MA907

Does the amount of income left in the trust during the month exceed $500.00?

• If YES, continue to step 2.

• If NO, STOP. A transfer penalty and undue hardship does not apply.

Was there excluded income deposited into the IOT for the month?

• If YES, subtract the excluded income from the income amount left in the trust and continue to step 3.

• If NO, continue to 4.

After subtracting the excluded income, is there more than $500 left in the trust during the month?

• If YES, continue to step 4.

• If NO, STOP. A transfer penalty and undue hardship does not apply.

Review the Acknowledgement of Responsibilities as Trustee for a Special Treatment Trust (DE-522) form and the Income Only Trust Anticipated Disbursements (DE-313) form with the trustee. Talk to the trustee to determine if there are other expenses for the customer’s benefit that can be disbursed from the trust.

Are there additional disbursements that can be requested on the Anticipated Disbursements (DE-313) form that will reduce the amount of income left in the trust to $500.00 or less in the month?

• If YES, STOP. Undue hardship does not apply. Request an updated DE-313 and supporting proof for the requested disbursements. Put the proof in DocuWare and submit a Policy Clarification Request (PCR) for the funding and disbursement review.

• If NO, continue to step 6.

Are the funds left in the trust because the share of cost (SOC) is equal to the capitation rate?

• If YES, continue to step 7.

• If NO, STOP. Undue hardship does not apply. Calculate the transfer penalty and apply the transfer. Explain the trust and transfer policies to the trustee. Discuss options to stop ongoing partial month transfers that affect the customer’s eligibility.

Has the IOT been reviewed and the case approved with a period of acute care?

• If YES, the customer may be eligible for undue hardship. Continue to step 8.

NOTE     When there are ongoing partial month transfer penalties, set a calendar appointment to update the transfer prior to adverse action for all prospective months.Enter case notes.

• If NO, STOP. Undue hardship does not apply. The customer must be approved for limited ALTCS services in order to request undue hardship.

Does the customer want to request undue hardship to waive the penalty period?

• If YES, the customer may be eligible for undue hardship. Continue to step 9.

• If NO, STOP. Undue hardship does not apply.

Submit a PCR via PATS for the undue hardship request. In the body of the PCR describe the options offered to the customer during this procedure. Provide information for where the trust and transfer information are in DocuWare and any other relevant information or unique circumstances.

Once the undue hardship decision is received, verbally inform the customer of the decision.