2) The customer has income both inside and outside the Income-Only trust and lives in a HCBS living arrangement

The customer is applying for ALTCS in March 2020. She has an income-only trust.

The customer:

Lives in an assisted living home;

Gets $4,000.00 per month in annuity income that is assigned to the trust;

Gets $1,000.00 per month from Social Security that is NOT assigned to the trust; and

Pays $144.60 for Medicare Part B and $100.00 for a Medicare supplement plan. Both payments are automatically deducted from the customer’s Social Security payment.

If she is approved for ALTCS, her SOC before the Medicare Buy-in occurs will be $2,406.40 . Her SOC after the Medicare buy-in will be $2,551.00 .

Since the deductions for Medicare Part B and the supplemental plan are deducted from an income that is outside of the trust, the health insurance premiums should not appear on the form.

The DE-313 should be completed as follows:

NOTE The income outside the trust ($1,000.00) plus the countable Personal Needs Allowance disbursement ($1,349.00) equals $2,349.00, which is the income limit for 2020. Any additional countable disbursements would put the customer over the income limit. If the trustee wanted to disburse the $244.60 left over in the trust in March 2020, the disbursement would have to be a type of disbursement that is not countable, such as legal or professional expenses.

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: 4000.00 4000.00 4000.00 4000.00 4000.00 4000.00 4000.00 The ALTCS Share of Cost (SOC): 2406.40 2406.40 2406.40 2406.40 2551.00 2551.00 2551.00 Personal Needs Allowance:* 1349.00 1349.00 1349.00 1349.00 1349.00 1349.00 1349.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: Medical Expenses: 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: 3755.40 3755.40 3755.40 3755.40 3900.00 3900.00 3900.00

Month: Amounts Provided by Benefits and Eligibility Specialist 09/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 4000.00 4000.00 4000.00 4000.00 4000.00 4000.00 4000.00 The ALTCS Share of Cost (SOC): 2551.00 2551.00 2551.00 2551.00 2551.00 2551.00 2551.00 Personal Needs Allowance:* 1349.00 1349.00 1349.00 1349.00 1349.00 1349.00 1349.00 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: Medical Expenses: 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: 3900.00 3900.00 3900.00 3900.00 3900.00 3900.00 3900.00

3) The customer has all income assigned to the trust and lives in a long-term care medical institution

The customer is applying for ALTCS in March 2020. He has an income-only trust.

The customer:

Lives in a nursing facility;

Gets $1,000.00 per month in Social Security income and $2,000.00 per month from a pension. Both incomes are assigned to the income-only trust; 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 $2,537.95 . His SOC after the Medicare buy-in will be $2,682.55 .

The DE-313 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: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 The ALTCS Share of Cost (SOC): 2537.95 2537.95 2537.95 2537.95 2682.55 2682.55 2682.55 Personal Needs Allowance:* 117.45 117.45 117.45 117.45 117.45 117.45 117.45 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: 344.60 344.60 344.60 344.60 200.00 200.00 200.00 Medical Expenses: 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: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00

Month: Amounts Provided by Benefits and Eligibility Specialist 09/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 The ALTCS Share of Cost (SOC): 2682.55 2682.55 2682.55 2682.55 2682.55 2682.55 2682.55 Personal Needs Allowance:* 117.45 117.45 117.45 117.45 117.45 117.45 117.45 Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: 200.00 200.00 200.00 200.00 200.00 200.00 200.00 Medical Expenses: 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: 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00 3000.00

4) The customer has income both inside and outside the Income-Only Trust and lives in a long-term care medical institution

The customer is applying for ALTCS in March 2020. She has an income-only trust.

The customer:

Lives in a nursing facility;

Gets $2,000.00 per month in annuity income that is assigned to the trust;

Gets $800.00 per month from Social Security that is NOT assigned to the trust; and

Pays $144.60 for Medicare Part B which is automatically deducted from the customer’s Social Security payment.

If she is approved for ALTCS, her SOC before the Medicare Buy-in occurs will be $2,537.95 . Her SOC after the Medicare buy-in will be $2,682.55.

Since the SOC amount is greater than the amount going into the trust, the only allowable disbursement will be for the SOC. The SOC must be paid from the income going into the trust. The remaining amount due for the SOC will have to be paid from the customer’s income outside the trust.

The DE-313 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: 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 The ALTCS Share of Cost (SOC): 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 Personal Needs Allowance:* Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: Medical Expenses: 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: 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00

Month: Amounts Provided by Benefits and Eligibility Specialist 09/2020 10/2020 11/2020 12/2020 01/2021 02/2021 Income Assigned to the Trust: 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 The ALTCS Share of Cost (SOC): 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 Personal Needs Allowance:* Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees Medical Insurance: Medical Expenses: 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: 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00 2000.00