How to Complete and Submit the Arizona ALTCS Application Form

To start an Arizona ALTCS application, complete the combined DE-101/DE-202 form and submit it through the Health-e-Arizona Plus portal, by fax to 888-507-3313, or by mail to AHCCCS, P.O. Box 6050, MD 15023 ALTCS, Phoenix, AZ 85002-5520. You can also request a form by calling the ALTCS toll-free line at 888-621-6880.¹ After the form is logged, an eligibility specialist schedules a financial interview and a nurse or social worker conducts a Preadmission Screening. The full process generally takes about 45 days.²

Check Eligibility Before You Apply

ALTCS is Arizona’s Medicaid program for people who need nursing home care, assisted living, or ongoing in-home support. Three things have to line up before an application makes sense.

You must be an Arizona resident with a Social Security number (or proof you have applied for one), and a U.S. citizen or qualified immigrant.³ Your declaration of residency on the application is usually enough, though the state can ask for backup such as an Arizona driver’s license, a utility bill, or a landlord statement.⁴

The gross monthly income cap for an individual is $2,982, effective January 1, 2026. Gross means before deductions, so Social Security, pensions, VA benefits, rental income, and annuity distributions all count. Countable assets for a single applicant cannot exceed $2,000, including checking and savings balances, CDs, stocks, bonds, and the cash surrender value of life insurance policies with a face value above $1,500.³

Several assets do not count against that limit:

Your home, if it is not held in a revocable trust. A home equity limit of $752,000 applies in 2026 for applicants not living in the home at the time of application.
One vehicle, regardless of value.
Burial funds up to $1,500, plus burial plots and irrevocable prepaid burial plans.
Household furnishings and personal belongings.
ABLE accounts, Flexible Spending Arrangements, and Coverdell Education Savings Accounts.

If you are married and your spouse will continue living in the community, federal spousal protections apply. The community spouse keeps a protected share of combined countable assets ranging from $32,532 to $162,660 in 2026, and is allowed a minimum monthly income of $2,644 effective July 1, 2025.⁵

Financial eligibility is only half the picture. You also need to require a nursing-facility level of care, which is decided by the Preadmission Screening described below. Needing help with bathing or dressing is not automatically enough; the state scores your functional and medical needs against a threshold.

Documents to Gather First

Missing paperwork is the most common reason an ALTCS application stalls. Pull these items together before you start the form.

Social Security card, birth certificate or U.S. passport, and naturalization or permanent resident papers if you were born outside the United States.
Bank and financial statements covering the past 60 months for every checking, savings, and CD account, plus 401(k), IRA, and brokerage statements.
Life insurance policies showing face value and current cash surrender value.
Income documentation: Social Security award letters, pension stubs, VA benefit letters, rental income records, and annuity contracts or recent tax returns.
Deeds, mortgage statements, and property tax records for any real estate.
Records of any gifts, property transfers, or below-market-value sales in the past five years.
A current medication list with dosages, and contact details for your primary care physician and any specialists.

The 60-month bank statement requirement catches most applicants off guard. Pulling five years of records from multiple institutions takes time, especially for closed accounts. Start there.

AHCCCS reviews every financial transfer made during those 60 months. Gifts, title transfers, or sales below market value that did not bring back equal value can trigger a penalty period of ineligibility, calculated by dividing the transferred amount by the average private-pay nursing home rate in your county (roughly $8,667 per month in Maricopa, Pima, and Pinal counties for October 2025 through September 2026, and about $8,132 elsewhere). Transfers to a spouse or a disabled child are not penalized, and you can rebut a penalty by showing equal value received, the item was returned, or the transfer was made for a reason unrelated to qualifying for ALTCS.⁶

Filling Out the DE-101/DE-202 Form

The combined DE-101/DE-202 collects your contact information, the type of care you need, your current living arrangement, household composition, and financial details. Report a spouse accurately, because the community-spouse protections only apply if AHCCCS knows the spouse exists.

You can name an authorized representative on the form, typically a family member or someone holding power of attorney. That person can sign documents and speak with AHCCCS staff about your case. Include their full name, address, and phone number.

Submitting the Application

Three channels are available:

Online at healthearizonaplus.gov.
Fax, toll-free, to 888-507-3313. Send all pages in a single transmission and keep the confirmation report.
Mail to AHCCCS, P.O. Box 6050, MD 15023 ALTCS, Phoenix, AZ 85002-5520. Certified mail with return receipt gives you proof of delivery.⁷

Your filing date is the date AHCCCS receives the application, not the date you sent it. That timestamp starts the processing clock and can affect retroactive coverage. AHCCCS may cover eligible services for up to three months before your application month if you would have qualified during that period.⁸

What Happens After You Submit

Once your application is logged, an eligibility specialist schedules a financial interview, which is mandatory for every ALTCS application.⁹ It usually happens by phone. The specialist walks through your asset documentation, asks about specific transactions from the past five years, and may request updated statements if the ones you submitted are more than a few weeks old.

A separate Preadmission Screening (PAS) evaluates whether you need institutional-level care. A registered nurse or social worker reviews your ability to bathe, dress, eat, and move around, along with your medical conditions. The screening typically takes place where you live, whether that is your home or a healthcare facility.¹⁰

The evaluator scores you on a standardized instrument that produces a functional score and a medical score. For adults age 12 and older, the functional score can go up to 124.1 points and the medical score up to 21.4 points. There is no minimum in either category, but the combined total must reach the threshold for your eligibility group.¹¹

You will get written notice by mail with the date and time of both appointments. Missing either one results in an automatic denial. If you have to reschedule, contact your assigned specialist as far in advance as you can.

If Your Income Is Above the Cap: Miller Trust

Gross income above $2,982 does not automatically disqualify you. You can create an Income-Only Trust, commonly called a Miller Trust, which is a special bank account that receives the income pushing you over the cap. Income deposited into the trust is not counted for eligibility, though it still factors into your share-of-cost once benefits begin.

The trust has to meet all of these conditions:

The ALTCS applicant is named the primary beneficiary.
AHCCCS is named as a remainder beneficiary, so the state can recover from the trust after the beneficiary’s death.
A separate account titled to the trust is opened with a zero balance.
Only the applicant’s income goes into the account, deposited in the same month it is received.
Income is direct-deposited into the trust account unless the payer does not allow direct deposit to a trust.¹²

The trust must be in place before your eligibility determination is finalized. Many Arizona elder law attorneys prepare these for a flat fee, and some legal aid organizations can help if cost is a barrier.

Common Denial Reasons and How to Appeal

Applications typically fail for one of a handful of reasons: countable assets above $2,000, income above the cap with no Miller Trust in place, a PAS score below the medical threshold, an unresolved transfer penalty from a gift made in the last five years, or not responding to requests for additional documentation. A home held in a revocable trust can also trigger a denial because it is counted as a resource instead of an exempt residence.

If you receive a denial notice, you have 35 days from the date on the notice to request a fair hearing before an administrative law judge. Miss that window and the appeal option is gone. Requests go in writing to the AHCCCS Office of the General Counsel at 150 N. 18th Ave., MD-15013, Phoenix, AZ 85007, or by fax to 602-253-9115. For questions, call 602-417-4232 in Maricopa County or 1-800-654-8713 ext. 74232 statewide.¹³

A denial does not bar you from reapplying. If the issue was excess assets, you can spend down and file again. If a document was missing, gather it and try again. Many successful ALTCS recipients were denied the first time.

1
Arizona Health Care Cost Containment System. Request For Application For Arizona Long Term Care System
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Arizona Health Care Cost Containment System. ALTCS Services and Benefits
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Arizona Health Care Cost Containment System. Filing an Application for the Arizona Long Term Care System
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Arizona Health Care Cost Containment System. 531 Resident of Arizona
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Arizona Health Care Cost Containment System. ALTCS Policies on Community Spouse
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Arizona Health Care Cost Containment System. ALTCS Transfer Policies
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Arizona Health Care Cost Containment System. Request For Application For Arizona Long Term Care System
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Arizona Health Care Cost Containment System. Retroactive Coverage (also called Prior Quarter Coverage)
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Arizona Health Care Cost Containment System. 1303 ALTCS Application Process
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Arizona Health Care Cost Containment System. 1002 Preadmission Screening PAS Process
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Cornell Law Institute. Arizona Administrative Code R9-28-305 – Preadmission Screening Criteria
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Arizona Health Care Cost Containment System. ALTCS Policies on Special Treatment Trusts
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Arizona Health Care Cost Containment System. Grievance And Appeals