Do I Qualify?

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Quiz Questions

1.
Are you able to walk without assistance?
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- A.
  Yes, no help is needed.
- B.
  Yes, but I need someone to stand by in case I fall.
- C.
  No, I would need someone there to help me.
- D.
  No, I am not moving independently at all.
2.
Are you able to safely and effectively move from one fixed location to another?
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- A.
  Yes, no help is needed.
- B.
  Yes, but I need someone to stand by in case I fall.
- C.
  No, I would need someone there to help me.
- D.
  No, I am not moving independently at all.
3.
Are you safely and effectively able to shower, wash all parts of the body, turn off the water, get out of the shower, and towel off?
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- A.
  Yes, no help is needed.
- B.
  Yes, but I need some help with parts of the process.
- C.
  No, I would need someone to help me throughout the process.
- D.
  No, I am not able to complete any part of the process.
4.
On a cold winter day are you able to choose and put on appropriate clothes?
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- A.
  Yes, no help is needed.
- B.
  Yes, but I need some help with parts of the process.
- C.
  No, I would need someone to help me throughout the process.
- D.
  No, I am not able to complete any part of the process.
5.
Are you able to eat and drink, also cut, chew and swallow foods without choking?
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- A.
  Yes, no help is needed.
- B.
  Yes, but I need some help with parts of the process.
- C.
  No, I would need someone to help me throughout the process.
- D.
  No, I am not able to complete any part of the process.
6.
Are you able to realize when you have to use the toilet, get to the toilet, undress, wash and dry hands, and put clothes back on?
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- A.
  Yes, no help is needed.
- B.
  Yes, but I need some help with parts of the process.
- C.
  No, I would need someone to help me throughout the process.
- D.
  No, I am not able to complete any part of the process.
7.
How is your hearing? If an aid is used, rate hearing while using the device .
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- A.
  Hears adequately (e.g., conversations, TV, phone) / Unable to assess.
- B.
  Minimal difficulty when not in a quiet setting (understands conversations when in one-on-one situations).
- C.
  Hears in special situations only (e.g., the speaker has to adjust the tonal quality and speak distinctly or when the speaker’s face is clearly visible); able to follow only loud conversation.
- D.
  Highly impaired/absence of useful hearing (e.g., will hear only very loud voice); totally deaf.
8.
How adequately are you able to see?
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- A.
  Sees adequately (e.g., newsprint, TV, medication labels) / Unable to assess.
- B.
  Impaired. Difficulties focusing at close (reading) range. Sees large print and obstacles, but not details or has monocular vision
- C.
  Highly impaired. Very poor focus at close range (e.g., unable to see large print); field of vision is severely limited (e.g., tunnel vision or central vision loss).
- D.
  Severe impairment. No vision or appears to see only light, colors or shapes.
9.
Have you been diagnosed with dementia/Alzheimer's disease?
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- A.
  Yes
- B.
  No
10.
What is the value of your assets?
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- A.
  Greater than $10,000
- B.
  $4,000 - $10,000
- C.
  $2,000 - $4,000
- D.
  Less than $2,000
11.
Are you married?
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- A.
  Yes
- B.
  No
12.
What is your monthly income including pension and SSI?
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- A.
  Greater than $4,000
- B.
  $2,500 - $4,000
- C.
  Less than $2,500

Quiz Outcomes

1.
Arizona Long Term Care System
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Based on your answers, we would like to share the ALTCS benefit with you.Click the link below to have one of our experienced patient navigators reach out to share the next steps with you.

Do I Qualify?

The Arizona Long Term Care System is health insurance for individuals who are age 65 or older, or who have a disability, and require a skilled nursing level of care. Services may be provided in an institutional, home or community-based setting.

Quiz Questions

Quiz Outcomes