Arizona Health Care Cost Containment System
Arizona Long Term Care System (ALTCS)
Initiation of Home and Community Based Services
For Elderly and Physically Disabled Members

October 2013
“Our first care is your health care”

Thomas J. Betlach
Director, AHCCCS

Prepared by the Division of Health Care Management

ABSTRACT
Home and Community-Based Services (HCBS) provide a wide array of services which assist
with activities of daily living (ADLs) for older adults and/or those with disabilities so they can
remain in their homes rather than an institutional facility such as a nursing home. The Arizona
Health Care Cost Containment System (AHCCCS) HCBS Program was introduced to offer
members and families the opportunity to actively participate in the selection of services that will
best meet the needs of the member. The HCBS program has proven to be a cost effective
alternative to institutional care. AHCCCS, Arizona’s Medicaid program, requires services for
HCBS members to be initiated within 30 days of enrollment into the Arizona Long Term Care
System (ALTCS).
The data in this report assesses the percentage of newly placed Elderly and Physically Disabled
(E/PD) HCBS members who received specific services within 30 days of enrollment, both
overall and by contracted health plan (Contractors). The methodology used includes a random
sample from each Contractor for the contract year end (CYE) 2012 measurement period
(October 1, 2011 through September 30, 2012). The findings indicate each Contractor met the
Minimum Performance Standard, which is 92 percent. Contractor rates ranged from 100 percent
to 93.3 percent with the aggregate rate being 96.3 percent.

Arizona Long Term Care System (ALTCS) Initiation of Home and Community Based
Services for Elderly and Physically Disabled Members, CYE 2011

INTRODUCTION
Americans regardless of age, gender, race or ethnicity want the same opportunities; the ability to
have successes and achievements as well as own their independence. Each wants to be in control
of their own lives so they may go to work, church, school and even explore their communities
with family and friends if they so choose. In the past, elderly and physically disabled populations
have not always been able to do such. In fact any abilities a person maintained seemed to
become irrelevant when one was identified as having a disability or reached a certain age.
Through strong advocacy, these ideas shifted into a different understanding; these populations
can receive a wide variety of needed services and remain in their own homes and communities,
thus allowing them to maintain their dignity and independence.
The Arizona Health Care Cost Containment System (AHCCCS) has implemented a long-term
care program through the Arizona Long Term Care System (ALTCS), which strongly supports
opportunities for individuals enrolled in the ALTCS program to live in a home or community
based setting (HCBS). The ALTCS program supports values of: choice, independence, selfdetermination, dignity and individuality. Guiding principals have also been established under the
belief that every effort should be made to support the ability of individuals to reside in HCBS
settings. These guiding principles are:
Members-centered case management
Accessibility of network
Collaboration with stakeholders

Consistency of services
Most integrated setting

Millions of Americans require long term care services and supports to assist them with activities
of daily living. Activities of daily living include: toileting, dressing, grooming, bathing, eating
and walking. Long term care consists of a variety of medical and social services to help meet the
health and personal needs of individuals with a chronic illness or disability. Most prefer to
receive these services in their home in order to maintain their dignity, privacy and independence
while being closer to their families rather than residing in an institutional facility, such as a
nursing home.
Medicaid has become the largest payer of these services in the nation, financing 43 percent of all
long term care services.1 Nationally, Medicaid long term care recipients make up 6 percent of the
Medicaid population but account for nearly half of its spending.1 In addition, nearly half of
Medicaid long-term care spending goes toward institutional care while 29 percent is spent on
community-based care.1 A study conducted by Met Life in 2011 indicate the average national
price for home care is $20,800 annually, followed by assisted living at a rate of $41,742 annually
for a basic package, and the average cost of a nursing home is $78,235 for a semi-private room.2
The need for long term care services in the United States is on the rise, with the older population
projected to grow significantly between 2010 and 2030 as a result of the “baby boom” generation

reaching 65 years of age and the life expectancy of people with disabilities increasing due to
medical advances and enhanced living conditions.3 Nationally, 58 percent of this population is
65 years or older while the remaining 42 percent is under 65.4
AHCCCS HCBS PROGRAM
AHCCCS has provided HCBS through a waiver from the Centers for Medicare and Medicaid
Services (CMS) since 1989. Through ALTCS, AHCCCS provides comprehensive coverage for
HCBS members residing in their own homes or approved alternative residential settings, such as
assisted living facilities or group homes. Covered services include care such as home health
nursing, attendant or personal care, and home delivered meals. Members may designate a family
member or friend to provide attendant care. After completion of training, these caregivers may
be paid by AHCCCS.
As of September 2012, there were 25,989 ALTCS Elderly and Physically Disabled (E/PD)
members served by AHCCCS; 33 percent were ages 0-64 years and 67 percent were 65 years of
age or older. Of those, 72.7 percent resided in home and community-based settings. By providing
a variety of alternative settings along with a wide array of HCBS options, ALTCS members are
able to delay institutionalization for a longer period of time and some are able to transfer from an
institutional setting to their home or other community-based settings.
Once eligibility for ALTCS is determined, based on financial and medical criteria, members
enroll with a contracted health plan (Contractor). Each member is assigned a case manager who
coordinates care with the member’s primary care physician (PCP) and other providers, addresses
and coordinates service delivery, and modifies the member’s care plan based on changes in
health status. Case managers visit new members and assess needs to determine the most
appropriate services and placement setting. AHCCCS requires that Contractors initiate home and
community-based services within timelines to meet members’ medical needs, but no later than
30 calendar days from the member’s date of enrollment. To ensure that member needs continue
to be met in the most appropriate setting, case managers reassess members’ physical and
functional status at regular intervals and AHCCCS monitors the ongoing provision through
regular reviews of Contractor operations.
AHCCCS annually measures the percentage of newly placed E/PD HCBS members who receive
specific services within 30 days of enrollment. This measurement is conducted to determine
individual Contractor compliance with contract performance standards as well as to analyze
overall rates of initiation of services for HCBS members. It should be noted that this
measurement does not include all covered home and community-based services. For example,
emergency-alert and home-modification services are not included because they are typically
provided in conjunction with nursing, personal care or other supportive services. This
measurement focuses on the health-related services that allow ALTCS members to remain in
their homes as long as possible.

Purpose:
The purpose of this performance measure is to monitor the performance of the AHCCCS
Contractors who provide services to the ALTCS members. This measure evaluates the
percentage of newly placed HCBS ALTCS members who received specific home and
community based services within 30 days of enrollment, overall and by Contractor.
Methodology:
The measurement period for the current study was October 1, 2011 through September 30, 2012.
A representative random sample was selected for each Contractor. The sample frame consisted
of E/PD members who:
were enrolled for 30 days or more with an ALTCS Contractor during the measurement
period,
were newly placed in an HCBS setting, other than an assisted living facility, and
were not ventilator-dependent, as Contractors are required to initiate services to those
members within 14 days of enrollment.
Excluded from this study were members who died, were hospitalized, were receiving hospice
services, or refused services when these situations were documented as occurring within 30 days
of enrollment.
Data was first collected from the AHCCCS encounter data (records of claims paid by
Contractors). If initiation of services within 30 days of enrollment were not found in the
AHCCCS encounter data, Contractors were asked to provide information from medical or case
management records or their claims data. Contractor-submitted data was validated against
supplemental documentation, such as copies of the pertinent sections of case management
records, medical/service records from providers, or verification of claims paid by Contractors for
qualifying services.
Minimum Performance Standards and Goals:
AHCCCS has established a Minimum Performance Standard (MPS) that Contractors must
achieve. This standard is specified in the Contract Year Ending (CYE) 2012 ALTCS E/PD
contract.
Measure
HCBS services within 30 days

MPS

Goal

92%

98%

If a Contractor does not meet the minimum performance standard, a Corrective Action Plan
(CAP) must be implemented and the Contractor may face a financial sanction if the measure fails
to show a significant improvement. AHCCCS also has set a goal that Contractors must strive to
meet if they are already meeting the minimum performance standards.

RESULTS AND ANALYSIS
The study sample included 400 HCBS members enrolled with three different ALTCS
Contractors. Of those, 48 people were excluded for one of six different reasons as indicated on
Table 1.
Table 1: Study Exclusions
Reasons for Exclusions
Assisted living/nursing facility

10

Admitted to Hospital
Received Hospice service
Refused services
Awaiting designated caregiver to be
trained
Died

1
6
19

Total:

48

12
0

Among the remaining 352 members, 96.3 percent received services within 30 days of
enrollment, a non-statistically significant decrease from the previous rate of 97.3 percent
(p=.507). All three Contractors met the Minimum Performance Standard and one achieved the
AHCCCS Goal. Contractor specific performance is shown in Table 2.
Table 2: Initiation of Home and Community Based Services, By Contractor
Measurement Period: Oct. 1, 2011 through Sept. 30, 2012
Minimum Performance Standard: 92%

Contractor
Bridgeway Health Solutions

Percent who
Received Service
Within 30 Days

Relative Percent
Change

Statistical
Significance

93.3%

-1.6%

p=.648

0.6%

p=.865

0.0%

N/A

-0.1%

p=.507

94.9%
Evercare Select

95.7%
95.1%

Mercy Care Plan

100.0%
100.0%

TOTAL

96.3%
97.3%

Notes:
A change in a rate from the previous measurement is considered statistically significant when p< .05.
Shaded rows show results of previous measurement, Oct. 1, 2010, through Sept. 30, 2011.

There was no significant difference in performance rates between rural and urban counties or by
members’ race or ethnicity.
DATA QUALITY AND RELIABILITY
AHCCCS conducts validation studies to evaluate the completeness of its encounter data. To
validate additional information collected by Contractors, AHCCCS requires documentation of
services provided or reasons why a member did not receive services. Documentation provided by
Contractors included copies of the pertinent sections of case management records,
medical/service records from providers, or verification of claims paid by Contractors for
qualifying services. These documents were reviewed by AHCCCS staff with expertise in
ALTCS case management.
DISCUSSION
Given the variety and complexity of members’ needs and personal situations when they enroll in
the ALTCS program, Contractor case managers face distinct challenges in ensuring that
enrollees have prompt access to home and community based services that fit with their individual
choices and needs. Despite these challenges, the overwhelming majority of new ALTCS
members placed in HCBS settings receive services within 30 days of enrollment.
Since much of the data for this measure is collected from case management records when claims
or encounters for services are not available, Contractors must ensure that case managers
thoroughly and consistently document when home and community-based services are initiated
for new members or when members or authorized representatives refuse services. Over the past
few years, AHCCCS has worked with Contractors to improve this documentation and AHCCCS
continues to monitor to ensure appropriate documentation practices are in place.
QUALITY IMPROVEMENT INITIATIVES
ALTCS Contractors have developed numerous initiatives over the years to enhance the quality of
life of HCBS members, several of which facilitate timely access to care. These include:
Monitoring service provision to HCBS members within one to two weeks of enrollment.
Contractor reports are run at regular intervals and provided to case managers for followup as necessary.
The use of automated case management systems, which can be used to track timelines of
service initiation and generate reminders for case managers to follow up.
The development of multi-disciplinary teams that coordinate case management, medical
management and quality management staff to more closely monitor needs of members in
the HCBS program and to facilitate the development of new ways to facilitate timely
access to care.

CONCLUSIONS
AHCCCS raised the minimum performance level in 2008 in order to encourage continued
improvement. As a result, ALTCS Contractors implemented interventions that have continued to
lead to overall improvement and continued progress toward the long-range goal of ensuring
timely initiation of services for members in home and community based settings. Two of three
Contractors maintained their success rate, while one showed a non-statistically significant
decline; however, all Contractors were above the MPS. The three Contractors will continue to
monitor the initiation of home and community based services to ensure members receive
appropriate and timely services. AHCCCS encourages all Contractors to strive to achieve the
AHCCCS goal of 98 percent for CYE 2013.

Works Cited
1.

The Henry Kaiser Family Foundation. October 2011. Medicaid’s Long-Term Care users: Spending Patterns
Across Institutional and community-based Settings. Kaiser Commission on Medicaid and the Uninsured.
Doi: http://www.kff.org/medicaid/upload/7576-02.pdf

2.

Institute, The MetLife Mature Market. Market Survey of Long-Term Care Costs: The 2011 MetLife
Market Survey of Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs. Westport :
The MetLife Mature Market Institute, 2011.

3.

U.S. Department of Health and Human Services. 2011. A Profile of Older Americans: 2011, Administration
on Aging

4.

The Henry J. Kaiser Family Foundation. March 2011. Medicaid and Long-Term Care Services and
Supports. Kaiser Commission on Medicaid Facts, Figure 1. doi: http://www.kff.org/medicaid/upload/218608.pdf

For questions or comments about this report, please contact:
Jakenna L. Lebsock, MPA; Quality Improvement Manager
Clinical Quality Management Unit
Division of Health Care Management, MD 6700
701 E. Jefferson St.
Phoenix, AZ 85034
Jakenna.Lebsock@azahcccs.gov