D Income-Only Trust Anticipated Disbursements Form (DE-313)

Programs	Manual Section
ALTCS	MA803E

These examples are divided by customer situations. In general, the following information applies to every DE-313:

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 health insurance, “100.00” will be in the space for health insurance for all 12 months. Writing “100.00” and drawing an arrow or line through the following months is not acceptable.
The amount of total disbursements should not be greater than the amount of income assigned to the trust.
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:
- Income that is not assigned to the trust should not appear on this form.
- Any disbursement that is automatically deducted from income that is not assigned to the trust should not appear on this form.

1) The customer has all of their income assigned to the Income-Only Trust and lives in a Home and Community Based Services (HCBS) living arrangement

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

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. 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 $306.40. His SOC after the Medicare buy-in will be $451.00.

The DE-313 should be completed as follows:

Msh:	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):	306.40	306.40	306.40	306.40	451.00	451.00	451.00
Personal Needs Allowance:*	2349.00	2349.00	2349.00	2349.00	2349.00	2349.00	2349.00
Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees
Medical Insurance:	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):	451.00	451.00	451.00	451.00	451.00	451.00	451.00
Personal Needs Allowance:*	2349.00	2349.00	2349.00	2349.00	2349.00	2349.00	2349.00
Legal & Professional Expenses: Related to the trust administration Trust taxes Investment and accounting fees Trustee and attorney fees Guardian and Conservator fees
Medical Insurance:	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

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