Agency with Choice Arizona ALTCS: How Self-Directed Attendant Care Works

Two Ways to Self-Direct Care Under ALTCS

When your parent is approved for ALTCS, the default is agency-directed care — the managed care organization (MCO) assigns a contracted home care agency to send caregivers according to the care plan. The member has little say in who shows up.

Arizona offers two self-directed alternatives that give the member (or their representative) control over who provides care, when they work, and how tasks are performed:

Agency with Choice (AWC) is a shared-employer model. The member recruits, schedules, and supervises the caregiver. A contracted ALTCS provider agency handles the legal employer duties — hiring paperwork, payroll, tax withholding, workers' compensation, training compliance, and background checks. The agency is the employer of record; the member is the managing employer.

Self-Directed Attendant Care (SDAC) gives the member full employer authority. The member or their legal guardian is the direct legal employer of the caregiver. A state-contracted Fiscal Employer Agent handles payroll processing, tax withholding, and workers' compensation — but the member makes every staffing decision independently.

The Critical Differences

The spouse eligibility rule is the deciding factor for most families. If your parent's husband or wife wants to be compensated for providing daily care, AWC is the only path. SDAC explicitly excludes spouses from being hired as caregivers.

Hiring a Spouse as a Paid Caregiver

Under Arizona Administrative Code R9-28-506, a legally married spouse can be paid through ALTCS to provide care — but the state enforces strict conditions:

1. The care must be "extraordinary." This means physical assistance that significantly exceeds normal domestic help. Cooking dinner is not extraordinary care; helping a spouse with dementia bathe, dress, toilet, and transfer safely is.
2. Hours are capped at 40 per week. A spouse cannot be paid for more than 40 hours in any seven-day period. Any care needed beyond that cap must come from other sources — unpaid family, volunteers, or separate agency staff.
3. The member must live at home. Spousal caregiver payments are not authorized if the member lives in an assisted living facility, group home, or nursing home.
4. The spouse must be hired through an AWC provider agency. The agency handles the employment relationship, ensuring the spouse meets training requirements, holds a Level 1 Fingerprint Clearance Card, and complies with all ALTCS caregiver standards.
5. The case manager must document the arrangement in the member's care plan at every annual review.

The hourly rate is set by the provider agency within the range the MCO authorizes — typically $13 to $16 per hour in 2026. At 40 hours per week and $15/hour, that is roughly $31,200 per year. Not a generous income, but it is legally earned compensation for work that would otherwise go uncompensated.

How to Set Up Agency with Choice

1. Confirm your parent's MCO. Contact the ALTCS managed care organization (Mercy Care, Banner-University Family Care, or UnitedHealthcare Community Plan) and ask for the list of AWC provider agencies in your county.
2. Select a provider agency. Not all contracted agencies participate in AWC. Ask specifically whether they support the AWC model and whether they have experience processing family-member hires (spouse or adult child).
3. The family member applies through the agency. The caregiver candidate undergoes the same onboarding as any other hire — Level 1 Fingerprint Clearance Card verification, APS Registry check, TB screening, CPR/First Aid training, and fundamentals-of-caregiving coursework. The agency arranges and often pays for the required training.
4. The case manager updates the care plan. The ALTCS case manager must formally document the AWC arrangement, including the caregiver's name, relationship to the member, authorized hours, and scope of services.
5. The agency processes payroll. The family member submits timesheets to the agency, which issues paychecks, withholds taxes, and provides workers' compensation coverage.

When SDAC Makes More Sense

SDAC is the better fit when:

• The member wants to hire a non-family caregiver they found independently — a neighbor, a church member, a friend — and wants full control over scheduling and supervision without an agency intermediary.
• The caregiver needs to perform delegated skilled tasks. Under SDAC, a caregiver can perform specific skilled tasks (like medication administration or wound care) under written physician delegation. AWC restricts caregivers to non-medical tasks only.
• The member is highly capable of managing the employer role — or has a representative who is. SDAC requires the member to handle recruitment, scheduling, task assignment, and performance management. The Fiscal Employer Agent handles only the financial paperwork.

The tradeoff is clear: SDAC gives more control but excludes spouses and requires more administrative responsibility from the member or their family.

Getting Started

Both AWC and SDAC require that your parent is already enrolled in ALTCS with an active care plan. The case manager initiates the self-direction conversation during care plan development or at any subsequent review.

For a complete walkthrough of the ALTCS application process, financial eligibility requirements, and how to navigate managed care enrollment and care plan development, the Arizona Home Care, Waivers & Support Guide covers every step from initial application through paid family caregiving setup.

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