will be $451.00.

The DE-313 should be completed as follows:

Month: Amounts Provided by Benefits and Eligibility Specialist 03/2020 04/2020 05/2020 06/2020 07/2020 08/2020 Income Assigned to the Trust: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 The ALTCS Share of Cost (SOC): 306.40 306.40 306.40 306.40 451.00 451.00 451.00 Personal Needs Allowance:* 2349.00 2349.00 2349.00 2349.00 2349.00 2349.00 2349.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: 344.60 344.60 344.60 344.60 200.00 200.00 200.00 Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00

Month: Amounts Provided by Benefits and Eligibility Specialist 09/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 The ALTCS Share of Cost (SOC): 451.00 451.00 451.00 451.00 451.00 451.00 451.00 Personal Needs Allowance:* 2349.00 2349.00 2349.00 2349.00 2349.00 2349.00 2349.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: 200.00 200.00 200.00 200.00 200.00 200.00 200.00 Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00

The customer is applying for ALTCS in March 2020. She has an income-only trust.

The customer:

Lives in an assisted living home;

Gets $4,000.00 per month in annuity income that is assigned to the trust;

Gets $1,000.00 per month from Social Security that is NOT assigned to the trust; and

Pays $144.60 for Medicare Part B and $100.00 for a Medicare supplement plan. Both payments are automatically deducted from the customer’s Social Security payment.

If she is approved for ALTCS, her SOC before the Medicare Buy-in occurs will be $2,406.40 . Her SOC after the Medicare buy-in will be $2,551.00 .

Since the deductions for Medicare Part B and the supplemental plan are deducted from an income that is outside of the trust, the health insurance premiums should not appear on the form.

The DE-313 should be completed as follows:

NOTE The income outside the trust ($1,000.00) plus the countable Personal Needs Allowance disbursement ($1,349.00) equals $2,349.00, which is the income limit for 2020. Any additional countable disbursements would put the customer over the income limit. If the trustee wanted to disburse the $244.60 left over in the trust in March 2020, the disbursement would have to be a type of disbursement that is not countable, such as legal or professional expenses.

Month: Amounts Provided by Benefits and Eligibility Specialist 03/2020 04/2020 05/2020 06/2020 07/2020 08/2020 Income Assigned to the Trust: 4000.00 4000.00 4000.00 4000.00 4000.00 4000.00 4000.00 The ALTCS Share of Cost (SOC): 2406.40 2406.40 2406.40 2406.40 2551.00 2551.00 2551.00 Personal Needs Allowance:* 1349.00 1349.00 1349.00 1349.00 1349.00 1349.00 1349.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 3755.40 3755.40 3755.40 3755.40 3900.00 3900.00 3900.00

Month: Amounts Provided by Benefits and Eligibility Specialist 09/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 4000.00 4000.00 4000.00 4000.00 4000.00 4000.00 4000.00 The ALTCS Share of Cost (SOC): 2551.00 2551.00 2551.00 2551.00 2551.00 2551.00 2551.00 Personal Needs Allowance:* 1349.00 1349.00 1349.00 1349.00 1349.00 1349.00 1349.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 3900.00 3900.00 3900.00 3900.00 3900.00 3900.00 3900.00

3) The customer has all income assigned to the trust and lives in a long-term care medical institution

The customer is applying for ALTCS in March 2020. He has an income-only trust.

The customer:

Lives in a nursing facility;

Gets $1,000.00 per month in Social Security income and $2,000.00 per month from a pension. Both incomes are assigned to the income-only trust; and

Pays $144.60 for Medicare Part B and $200.00 per month for other health insurance.

If he is approved for ALTCS, his SOC before the Medicare Buy-in occurs will be $2,537.95 . His SOC after the Medicare buy-in will be $2,682.55 .

The DE-313 should be completed as follows:

Month: Amounts Provided by Benefits and Eligibility Specialist 03/2020 04/2020 05/2020 06/2020 07/2020 08/2020 Income Assigned to the Trust: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 The ALTCS Share of Cost (SOC): 2537.95 2537.95 2537.95 2537.95 2682.55 2682.55 2682.55 Personal Needs Allowance:* 117.45 117.45 117.45 117.45 117.45 117.45 117.45 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: 344.60 344.60 344.60 344.60 200.00 200.00 200.00 Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00

Month: Amounts Provided by Benefits and Eligibility Specialist 09/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 The ALTCS Share of Cost (SOC): 2682.55 2682.55 2682.55 2682.55 2682.55 2682.55 2682.55 Personal Needs Allowance:* 117.45 117.45 117.45 117.45 117.45 117.45 117.45 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: 200.00 200.00 200.00 200.00 200.00 200.00 200.00 Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00

4) The customer has income both inside and outside the Income-Only Trust and lives in a long-term care medical institution

The customer is applying for ALTCS in March 2020. She has an income-only trust.

The customer:

Lives in a nursing facility;

Gets $2,000.00 per month in annuity income that is assigned to the trust;

Gets $800.00 per month from Social Security that is NOT assigned to the trust; and

Pays $144.60 for Medicare Part B which is automatically deducted from the customer’s Social Security payment.

If she is approved for ALTCS, her SOC before the Medicare Buy-in occurs will be $2,537.95 . Her SOC after the Medicare buy-in will be $2,682.55.

Since the SOC amount is greater than the amount going into the trust, the only allowable disbursement will be for the SOC. The SOC must be paid from the income going into the trust. The remaining amount due for the SOC will have to be paid from the customer’s income outside the trust.

The DE-313 should be completed as follows:

Month: Amounts Provided by Benefits and Eligibility Specialist 03/2020 04/2020 05/2020 06/2020 07/2020 08/2020 Income Assigned to the Trust: 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 The ALTCS Share of Cost (SOC): 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 Personal Needs Allowance:* Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00

Month: Amounts Provided by Benefits and Eligibility Specialist 09/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 The ALTCS Share of Cost (SOC): 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 Personal Needs Allowance:* Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: Medical Expenses: Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00

Programs Manual Section ALTCS MA803E

The customer has Arizona Long Term Care System (ALTCS) benefits and has a special treatment trust. His rent is $1500 a month and he has two roommates. He wants to disburse $1500 a month to pay rent.

Only the customer’s share of the expense may be paid from the trust. $1500/3 people in the home= $500 per person. Only $500 is allowed to be disbursed from the trust.

The customer has Arizona Long Term Care System (ALTCS) benefits and has a trust for people under age 65 with a disability. She owns her home, but it is not titled to the trust. She requests a one-time disbursement for a full kitchen remodel. The remodel of the kitchen is cosmetic and is not needed for her to be able to use it.

Since the home is not titled to the trust, the one-time trust disbursement would not be approved.

The customer has Arizona Long Term Care System (ALTCS) benefits and has a Pooled trust. The trustee submits a one-time disbursement request for the following expenses:

Airfare for the customer, his caregiver, and his best friend to travel to Florida;

Hotel stay for 3 days; and

Tickets for the customer, his caregiver, and best friend to go to an amusement park.

Disbursements for vacations are allowable as entertainment expenses. However, only expenses for the customer and one caregiver may be approved. Any portion of the disbursement request for the customer’s best friend would not be approved.

The customer has Arizona Long Term Care System (ALTCS) benefits and has a trust for people under age 65 with a disability. She has a trustee for her trust. The trustee submitted a one-time disbursement request to reimburse himself for moving expenses he paid on Michelle’s behalf.

Reimbursements to trustees are not allowable disbursements from special treatment trusts. The disbursement would not be approved.

The customer has Arizona Long Term Care System (ALTCS) benefits and has a Pooled trust. He requests a one-time disbursement to pay off a credit card. Payments on past debts are not allowable trust disbursements. The disbursement would not be approved.

The customer has Arizona Long Term Care System (ALTCS) benefits and has an Income-Only Trust (IOT). She submitted a new Income-Only Trust Anticipated Disbursements (DE-313) form requesting an ongoing disbursement of $200 for health insurance. The health insurance bill shows that $50 of the payment would cover her spouse’s health insurance.

Only the customer’s portion of the health insurance premium may be disbursed from the IOT. $200-$50= $150 would be approved as an ongoing trust disbursement.

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Programs Manual Section ALTCS MA901

The customer applied for ALTCS for the first time on October 18, 2015. During the application process, it is discovered that he gave a vacation property to each of his children on their 30 th birthdays. His oldest daughter turned 30 in June 2010, and the customer transferred the title to her on June 17, 2010. His other daughter turned 30 in August 2012, and he transferred the title to the second property to her on August 3 rd , 2012.

The customer’s look back period goes back to 09/1/2010.

Since the earliest transfer to the oldest daughter happened before 10/1/2010, it is before the look-back period. The second transfer is after 10/1/2010 and must be evaluated as a transfer.

Programs Manual Section ALTCS MA901

The customer and his spouse transfer their home property to their daughter and their vacation home to their son in May 2009.

The customer applies and is approved for ALTCS in February 2010 and is assessed a penalty period of 80 months for the two transfers, beginning 02/01/2010 and ending 9/30/2016.

The customer receives ALTCS Acute for 12 months, but his eligibility is discontinued when he does not complete the renewal process in February 2011.

In October 2015, the customer reapplies for ALTCS. Because a penalty period was established by the earlier application and has not ended, the remaining penalty period of 12 months ending 9/30/2016 applies to this application, even though the transfer date is before the look-back date for his new application in 10/2015.

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Programs Manual Section ALTCS MA902

The customer invested in a ROTH IRA while he was working.

It was converted to an irrevocable annuity when he retired in August and named AHCCCS as the beneficiary.

Since the annuity meets the conditions of naming AHCCCS as the primary beneficiary and was created using funds in a ROTH IRA, the annuity is considered a compensated transfer.

The community spouse used $126,500 of the couple’s resources to purchase a 9-year period-certain immediate annuity from a life insurance company. The community spouse is the annuitant. The annuity names AHCCCS as the beneficiary in the position after the institutionalized spouse.

The community spouse was 74-years-old on the date the annuity was purchased and according to the SSA Period Life Table had a life expectancy of 9.75 years or 117 months.

The annuity will issue regular monthly checks of $1,488.75 for a set period of 9 years or 108 total months. The insurance company will pay out a total of $160,785.00 over the period of the annuity contract.

Since the annuity meets all of the following requirements, it is a compensated transfer:

Names AHCCCS as the beneficiary;

Purchased from a life insurance company;

Issuing regular monthly payments; and

Will provide for full return of principal and interest during the community spouse’s life expectancy.

Programs Manual Section ALTCS MA902

The customer applied for ALTCS and used $20,000 of his resources to purchase an immediate annuity from the ABC Insurance Company. The annuity does not name AHCCCS as the primary beneficiary.

The contract date is 9/15 and the first payment will be issued on 10/15.

The annuity will issue payments of $200 per month for 10 years in 120 monthly payments. This would result in a return of $24,000 over the period of the contract.

The customer is currently 79-years-old and has a life expectancy of 7.40 years or 88.8 months. At $200 per month, the contract will pay out $17,600 over the customer’s life expectancy.

In this example, the annuity was purchased from a life insurance company, will issue regular monthly payments and is currently issuing payments.

However, the annuity does not meet the requirements to name AHCCCS as the primary beneficiary and does not provide for full return of principal and interest during the customer’s life expectancy. The full purchase price of the annuity is a transfer with uncompensated value.

Programs Manual Section ALTCS MA902

The customer borrowed $25,000 from his sister in April two years ago. They had an oral loan agreement that the customer would pay back the full amount in 10 monthly installments of $2,500 beginning that May.

The customer missed a few payments and still owed his sister $7,500 that he paid her this month, after the oral agreement was no longer valid because a year had already passed since the oral agreement.

The $7,500 the customer repaid his sister after the loan was no longer valid is considered a transfer with uncompensated value.

Programs Manual Section ALTCS MA902

The customer receives $1,600 in monthly income that is assigned to his IOT. The trustee issues $1,500 for the benefit of the customer. The $100 that was not disbursed is considered a transfer.

Programs Manual Section ALTCS MA902

The customer has a revocable trust with a corpus of $300,000. Under the terms of the revocable trust, the Trustee has complete discretion in disbursing funds from the trust. Each month the Trustee disburses $100 to the customer as an allowance and $500 to a property management firm for the upkeep of the customer’s home from the income earned by the trust.

On June 15, 2015, the Trustee gives $250,000 from the trust corpus to the customer’s brother. In September 2015, the customer applies for ALTCS benefits and is approved.

The $250,000 from the trust was given away by the trustee within the 60-month look-back period, and is evaluated as a transfer with uncompensated value and a transfer penalty is imposed, beginning September 1, 2015.

NOTE Since the trust is revocable, the entire remaining value of the corpus is a counted resource. In this case the remaining $50,000 is counted. The $100 personal allowance and the $500 for upkeep of the home property are treated as counted income since they are being paid from the trust income.

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Programs Manual Section ALTCS MA902

The customer established an irrevocable trust with a corpus of $300,000 on March 1, 2009. He enters a nursing facility on August 15, 2015, and applies for ALTCS benefits that month.

On January 15, 2010, the Trustee gave $100,000 from the trust corpus to the customer’s brother.

Under the terms of the irrevocable trust, the Trustee has complete discretion to disburse the entire trust corpus and all income from the trust to anyone, including the customer. Each month the Trustee disburses $100 to the customer as an allowance and $500 to a property management firm for the upkeep of the customer’s home. This money comes from interest earned by the trust corpus.

The $100,000 gift to the customer’s brother is evaluated as a transfer with uncompensated value. However, the transfer was made before the look-back period begin date of 8/1/2010, and a transfer penalty period is not imposed.

NOTE Since the trustee has discretion to disburse the entire trust corpus to the customer, the entire remaining value of the corpus is a counted resource. In this case the remaining $200,000 is counted. The $100 personal allowance and the $500 for upkeep of the home property are treated as counted income since they are being paid from the trust income.

The customer established an irrevocable trust with a corpus of $350,000 on April 15, 2012. He enters a nursing facility on November 15, 2015, and applies for ALTCS benefits that month.

On January 15, 2015, the Trustee gave $100,000 from the trust corpus to the customer’s brother.

Under the terms of the irrevocable trust, the Trustee cannot disburse any of the trust corpus to the customer. The trust terms do allow the Trustee to make disbursements to the customer from the trust income. Each month the Trustee disburses $100 to the customer as an allowance and $200 for the customer’s car payment.

Since none of the corpus can be disbursed to the customer, the entire value of the trust corpus at the time it became irrevocable is evaluated as a transfer with uncompensated value. The date of the transfer into the trust is within 60-month look-back period. An uncompensated transfer of $350,000 occurred on 4/15/2012. The fact that $100,000 of those funds was later transferred out of the trust to the customer’s brother does not change the amount of the transfer on which the penalty is based. That amount remains $350,000.

NOTE The $100 and $200 disbursed from the trust earnings count as unearned income to the customer.

Programs Manual Section ALTCS MA903

The customer is listed as a joint owner on his son’s bank account. The customer rebuts ownership of the account and provides evidence to prove that only his son’s money is in the account. As part of the successful rebuttal of account ownership ( MA705I ), the customer removes his name from the bank account.

The customer’s eligibility for ALTCS is not affected by removing his name from the account. The account did not include any of the customer’s resources.

The customer, co-signed a car loan for her niece. The customer’s name is listed on the title and the loan documents. The niece provides proof that she made all of the payments for the car loan, as well as the maintenance of the car. After the car was paid off, the niece gave the vehicle to charity.

Even though the customer’s name was on the title, the equity in the car belonged only to the niece ( MA704C.1 ). The vehicle was not the customer’s resource.

The customer’s bank statement showed a purchase in the amount of $2,877.32. When asked about this purchase by a Benefits and Eligibility Specialist, the customer states that he used the money to buy a new TV at a local electronics store. He purchased it for himself to replace his old TV, which was broken.

The new TV was purchased for the customer at the current market value and does not affect his eligibility for ALTCS.

The customer holds a credit card with a balance of $4,200.00. The month before she applied for ALTCS, she paid off the entire balance and closed out the credit card account.

The credit card balance was a debt owed by the customer. Repayment of the debt does not affect her eligibility for ALTCS.

Programs Manual Section ALTCS MA905

The customer gives her home to her cousin without receiving compensation. The equity value of the home is $1,000,000. If the average private pay rate at the time the customer applied for ALTCS is $4,027.61, the penalty period would be 248 months, and 8 days.

($1,000,000 / $4,027.61 = 248.28; .28 x 30 = 8.4 days; the fraction is dropped.)

Programs Manual Section ALTCS MA905

Each of the following customers transfers $35,000 with no compensation.

Customer A was first approved for ALTCS for March 2007, and lived in Yuma County at the time. The PPR used would be $4,445.00, and the penalty period would be 7.87 months, or 7 months and 26 days (.87 x 30 = 26.1 days; fraction is dropped).

Customer B was first approved for ALTCS for October 2013, and lived in Maricopa County at the time. The PPR used would be $6,648.77, and the penalty period would be 5.26 months, or 5 months and 7 days (.26 x 30 = 7.8 days; fraction is dropped).

Customer C was first approved for ALTCS for June 2014, and lived in Graham County at the time. The PPR used would be $5,595.31, and the penalty period would be 6.25 months, or 6 months and 7 days (.25 x 30 = 7.5 days; fraction is dropped).

Customer D was first approved for ALTCS for April 2010 and lived in Pinal County at the time. The customer was discontinued from ALTCS in December 2017. The customer reapplied for ALTCS for June 2020. The PPR used would be $5,942.65 (Pinal County for April 2010), and the penalty period would be 5.88 months, or 5 months and 26 days (.88 x 30 =26.4 days; fraction is dropped).

Programs Manual Section ALTCS MA905

The customer applies for ALTCS in November. He gave a piece of land to his daughter two years ago, which is within the look-back period. The customer is over income in November but is eligible and approved for December. The transfer penalty begins in December, the first approved month.

The customer was approved for ALTCS in July. In November, she gives her home property to her son. Since the customer is already on ALTCS, the transfer penalty period begins in November, the month of the transfer.

The customer applied for ALTCS in October and applied for prior quarter coverage for September. On November 10, while the application is still pending, the customer gives $15,000 cash to her nephew. On November 30, the application is approved for September, October and ongoing. The transfer penalty period begins in September, the first approved month.

The customer was approved for ALTCS Acute beginning in May, due to a transfer penalty period. The penalty period ends after 22 months in March.

The next May, his ALTCS eligibility ended because he did not complete a renewal.

In September of that year, he reapplies, and the ALTCS worker discovers that the customer sold his home property and gave the money to his children that August while he was not on ALTCS.

The customer’s penalty period from the earlier application does not end until March 31 of the next year. The new penalty period for the transfer in August begins April 1.

Programs Manual Section ALTCS MA905

The customer applied for ALTCS in October. She made the following uncompensated transfers:

$2,000 in July

$3,000 in August

$38,000 in September

October is the first month that the customer is otherwise eligible for ALTCS except for the transfer.

All transfers that were made by the customer from July through September are added together and then divided by the customer’s PPR for her county of residence to get the penalty period.

The customer in the example above is approved in November. In December, the $2,000.00 transfer is returned to the customer.

The transfer penalty period does not change. After the month in which the transfer penalty started, all transfers that were added together must be returned to the customer in order to end the transfer penalty period.

Programs Manual Section ALTCS MA905

The customer is on ALTCS when she sells her home for $60,000 . She gives one of her grandchildren $20,000 in each month from April through June.

The three consecutive transfers are added together . The penalty period begin s in April , the month of the first transfer .

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Programs Manual Section ALTCS MA905

The customer sold his home and transferred the $40,000 proceeds to his children. He transferred $10,000 per month in the months of April, May, July and August. The private pay rate for the customer’s county of residence when he was first approved for ALTCS was $5,942.65.

The $20,000 in transfers made in the consecutive months of April and May divided by $5,942.65 equals 3.36 months of ineligibility. The penalty period starts April 1 st and the partial month penalty ends in July.

Since the penalty period resulting from the consecutive months’ transfers ended in the same month the next transfer was made, all four transfers are added together. The penalty period begins in April, the month of the first transfer.

The customer transfers $5,500 in May, $5,500 in June and $2,500 in July. She later transfers $35,000 in November. The private pay rate for the customer’s county of residence when she was first approved for ALTCS was $5,942.65.

The earliest transfers made in the consecutive months of May, June and July total $13,500. Divided by $5,942.65, this equals 2.27 months. The penalty period would begin in May and end with a partial month penalty in July. Since the first penalty period would end before the month of the later transfer of $35,000, the penalty periods are calculated separately. The penalty period for the $35,000 transfer would begin in November, the month in which the transfer was made.

Programs Manual Section ALTCS MA905

The customer and her spouse gave their home to their son last March, receiving no compensation.

The customer applies for ALTCS in January. A transfer penalty period of 22 months is assessed, beginning January 1, and ending October of the next year. The customer is approved for ALTCS Acute beginning January 1.

On December 18, the customer’s spouse applies for ALTCS and is approved on January 4th. When the spouse is approved in January, there are 10 months left of the penalty period. Beginning January, the remaining 10 months of the penalty period are equally divided between the spouses. Each spouse has a penalty period of 5 months beginning January 1, and ending May 31.

One of the spouses dies in April. The remaining month of his half of the penalty period (for May) is applied to his spouse, extending her penalty period to June 30.

Programs Manual Section ALTCS MA905

The customer applies for ALTCS in March. He learns that the home he gave to his son three years ago without receiving compensation will result in a transfer penalty period of 19 months and 2 days.

He is approved for ALTCS Acute beginning March 1. To allow his father to qualify for long-term care services, the son transfers the property back to the customer in June. The penalty period ends on May 31, the last day of the month before the property was returned.

The customer applies for ALTCS in February. The customer transferred a sports car to his son in January. The transfer will result in a penalty of 13 months and 9 days.

To allow his father to qualify for long-term care services, the customer’s son transfers the title of the vehicle back to the customer. The title transfer is effective February 27.

Since the transfer penalty would have begun in February, and the vehicle was returned in the same month, no transfer penalty is applied.

The customer applies for ALTCS in June. The customer transferred her home to her brother the year before. The Benefits and Eligibility Specialist determines a transfer penalty of 7 years and 6 months, which will ends in December.

Two years later, the customer’s condition improves, and she is determined medically ineligible. Her ALTCS coverage ends.

Six years later, eight years after the initial application, in June, the customer reapplies and is eligible for ALTCS. Since the previous penalty has already ended, the customer is not penalized any further for the initial transfer. She is eligible for full ALTCS services in the application month.

The customer applies for ALTCS in July 2020. The customer transferred her mobile home to her brother in 2016. The Benefits and Eligibility Specialist determines a transfer penalty of 3 years and 6 months, which will end January 31, 2024.

The customer receives an inheritance in August 2021 that puts her over the resource limit. Her ALTCS coverage ends August 31, 2021.

In December 2023, the customer reapplies but the previous penalty period is still active. The customer is only eligible for ALTCS Acute coverage for December 2023 and January 2024. She is eligible for full ALTCS services in February 2024.

Programs Manual Section ALTCS MA905

The Private Pay Rates vary according to the county where the customer lives. Private Pay Rates are generally updated once per year in October but may be updated more frequently.

The Private Pay Rates for 10/1/1988 to present are listed below.

NOTE From 10/1/1997 to 9/30/2002, DD customers had a separate Private Pay Rate. When the DD field in the table below is blank, use the Private Pay Rate for the county the customer lived in during their first month of ALTCS eligibility.

Period DD Maricopa Pinal Pima All Other Counties 10/1/88 – 9/30/89 $1,785.90 $1,627.20 $1,739.40 $1,627.20 10/1/89 – 9/30/90 $1,972.80 $1,885.80 $1,931.40 $1,885.80 10/1/90 – 9/30/91 $1,987.20 $1,926.00 $1,965.30 $1,926.00 10/1/91 – 9/30/92 $2,178.00 $2,083.50 $2,134.80 $2,083.50 10/1/92 – 9/30/93 $2,283.00 $2,181.00 $2,238.00 $2,181.00 10/1/93 – 9/30/94 $2,406.30 $2,321.10 $2,406.30 $2,321.10 10/1/94 – 9/30/95 $2,509.50 $2,509.50 $2,509.50 $2,426.40 10/1/95 – 9/30/96 $2,651.42 $2,651.42 $2,651.42 $2,530.67 10/1/96 – 9/30/97 $2,767.92 $2,767.92 $2,767.92 $2,642.60 10/1/97 – 9/30/98 $4,608.30 $2,823.90 $2,823.90 $2,823.90 $2,688.60 10/1/98 – 3/31/00 $2,651.42 $2,943.42 $2,943.42 $2,943.42 $2,802.28 04/1/00 – 9/30/00 $2,651.42 $3,061.16 $3,061.16 $3,061.16 $2,914.37 10/1/00 – 9/30/01 $3,303.09 $3,352.91 $3,352.91 $3,352.91 $3,115.69 10/1/01 – 9/30/02 $3,303.09 $3,540.67 $3,540.67 $3,540.67 $3,290.17 10/1/02 – 9/30/03 $3,898.95 $3,898.95 $3,898.95 $3,624.18 10/1/03 – 9/30/04 $4,027.61 $4,027.61 $4,027.61 $3,743.78 10/1/04 – 9/30/05 $4,188.72 $4,188.72 $4,188.72 $3,893.53 10/1/05 – 9/30/06 $4,507.06 $4,507.06 $4,507.06 $4,189.44 10/1/06 – 9/30/07 $4,781.99 $4,781.99 $4,781.99 $4,445.00 10/1/07 – 9/30/08 $5,119.12 $5,119.12 $5,119.12 $4,758.37 10/1/08 – 9/30/09 $5,808.25 $5,808.25 $5,808.25 $5,158.40 10/1/09 – 9/30/10 $5,942.65 $5,942.65 $5,942.65 $5,321.94 10/1/10 – 9/30/11 $5,777.74 $5,777.74 $5,777.74 $5,135.38 10/1/11 – 9/30/12 $6,481.94 $6,481.94 $6,481.94 $5,688.34 10/1/12 – 9/30/13 $6,646.35 $6,646.35 $6,646.35 $5,282.23 10/1/13 – 9/30/14 $6,648.77 $6,648.77 $6,648.77 $5,595.31 10/1/14 – 9/30/16 $6,726.48 $6,726.48 $6,726.48 $5,575.29 10/1/16 – 9/30/17 $6,905.11 $6,905.11 $6,905.11 $5,667.81 10/1/17 – 9/30/18 $7,134.44 $7,134.44 $7,134.44 $6,307.74 10/1/18 – 2/28/19 $7,204.17 $7,204.17 $7,204.17 $6,334.17 3/1/19 – 9/30/19 $7,253.13 $7,253.13 $7,253.13 $6,377.20 10/1/19 – 12/31/19 $7,429.58 $7,429.58 $7,429.58 $6,592.52 1/1/2020 – 9/30/2020 $7,533.59 $7,533.59 $7,533.59 $6,684.82 10/1/2020 –12/31/2020 $7,204.78 $7,204.78 $7,204.78 $6,451.92 1/1/2021 – 9/30/2021 $7,366.21 $7,366.21 $7,366.21 $6,708.84 10/1/2021 – 12/31/2021 $7,968.11 $7,968.11 $7,968.11 $7,275.76 1/1/2022 – 09/30/2022 $8,029.46 $8,029.46 $8,029.46 $7,331.78 10/1/2022 – 9/30/2023 $8,912.70 $8,912.70 $8,912.70 $8,138.28 10/1/2023 – 12/31/2023 $7,826.46 $7,826.46 $7,826.46 $7,281.17 1/1/2024 – 09/30/2024 $7,867.16 $7,867.16 $7,867.16 $7,319.03 10/1/2024 – 09/30/2025 $8,201.34 $8,201.34 $8,201.34 $7,752.73 10/1/2025 – 09/30/2026 $8,666.72 $8,666.72 $8,666.72 $8,132.22

Programs Manual Section ALTCS MA1104

The customer applied for ALTCS on March 25th. On April 10th she applied for AHCCCS Medical Assistance programs other than ALTCS. On April 20th, she was approved for SSI-MAO and enrolled with a health plan effective April 1st.

On May 7th her ALTCS application was approved effective March 1st. Because her ALTCS eligibility begin date is before her enrollment started with the AHCCCS Complete Care (ACC) plan, she is enrolled with the ALTCS Health Plan beginning March 1st.

Programs Manual Section ALTCS MA1104

The customer applies for ALTCS on January 19th. He is not currently receiving AHCCCS Medical Assistance. On March 3rd his application is approved effective January 1st. He is enrolled with the ALTCS pHealth Plan beginning January 1st.

Programs Manual Section ALTCS MA1104E

The customer lived in his own home in Pinal County for the last five years before applying for ALTCS. He intends to receive long-term care services in his home. Pinal is the county of fiscal responsibility.

The customer has lived in Pima County the last twenty years. In March, she moved to a new home in Cochise County. She also applied for ALTCS in March, and intends to receive long-term care services in her home. Cochise is the county of fiscal responsibility.

The customer has been living in a nursing home in Colorado. In July, his daughter moves him to a nursing home in Maricopa County. Maricopa is the county of fiscal responsibility.

The customer has been living in his own home in Yavapai County for several years. On June 12, he had a stroke. He was hospitalized briefly in Yavapai County, then moved to a hospital in Maricopa County. On August 15th, the customer is admitted to a nursing facility in Maricopa County, where he intends to stay. Yavapai is the county of fiscal responsibility.

Programs Manual Section ALTCS MA1104F

On September 25th, the customer reports that she has moved from her home in Pima County to her new home in Maricopa County. On September 29th, the worker completes makes the change. The effective date of the fiscal county change and an enrollment change (if necessary) is September 29th.

A six-year old customer and his parents all move from Coconino County to Pinal County. The county of fiscal responsibility is changed to Pinal County.

The parents of a 12-year old customer move from Pima County to Yavapai County, but the customer remains in a facility in Pima County. The county of fiscal responsibility is changed to Yavapai County.

A 16-year old customer moves to a group home in Maricopa County, but her parents remain in Gila County. Gila County remains the county of fiscal responsibility.

The customer has been living in Yavapai County and receiving long-term care services in his home. His county of fiscal responsibility is Yavapai. A few months later, he decides to give up his apartment and move into his son’s home in Pima County. The county of fiscal responsibility is changed to Pima County. However, the ALTCS Health Plan that the customer was enrolled with in Yavapai County does not provide services to Pima County. The customer’s enrollment must also be changed to an ALTCS Health Plan that serves Pima County.

The customer was living in her own home in Maricopa County for many years. When ALTCS was approved, her county of fiscal responsibility was Maricopa. A year later, she moves to her daughter’s home in Cochise County. The county of fiscal responsibility must be changed to Cochise, but because the customer’s current ALTCS Health Plan serves both counties, enrollment does not change.

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Programs Manual Section ALTCS MA1201C

The customer applies in July 2026. The customer's spouse lives at home. The spouse has the following counted monthly income and expenses:

$1,200.00 – Pension benefit

$400.00 – Mortgage (includes property taxes)

$130.00 – Condominium maintenance fee (includes $15 utility charge)

$70.00 – Homeowner’s insurance

The spouse’s CSMIA calculation is shown in the following table:

Step Action 1 Calculate the total excess shelter costs: $600.00 Spouse’s shelter costs ($400.00 + $130.00 + $70.00) + $314.00 Utility allowance ($329 SUA - $15 maintenance fee utility charge) $914.00 Total excess shelter costs 2 Calculate the Excess Shelter Allowance: $914.00 Total excess shelter costs - $812.00 30% of the Monthly Spousal Need Standard $102.00 Excess Shelter Allowance 3 Calculate the Minimum Monthly Maintenance Needs Allowance: $102.00 Excess Shelter Allowance + $2,705.00 Monthly Spousal Need Standard $2,807.00 Minimum Monthly Maintenance Needs Allowance (MMMNA). 4 $2,807.00 (MMMNA from Step 3) is less than $3,853.50 ( Maximum Monthly Maintenance Needs Standard) 5 Calculate the CSMIA: $2,807.00 MMMNA from Step 3 - $1200.00 spouse’s counted monthly income $1,607.00 is the CSMIA.

Customer is receiving ALTCS and has two dependents living at home with the community spouse. One dependent is the spouse’s brother, and the other is the 30-year-old child of the customer and spouse.

The brother’s total monthly income is $824.00 in Social Security Retirement benefits. His family allowance amount is calculated below:

Monthly Spousal Need (Effective 7/1/2026) $2,705.00 Brother’s income - $824.00 Remainder $1,881.00 Divide remainder by 3 /3 Family Allowance for the brother, rounded up $627.00

The adult child’s total monthly income is $300.00 in spousal support (alimony). Her family allowance amount is calculated below:

Monthly Spousal Need (Effective 7/1/2026) $2,705.00 Adult child's income - $300.00 Remainder $2,405.00 Divide remainder by 3 /3 Family Allowance for the adult child, rounded up $802.00

Add the Family Allowance for each dependent together to get the total Community Spouse Family Allowance.

Family Allowance for the brother rounded up $627.00 Family Allowance for the adult child, rounded up + $802.00 The total Community Spouse Family Allowance $1,429.00

The total Community Spouse Family Allowance is $1,429.00.

Programs Manual Section ALTCS MA1201C

The customer applied for ALTCS in July and is eligible. She has an unpaid bill for a non-covered medical expense incurred in June. The unpaid expense is deducted from the July SOC. If the expense is more than the share of cost without the deduction, the remaining unpaid balance is allowed as a share of cost deduction for August and ongoing months until the full amount has been allowed.

The customer applies for ALTCS in May. He does not qualify for ALTCS in May, but is approved for June and ongoing. The customer incurred and paid a non-covered medical expense in May. Since the bill was paid in a month in which the customer was ineligible, it cannot be allowed as a SOC deduction for a later eligible month.

Programs Manual Section ALTCS MA1201C

The customer lives in a nursing facility. His wife lives at home with their three young children. There is no proof of legal marriage. The wife has gross earned income of $600/month. Each child gets Social Security Survivors benefits of $132 per month.

The AFDC Need Standard for a family of 4 (wife + 3 children) is $1,162.00.

Total AFDC Need Standard based on household size $1,162.00 Spouse’s income -$600.00 Child’s income -$132.00 Child’s income -$132.00 Child’s income -$132.00 Total Family Allowance = $166.00

Programs Manual Section ALTCS MA1201C

The customer is billed quarterly for a $120.00 health insurance premium. The customer chooses to have the premium payment divided across all three months. The quarterly payment is divided by three to get a monthly amount of $40.00.

The customer receives $100.00 from his pension every month to help pay for his medical insurance. His premium is $250.00. The $100.00 payment is not counted as income. The entire $100.00 is a reimbursement.

The reimbursement does not cover the whole insurance premium. The customer gets a $150.00 SOC deduction for the part of his premium not covered by the pension.

The customer receives $100.00 from his pension every month to help pay for medical insurance for himself and his spouse. The total premium for both is $150.00.

The $100.00 payment is not counted as income. The entire $100.00 is a reimbursement.

For SOC, only the customer’s share of the premium is considered. The $100.00 reimbursement is more than his share of the premium ($75.00). No SOC deduction is allowed.

The customer receives $297.00 from his pension every month as reimbursement for Medicare premiums for himself and his spouse. Social Security deducts Medicare premiums of $148.50 from each spouse’s gross SSA benefit.

The customer's half of the reimbursement is not counted as income. The customer does not receive a SOC deduction for Medicare expenses because the pension reimburses his cost.

Because his wife pays her own Medicare premium, the wife's half of the reimbursement ($148.50) is counted unearned income to the customer. When AHCCCS begins paying the customer’s Medicare Part B premium, the entire $297.00 will be counted unearned income to the customer.

The customer receives Extra Help to help pay her Medicare Part D premium. Her Part D premium is $56.00 per month. Extra Help pays $30.10 of that amount. The customer gets a $25.90 SOC deduction for the Part D premium that she pays.

Programs Manual Section ALTCS MA1201C

The customer is an unmarried woman. She entered the nursing home in October. She applied for ALTCS in November. On December 15, the ALTCS local office received a written statement from the customer’s doctor certifying that she is likely to return to her home sometime in April.

October through April is exactly six months. The customer qualifies for a home maintenance allowance for the months of November through April.

The customer is an unmarried man. He entered a nursing home in August. He applied for ALTCS at the end of August. The customer’s doctor provided a statement that certifying that the customer would most likely return to his home in April the following year. Since he is expected to remain institutionalized for more than six months, he does not qualify for a home maintenance needs allowance.

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Programs Manual Section ALTCS MA1201C

The customer is on ALTCS and has a SOC of $583.00. On August 5th, she turns in proof that she paid a $700 dental bill on July 30th.

The customer's July SOC is reduced from $583.00 to zero. The $117.00 left over does not carry over to the August SOC.

The customer’s SOC is $120.00. In May, he provides proof that he owes $525.00 for dental expenses from January. The customer's insurance company paid $225.00. The customer is responsible to pay $300.00.

The unpaid balance is higher than the customer’s monthly SOC. The SOC is reduced to $0.00 for June, $0.00 for July and $60.00 for August.

In February, the customer received a bill of $400.00 for a hearing aid and batteries. In March, the customer began paying $25.00 per month toward the bill. The customer did not report the bill to AHCCCS until July.

The payments for March, April, and May are not allowed as deductions because the expense was report in July.

The payments for June and July are allowed as SOC deductions in the month that each payment was made.

The unpaid balance of $175.00 is allowed as an SOC deduction in the next prospective month (August).

Programs Manual Section ALTCS MA1201C

The customer is on ALTCS and has total income of $1000.00 per month. He lives in a nursing facility. His PNA for August 2026 is $149.10.

In September 2026, a court-ordered child support garnishment of $100.00 per month takes effect. The $100.00 garnishment is added to his PNA, increasing it to $249.10.

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Programs Manual Section KidsCare MA1204A.3

The customer lives with and cares for the following children:

Her 15-year-old-daughter;

Her 6-year-old-niece (her brother’s daughter); and

Her 10-year-old-nephew (her sister’s son).

The customer makes $2,400.00 per month. She only claims her daughter on her taxes. Her niece receives $2,000 per month in SSDI. Her nephew receives $2,300 per month in SSDI.

The following table describes the income groups and total monthly income for the customer and the children she lives with:

Income Group Total Monthly Income Income Range The customer’s income group includes her and her daughter (household size of 2) $2,400.00 0 – 150% The niece’s income group only includes the niece (household size of 1) $2,000.00 151 – 175% The nephew’s income group only includes the nephew (household size of 1) $2,300.00 176 – 225%

Because the highest income level is at the 176 - 225% range and there are 2 or more eligible children in the case, the premium for all members in the case is $70.00 for the entire case.

Programs Manual Section HPE MA1302C

A customer applying for ALTCS is incapacitated. A social worker completed the financial interview but does not want to be the authorized representative. The social worker thinks the customer has two accounts with a local bank. Neither account was in the Asset Verification Service (AVS) report.

No proof of the bank accounts was provided by the request for information (RFI) due date. The social worker can’t get bank records because no one is authorized to access the customers bank information.

No one can legally represent the customer and they are unable to represent themselves. The customer should be referred to the County Public Fiduciary.

A customer renewing their Medical Assistance is incapacitated. They have an authorized representative. The representative said the customer’s Social Security benefits stopped because the Social Security Administration (SSA) needs to verify the customer’s address. SSA will not let the representative help reinstate benefits because they are not authorized.

A customer must take all steps to get any cash benefits they are entitled to as a condition of eligibility. The customer must reinstate the SSA benefits to stay eligible for Medical Assistance. Since the authorized representative can’t help, the customer should be referred to the County Public Fiduciary.

Programs Manual Section All programs MA1309C

The customer applies for QMB in January. Requested proof is received in February. The information provided shows the customer meets all conditions of eligibility in the month of January and ongoing. The approval is dispositioned on February 20th. The QMB eligibility begin date is March 1st.

Programs Manual Section All programs MA1309C

The BCCTP diagnosis was July 24th. AHCCCS received the application on August 3rd. Eligibility would be effective July 1st if all requirements are met.

The BCCTP diagnosis was July 24th. AHCCCS received the application on August 3rd, but the customer had a job that provided creditable coverage until July 31st. Eligibility would be effective August 1st (the first month that all requirements are met).

Programs Manual Section All programs MA1309C

The customer’s determination of eligibility is completed on January 23rd. The eligibility begin date is February 1st.

The customer’s determination of eligibility is completed on January 27th. The eligibility begin date is March 1st.

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Programs Manual Section ALTCS MA1502P

An active ALTCS customer lived in an ALF in January 2026. The ALF is licensed and registered with AHCCCS. The customer is not married and has no other health insurance. The share of cost calculation is as follows:

Total countable income $2200.00 Personal Needs Allowance -$2982.00 Total Share of Cost =$0.00

On February 23, 2026, the customer moved to a skilled nursing facility. The skilled nursing facility is licensed and registered with AHCCCS. The customer notified AHCCCS of the move on the same day. The new SOC calculation is as follows:

Total countable income $2200.00 Personal Needs Allowance -$149.10 Total Share of Cost =$2050.90

Since the new SOC amount is higher, the customer must be notified of the change 10 days before it is effective. The effective date of the new SOC will be April 1, 2026.

An active ALTCS customer lives in a skilled nursing facility in February 2026. The nursing facility is licensed and registered with AHCCCS. The customer is not married and has no other health insurance. The share of cost calculation is as follows:

Total countable income $1823.00 Personal Needs Allowance -$149.10 Total Share of Cost =$1673.90

On March 10, 2025, the customer moved to an assisted living home. The assisted living home is licensed and registered with AHCCCS. The customer notified AHCCCS of the move on the same day. The new SOC calculation is as follows:

Total countable income $1823.00 Personal Needs Allowance -$2982.00 Total Share of Cost =$0.00

Since the new SOC is lower and for the benefit of the customer, the effective date is March 1, 2026.

An active ALTCS customer lives in a skilled nursing facility in January 2026. The nursing facility is licensed and registered with AHCCCS. The customer is not married and has no other health insurance. The share of cost calculation is as follows:

Total countable income $2053.00 Personal Needs Allowance -$149.10 Total Share of Cost =$1903.90

On April 25, 2026, the customer moved to an ALF. The ALF is licensed but is NOT registered with AHCCCS. The customer notified AHCCCS of the move on the same day.

Because the ALF is licensed but not registered with AHCCCS, the net income test is used when the customer is in the unregistered facility for the full month. The customer is over income using the net test income limit of 100% of the Federal Benefit Rate for May 2026. The change is an adverse action in which the customer must be notified at least 10 days before it is effective. As a result, the customer will be discontinued for ALTCS effective June 1, 2026.

The customer’s personal needs allowance (PNA) will be increased in April 2026 because the customer is HCBS for part of the month. The increase in the PNA reduces the customer’s share of cost (SOC). A reduction in SOC is not an adverse action and is effective April 1, 2026.

Programs Manual Section ALTCS MA1502G

On March 13, 2021, an ALTCS customer died at a nursing home in Maricopa County. The share of cost (SOC) was $1472.00. The customer had Medicare A and B and was enrolled with United Healthcare. The daily capitation rate for United Healthcare in Maricopa County in March 2021 for a person with Medicare is $101.80.

101.80 x 13 (the number of days in March the customer was at the nursing home) = $1323.40. The prorated capitation rate (1323.40) is less than the customer’s SOC. $1323.40 is the adjusted SOC for March 2021.

On April 28, 2021, an ALTCS customer died at a nursing home in Pima County. The assessed share of cost (SOC) was $1335.00. The customer did not have Medicare and was enrolled with Banner University Family Care. The daily capitation rate for Banner University Family Care in Pima County in April 2021 for a person without Medicare is $238.80.

238.80 x 28 (the number of days in April the customer was at the nursing home) = $6686.40. The prorated capitation rate is more than the customer’s share of cost. The customer’s SOC is not adjusted and is still $1335.00.

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Programs Manual Section BCCTP MA1502D

If treatment ends or is expected to end on... And treatment was... Then eligibility continues for an additional... AND BCCTP eligibility ends on... August 10th For a pre-cancerous cervical lesion 4 full calendar months December 31st August 10th Specific treatment for breast or cervical cancer 12 full calendar months August 31st of the following year August 10th Hormone therapy for breast cancer No additional period August 31st, the end of the month in which the hormonal therapy ends

Programs Manual Section All Programs MA1801

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.

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This section provides examples of how policy is applied in various situations. Sections are numbered relating to the MA section the example is for.

Programs Manual Section FTW MA613.3

The customer is a 45-year-old man with a disability. He is quadriplegic. He works full time as a bookkeeper but because of his disability, he requires an attendant care worker and several IRWE items in order to work. He applies for AHCCCS FTW in February 2026. The customer also receives a $100.00 alimony payment each month.

His earned income from his job in February 2026 is $5,000.00. His IRWE expenses in order to work were verified to total $500.00.

The following steps are used to calculate the customer’s eligibility using the net income test:

Step Action 1 Disregard the customer’s unearned income. -$100.00 alimony payment $0.00 (counted unearned income) 2 Calculate net earned income: $5,000.00 (customer’s total countable earned income) - $20.00 (general income deduction) - $65.00 ($65.00 work expense deduction) - $500.00 (IRWE deduction) =$4,415.00 (subtotal of earned income) - $2,207.50 (½ of subtotal of earned income) - $0.00 (blind work expense deduction) =$2,207.50 (net earned income) 3 Compare the result in Step 2 above to $3,325.00 (250% of the FPL): Because $2,207.50 is less than $3,325.00, the customer is income eligible for AHCCCS FTW.

NOTE The customer is eligible for AHCCCS FTW. If he passes the PAS, he is eligible for ALTCS AHCCCS FTW.

Programs Manual Section Children Pregnant Woman Caretaker Relative Adult KidsCare MA614

The customer lives with her daughter, age 17, and granddaughter, age 1.

The customer is a tax filer and claims her daughter and granddaughter as dependents. The customer earns $2,200 per month. Her daughter earns $300 per month. The daughter’s income is expected to be too low to have to file a tax return.

The customer’s budget group = Self, daughter, and granddaughter. The daughter’s income is below the tax filing threshold, she is the customer’s child, and they are both in the budget group. Since all three conditions are met, the daughter’s income is not counted in the customer’s budget. Total monthly income counted is $2,200 (the customer’s monthly income).

The daughter’s budget group = The customer, self, and granddaughter. The daughter’s income is below the tax filing threshold, she is the customer’s child, and they are both in the budget group. Since all three conditions are met, the daughter’s income is not counted in her own budget. Total monthly income counted is $2,200 (The customer’s monthly income).

The granddaughter’s budget group = Daughter and self. The daughter’s income is still below the tax filing threshold, and she is under 19, but her parent (the customer) is not part of the granddaughter’s budget group. So, the daughter’s income is counted in the granddaughter’s budget. Total monthly income counted is $300 (The daughter’s monthly income).

The customer, age 42, is a tax filer and claims her mother, age 63, as a tax dependent.

The customer makes about $1,300 a month from her job while her mother’s income is $200 a month from her part-time job. The mother’s income is expected to be too low to have to file a tax return.

The customer’s budget group = Self and mother. The mother is the customer’s tax dependent, her income is below the tax filing threshold, and they are both in the budget group. Since all three conditions are met, the mother’s income is not counted in the customer’s budget. Total monthly income counted is $1,300.

The mother’s budget group = Self. The mother is the customer’s tax dependent, her income is still below the tax filing threshold, but the customer is not part of the mother’s budget group. The mother's income is counted in her own budget. Total monthly income counted is $200.

Programs Manual Section FTW MA1203A.2 MA1203B.5

The customer applies for AHCCCS on January 25th. AHCCCS approves his application on February 6th for Freedom to Work. Based on his income, his monthly premium is $15.00. His eligibility begins January 1st, and his first premium payment is due in March. He does not owe a premium for January and February.

The customer is receiving AHCCCS Medical Assistance in the SSI MAO program. In February she reports that she began a job in January and just received her first paycheck.

AHCCCS determines that her countable income puts her over the SSI MAO income limit. On February 18th, FTW eligibility is approved beginning March 1st. The customer’s first premium payment is due in March.

The customer is receiving AHCCCS Medical Assistance in the FTW program. The customer reports a change in income and provides all verification on July 22nd. The application is assigned to a worker for processing. The worker dispositions the application on August 5. The premium is reduced from $35.00 to $10.00 effective September 1. The effective date should be changed to August 1st due to untimely processing.

Programs Manual Section HPE MA1314

Example: HPE is approved by the hospital on 01/20/15 for the period 01/20/15 through 02/28/15. The customer does not submit a full application by 02/28/15. HPE eligibility ends on 02/28/15.

Example 1: HPE is approved by the hospital on 01/15/15 for the period 01/15/15 through 02/28/15. The customer submits a full application on 02/25/15. Because the full application was received timely, HPE may continue past 02/28/15. The full application is processed and approved by the state on 03/15/15. The HPE period ends on 03/15/15.

Example 2: HPE is approved by the hospital on 01/30/15 for the period 01/30/15 through 02/28/15. The customer submits a full application on 02/05/15. The full application is processed and denied by the state on 02/06/15. The HPE period ends on 02/06/15.

Example 3: HPE is approved by the hospital on 01/25/15 for the period 01/25/15 through 02/28/15. A full application is also submitted by the hospital on 01/25/15. The full application is processed and approved by the state on 02/23/15. The HPE period ends on 02/23/15.

Programs Manual Section All Programs MA1706

At his June renewal, the customer had $10,000 in his savings account, and the worker took action to end ALTCS eligibility. His ALTCS is ending after June 30th.

On June 28th, the customer appeals this decision. Because the appeal was requested before the date his coverage stops, the customer’s ALTCS eligibility is continued during the appeal process.

On July 5th, AHCCCS discovers that the customer also has a promissory note with a countable value of $30,000. Because the customer was approved for continued benefits during the appeal process, the change is not processed pending a hearing decision.

In January the customer’s Social Security income increased by $20.00. This change in income is processed on February 4th. Because of the higher income, the customer’s share of cost (SOC) is increasing as of March. AHCCCS sends her a letter about this change in the SOC.

The customer files an appeal on February 19th, before the change is effective. Her SOC is changed back to the previous amount during the appeal process. On March 1st, the customer reports that she started receiving another pension. Because the customer was approved for the prior SOC amount during the appeal process, the change is not processed pending a hearing decision.

Cash Assistance and Nutrition Assistance Policy Please see the Cash and Nutrition Assistance Policy Manual located at https://DBMEFAAPolicy.azdes.gov for policy and procedures.

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Medical Assistance Eligibility Policy Manual

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Last Updated: 09/02/2026

Arizona Health Care Cost Containment System Processing Active FTW, SSI-MAO and MSP When Denying ALTCS Update 08/25/2026

Program Impact : ALTCS

“Processing Active FTW, SSI-MAO and MSP when denying ALTCS” step/action table updated: Added a new step to determine if the customer has other AHCCCS eligibility when ALTCS is denied. Clarified processing requirements for ALTCS denials due to missed financial appointments or voluntary withdrawals. Added clarification on the appropriate denial, approval, and redetermination actions for ALTCS, SSI-MAO, FTW, and MSP eligibility. Removed “Application Taken in Error” for SSI-MAO, FTW, and MSP when no eligibility changes were identified.

Note to staff: Do not use “Application Taken in Error” for the SSI MAO, FTW or MSP.

The purpose of the PAS is to determine medical eligibility for long-term care services.

The PAS tool contains a combination of functional and medical factors that are assigned weighted, numerical values. The customer is evaluated on these factors and the assessed scores are added together to get a total score.

The DD PAS tool is used to assess:

Developmental and Independent Living Skills;

Medical;

Nursing; and

Social needs of the customer.

In general, a customer scoring at or above a threshold score on the PAS is considered to be at immediate risk of institutionalization. This means that the customer needs the level of care typically provided in an institution, like a skilled nursing facility.

Follow the steps below for the Initial PAS process

Step Action 1 Schedule the ALTCS PAS Appointment. Take the following actions: Explain the ALTCS program and the purpose of the PAS. Ask if any accommodations are needed. Enter a case note in HEAplus that this was completed. 2 At the beginning of the PAS interview, take the following actions: Reexplain the ALTCS program and the purpose of the PAS to everybody attending the PAS interview. If the DE-202 has not already been obtained, explain the reason it is needed. Obtain a signature for the DE-202 using DocuSign. If DocuSign is not available, use another method to get the DE-202 signed, such as fax or mail. 3 Use the appropriate PAS tool to conduct the PAS interview. Follow the guidance in Investigative Interviewing . 4 Ask the customer or representative for the names of providers needed for medical records. 5 At the end of the PAS interview, explain the following to the customer or representative: What happens next in the PAS Process; They may hear from the ALTCS Benefits and Eligibility Specialist; The Appeal Process; and The customer’s right to reapply at any time if they are medically ineligible. 6 Provide a list of Community Resources for the customer and representative and include a statement in the PAS summary that the list was provided. 7 Inform the customer and representative that they will receive a call and a letter telling them of the medical eligibility determination.

A PAS may be requested for a deceased person, a prior quarter month, or before applying for ALTCS. There is a special process when a PAS is requested for one of these reasons. Information for each process is found below.

A posthumous PAS is completed after a customer has passed away. Reasons for a posthumous PAS are:

The customer passed away after the application was made; or

Someone applied for the deceased customer.

Things to Keep in Mind When Completing a Posthumous PAS:

For a posthumous PAS, the date of death must be entered on the application before the PAS is opened. Without a date of death, the PAS is completed as an Initial PAS and all questions must be answered.

No comments are required when scoring. However, a brief summary must be included on the PAS Summary screen.

The following are not required: Deterioration in overall function; Medications, assistance required for administration, and any allergies to medications; Therapeutic diet; Number of hospitalizations, ER visits, and falls; and Whether the client was hospitalized or had plans for discharge.

A posthumous PAS can be completed for a deceased customer regardless of the living arrangement.

It is the PAS assessor’s responsibility to notify the financial Benefits and Eligibility Specialist when the customer dies after the PAS referral has been made. Give the financial Benefits and Eligibility Specialist the following information: The date of death; The place of death; and The person who provided this information.

Prior Quarter (PQ) coverage provides medical coverage for up to three months prior to the month of application. Children under age 19 and women ages 19-60 who are pregnant or in the postpartum period may qualify for prior quarter coverage. To be eligible the customer must:

Have a medical expense in the PQ month. The medical expense can be paid or unpaid; and

Meet all eligibility requirements in the month the medical expense was incurred.

Things to Keep in Mind When Completing a Prior Quarter (PQ) PAS:

To get the PQ PAS to autofill the answers, enter the Initial PAS first, then open the oldest PQ PAS, then the next oldest PQ, and then the most recent PQ.

If the Initial PAS and all the PQs score Eligible and do not need Physician Review (PR), select “Complete PAS” starting with the Initial PAS, then the oldest to most recent PQ PAS.

When the Initial PAS and PQ months need PR, do NOT select “Complete PAS” on the Initial or PQ months until the case is returned from PR.

A Private Request PAS (PRP) is a courtesy provided to see if the customer is at risk of institutionalization before an ALTCS application is submitted. Because the PRP does not include an application, a decision notice is not sent and the customer cannot appeal the decision.

An eligible PAS, including a Private Request PAS, may be used for up to 180 days when a customer is denied financially and later reapplies. An ineligible PAS is never used for a new application.

A PRP may be requested when the customer:

Plans to move to Arizona and wants to know if they are medically eligible;

Knows they are within the financial limits, but are not sure about medical eligibility; or

Knows they are over the resource limit and wants to know if they are likely to be medically eligible before they consider reducing resources.

Things to Keep in Mind When Completing a Private Request PAS:

When the customer is a resident of Arizona Make an appointment and complete the PAS just as you would any other PAS. Request medical records as usual. After completing the PAS in the system, tell the customer that based on the courtesy assessment, they do or do not meet medical eligibility criteria. An eligible PRP can be used when the customer applies within six months from the date the PRP was completed. When the customer is NOT a resident of Arizona Contact the customer and any caregivers to obtain PAS information. Request medical records as usual. If a PR is needed but the customer does not have solid plans to move to Arizona, discuss the case with your Benefits and Eligibility Manager. Tell them that it appears they do or do not meet the medical eligibility criteria. Make it clear that when they apply for ALTCS, another PAS assessment may need to be completed.

In this chapter, you will learn about:

The Preadmission Screening (PAS) Process and Purpose;

Standards and best practices for PAS documentation; and

Investigative interviewing.

For each section in this chapter, you will find:

An overview of the topic;

Any definitions needed; and

Best practices or examples.

The PAS, with all comments and documents, is the legal basis for ALTCS medical eligibility decisions. Documentation is the critical key to objective and accurate PAS decisions. The PAS should be clear, complete and correct. The PAS documentation should support the score. Information from the PAS is shared with the ALTCS Health Plan and may be shared with federal and state auditors, the customer, the Office of Administrative Hearings, and when authorized, with other parties.

Investigative interviewing involves collecting detailed and accurate information about the customer’s development, motor skills, independent living skills (ILS), and behavioral concerns. Use your knowledge and expertise of the PAS assessment to do this.

NOTE Tips for collecting accurate, complete information for specific functions and conditions have been added to the Appendix sections for those areas.

It is important to be prepared. Always check to see if there is a prior PAS for the customer. When the customer has a prior PAS, take the following actions:

Review the prior PAS. Do the comments and records support the scores? Was a Physician Review completed on the prior PAS? If so, what was the physician’s decision?

Review the previous medical records. Make note of the customer’s medical conditions. Look for any developmental or functional limitations mentioned. Make note of any behavioral health providers listed and services provided.

If there is no prior PAS, review the current PAS referral and gather as much information as possible, including records from the DDD Support Coordinator.

Use the tips below for the PAS Interview:

Tip Steps Build rapport with the customer and others involved. Be on time. If you are running late, call the customer and let them know. The PAS may need to be rescheduled to ensure there is enough time to do a thorough interview. Extend a warm greeting and introduce yourself. Be prepared. Make sure your equipment is working properly before the interview begins. Have all needed paperwork available. Review and describe the medical criteria for eligibility, the PAS, and its purpose, and what will be covered during the interview. Make sure the people involved have a clear understanding of the interview and ask if they have any questions. Review the PAS questions and information with the people involved. Use the tips in the Investigative Interviewing Skills section below to gather clear, complete information for the DD PAS. Avoid asking leading questions. Give the person time to answer each question. Make sure to get enough information to provide a clear, complete, and correct picture of the question being asked. If the customer has a previous PAS, discuss any information that has changed since the previous PAS. Make sure changes in the customer’s status are clearly and accurately explained in summary. Ask about any decline in health or regression in developmental milestones or ILS skills. HAS the decline or regression been discussed with a medical provider?

Ask questions and use statements that encourage the person to give information. The tips in the table below give ways to gather clear, correct, and complete information.

Skill Type Description Examples Open-ended questions Are worded so the question cannot be answered with “yes,” “no” or just one-word. Encourage discussion. Begin with words like "who", "what", "where", "when", and "how". NOTE Most questions in the DD 0-5 tool are “yes” or “no”, but still need more details. For example, how often the customer completes the task or how long it takes. Who helps the customer get dressed? What does the customer’s personal hygiene routine look like? What is the customer doing on their own, and what do they need assistance with? How was the customer physically aggressive? When was the last time the customer was physically aggressive? Where did the customer go when he ran away? Inquiry statements Encourage the person to volunteer information. Allow for a wide range of answers. Tell me more about what happens when she is having a tantrum. Please explain how your child… Describe how the... Clarifying questions Prevent or correct misunderstanding and confusion. You may need to ask more than one question to clarify the information. The customer’s mother said: “Johnnie can make a bowl of cereal and a peanut butter and jelly sandwich, but he’s really messy." You say: “So you said Johnnie can make a bowl of cereal and a sandwich. Does he do this all by himself? Is he able to clean up after himself when he is done?" Restating information Repeating exactly what was said to be sure it was heard correctly. This confirms what was said and avoids misunderstanding. You said you “check the customer after she bathes by smelling her hair and checking her hands and feet to make sure they are clean.” Is that right? Paraphrasing Restating information using your own words. Paraphrasing confirms that the information is understood correctly. The customer’s father said: “When Johnnie is having a bad day and gets really mad, he just loses control and breaks everything around him.” You say: “So Johnnie only loses control and starts breaking things when he gets really angry? Is that correct?”

Tip Steps Documentation For eligibility, this means all entries in HEAplus screens, written comments and notes, and any documents in HEAplus or EDMS.

Medical records are a critical part of making an objective and accurate PAS decision.

Review all available medical records and use the information when scoring the PAS. A few examples of medical records that are useful in the PAS assessment include:

DDD/DES Person-Centered Planning Document;

Department of Special Education Individualized Education Program (IEP);

Multidisciplinary Evaluation Team (MET) record;

Clinical Autism Diagnostic Evaluation;

Consultations by specialists (for example, psychology, psychiatry, neurology, or cardiology reports);

Therapy notes (for example, speech, occupational, behavioral health, and physical therapy);

Primary Care Physician (PCP) reports.

When reviewing medical records:

Make sure that the customer’s name is on all records and is correct.

For records that include the customer’s date of birth (DOB), check that it matches the DOB on file. If it does not, determine which one is correct by contacting the provider about the discrepancy. If the provider has the incorrect DOB, but the records are for the customer, add a sentence to the summary stating the provider entered the wrong DOB, but the records are correct. If our records are incorrect contact the Benefits and Eligibility Specialist (BES) and report that the DOB in HEAplus appears to be incorrect.

Review the dates on medical records used to support your scores and decision. The records should be current and relevant to the customer’s condition, typically within the past six months. When older records are relevant, include the explanation in comments. For example, a 50-year-old customer was diagnosed with moderate intellectual disability 35 years ago and that is the most current record of the diagnosis.

Follow the steps below when the information provided by the customer, caregiver, or representative during the PAS conflicts with the medical records, or medical records are not available:

Step Action 1 Were medical records provided for the customer? If YES, continue to step 2. If NO, STOP. Score based on what the caregiver or representative reported, noting any differences between what was and what you observed. 2 Do the medical records support the customer’s responses? If YES, STOP. Score based on the customer’s responses. If NO, contact the caregiver to discuss and clarify the differences. Continue to step 3. 3 Does the caregiver have a valid reason explaining why the medical records contradict what is being reported? If YES, score based on the caregiver’s report and add comments to each section that has a discrepancy describing the reason the reported information was used instead of the medical records. If NO, score based on the most relevant records and add comments to each section that has a discrepancy explaining why the reported information was not used. Contact your Benefits and Eligibility Manager (BEM) requesting review. The BEM determines if the PAS scores are accurate, if able. When the BEM is unable to determine the accuracy of the scores, a M.A.R.S. Inquiry is sent to PAS Policy.

Term Definition Valid reason explaining why the medical records contradict what is being reported Based on the PAS Assessor’s knowledge and experience, a valid reason is a logical explanation of why the reported information conflicts with the medical records. Reasons may vary and could cover dozens of scenarios. For example: The customer is a 55-year-old female diagnosed with moderate intellectual disability and lives alone. She says that she can walk “just fine” with her cane. Recent medical records state the customer is an extreme fall risk, and EMS has been contacted by neighbors four times in the past 45 days. The PAS Assessor contacts the customer to ask about the falls reported in the records and the customer says she does not remember falling. The PAS Assessor does not find a valid reason to use the customer’s statement instead of medical records and explains why in the comments. A Clinical Autism Diagnostic Evaluation from six months ago indicates the customer was using a few words and making frequent eye contact with his parents. The customer’s mother reports that when her child was 12 months old, he was saying a few words and looking at her often. She explained that at 17 months of age he became completely non-verbal and no longer makes eye contact with anyone. The mother is extremely concerned and has scheduled an appointment with the licensed psychologist who evaluated her son six months ago. The PAS Assessor finds the explanation a valid reason to use the statement instead of medical records, explains why in the comments.

There is no Functional Scores section for infants less than 6 months old.

Take the following steps to complete a PAS for this age group:

Step Action 1 Complete all available sections of the PAS in HEAplus. There will not be a Developmental Domain section for infants less than 6 months old. 2 Add a description of the child’s emerging developmental patterns to the PAS Summary, including: Muscle tone, such as lifting their head when lying down; Visual and hearing perception, such as following objects with their eyes or turning their head towards a sound; Sleep and feeding habits; and Social interaction, such as smiling or cooing at a face or a touch. 3 Request all pertinent medical documentation, including evaluations and assessments. 4 Once the medical records are in EDMS, submit a request for a mandatory Physician Review (PR).

In this chapter, you will learn about completing the Functional Scores section for customers at least 6 months old, but younger than 6 years old. There is no Functional Scores section for infants less than 6 months old. There are nine sections of developmental questions that are asked depending on the age of the child. They are as follows:

For ages... Ask Questions... 6 months and older 1-9 9 months and older 1-19 12 months and older 1-28 18 months and older 1-44 24 months and older 1-56 30 months and older 1-65 36 months and older 1-79 48 months and older 1-93 60 months, but less than 72 months old. 1-101

NOTE Check the customer’s date of birth to see if they are nearing an age where additional questions are asked. It is usually beneficial to complete the PAS assessment after the age change. Discuss these cases with a supervisor.

The following tables include guidance for the developmental questions that are asked for each age group. The questions must be read exactly as they are written. Clarity can be given if requested.

For 6 months and older

Question (Answer Yes or No) Helpful Hints and Things to Consider 1. Does your child lift their head when laying on their back? Answer “Yes,” even if the child is only able to lift their head briefly. Include this information in the comments. Answer “Yes,” if the child is starting to do this, but not all the time. Include this information in the comments. 2. When your child is on their tummy, does s/he straighten both arms and push their whole chest off the bed or floor? Answer “Yes,” even if the child is only able to straighten both arms and push their whole chest off the bed or floor briefly. Include this information in the comments. Answer “No,” if the child in unable to be on their tummy due to medical or physical limitations. Include this information in the comments. 3. If you hold both hands just to balance your child, does s/he support their own weight while standing? (That is, can s/he bear weight?) This is a precursor skill for fine and gross motor skills. Answer “Yes,” even if the child can only bear weight and balance briefly. Answer “Yes,” if the child is walking around furniture while holding on with one hand. The child has moved beyond this stage to a higher level of development. Answer “Yes,” if assessing an older child who can bear weight and balance, even if it is only briefly. Add comments to explain anything that is atypical. 4. Does your child reach for OR grasp a toy? The child does not have to do both to achieve a “Yes” response. If an older child has a physical impairment and is unable to reach for an object but does grasp, the answer would be “Yes”. Include this information in the comments. If the child only uses one hand to complete this task, the answer would be “Yes”. Most children will have a dominant side and tasks will primarily be performed with that hand. If the child has the use of only one hand but can complete the task with that hand, the answer would be “Yes.” Include this information in the comments. 5. Does your child try to pick up a crumb or Cheerio by using their thumb and all their fingers in a raking motion, even if they aren't able to pick it up? (If they already pick up the crumb or Cheerio, check "yes" for this item.) Answer “Yes,” if the child tries to pick up a crumb or Cheerio. This question is asking if the child attempts to do the task, not if they can actually do it. 6. Does your child make high-pitched squeals? This is a precursor skill for saying words or speaking in phrases. If the parent is unsure, some follow up questions include: Does the child scream when upset or scared? Does the child cry making a high-pitched sound when sad, angry, or scared? 7. Does your child show two or more emotions? (For example, laughs, cries, screams, etc.) If the child does not do this consistently, include a description of when it does happen in the comment section. Include the emotions the child does show in the comment section. Other examples include, startled, angry, surprised, sad. 8. Does your child act differently toward strangers than s/he does with you and other familiar people? (Reactions to strangers may include, for example, staring, frowning, withdrawing, or crying.) Include the child’s reaction to strangers and the child’s reaction to familiar people in the comment section. When an in-person interview in conducted, include how the child responded to you in the comment section. 9. Does your child stiffen and arch their back when picked up? This is a Reverse Scoring Question used to establish typical neurological development or GI concerns. If a parent or caregiver does not understand the question, ask follow-up questions for clarification. For example: Is there a medical concern that causes the child’s muscle tone to change? Does the child pull away when you try to pick him up for no apparent reason? Does this behavior happen regularly or only at certain times? A “Yes” answer to this question could be an indicator of a serious neurological disorder or severe gastrointestinal problem. Include the medical condition in the comment section if applicable. This question is not assessing if a child does this because they are upset, do not want to stop what they are doing, or are resistive to being picked up.

NOTE STOP HERE IF THE CHILD IS LESS THAN 9 MONTHS

For 9 months and older

Question (Answer Yes or No) Helpful Hints and Things to Consider 10. Does your child roll from their back to their tummy, getting both arms out from under them? This is a precursor skill for standing, crawling, or walking. If the child is standing, crawling, or walking, they have progressed beyond this stage and the answer is “Yes” even though they may no longer roll from their back to their tummy. Answer “Yes,” if the child does this sometimes, and add the specific or estimated frequency, and when it is done to the comments. For example, the child only rolls from their back to their tummy with certain people. 11. When you stand your child next to furniture or the crib rail, does s/he stand, holding onto the furniture for support? This is a precursor skill for standing alone, walking, running, or climbing. If the child is standing alone, walking, running, or climbing, they have progressed beyond this stage and the answer is “Yes”. 12. Does your child creep or move on their stomach across the floor? This is a precursor skill for crawling or walking. If the child is walking, they have progressed beyond the creeping stage and the answer is “Yes” even though they may no longer creep or move across the floor on their stomach. If the parent indicates the child never crept, it would be inaccurate to answer “No” to this question if they are now walking. 13. Does your child sit supported (for example, in a chair with pillow, etc.) for at least 1 minute? This is a precursor skill for sitting independently. If the child is sitting independently, they have progressed beyond this stage and the answer is “Yes”. Include in the comment how long the child sits with supports. If the child sits without support for at least a minute, include that in the comments. If the child falls or slides after a minute, include that in the comments too. 14. When a loud noise occurs, does your child respond? (For example, act startled, cry or turn toward the sound.) Answer “Yes,” even if the child does not respond every single time a loud noise occurs. If the caregiver responds, “Sometimes” answer “Yes” and ask questions to clarify when the child does and does not respond. For example, the child does not respond to loud noises when watching her favorite movie. Include this information in the comments. 15. If you call your child when you are out of their line-of-sight, does s/he look in the direction of your voice? This question is not asking if the child goes to look for the person calling them or looks in their eyes once they find them. It is specifically asking if the child looks in the direction from where the voice is coming from. Answer “Yes,” if the child does this briefly or “sometimes” and include this information in the comments. 16. Does your child make non-word sounds? (That is, babble or jabber?) This is a precursor skill for talking. A child who now has meaningful words probably no longer babbles. The answer would still be “Yes”. In this case, there is no need to determine whether the child did babble or can babble because they have moved beyond this stage to a higher level of development. 17. Does your child look toward you (parent or caregiver) when hearing your (parent or caregiver’s) voice? This question is not asking if the child makes eye contact or looks into the parent’s eyes. Answer “Yes,” if the child looks in the direction of their parent or caregiver. Answer “Yes,” if the child does this briefly or “sometimes” and include this information in the comments. 18. Does your child enjoy playing peek-a-boo/pat-a-cake? This is a precursor skill to assess the child’s enjoyment of joint attention or reciprocity-based games. The question is asking if the child “enjoys” one of these games, not if they physically participate. The parent may be the one doing the activity, but the child still shows signs of enjoyment. A child who is older may no longer be interested in these types of games so follow-up questions should be asked for accuracy. Did the child enjoy peek-a-boo or pat-a-cake when they were younger but now enjoy more advanced interactive games? For example, Chutes and Ladders, Candy Land, or Connect 4. 19. Does your child feed themselves a cracker or cookie? This question is assessing the physical act of getting food from hand to mouth, chewing and swallowing. Answer “Yes,” if the child can begin feeding themselves a cracker or cookie, but then the parent finishes. Answer “Yes,” if the child does this inconsistently. Include this information in the comments. If the parent answers “No,” ask follow-up questions to find out if the child feeds themselves any other types of foods. For example, the child feeds themselves Cheerios. The answer would still be “Yes”.

NOTE STOP HERE IF THE CHILD IS LESS THAN 12 MONTHS

For 12 months and older

Question (Answer Yes or No) Helpful Hints and Things to Consider 20. Does your child walk around the furniture while holding on with only one hand? This is a precursor skill for walking without holding onto anything. If the child is walking without holding onto anything, they have progressed beyond this stage and the answer is “Yes”. Answer “Yes,” if the child does this, but falls. Include this information in the comments 21. Does your child crawl at least 5 feet on hands and knees, without stomach touching the floor? This is a precursor skill for walking, running, or climbing. If the child never crawled, but is now walking, running, or climbing, answer “Yes,” UNLESS there is a physical impairment that keeps them from being able to crawl on their hands and knees. If so, answer “No,” and include this information in the comments. If the child is physically unable to perform this milestone, include what the limitations are in the comments. Also, include how they do move. For example, scoot on their bottom, creep, or the parent moves them. 22. Does your child hold a bottle or cup? This is a precursor skill for drinking from a cup or glass. Answer “Yes,” if the child drinks from a cup or glass, even if they never performed this skill. Answer “Yes,” if the child can hold a “sippy cup”. The cup does not have to be open for the answer to be “Yes”. 23. Does your child move an object from one hand to the other? This question is assessing whether the child can coordinate the two sides of their body together. If the child is unable to do this, describe what they do instead. For example, the child turns his whole body to get the object to avoid crossing the midline, or the child drops the object on the floor first and then picks it up with the other hand. 24. Does your child pick up a small object with thumb and fingers? Answer “Yes,” if the child only has the use of one hand but can complete the task with that hand. If the parent is not sure what the question means, ask if the child can pick up an object using a pincer grasp and show, or explain, what that means. 25. Does your child coo or laugh or make other sounds of pleasure? Ask how the child shows excitement or happiness to those they are comfortable around. If the parent or caregiver reports they do not show excitement or happiness, ask what the child does instead and include this information in the comments. 26. Does your child reach for familiar person when person holds out arms to them? This is to assess understanding and response of non-verbal communication. Answer “Yes,” if the child does it with only some familiar people, or sometimes, briefly. Include comments to explain. If the parent reports “sometimes” ask and include a more specific or average frequency. Explain under what circumstances a child might not do it. For example, the child doesn’t do it when they are mad or busy with another activity. Answer “No” if a child responds but cannot physically lift their arms. Include comments to explain that the child appears to understand and respond to non-verbal communication but has a physical barrier. 27. Does your child play with a doll or stuffed animal by hugging it? This is to assess if a child shows affection or self-soothes. Answer “Yes,” if the child initiates hugging other objects, toys, pets, or people. Include this information in the comments. Answer “No,” if the child hugs a doll or stuffed animal only because a parent tells them to but does not initiate it on their own. Include this information in the comments. 28. Does your child suck OR chew on finger foods? (For example, crackers, cookies, toast, etc.) This is to assess the child’s oral feeding abilities needed for swallowing. The child does not have to do both to achieve a “Yes” response. Answer “No,” if the child is tube-fed and unable to consume any food orally. Include this information in the comments. Answer “No,” if a child can only consume a meal that has been altered, for example pureed, to avoid choking or swallowing issues. Include this information in the comments.

NOTE STOP HERE IF THE CHILD IS LESS THAN 18 MONTHS

For Ages 18 months and older

Question (Answer Yes or No) Helpful Hints and Things to Consider 29. Does your child stand in the middle of the room by themselves and take several steps forward? This is a precursor skill for walking independently, climbing, jumping, and running. Answer “Yes,” if the child is able to take several steps forward and then falls. Include this information in the comments. 30. Does your child climb on furniture? Helpful follow-up questions include: How does the child get on and off a bed? How does the child get on and off a sofa? How does the child get on and off a chair? 31. Does your child turn the pages of a board, cloth, or paper book by himself/herself? (S/he may turn more than one page at a time.) Answer “Yes,” if the child can turn the pages of any type of book. Include what the child does and how they do it in the comments. 32. Without showing them how, does your child scribble back and forth when you give them a crayon (or pencil or pen)? This is a precursor skill for writing letters or words and making shapes. Answer “Yes,” if the child is able to make any type of back-and-forth scribble, regardless of how they hold the writing object. Answer “Yes,” if the child no longer scribbles because they are now writing letters or words and making shapes. The child has moved beyond this stage to a higher level of development. 33. Does your child stack a small toy, block, cup, dish, or other object on top of another one? This question is not asking for a specific number of objects or the length of time the child stacks objects. Answer “Yes,” if the child is beginning to stack objects, briefly stacks objects, or does so but inconsistently. Include this information in the comments. If question 49 is answered “Yes,” it would be incorrect to answer “No”. Confirm the scoring is consistent and correct. 34. Does your child respond to their name when you call? Answer “Yes,” even if the child does not respond every time their name is called. Include a comment to explain how often and the reasons the child might not respond. For example, the child is watching their favorite movie and does not respond to anything when he is watching it. Responses can include: Turning toward the person calling their name. The child does not need to make eye contact. Verbal acknowledgement Change in behavior once their name is called Head movement Pause in activity Eye contact Inquire to find out if there is another name or word, such as a nickname, that the child responds to. If so, include this information in the comments. If the child is hearing impaired, and does not respond because of it, answer “No”. Include this information in the comments. 35. When playing with sounds, does your child make grunting, growling, OR deep-toned sounds? This question is asking if the child makes these sounds, not what they are doing when they make the sounds. Answer “Yes,” if the child makes grunting, growling, OR deep-toned sounds. The child only needs to do at least one of the sounds for the answer to be “Yes”. Examples include the sounds of the following: A car; A motor; A train; or An animal. 36. Does your child say “Da-da” or “Ma-ma” or another name for parent or caregiver (including parents or caregiver’s first name or nickname)? This is a precursor skill for more advanced language. In nearly all cases, if question 36 is answered "Yes,” question 16 should also be answered "Yes". Confirm the scoring is consistent and correct. Answer “Yes,” if the child uses another name for the parent or caregiver consistently. For example, the child calls the parent by their first name, or a nickname. Answer “No,” if the child says “Da-da” or “Ma-ma” for every person they encounter. Answer “Yes,” if the child uses Sign Language or any other method of communication and can sign or identify the parent or caregiver’s name. Include this information in the comments. 37. When you ask your child to point to their nose, eyes, hair, feet, ears and so forth, does your child correctly point to at least one body part? (They can point to themselves, you, or a doll). Answer “Yes,” if the child is starting to learn how to point to their body parts but does not get it right all of the time. Include this information in the comments. 38. If you point at a toy across the room, does your child look at it? Answer “Yes,” if the child looks at a toy or object across the room when a parent points and asks them to look. The intent of this question is not asking if the parent is only pointing and not speaking. 39. Does your child ever use their index finger to point, to indicate interest in something? This question is specifically looking for the ability to isolate the index finger. Answer “Yes,” only if the child points with an index finger. Inquire to find out if the child has any motor limitations that may impact their ability to do this. If so, include this information in the comments. 40. Does your child ever bring objects over to you? Answer “Yes,” if the child takes the parent over to the object to show them. This question is intended to find out if a child shows interest in an item, so it is not specifically asking if the child only brings an object to the parent. 41. Does your child imitate you? For example, you make a face - will your child imitate it? The child can imitate people other than a parent and still score “Yes”. Include this information in the comments. Imitations can include: Imitation of faces Gesture or body movements Sound or word production 42. Does your child take interest in other children? Other children include siblings. A child does not need to interact with other children to show interest. Ways a child may show interest in other children include: Trying to imitate what another child is doing Observing, tracking, and monitoring other children with their eyes Responding to another child’s actions Getting excited when other children are around Use investigative interviewing skills to make sure the child is not just interested in an object another child is holding, like a toy. Answer “No,” if this is the case and include this information in the comments. 43. Does your child eat solid foods? (For example, cooked vegetables, chopped meats, etc. Not assessing nutritional value or adequate intake. ) Answer “Yes,” if the child is a picky eater and only eats specific solid foods. Include this information in the comments. Answer “No,” if the child is only eating pureed foods or is fed through a feeding tube. Include this information in the comments. 44. Does your child like being hugged or cuddled? A child does not have to like being hugged or cuddled by multiple people for the answer to be “Yes.” If a child only likes to be hugged or cuddled by one person, for example their mom, answer “Yes,” and include this information in the comments. A child does not have to enjoy being hugged or cuddled all the time for the answer to be “Yes.” There might only be certain times, for example, they like to be hugged or cuddled when they are happy or sad. Include this information in the comments Answer “Yes,” if a child seeks ANY close physical contact with another person, such as sitting in someone’s lap or wanting a quick embrace. The amount of time the child likes being hugged or cuddled is not factored into this question.

NOTE STOP HERE IF THE CHILD IS LESS THAN 24 MONTHS

For Ages 24 months and older

Question (Answer Yes or No) Helpful Hints and Things to Consider 45. Does your child run? Answer “Yes,” if a child can run but is clumsy or falls. Include this information in the comments. Answer “No,” if the child walks fast but does not actually run. 46. Does your child jump, with both feet leaving the floor at the same time? (That is, can s/he jump up?) This question is specifically asking if a child can jump up, off the floor. Other areas, such as on a trampoline or bed, are not considered here. Answer “No,” if the child is not able to jump with both feet leaving the floor at the same time, for example, only does a gallop or tries. Include this information in comments. 47. Does your child flip light switches off and on? If a parent says the child is too short and cannot reach, ask if the child can do this when picked up so they can reach. Ask follow-up questions to find out if the child understands cause and effect tasks like pushing a button to get a response. For example, if the child pushes a doorbell, they know the doorbell will ring. 48. Does your child put a small object in a cup and dump it out? (You may show them how.) Answer "No," if the child is unable to dump the object out. Ask follow up questions to find out what they do instead. For example, the child will put his hand in the cup to take the object out. Include this information in the comments. 49. Does your child stack at least four small toys, blocks, cups, dishes, or other objects on top of each other? Answer “No,” if the child is stacking some objects, but less than four. Include this information in the comments. Check question 33 to confirm the scoring is consistent and correct. 50. Does your child name at least three objects? (For example, bottle, dog, favorite toy, etc.) This question is asking if the child can identify at least three objects, either in spoken language, sign language, or any other method of communication. These objects can be the names of any person, place, or thing. Answer “Yes,” even if the child is not able to say the words accurately. An approximation of the word is ok if it is only used for that object. For example, the child says “baba” instead of “bottle”. Include the objects the child can name in the comments. Answer “No,” if the child just repeats sounds or words another person makes but is not actually identifying an object. Include this information in comments, clearly describing this type of behavior. 51. Does your child follow instructions with one action and one object? (For example, “Bring me the book,” “Close the door,” etc.) Answer “Yes,” if the child follows instructions, but not every time. Include times the child may not follow instructions in the comments. For example, when they are busy doing something else, or are not interested in following a certain instruction. Answer “Yes,’ if the child is able to follow instructions, but does so with a picture schedule rather than from verbal commands. Include this information in the comments. 52. Does your child demonstrate understanding of the meaning “no”, or word or gesture with the same meaning? (For example, stops current activity briefly.) Answer “Yes,” if the child demonstrates they understand the meaning of “no.” The child does not need to comply or actually stop what they are doing, to demonstrate they understand the meaning of “no.” Responses may include: Briefly stopping what they are doing Arguing, talking back, or showing resistance Asking why Answer “Yes,” if the child uses the word “no” in the right context. Include this information in the comments. Answer “Yes,” if the child demonstrates an understanding of the meaning “no,” but uses another word, such as nope, uh-uh, or stop. Include this information in the comments. 53. Does your child copy the activities you do, such as wipe up a spill, sweep, shave, or comb hair? Answer “Yes,” if the child copies the activities with prompts. Include this information in the comments. Answer “Yes,” if the child copies some activities but not others. Include this information in the comments. 54. Does your child play near another child, each doing different things? This question is assessing the child’s tolerance of others in their same space. This includes the same room or the same playground. The children do not need to be right next to each other. This is a base skill for more complex social development. Answer “Yes,” if the child plays near their siblings, but not near other children. Include this information in the comments. Answer “Yes,” if the child will tolerate playing close to another child, even if they are each doing something different and not interacting. The child does not need to initiate play or interact. Answer “Yes,” if the activity itself is the same as the activity other children are doing, but they are doing the activity individually, and not interacting. 55. Does your child hold and drink from a cup or glass? (Includes “sippy” cups.) If this question is answered “Yes,” check question 22 to confirm the scoring is consistent and correct. 56. Does your child look at you when you talk to them? Answer “Yes,” if the child does this, but only briefly. Duration is not a factor. Answer “Yes,” if the child does this sometimes, but not every time. Include times the child may not look at someone in the comments. For example, when they are busy doing something else, or are being disciplined.

NOTE STOP HERE IF THE CHILD IS LESS THAN 30 MONTHS

For Ages 30 months and older

Question (Answer Yes or No) Helpful Hints and Things to Consider 57. While standing, does your child throw a ball or toy? This question is asking if the child can stand and throw an object. It is not asking if the child can throw the object far or straight. 58. Does your child ask questions beginning with what or where? (For example, “What’s that?” “Where doggie go?” etc.) This question is asking if the child can ask questions beginning with what or where. This applies to spoken language, sign language, or any other method of communication. 59. Does your child call themselves “I” or “me” more often than their own name? (For example, “I do it” more than “Mary (John) do it.”) This question applies to spoken language, sign language, or any other method of communication. If the child uses both I or me and their first name, ask to get a more specific frequency to determine the best scoring based on what they use more often. 60. Does your child take off clothing that opens in the front (for example, a coat or sweater)? (Does not have to unbutton or unzip the clothing, etc.) Answer “Yes,” if the child can perform the task with prompts, but no hands-on help. The child must be able to completely remove items without hands-on assistance for the answer to be “Yes.” Answer “No,” if the child needs hands on help to initiate or finish the task, except for unfastening the zipper or buttons. Include this information in the comments. 61. Does your child use a spoon to feed themselves? Answer “No,” if the child can use a fork but not a spoon. Include this information in the comments. Answer “No,” if the child requires hand over hand feeding with the spoon ALL the time. Include this information in the comments. Answer “Yes,” if the child starts the meal by spoon feeding independently or can use a spoon but prefers to use their hands or uses their hands more often than a spoon. Answer “Yes,” if the parent or caregiver puts the food in the spoon and then the child feeds themselves using the spoon. 62. Does your child sleep at least 8 hours in a 24-hour period? Answer “yes,” if the child is not sleeping through the night but takes a nap later that day to make up the time. Include how long the child sleeps in the full 24-hour period in the comments. 63. Does your child do things over and over and can’t seem to stop? (Examples are rocking, hand flapping or spinning.) * This is a Reverse Scoring Question used to assess a behavior that is atypical. This question is not assessing a behavior that occurs one time or on rare occasion. It is assessing repeated behaviors that go beyond normal “bad days,” “terrible twos,” sibling rivalry, or accidents. Describe the behavior in detail. Include: What does the child do; How often the behavior occurs; Under what circumstances the behavior occurs; and What is done to decrease, prevent, or stop behavior. If no intervention is needed, explain the reason for this. 64. Does your child destroy or damage things on purpose? * This is a Reverse Scoring Question used to assess Emotional Regulation. This question is not assessing a behavior that occurs one time or on rare occasion. It is assessing repeated behaviors that go beyond normal “bad days,” “terrible twos,” sibling rivalry, or accidents. Answer “Yes,” if the child has intentionally destroyed something on multiple occasions, and it is considered a consistent behavior. ONLY answer “Yes,” if actual damage was done with intent. Accidentally destroying or damaging something, should not be scored here. Describe the behavior in the comment section and score accordingly. Ask follow up questions to find out if the parent or caregiver has noticed a consistent trigger that occurs prior to these events. Include this information in the comments. Describe the behavior in detail. Include: What does the child do; How often the behavior occurs; Under what circumstances the behavior occurs; and What is done to decrease, prevent, or stop behavior. If no intervention is needed, explain the reason for this. 65. Does your child hurt themselves on purpose? * This is a Reverse Scoring Question used to assess Emotional Regulation. This question is assessing behavior that is intentional, not accidental. Answer “Yes,” if the child has intentionally hurt themselves and the behavior caused an injury. For example, draws blood, leaves bruise, causes red marks, or the child is taken to the ER or doctor for medical attention. Answer “Yes,” if the child experienced injuries in the past, but no longer does because the intervention prevents it. For example, the child no longer bruises their face because the caregiver puts a pillow between the child’s head and the floor to prevent it. Ask follow up questions to find out if the parent or caregiver has noticed a consistent trigger that occurs prior to these events? Include this information in the comments. Describe the behavior in detail. Include: What the child does to hurt themselves; How often the behavior occurs; Under what circumstances the behavior occurs; and What is done to decrease, prevent, or stop the behavior. If no intervention is needed, explain the reason for this.

NOTE STOP HERE IF THE CHILD IS LESS THAN 36 MONTHS

For Ages 36 months and older

Question (Answer Yes or No) Helpful Hints and Things to Consider 66. Does your child stand (balance) on one foot for about 1 second without holding onto anything? Answer “Yes,” if the child can balance on one foot without holding onto someone or something for at least 1 second. Include in the comments how long the child can do this. 67. Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) S/he may hold onto the railing or wall. If the child is able to move up stairs alternating feet AND not holding onto anything, check question 66 to make sure the answers are consistent. Answer “No,” if the child is unable to use one foot on each step while going up stairs. Include how the child does move up the stairs in the comment. 68. Does your child turn the pages of a book one at a time? If the question is answered “Yes,” check question 31, which should also be answered “Yes”. Answer “Yes,” if the child turns the pages of any type of book one at a time. Examples include, cloth, board, paper, magazine. Include what type of book in the comments. 69. Does your child use simple words to describe things? (For example, dirty, pretty, big, loud, etc.) This question is asking if the child can use simple, descriptive words. This applies to spoken language, sign language, or any other method of communication. Answer “No,” if the child just repeats descriptive words another person uses but is not actually using the word to describe something. Include this information in the comments, clearly describing this type of behavior. 70. Does your child state their own first name OR nickname? This question is asking if the child can state their own name or nickname. This applies to spoken language, sign language, or any other method of communication. The child does not need to state both their first name and nickname for the answer to be “Yes”. Answer “No,” if the child just repeats their first name or nickname when another person says it but is not actually associating the word with their name. Include this information in the comments, clearly describing this type of behavior. 71. Does your child follow instructions with two actions or an action and two objects? (For, example, “Bring me the crayons and the paper”, “Sit down and eat your lunch”, etc.) Use investigative interviewing skills to determine if the child is actually following two step instructions, rather than associating activities by habit and repetition. For example, the child is told “put on your socks and shoes” and does so because the child only puts shoes on when he has socks on. But when asked, “bring me the pen and pad of paper” the child only brings the pen and has to be told again to bring the pad of paper. 72. Does your child pretend objects are something else? (For example, does your child hold a cup to their ear, pretending it is a telephone? Does s/he put a box on their head, pretending it is a hat? Does s/he use a block or small toy to stir food?) This question is asking if the child can pretend an object is something else, not if the child can play pretend games, such as being superheroes, playing dress-up, tea parties, or playing “mommy” or “daddy”. 73. Does your child know if s/he is a boy or a girl? This question is assessing the child’s self-awareness and knowledge of how they view themselves. If the parent is unsure, because the child is non-verbal, ask follow-up questions. For example, ask the parent if the child can point to a picture of a boy or a girl, or shake their head “yes” or “no” when asked if they are a boy or a girl. If the parent, answers by saying “Yes” because the child prefers colors or toys that are associated with the opposite gender, ask more questions to make sure the child actually understands gender. For example, ask the parent to show the child a picture of a boy, point to the picture and ask, “Are you a boy?” Show a picture of a girl, point to the picture and ask, “Or are you a girl?” 74. Does your child pull up clothing with elastic waistbands? (For example, underwear or sweatpants) Answer “No,” if the child needs hands-on help to initiate or complete the task. Include this information in the comments. Answer “Yes,” if the child is able to perform the task with verbal prompts. Include this information in the comments. 75. Does your child suck from a straw? Answer “Yes,” if the child can suck from a straw even if the parent is holding the cup. Answer “Yes,” if the child can perform the task using any type of straw and include the information in the comments. 76. Does your child cry, scream, or have tantrums that last for 30 minutes or longer?* This is a Reverse Scoring question used to assess Emotional Regulation. Describe the behavior in detail. Include: What the child does when they have a tantrum. For example, throw themselves on the floor, scream. How often the behavior happens. How long the episodes last. What the triggers are, if any, that cause the tantrums. What is being done to decrease, prevent, or stop the behavior. If there is no intervention, explain the reason. For example, when the parent intervenes the behavior escalates. How the child stops the behavior. For example, falls asleep, gets distracted by something else, or parent gives the child a treat. 77. Does your child act physically aggressive? (For example, hits, kicks, bites, etc)* This is a Reverse Scoring question used to assess Emotional Regulation. This question is not assessing a behavior that occurs one time or on rare occasion. It is assessing repeated behaviors that go beyond normal “bad days”, “terrible twos”, sibling rivalry, or accidents. Describe the behavior in detail. Include: What the behavior looks like. Who it is directed towards. How often the behavior happens. What the triggers are, if any, that cause the behavior. If the behavior caused any injuries. If so, what the injuries are, and how the situation is dealt with. What is being done to decrease, prevent, or stop the behavior. 78. Does your child have eating difficulties? (For example, eats too fast or too slowly, hoards food, overeats, refuses to eat, etc.)* This is a Reverse Scoring question used to assess atypical behavior. Many children eat a little too fast, slow, or refuse certain foods and are considered “picky eaters”. Use investigative interviewing skills to assess if the behavior puts the child at risk or disrupts the family. Include this information in the comments. Ask if the child is being treated by a physician, nutritionist, or speech therapist because of eating difficulties. 79. Does your child sometimes stare at nothing or wander with no purpose?* This is a Reverse Scoring question used to assess Self-Management, dysregulation by disengaging with the environment, and repetitive wandering behaviors. Examples include, walking the perimeter without intention to go somewhere, or pacing. Describe the behavior in detail. Include: How often the behavior occurs How long the behavior lasts. What is done to decrease, prevent, or stop behavior. If no intervention is needed, explain the reason for this.

NOTE STOP HERE IF THE CHILD IS LESS THAN 48 MONTHS

For Ages 48 months and older

Question (Answer Yes or No) Helpful Hints and Things to Consider 80. Does your child hop up and down on one foot? Answer “Yes,” if the child only hops up and down a few times and then falls. Answer “No,” if the child performs the task while holding on to someone or something. Include this information in the comments. 81. Does your child pedal a tricycle or other three-wheeled toy at least 6 feet? Answer “Yes,” if the child is now riding a bike with or without training wheels. Answer “Yes,” if the child is able to pedal six feet or more but is not doing it consistently. Include this information in the comments Answer “No,” if the child moves the tricycle by using their feet, but not actually pedaling. Include this information in the comments. 82. Does your child walk down stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) S/he may hold onto the railing or wall. Answer “No,” if the child is unable to use one foot on each stair while going down stairs, and include how they do move down stairs in the comments. Check question 67 to make sure the answers are consistent. Explain in the comments if they are different. 83. Does your child wiggle their thumb, for example when using a TV remote control or video game controller? This question is asking about the child’s functional use of their thumb. Answer “Yes,” if the child is able to do other tasks that involve the thumb. For example, the child is able to use their thumb to push buttons on a tablet. 84. Does your child unbutton one or more buttons, OR unfasten one or more Velcro straps? Your child may use their own clothing or a doll’s clothing. Answer “Yes,” if the child is able to unbutton buttons OR Velcro straps. They do not need to do both. Answer “Yes,” if the child is only able to do one button or one Velcro strap, but not the rest. Include this information in the comments. 85. Does your child use in, on, or under in phrases or sentences? (For example, “Ball go under chair,” “Put it on the table,” etc.) This question applies to spoken language, sign language, or any other method of communication. Answer “No,” if the child just repeats what another person says but is not actually saying the phrase or sentence on their own. Include this information in the comments, clearly describing this type of behavior. 86. Does your child say their first AND last name? This question applies to spoken language, sign language, or any other method of communication. Answer “Yes,” if the child is asked what their name is and responds accurately. Answer “Yes,” if the child does not respond when asked, but has been heard to say their first and last name in the right context. 87. Does your child follow instructions in “if-then” form? (For example, “If you want to play outside, then put your things away,” etc.) Answer “Yes,” if the child only follows the instructions when it is a preferred activity, but other times does not because they are not motivated by the “if” part. The child does not need to do it all the time for the answer to be “Yes.” 88. Does your child share toys or possessions when asked? Answer “Yes,” if the child shares, but is not happy about doing so. Include this information in the comments. Answer “Yes,” if the child only shares with certain playmates or siblings. Include this information in the comments. 89. Does your child tell you the names of two or more playmates, including brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.) This question applies to spoken language, sign language, or any other method of communication. Answer “Yes,” even if the child is not able to say the names accurately. An approximation of the name or nickname is ok if it is understood. 90. Does your child brush their teeth? Answer “Yes,” if the child starts the task, for example only brushes the front teeth, or does the task but the parent brushes again because the child does not do an adequate job. Answer “No,” if the child only performs the task with hand over hand assistance. 91. Does your child urinate in a toilet or potty chair? Answer “Yes,” if the child does urinate in a toilet or potty chair, but still has some accidents. Answer “Yes,” if the child urinates in the toilet or potty chair with prompts. Answer “Yes,” if a parent sits the child on a toilet or potty chair, and the child urinates. 92. Does your child defecate in a toilet or potty chair? Answer “Yes,” if the child defecates in a toilet or potty chair, but still has some accidents. Answer “Yes,” if the child defecates in the toilet or potty chair with prompts. Answer “Yes,” if a parent sits the child on a toilet or potty chair, and the child defecates. 93. Does your child put on clothing that opens in the front (for example, a coat or sweater)? (Does not have to button or zip the clothing.) Answer “Yes,” if the child can perform the task with verbal prompts. Include this information in the comments. Answer “No,” if the child needs hands-on assistance to initiate or complete the task.

NOTE STOP HERE IF THE CHILD IS LESS THAN 60 MONTHS

For Ages 60 months old, but less than 72 months old

Question (Answer Yes or No) Helpful Hints and Things to Consider 94. Does your child open doors by turning doorknobs? (Includes doors that open and close with levers rather than traditional round knobs). Answer “Yes,” if the child is unable to reach the knobs but can open doors if picked up to reach the knob. Answer “Yes,” if the child can open doors sometimes. Include this information in the comments. Answer “No,” if the child is only able to open doors turning doorknobs with hand over hand assistance. 95. Does your child identify and name most common colors (that is, red, blue, green, and yellow)? This question applies to spoken language, sign language, or any other method of communication. Answer “No,” if the child just repeats the names of colors when another person says them but is not actually associating the word with the color. Include this information in the comments, clearly describing this type of behavior. 96. Does your child follow three-part instructions? (For example, “Brush your teeth, get dressed, and make your bed,” etc.) Answer “Yes,” if the child follows some three-part instructions and understands them. Include this information in the comments. Answer “No,” if the instructions have to be broken down and given one at a time in order for the child to follow them. Include this information in the comments. 97. Does your child take turns when asked while playing games or sports? Answer “Yes,” if the child does this when asked. They do not have to initiate the turn taking. Answer “Yes,” if the child only takes turns when playing some games, but not others. Include this information in the comments. 98. Does your child play informal group games? (For example, hide-and-seek, tag, jump rope, catch, etc.) Answer “Yes,” if the child plays and participates in these types of games. They do not have to initiate the play, and caregivers or friends can tell them what to do. 99. Does your child put shoes on correct feet? (Does not need to tie laces.) Answer “No,” if the child can physically perform the task, but is unable to identify which shoe goes on which foot. Answer “No,” if the child has to be told which shoe goes on which foot. 100. Does your child wash their hands using soap and water? (May be reminded.) Answer “Yes,” if the child can start or finish washing their hands, but the parent re-washes to make sure their hands are clean. Include this information in the comments. 101. Does your child use the toilet by themselves? (S/he goes to the bathroom, sits on the toilet, wipes, and flushes. May be reminded.) Answer “No,” if the child is not able to perform all parts of this task independently. Include what tasks the child in unable to perform, how they are being helped, and by whom in the comments.

The DD 0-5 PAS tool is designed to assess the following:

Gross motor skills;

Fine motor skills;

Communication skills;

Socialization skills;

Daily living skills; and

Behaviors.

During the interview, write down your observations, and take the time to discuss any differences between what is reported by the caregiver and what is seen or read in medical records to ensure accurate scoring. See “Scoring when medical records are not available or conflict with reported function” in PAS Documentation for more guidance.

Answer items based on the child’s performance now, not based on the way the skills were performed at the ages indicated on the PAS tool.

NOTE There are some questions with an exception. These questions are called Precursor Skills. See definition below.

All available, pertinent records should be reviewed prior to completing the PAS scoring to supplement information gathered at the interview.

Don’t assume a child can perform skills based on their performance in other developmental age ranges. Many children with developmental delays have Scattered Skills. See definition below.

At the PAS interview, read all the questions exactly as they are worded on the PAS tool. Do not paraphrase the questions. Further explanation can be given if the question is not understood, however that should be done only after reading the full question as it is written.

If the parent or caregiver’s response to the question is “sometimes” ask more questions to assess what is meant by “sometimes” and determine the proper score. If the skill is emerging, and a child has just begun to perform the milestone, the answer would be “Yes” regardless of how well they do it.

Enter a comment for ALL questions asked. Include who reported the information, what the answer was (Yes or No), and any additional information given.

Term Definition Emerging Skills New skills that the child is just beginning to do. They are skills that the child has not mastered yet. Precursor Skills Developmental skills that are usually attained before learning a more advanced skill. Reverse Scoring The scoring is reversed for questions 9, 63, 64, 65, 76, 77, 78, and 79. A “Yes,” response indicates potential for a serious problem and has a weighted numerical score. Scattered Skills Scattered skills are common with children diagnosed with autism spectrum disorder (ASD). A child may perform several skills within a certain range of developmental checklists but may have some skills in that range that are missing completely. For example, a child has age-appropriate gross and fine motor skills but shows significant delays with their communication and social skills.

Age Cohort Services and Treatments Drug Reg. + Admin. Non-B/B Ostomy Care Tube Feeding PT or OT Acute Hospital Admits* Direct Care Staff Train Special Diet Under 9 Mos 1.0 7.0 7.0 1.0 1 x # 0.5 2.0 9 - 11 Mos 1.0 7.0 7.0 1.0 1 x # 0.5 2.0 12 - 17 Mos 1.0 7.0 7.0 1.0 1 x # 1.0 2.0 18 - 23 Mos 1.0 7.0 7.0 1.0 1 x # 1.0 2.0 24 - 29 Mos 1.0 7.0 7.0 1.0 1 x # 1.0 2.0 30 - 35 Mos 1.0 7.0 7.0 1.0 1 x # 1.0 2.0 36 - 47 Mos 1.5 5.0 5.0 1.5 1 x # 1.0 2.0 48 - 59 Mos 1.5 5.0 5.0 1.5 1 x # 1.0 2.0 60 Mos+ 1.5 5.0 5.0 1.5 1 x # 1.0 2.0

*Capped at 2 points

Age Cohort Medical Conditions / Medical + Developmental Combinations Cerebral Palsy Epilepsy Moderate/Sever/Profound MR Autism + MCHAT* Autism + Behaviours* Under 9 Mos 5.0 5.0 9 - 11 Mos 5.0 5.0 12 - 17 Mos 5.0 5.0 18 - 23 Mos 5.0 5.0 7.0 24 - 29 Mos 5.0 5.0 7.0 30 - 35 Mos 5.0 5.0 7.0 5.0 36 - 47 Mos 5.0 5.0 15.0 7.0 10.0 48 - 59 Mos 5.0 5.0 15.0 7.0 10.0 60 Mos+ 5.0 5.0 15.0 7.0 10.0

*See explanation below

Autism + MCHAT – 18 months and Older

P Diagnosis of Autism, PDD or Autism-like behaviors

P Fails at least six of the following eight MCHAT (or MCHAT-based) milestones:

34. Does your child respond to their name when you call?

38. If you point at a toy across the room, does your child look at it?

39. Does your child ever use their index finger to point, to indicate interest in something?

40. Does your child ever bring objects over to you?

41. Does your child ever imitate you? For example, you make a face – will your child imitate it?

42. Does your child take an interest in other children?

44. Does your child like being hugged or cuddled?

56. Does your child look at you when you talk to them?

Autism + Behaviors – 30 to 35 Months

P Diagnosis of Autism, PDD or Autism-like behaviors

P Exhibits at least three of the following four behaviors:

62. Does your child sleep at least 8 hours in a 24-hour period? (“No” response indicates presence of behavior)

63. Does your child do things over and over and can’t seem to stop? (Examples are rocking, hand flapping or spinning)

64. Does your child destroy or damage things on purpose?

65. Does your child hurt themselves on purpose?

Autism + Behaviors – 36 Months and Older

P Diagnosis of Autism, PDD or Autism-like behaviors

P Exhibits at least six out of the following eight behaviors:

62. Does your child sleep at least 8 hours in a 24-hour period?

63. Does your child do things over and over and can’t seem to stop?

64. Does your child destroy or damage things on purpose?

65. Does your child hurt themselves on purpose?

76. Does your child cry, scream or have tantrums that last for 30 minutes or longer?

77. Does your child act physically aggressive? (For example, hits, kicks, bites etc.)

78. Does your child have eating difficulties? (For example, eats too fast or too slowly, hoards food, overeats, refuses to eat etc.)

79. Does your child sometimes stare at nothing or wander with no purpose?

Algorithm & Weights – Developmental Milestones

Age Cohort 6mos+ 8mos+ 12mos+ 18mos+ 24mos+ 30mos+ 36mos+ 48mos+ 60mos+ 9 milestones 19 milestones 28 milestones 44 milestones 56 milestones 65 milestones 79 milestones 93 milestones 101 milestones Under 9 Mos 5.000 9 - 11 Mos 4.100 4.100 12 - 17 Mos 2.900 2.900 2.900 18 - 23 Mos 2.125 2.125 2.125 2.125 24 - 29 Mos 1.750 1.750 1.750 1.750 1.750 30 - 35 Mos 1.550 1.550 1.550 1.550 1.550 1.550 36 - 47 Mos 1.340 1.340 1.340 1.340 1.340 1.340 1.340 48 - 59 Mos 1.140 1.140 1.140 1.140 1.140 1.140 1.140 1.140 60 Mos+ 1.030 1.030 1.030 1.030 1.030 1.030 1.030 1.030 1.030

In this chapter, you will learn about completing a PAS for customers ages 12 and older who have a developmental disability. The sections in this chapter are:

Motor and Independent Living Skills (ILS)

Communication and Cognitive Domain

Behavioral Domain

For each section in this chapter, you will find:

An overview of the topic

Definitions

Other helpful information

Aggression is physically attacking another person. Some examples of aggression are:

Throwing objects at a person

Punching

Biting

Pushing

Pinching

Pulling hair

Scratching

The following are not included in the score, but are included in the PAS summary:

One-time incidents that did not result in a serious injury needing medical attention

Self-injurious behavior

Physically hurting a pet or animal

Making verbal threats without any physical contact

Destruction of property not directed towards another person

The following table includes tips for getting clear, complete information during the interview. Include the information when entering the comment. The comment should always include who gave the information.

Aggression Components Factors to consider Tips to gather the correct information Does the behavior fit the definition of aggression Is the behavior directed toward another person? Ask questions or use inquiry statements such as: Describe the customer’s physical attacks towards another person. What does he do? When the customer throws things “all over the place”, does she ever throw these items at another person? You said she threw a bottle and broke the television. What the target was when she threw the bottle. Are there safety concerns or risks with the behavior Ask questions such as: Does the customer put others at risk by doing this? What are the risks involved? Has he hurt another person before due to this behavior? How does this jeopardize the safety of others? Determine the intensity of the intervention How often someone intervenes, as well as the effort and physical involvement Ask questions such as: What is done in response to this aggressive behavior? How often is the intervention used? What type of intervention is used most often? How does the customer respond to you doing that? How well does the intervention work? What happens if you do not intervene? What happens when this does not stop the aggression? NOTE Document all information received about any interventions for aggression in the comment section. Determine the frequency of the behavior The past year Ask questions such as: How often does the behavior occur? Did the customer’s behavior cause a serious injury in the past year that required medical attention? If so, when did it happen and what type of medical attention was received. When was the last time this behavior happened?

Follow the steps below to determine the score for Aggression.

Step Action 1 Has the behavior caused one or more injuries that required medical attention in the last year? AND Does the behavior require close supervision and physical interruption? If YES to both questions, STOP. Give the customer a score of 4 - Extremely Urgent Problem. If NO to either question, continue to step 2. 2 Does the behavior: Occur at least once a day and require close supervision, CONSTANT verbal redirection or physical interruption, or a combination of the three interventions? OR Occur less than daily but requires physical interruption? If YES to either question, STOP. Give the customer a score of 3 - Serious Problem. If NO to both questions, continue to step 3. 3 Does the behavior: Occur weekly to every other day? AND Require close supervision, verbal or physical redirection, or a combination of the three interventions? If YES to both questions, STOP. Give the customer a score of 2 – Moderate Problem. If NO to either question, continue to step 4. 4 Does the behavior: Occur less than weekly? AND Require some additional supervision or verbal redirection in a few situations, or a combination of both? If YES to both questions, STOP. Give the customer a score of 1 – Minor Problem. If NO to either question, continue to step 5. 5 Has the aggressive behavior either: Not been observed? OR Occurred, but not at a level that requires intervention? If YES to either question, STOP. Give the customer a score of 0. If NO to both questions, the customer meets some scoring criteria above, go back to step.

This section identifies certain behaviors that may indicate the need for caregiver intervention. Scores are based on the frequency and level of intervention needed to control the problem behavior.

These behaviors include:

Aggression

Verbal or Physical Threatening

Self-Injurious Behavior

Resistiveness or Rebelliousness

Behaviors should be assessed based on the last 12 months with emphasis on current behavior.

The level of the intervention has more impact than the frequency of the behavior. For example, a minor behavior such as whining may occur daily but not be a serious problem because verbal redirection is only provided in a few situations. Verbal redirection happens when out in public, but no intervention is given at home.

Behaviors and the intervention scored above a zero must be described in the comment section. If a behavior occurs but the score is zero, the details must be put in the summary.

When more than one type of intervention is used, score based on the most common method. For example, if verbal redirection is used once or twice a week, but a chemical restraint is given daily, score based on the use of a chemical restraint.

Term Definition Constant At least once a day. Frequent Weekly to every other day. Intervention Therapeutic treatment, including the use of medication, behavior modification and physical restraints to control the customer’s behavior. Intervention may be formal or informal and includes actions taken by friends or family. Medical attention Examination and treatment by a medical professional or Primary Care Provider (PCP) resulting from inappropriate behavior. Some examples of medical attention include, but are not limited to: Treatment received by an emergency medical technician (EMT) Treatment or examination by a psychiatric hospital provider Examination or treatment received at a medical hospital Occasional Less than weekly. Physical interruption Requires immediate hands-on interaction of the caregiver to stop the customer’s behavior or the customer is receiving a chemical restraint for the behavior. See the comparison of Physical interruption, Physical redirection, and Verbal redirection below. Physical redirection Using touch to redirect the customer to perform more appropriate behavior. For example, a parent takes away a dangerous object from the customer and replaces it with a safer one. See the comparison of Physical interruption, Physical redirection, and Verbal redirection below. Verbal redirection A way of managing behavior by verbally expressing a command or request. For example, “Chairs are for sitting. No standing, please.” See the comparison of Physical interruption, Physical redirection, and Verbal redirection below.

Background information:

The customer is a 13-year-old male diagnosed with Autism and ADHD. The father reports when the customer starts feeling overwhelmed his body will start shaking, his fists clench, and he makes growling sounds. The father reports the customer is working with a therapist to identify coping skills that relieve stress and decrease adverse behaviors. The customer told his parents that when he is feeling overwhelmed the thing that helps the most is to go out to the backyard and “shoot hoops.” He said it also helps to eat Frito’s corn chips. He’s not sure why, “maybe because crunching on something that tastes good calms me down.”

Intervention Example Physical interruption The customer’s father reports that last week the customer was playing a video game in the living room. His two younger sisters were also in the living room playing and jumping on the couch. The father said he was in the other room and heard the customer start yelling at his sisters, “shut up and stop jumping or I am going to shut you up.” The father said he immediately stopped what he was doing to go to the living room but by the time he got there, the customer had both of his sisters pinned down on the couch. The father immediately pulled the customer off his sisters, took him by the arm to the backyard and told him to go cool off and shoot some hoops. Physical redirection The customer’s father reports that last week the customer was playing a video game in the living room. The father said he was in the living room playing a board game with his daughters and noticed that the customer was getting frustrated with the game he was playing. The customer’s body started shaking, he stated yelling “I hate this stupid game” and then started to hit himself in the head with the controller. The dad stopped what he was doing, put his hand on the customer’s shoulder, took the video controller away and said, “come on let’s go outside and shoot some hoops.” Verbal redirection The customer’s father reports that last week the customer was playing a video game in the living room. The father said he was in the living room playing a board game with his daughters and noticed that the customer was getting frustrated with the game he was playing. The customer’s body started shaking, he stated yelling “I hate this stupid game” and then started to hit himself in the head with the controller. The dad was able to stop the behavior by saying, “Snack time everybody! Let’s go to the kitchen and get some Frito’s and apple juice.”

Resistiveness or Rebelliousness are inappropriately stubborn and uncooperative behaviors, which include:

Passive or obvious behaviors

Obstinance

Unwillingness to participate in self-care or take necessary medications

The following are not included in the score:

Difficulties with processing information (customers who are slow to respond)

Reasonable acts of self-advocacy

Verbal threats

Physical aggression

Self-injurious behavior

NOTE Comments must include the specific behaviors and the intervention required.

The following table includes tips for getting clear, complete information during the interview. Include the information when entering the comment. The comment should always include who gave the information.

Resistiveness or Rebelliousness Components Factors to consider Tips to gather the correct information Does the behavior fit the definition of resistiveness or rebelliousness? Is the behavior inappropriately stubborn and uncooperative? Ask questions such as: What does the customer not want to do? What is the reason the customer does not want to do that activity? Is it reasonable for the customer to not want to do the activity? How is this behavior inappropriate? What does the customer do that shows she is being uncooperative or stubborn? Is the customer able to follow directions or advocate for himself? Determine the intensity of the intervention. How often the intervention is needed, and how much time and effort the intervention takes. Ask questions such as: What do you do when the customer resists? How often do you have to do that? How does the customer respond to you doing that? How well does the intervention work? What happens if you do not intervene? What happens if the intervention does not work? Determine the frequency of the behavior Consider the past year. Ask questions such as: How often, if know, does the behavior occur? Who is affected? What triggers the behavior, if known?

Follow the steps below to determine the score for Resistiveness or Rebelliousness

Step Frequency 1 Does the behavior meet the following criteria? Occurs at least once daily; AND Requires constant attention, prompting, physical redirection, or a combination of these interventions. If YES, STOP. Give the customer a score of 3 – Serious Problem. If NO, continue to step 2. 2 Does the behavior meet the following criteria? Occurs at least weekly but less than daily; AND Requires frequent attention, prompting, physical redirection, or a combination of these intervention If YES, STOP. Give the customer a score of 2 – Moderate Problem. If NO, continue to step 3. 3 Does the behavior meet the following criteria? Occur less than weekly; AND Requires occasional attention, prompting, or verbal redirection. If YES, STOP. Give the customer a score of 1 – Minor Problem. If NO, continue to step 4. 4 Does the behavior not occur or occurs at a level not requiring intervention? If YES, STOP. Give the customer a score of 0. If NO, the customer meets some scoring criteria above, go back to step 1.

Term Definition Self-advocacy Speaking up for oneself and one’s views or interests

Self-Injurious Behavior (SIB) is repeated actions that cause physical injury to a person’s own body. Some examples of SIB are:

Biting

Repeatedly cutting or scratching skin

Putting inappropriate objects into ear, mouth, or nose

Repeatedly picking at skin or sores

Head slapping or banging

The following are not included in the score:

Suicide attempts

Medical non-compliance issues, such as not following medical advice

Lifestyle choices, such as sexual activity, smoking, or drug abuse

Scratching in response to a rash or other skin condition

The table below has tips for getting clear, complete information during the interview. Put this information in the comments and always include who gave the information.

Self-Injurious Behavior Components Factors to consider Tips to gather the correct information Does the behavior fit the description of self-injurious behavior Does the repeated behavior cause physical harm to the body? Ask questions or use inquiry statements such as: Describe what the customer does that causes harm to his body. How is this causing physical harm to her body? Determine the intensity of the intervention How often the intervention is needed, and how much time and effort the intervention takes. Ask questions such as: What is done in response to this behavior? How often do you respond that way? How well does this intervention work? What happens when you don’t respond this way? What happens when the action taken does not stop the behavior? Determine the frequency of the behavior The past year Ask questions such as: How often does this behavior happen? How seriously was he hurt? Has the customer needed medical attention due to this behavior? Tell me more about that. When was the last time this behavior happened?

Follow the steps below to determine the score for Self-Injurious Behavior. When the behavior and intervention don’t fall into the same scoring criteria, score based on the intervention most frequently used.

Step Action 1 Does the behavior meet the following criteria? Has the behavior caused one or more serious injuries in the last year requiring immediate medical attention? AND Does the behavior require close supervision and physical interruption? If YES to both questions, STOP. Give the customer a score of 4 - Extremely Urgent Problem. If NO to either question, continue to step 2. 2 Does the behavior: Occur at least once a day and require close supervision, CONSTANT verbal redirection, physical interruption, or a combination of these interventions? OR Occur less than daily but requires physical interruption? If YES to either question, STOP. Give the customer a score of 3 – Serious Problem. If NO to both questions, continue to step 3. 3 Does the behavior: Occur at least weekly but less than daily? AND Require close supervision, verbal redirection, physical redirection, or a combination of these interventions? If YES to both questions, STOP. Give the customer a score of 2 – Moderate Problem. If NO to either question, continue to step 4. 4 Does the behavior: Occur less than weekly? AND Require some additional supervision, verbal redirection, or a combination of both in a few situations? If YES to either question, STOP. Give the customer a score of 1 – Minor Problem. If NO to both questions, continue to step 5. 5 Does the behavior occur, but not at a level that requires intervention? OR Has the behavior not occurred in the last year (including if chemically controlled)? If YES to either question, STOP. Give the customer a score of 0. If NO to both questions, the customer meets some scoring criteria above, go back to step 1.

Score of 4:

The customer is an 18-year-old male diagnosed with Autism and Pica. The caregiver reports that at least once a month, the customer puts objects in his ears, and eats his own feces, sand, or other household objects. This causes balance and gastrointestinal issues. The caregiver reports that if she sees the behavior when it is happening, she immediately grabs the customer’s hand to stop the behavior. The caregiver reports three months ago he was hospitalized after eating glass. He must be closely supervised at all times.

The behavior has caused immediate medical attention (one hospitalization) in the past year and requires close supervision and physical interruption.

Score of 3:

The customer is a 12-year-old male diagnosed with Autism and Mild Intellectual Disability. His father reports that when the customer gets upset, he pinches himself on the arms and legs. The father reports this behavior happens at least five times a week. The father said that the customer pinches himself so hard he has broken the skin and left bruises, but he has not needed immediate medical attention. The father said the only thing that stops the behavior is when he or his wife intervene and hold the customer’s arms tightly to his side until he calms down. This can take up to 30 minutes.

Although the behavior does not occur daily, the intervention is always physical interruption.

Score of 2:

The customer’s mother reports that the customer punches himself in the head when he is angry or upset. This happens about once a week. The behavior has caused headaches and bruising. The mother reports she or her husband talk to the customer until he calms down.

The behavior occurs weekly and requires supervision and verbal redirection.

Score of 1:

The customer’s mother reports that approximately once a month the customer will have a “meltdown” when doing homework that she doesn’t understand. The mother said the customer will grab her hair on each side of her head with her hands. The mother said sometimes the customer just does this for a second, and mom doesn’t do anything about it. But every other month the customer has pulled her hair out in clumps. The mother said, she will calmly tell the customer that she can take a break and come back to her homework later.

The behavior occurs less than weekly and sometimes requires verbal redirection.

Score of 0:

The customer is a 12-year-old female diagnosed with Moderate Intellectual Disability. Her mother reports that every other day the customer gets upset when her mom does not let her eat sweets for breakfast. The customer will cry and beat her fists on her chest. The mother said the customer never hurts herself, and mom ignores the behavior.

The customer acts physically aggressive but the behavior is occurring at a level that does not require intervention.

Verbal or physical threatening is behavior in which the customer verbally or physically threatens to hurt themselves or others, or break objects.

Do not include acts of physical aggression or self-injurious behavior.

The following table includes tips for getting clear, complete information during the interview. Include the information when entering the comment. The comment should always include who gave the information.

Verbal or Physical Threatening Components Factors to consider Tips to gather the correct information Does the behavior fit the definition of verbal or physical threatening? Is the customer making verbal or physical threats towards themself, others, or objects? Ask questions and use inquiry statements such as: Describe what the customer says to threaten themself, others, or objects. How does the customer physically threaten others? You said the customer threatened to smash the car windows with a bat. Tell me more about that incident. How often do these threats cause fear or aggression in others? How do others react to the customer’s threats? Determine the intensity of the intervention How often someone intervenes, as well as the effort and physical involvement Ask questions such as: What is done in response to this threatening behavior? How often is the intervention used? How does the customer respond to you doing that? How well does the intervention work? What happens if you do not intervene? What happens when this does not stop the threatening behavior? NOTE Document all information received about any interventions for threatening behavior in the comment section. Determine the frequency of the behavior The past year Ask questions such as: How often does the behavior happen? Did the customer’s behavior cause a serious incident in the past year that resulted in aggression from another person? When was the last time this behavior happened?

Follow the steps below to determine the score for Verbal or Physical Threatening.

Step Action 1 Has the behavior caused one or more incidents in the last year that meets both of the criteria below: Always generates fear or is likely to result in aggression from others; AND Requires close supervision and physical interruption. If YES, STOP. Give the customer a score of 4 – Extremely Urgent Problem. If NO, continue to step 2. 2 Does the behavior: Occur at least once a day, sometimes cause fear or aggression in others, AND require close supervision, CONSTANT verbal redirection, physical interruption, or a combination of the three interventions? OR Occur less than daily, sometimes causes fear or aggression in others, AND requires physical interruption? If YES, STOP. Give the customer a score of 3 – Serious Problem. If NO, continue to step 3. 3 Does the behavior meet ALL the following criteria? Occurs weekly to every other day; Sometimes cause fear or aggression in others; AND Requires close supervision, frequent verbal or physical redirection, or a combination of the three interventions? If YES, STOP. Give the customer a score of 2 – Moderate Problem. If NO, continue to step 4 4 Does the behavior meet ALL the following criteria? Occurs less than weekly; AND Is not taken seriously, does not frighten others, or result in aggression from others; BUT Requires some additional supervision or verbal redirection, or a combination of both? If YES, STOP. Give the customer a score of 1 – Minor Problem. If NO, continue to step 5. 5 Has the behavior not been observed? OR Does the behavior occur, but not at a level that requires intervention? If YES to either question, STOP. Give the customer a score of 0. If NO to both questions, the customer meets some scoring criteria above, go back to step 1.

The following examples only provide guidance on scoring. They do not cover every possible situation.

Score of 4:

The customer is a 16-year-old male diagnosed with Autism and Oppositional Defiant Disorder. Once a week, he raises his fist, shakes it at his peers and yells, “I’ll beat the crap out of you.” This frightens his peers because the customer is taller and bigger than most of his peers. He also threatens and taunts his peers by saying he is going to hurt their mothers and sisters. These threats anger his peers. Three of the incidents in the last year resulted in peers attacking the customer. These incidents resulted in a black eye, broken arm, and a knocked-out tooth. Staff have had to intervene by stepping in the middle of the fights and breaking them up.

The behavior always generates fear, has resulted in aggression from others resulting in more than one serious incident, and requires physical interruption.

Score of 3:

The customer is a 17-year-old female who lives in a group home with 6 other females. She is diagnosed with Mild Intellectual Disability, ADHD, and Bipolar Disorder. Staff report that she is easily agitated by others in the group home and will yell and scream at them and say things like, “if you don’t shut your mouth, I will shut it for you.” Often the customer is in the other room when she makes this threat, but when she is in close proximity of others, they are afraid of her. Each day, the staff must stop what they are doing and ask her to calm down, and when the customer is extremely agitated, they will take her by the arm and escort her to her room.

The behavior occurs at least once a day, sometimes causes fear in others, and requires constant verbal redirection and sometimes physical interruption.

Score of 2:

The customer’s teacher reports that the customer threatens his peers by saying things like; “shut your mouth, or I’ll shut it for you!”, “I’m going to smash your face in with my boot.” The teacher reports that the customer is triggered by minor things, like someone standing too close to him. The customer is larger than most of his peers, and they are frightened by him. The teacher’s aide keeps a close eye on the customer and tells him he needs to take a time out and calm down. This happens every other day.

The behavior occurs every other day and requires close supervision and frequent verbal and physical redirection.

Score of 1:

The customer’s mother reports that once a month the customer raises her fists to start hitting whoever is nearby when she is angry. The behavior is not taken seriously and does not frighten others or result in aggression from others. Her parents ask her to cool down and keep a close eye on her.

The behavior occurs occasionally and requires some additional supervision and redirection.

Score of 0:

The customer is a 12-year-old female diagnosed with Epilepsy. Her mother reports that when the customer gets angry she shakes her fists at the rest of the family. Her siblings laugh, and her parents have to tell the siblings not to bother her.

There is no intervention for the customer, only for her siblings.

This section is used to assess the customer’s ability to associate time with events and actions. This section does not assess the customer’s ability to tell time.

Use the questions in the scoring table below to get a clear, complete picture of the customer’s ability to associate time with events and actions. Include the information when entering the comment. The comment should always include who gave the information.

NOTE Document any differences between what is reported by the caregiver or in the medical records and what is observed during the interview.

Follow the steps below to determine the score for Association of Time with Events and Actions.

Step Action 1 Does the customer associate events with specific times? For example, the concert started at 7:45 pm. If YES, STOP. Give the customer a score of 0. If NO, continue to step 2. 2 Does the customer associate regular events with specific hours? For example, dinner is around six, bedtime is around ten. If YES, STOP. Give the customer a score of 1. If NO, continue to step 3. 3 Does the customer associate regular events with morning, noon, or night or does not understand time but knows the sequence of daily events? For example, I go to school in the morning, have lunch in the afternoon, or go to bed at night. If YES, STOP. Give the customer a score of 2. If NO, continue to step 4. 4 Is the customer unable to associate events and actions with time? If YES, STOP. Give the customer a score of 3. If NO, the customer meets some scoring criteria above, go back to step 1.

Clarity of communication is the customer’s ability to speak in a recognizable language or use a formal symbolic substitution, such as American Sign Language. When the customer has more than one form of communication, score based on what is best understood.

Use open-ended questions and inquiry statements to get a clear, complete picture of the customer’s ability to communicate effectively. Some suggested questions and inquiry statements are:

What does the customer do to communicate with others?

Please tell me more about how the customer lets you know something is needed.

Include the information when entering the comment. The comment should always include who gave the information.

NOTE Document any differences between what is reported by the caregiver or in the medical records and what is observed during an in-person interview.

Follow the steps below to determine the score for Clarity of Communication.

Step Action 1 Does the customer use a recognizable language, non-verbal form of communication, or formal symbolic substitutions, such as writing a note or American Sign Language? If YES, continue to step 2. If NO, STOP. Give the customer a score of 4. 2 Does the customer use speech or another form of communication that is ONLY understood by those who know the person well or who are trained in the alternate form of communication? If YES, STOP. Give the customer a score of 3. If NO, continue to step 3. 3 Does the customer use a non-verbal form of communication that others understand, such as writing, communication board, gestures, or pointing? If YES, STOP. Give the customer a score of 2. If NO, continue to step 4. 4 Does the customer use speech that is understood by strangers with some difficulty? For example, the customer’s speech is unclear and others can only understand most of the words by paying close attention. If YES, STOP. Give the customer a score of 1. If NO, continue to step 5. 5 Does the customer speak clearly and is easily understood? If YES, STOP. Give the customer a score of 0. If NO, the customer meets some scoring criteria above. Go back to step 1.

In this chapter, you will learn about:

Expressive verbal communication