What is a Qualified Income Trust (Miller Trust)?

Why Florida requires it

Florida is an income cap state. Eligibility for long-term care Medicaid, meaning nursing home Medicaid (the Institutional Care Program), institutional hospice, the home and community-based waiver, and PACE, is measured against gross monthly income, before the Medicare premium and other deductions are taken out. The limit is 300 percent of the federal SSI benefit rate. A person can have almost nothing in the bank and still be turned down because their Social Security and pension together are over it.

Federal law lets that person qualify anyway if the income over the limit is placed in a trust that meets strict rules. Money that goes into the trust each month is not counted against the limit. That trust is the QIT.

What the trust must say

A QIT is a short document, but every requirement matters. It must be irrevocable. It may hold only the person's own income, never their savings and never anyone else's money. It must be for the person's benefit. And when the person dies, whatever is left in the trust goes to the State of Florida, Agency for Health Care Administration, up to the total Medicaid paid for their care.

DCF sends every income trust through its Region or Circuit Program Office to the Circuit Legal Counsel, who decides whether it qualifies. The trust still has to be funded every month while that review is pending.

How money flows in and out each month

Income keeps arriving where it always has, in the person's own checking account. Each month, an amount moves from checking into the QIT bank account. From the QIT, the trustee pays what the rules allow: the patient responsibility owed to the nursing home, the provider, or the PACE organization; health insurance premiums; and, for a married person, any allowance owed to the spouse at home.

The deposit has to happen in the same month the income arrives. A QIT cannot be funded after the fact. A missed or short month can cost Medicaid coverage for that month.

Who serves as trustee

Usually a spouse or an adult child, sometimes a trusted friend. The trustee makes sure the transfer happens every month, pays the patient responsibility and other allowed expenses from the trust, and keeps the bank statements; DCF's policy requires the trustee to provide quarterly statements showing each month's deposits. Money paid from the trust back to the person counts as their income, so the trustee pays third parties, not the person.

What happens at death

The trustee pays the balance in the QIT account, plus any refund the facility owes for the unused part of the month, to the Agency for Health Care Administration, up to the total Medicaid paid. A QIT is not a way to pass money to family. It is a way to qualify.

Questions

Is a Miller Trust the same as a Qualified Income Trust?

Yes. "Miller Trust" comes from the federal court case that led to the rule. Florida's DCF calls it a Qualified Income Trust or an income trust. Lawyers also call it an income-only trust or a (d)(4)(B) trust, after the federal statute that authorizes it.

What happens if the trust is not set up correctly?

DCF does not treat it as a qualified income trust and counts the income as usual. If the income outside the trust is still over the limit, DCF's guidelines enroll the person in the Medically Needy program instead, which does not pay for long-term care.

Does a QIT protect savings or a house?

No. A QIT holds income only. Savings, investments, and real estate are handled separately under Medicaid's asset rules.

Does gross income mean before the Medicare premium?

Yes. DCF counts the Social Security benefit before the Medicare Part B premium is withheld, and pensions before any insurance premium or tax is taken out. Using the bank deposit instead is the most common mistake families make.