Miller Trust (Qualified Income Trust): What It Is and How It Works

When a parent or spouse needs nursing-home care but their monthly income is too high for Medicaid in their state, a Miller trust can help. It is a special trust that receives the income over the state's limit. Medicaid can then treat that income differently, and the money is used each month toward care.

A parent's savings may be small, and Social Security and a pension may barely cover the bills. Yet a state's income limit for long-term-care Medicaid can still stand in the way. Adult children and spouses in this spot usually want to know three things. Does their state use this rule? How does the trust actually work month to month? And what happens to the money in it?

This page explains the qualified income trust, also called a Miller trust, within the larger picture of Medicaid for nursing-home and other long-term care. Each state runs its own program, so the details turn on where the person lives. The page covers Medicaid for long-term care only. It does not cover Medicare, private long-term-care insurance or veterans' benefits.

What a Miller Trust Is

A qualified income trust, or QIT, is a trust made up only of a person's income. Its main use is to help an applicant whose income is above a state's income limit qualify for Medicaid long-term care. "Miller trust" is the common name for the same tool.

The problem it solves is the income cap. That is a fixed monthly dollar limit on income, set by some state programs. In a state that applies it, a person whose income is over the cap does not meet that state's income test for nursing-home coverage. A state that uses this kind of limit is often called an income-cap state.

The federal authority is 42 U.S.C. § 1396p(d)(4)(B). It describes a trust "composed only of pension, Social Security, and other income to the individual (and accumulated income in the trust)." The usual trust-counting rules in § 1396p(d) do not apply to a trust that meets this section. Income paid into the trust is still used under the payout rules described below.

Some other states use a different route, called medically needy. In these states, a person with high income can become eligible after paying a share of their own medical costs. Medicaid.gov's eligibility policy page says the program "then pays the cost of services that exceeds the expenses the individual had to incur to become eligible."

Which States Use a Miller Trust

The QIT section of the statute points to one group of states. Under 42 U.S.C. § 1396p(d)(4)(B)(iii), the exception applies where "the State makes medical assistance available" through a special income group but "does not make such assistance available to individuals for nursing facility services" through the medically needy route. Put simply, the QIT exists for states that cover that special income group but do not use the medically needy route for nursing-home care.

Which group a state is in depends on that state's Medicaid program rules, not on federal law alone. States can change their programs over time, so a rule that applied a few years ago may not apply now.

For that reason, this page names no state as an income-cap or medically needy state. A state's current rules decide the answer for a particular family.

For reference, the federal 2026 SSI and Spousal Impoverishment Standards chart lists an "Income Cap Limit (300%)" of $2,982 for an individual, effective January 1, 2026. Whether a given state uses that figure depends on that state's rules. State-by-state pages on this site, such as Florida Medicaid planning, cover a state's own figures where its agency publishes them.

How a Miller Trust Works: The Income Flow

Each month, the income that pushes the person over the cap is deposited into the trust's account. That income is usually Social Security, a pension or other regular payments. The trustee then manages the account and pays it out. The trustee is the person in charge of the trust.

The payouts follow the rules for what a nursing-home resident keeps. Medicaid.gov's spousal impoverishment page lists these deductions from income, which it calls "protected amounts":

• A personal needs allowance of at least $30 for the resident's own small expenses.
• A community spouse monthly income allowance, if the spousal rules apply and the income is actually given to that spouse. The community spouse is the husband or wife who still lives at home.
• A family monthly income allowance, if other family members live in the household.
• An amount for medical expenses incurred by the spouse in the facility.

The same page says that "any remaining income is contributed toward the cost of his or her care in the institution." That remainder is often called the patient-pay amount. The exact order of payments and each allowance amount depend on the state's program.

For a community spouse, the federal chart sets the minimum monthly maintenance needs allowance at $2,705 in all states except Alaska and Hawaii, effective July 1, 2026. That is the federal figure; a state's own figure applies from the date its agency states.

Required Terms: Payback and Irrevocability

Federal law requires a payback term. Under 42 U.S.C. § 1396p(d)(4)(B)(ii), "the State will receive all amounts remaining in the trust upon the death of such individual up to an amount equal to the total medical assistance paid on behalf of the individual under a State plan under this subchapter."

The federal QIT section does not itself say whether the trust must be unchangeable (irrevocable) during the person's life. The state Medicaid agency's current requirements for the trust document apply.

What a Miller Trust Can Pay For

This is not a general spending account. Payments from the trust are limited to the categories the state program allows.

Typical uses follow the protected amounts above. They include the personal needs allowance, a community spouse's allowance where it applies, and health insurance premiums. The rest goes as the patient-pay amount to the nursing home or care provider.

At death, the state receives what remains in the trust, up to the total medical assistance paid, as the statute above requires.

That repayment works alongside estate recovery, which is the state's right to seek repayment from a deceased person's estate for benefits paid. Medicaid.gov's estate recovery page says states must seek recovery for nursing facility services, home and community-based services, and related hospital and prescription drug services for people age 55 or older. It adds that "money remaining in a trust after a Medicaid enrollee has passed away may be used to reimburse Medicaid." Federal law delays estate recovery, rather than cancelling it, while a spouse, a child under 21 or a blind or disabled child survives, and states must also have procedures for waiving recovery when it would cause an undue hardship.

What a QIT can pay for in a given state depends on that state's rules.

Setting Up a Miller Trust: What the Process Generally Involves

A QIT starts as a written trust document that meets the state Medicaid agency's requirements.

Next, an account is generally opened in the trust's name, and the income is paid into it rather than into the person's own account, under the state's rules.

Running the trust is an ongoing job. The trustee makes the right payments in the right order every month and keeps records. Broader timing questions are covered under Medicaid crisis planning.

When a Monthly Deposit Is Missed or Goes to the Wrong Account

Because the trust works month by month, a single error can matter. If the income for a month is not deposited into the trust account, or is deposited into the person's own account instead, eligibility for that month can be at risk under the state's rules.

Whether such a mistake can be corrected, and how, is set by each state's program rather than by the federal statute.

Miller Trusts and Pooled Trusts: A Brief Distinction

A pooled trust is run by a nonprofit group that combines many people's funds for investment while keeping a separate account for each person. Federal authority is 42 U.S.C. § 1396p(d)(4)(C). The statute lists four conditions:

• The trust is set up and managed by a nonprofit association.
• Each beneficiary has a separate account, but the funds are pooled for investment.
• Accounts are set up only for people who are disabled, by a parent, grandparent, legal guardian, the person, or a court.
• To the extent funds left at death are not kept by the trust, the trust pays the state up to the Medicaid benefits paid.

Which states allow a pooled trust for a given purpose, and what happens to funds at death, depend on each state's program.

If You'd Like to Talk Through a Miller Trust Question

A Miller trust can look simple on paper, but it depends on facts that change from family to family. These include the state's current rules, the exact income sources and amounts, and whether a spouse lives at home. Care setting and application timing matter too. For related background, see what a Medicaid planning attorney does.

A consultation request about your family's Medicaid and long-term-care options can be made through Medicaid Asset Protection Group.