C Special Treatment Trust Anticipated Disbursements Form (DE-312)

These examples are divided by customer situations. In general, the following information applies to every DE-312:

·        List ALL 12 months starting with the current month at the time the form is filled out. The row must show the month AND year. For example, “04/2020” or “April 2020” would be acceptable. Writing “April” without the year is not acceptable.

·        When amounts do not change from month to month, they must be written in the appropriate space for each month. For example, when a customer pays $100.00 per month in legal fees, “100.00” will be in the space for legal fees for all 12 months. Writing “100.00” and drawing an arrow or line through the following months is not acceptable.

·        When there is income assigned to the trust that is counted in the Share of Cost (SOC) calculation, the SOC must be paid from the trust income.

·        Focus on the money going into and coming out of the trust:

o       Income that is not assigned to the trust should not appear on this form.

o       Any disbursement that is automatically deducted from income that is not assigned to the trust should not appear on this form.

1) The trust does not receive income

Sarah is applying for ALTCS in June 2020. Sarah has a special treatment trust which requires a completed Special Treatment Trust Anticipated Disbursements Form (DE-312). She has $1,500.00 in countable income that is not assigned to the trust. She lives at home and does not have a share of cost.

The only thing titled to the trust is a financial account with $500,000.00 from a legal settlement.

Sarah is requesting the following disbursements:

·        $100.00 per month in legal fees for the attorney handling the trust

·        $200.00 per month for personal care services from an AHCCCS-registered provider

·        $500.00 per month for rent

·        A one-time disbursement of $750.00 for the purchase of a prepaid burial plan funded by an irrevocable life insurance policy, to be purchased in August 2020

All the requested disbursements are considered allowable disbursements. Since the $500.00 is for shelter, it is counted in the income determination. Her total countable income, including income outside the trust, would be $2,000.00. The other requested disbursements are not counted as income.

The DE-312 should be completed as follows:

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

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

Randal:

·        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.

Randal 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: