2) The trust receives income that is counted in the SOC calculation

The customer is applying for ALTCS in March 2020. He has a special treatment trust which requires a completed Special Treatment Trust Anticipated Disbursements Form (DE-312).

The customer:

Lives in an assisted living home;

Gets $1,000.00 per month in Social Security income and $2,000.00 per month from a pension; and

Pays $144.60 for Medicare Part B and $200.00 per month for other health insurance.

If he is approved for ALTCS, his SOC before the Medicare Buy-in occurs will be $306.40 . His SOC after the Medicare buy-in will be $451.00 .

His Social Security income is assigned to the trust. The trust is also funded with a financial account with $20,000.00.

The customer is requesting the following disbursements:

$75.00 per month in legal fees for the attorney handling the trust

$144.60 for Medicare Part B

$200.00 per month for his health insurance

$200.00 per month for his visits to the chiropractor that is not covered by insurance

All the requested disbursements are considered allowable disbursements. None of the requested disbursements are counted as income. Since the customer has a SOC and the income assigned to the trust is counted for the SOC determination, the SOC must be paid from the trust income.

The DE-312 should be completed as follows:

Month: Amounts Provided by Benefits and Eligibility Specialist 03/2020 04/2020 05/2020 06/2020 07/2020 08/2020 Income Assigned to the Trust: 1000.00 1000.00 1000.00 1000.00 1000.00 1000.00 The ALTCS Share of Cost (SOC): 306.40 306.40 306.40 306.40 451.00 451.00 451.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees 75.00 75.00 75.00 75.00 75.00 75.00 Medical Insurance: 344.60 344.60 344.60 200.00 200.00 200.00 Medical Expenses: 200.00 200.00 200.00 200.00 200.00 200.00 Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 926.00 926.00 926.00 926.00 926.00 926.00

Month: Amounts Provided by Benefits and Eligibility Specialist 9/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 1000.00 1000.00 1000.00 1000.00 1000.00 1000.00 The ALTCS Share of Cost (SOC): 451.00 451.00 451.00 451.00 451.00 451.00 451.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees 75.00 75.00 75.00 75.00 75.00 75.00 Medical Insurance: 200.00 200.00 200.00 200.00 200.00 200.00 Medical Expenses: 200.00 200.00 200.00 200.00 200.00 200.00 Family/Spouse Maintenance: Food and Clothing: Shelter, including room & board:* Pre-Paid Burial Expenses:(See back page) Payments to the Trust Beneficiary:* Entertainment/Vocational Items: Transportation: Total of all Disbursements: 926.00 926.00 926.00 926.00 926.00 926.00