A. Program contractor responsibilities
The program contractor:
Provides services through a managed care plan, also known as a Health Maintenance Organization (HMO).
Contracts with nursing facilities, HCBS facilities, hospitals, doctors, pharmacies, and other providers to form a network of service providers.
Assigns the case manager who, in conjunction with the customer’s primary care physician, develops a service plan for the customer. The case manager is responsible for authorizing all long term care services provided through ALTCS.
B. Who are the ALTCS program contractors?
There are three types of organizations that are program contractors:
The Department of Economic Security (DES/DDD) (MS 1103.02);
Native American contractors (MS 1103.03); and
Program contractors for the Elderly and/or Physically Disabled (EPD) that are determined by the customer’s county of fiscal responsibility (MS 1103.04).
AHCCCS currently has contracts with four program contractors to provide ALTCS services to Elderly and/or Physically Disabled (EPD) customers, who are not enrolled with a tribal contractor. The contracts specify which county or counties each program contractor serves.
ALTCS EPD Program Contractor |
Counties Served |
Bridgeway Health Solutions 1501 W. Fountainhead Corporate Park, Suite 201 Tempe, AZ 85282 Toll free 1-866-475-3129 |
Cochise, Gila, Graham, Greenlee, Maricopa, Pinal |
Evercare Select http://www.evercareselect.com/ AZ060-N120 3141 North 3rd Avenue Phoenix, AZ 85013 (602) 331-5100 Toll free 1-800-293-3740 |
Apache, Coconino, La Paz, Maricopa, Mohave, Navajo, Pima, Santa Cruz, Yavapai, Yuma |
Mercy Care Plan 4350 E. Cotton Center Blvd. , Bldg D Phoenix, AZ 85040 (602) 263-3000 Toll free 1-800-624-3879 |
Maricopa, Pima |
SCAN Long Term Care http://www.scanhealthplan.com/default.aspx 1313 E. Osborn Road, Suite 150 Phoenix, AZ 85014 (602) 778-3300 Toll free 1-888-540-7226 |
Maricopa
Note: Effective October 1, 2011, enrollment is capped with no new persons being enrolled. |
C. When does enrollment occur?
The effective date of enrollment is determined by the customer’s AHCCCS status on the date of approval.
IF the customer is |
THEN ALTCS enrollment and capitation |
Enrolled with an AHCCCS health plan at the time of approval |
Begins on the date ALTCS approval is posted in PMMIS. The customer is disenrolled from the AHCCCS health plan the day before.
EXCEPTION: If the effective date of ALTCS eligibility is before the date the customer was enrolled with a health plan, the prior period begins on the first day of the ALTCS application (or the first eligible month) and ends on the day before the health plan enrollment began.
EXAMPLE: Mrs. Y applied for ALTCS on March 25th. In April she was approved for SSI-MAO and was enrolled with a health plan effective April 1st. On May 7th her ALTCS application was approved effective March 1st. Mrs. Y is enrolled with a program contractor on May 7th and that program contractor is also responsible for prior period coverage from March 1st through March 31st. Her health plan enrollment is for the period of April 1st to May 6th. |
Not enrolled with an AHCCCS health plan |
Is retroactive to the effective date of eligibility (prior period coverage).
EXAMPLE: Mr. D applied for ALTCS on January 17th. On March 3rd his application was approved effective January 1st. The prior period begins on January 1st and ends on March 2nd. |
D. What happens after enrollment?
After enrollment occurs:
The program contractor gives the customer written information about their organization.
The customer chooses the doctor he or she prefers as a primary care physician (PCP) from the program contractor’s list of participating physicians. If the customer does not choose a PCP, one is assigned. The primary care physician coordinates care and acts as a gatekeeper. If the customer’s current doctor is a member of the program contractor’s network, the customer does not need to change doctors.
A case manager assigned by the program contractor contacts the customer and the customer’s representative soon after enrollment to establish a service plan that best meets the customer’s needs. Input from the customer and the customer’s family is encouraged.
The customer receives an ID card in the mail from AHCCCS that includes the name and phone number of the program contractor. The customer presents this ID card whenever medical services are requested or provided (e.g., doctors offices, hospitals, labs and pharmacies). DDD members receive their ID cards from DDD.