Updated August 7, 2026. Quick answer: in an income-cap state, being one dollar over the limit can disqualify you from Medicaid long-term care entirely — and a qualified income trust, often called a Miller trust, is the federal fix. 🔴 It has a condition most people are not told about until later: the state is repaid from whatever remains when you die.
Why the trust exists at all
States run two different systems. Some let you spend down — high medical costs offset income until you qualify. Others apply a hard ceiling: an applicant may be covered only with income “up to 300 percent of the SSI benefit rate”. 🔴 In a hard-cap state there is no partial credit. A dollar over is a denial, no matter how large the care bill is.
Honest gap: we could not verify the current dollar value of that 300% figure from a primary source we are able to reach, so we are not printing one. The rule is 300% of the SSI benefit rate; ask your state Medicaid agency for this year’s number rather than trusting a figure copied around the internet. Since this page was written we have read the 2026 rate at its federal source, and our Medicaid spend-down calculator prints the resulting figure alongside which of the two routes your state runs.
What the trust must look like
The federal exception is narrow and specific. The trust qualifies only if:
the trust is composed only of pension, Social Security, and other income to the individual (and accumulated income in the trust), (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; and (iii) the State makes medical assistance available to individuals described in section 1396a(a)(10)(A)(ii)(V) of this title, but does not make such assistance available to individuals for nursing facility services under section 1396a(a)(10)(C) of this title
⚠️ “Composed only of” is doing real work. Income goes in. Assets do not. A state administering these puts it plainly: the trust “will not be funded with the beneficiary’s resources, nor income or resources of other people.” Putting a savings account into it does not make it a bigger Miller trust — it makes it not a Miller trust.
🔴 The condition that outlives you
The exception is granted in exchange for a payback. As a state administering the programme describes it:
Upon the death of the beneficiary, the State will receive all remaining funds in the trust up to the amount of Medicaid expenditures paid on the individual’s behalf.
This is not estate recovery arriving later. It is written into the trust as the price of using it, and it is why a Miller trust is a qualification tool rather than a planning tool. How the payback interacts with Medicaid estate recovery is the part families most often meet unprepared.
Who can actually help you
⚠️ We should say this plainly: this is elder-law attorney work, and Clear Money Guide does not match people with attorneys. A qualified income trust has to be drafted to a state’s specifications and funded correctly every month; a mistake is a denial in the month it happens. We can tell you what the rule is. We are not the route to getting it done.
Sources
The qualified income trust exception and its funding limitation: 42 U.S.C. §1396p(d)(4)(B). The payback as administered: Indiana FSSA/OMPP provider manual, citing §1396p(d)(4)(B)(ii). The income-cap and spend-down pathways: MACPAC. All read 7 August 2026. General information about how these rules work, not legal advice on your document or your state. Probate law is state law and the details differ; confirm anything decision-critical with a lawyer in your state.
The rule in your state, all 51 jurisdictions
Every state below is either a qualified-income-trust (income-cap) state or a medically-needy spend-down state for institutional Medicaid; each row is that state’s own quick answer, from its own detail page.
| State | Quick answer |
|---|---|
| Alabama | Alabama publishes a hard number. Its eligibility grid states that “The 2026 nursing home income limit is $2,982.00”, and the state covers people above it the only way federal law allows: “As required by law, AL covers individuals who establish a Qualifying Income Trust.” Alabama calls it a Qualifying Income Trust, not a Qualified one; the same instrument other states call a Miller trust. |
| Alaska | Alaska runs a qualifying income trust, and its regulation puts one requirement ahead of all the others: “An applicant or recipient must submit a recognized Medicaid trust document to the department for review and approval before the department determines Medicaid eligibility.” The trust is not a thing you build and explain later. 7 AAC 100.610 then sets four conditions, and the department “will accept a properly executed qualifying income trust under 7 AAC 100.610 when determining income eligibility.” |
| Arizona | Arizona calls it an Income-Only Trust (IOT), and its policy carries a mechanical requirement most states do not state so plainly: the account “must be set up with all or a part of the customer’s current monthly income and have a $0 balance at the time it is set up.” You cannot seed it. And “Resources cannot be added to or used to fund the trust”; if resources go in, “the trust loses its special treatment until the resources are removed”. |
| Arkansas | Arkansas calls the instrument an “Irrevocable Income Trust (also known as a Miller Income Trust or MIT.)” The state’s fact sheet is unusually practical about the bank account, because that is where these fail: “This account must only be used for your income trust.” The reassurance most people want is also stated outright; “money in an income trust account is never considered a resource”. |
| California | California calls it share of cost, and the current instruction to counties is a withdrawal. ACWDL 24-10 revokes a planned increase: “Due to budgetary restrictions in the 2024-2025 fiscal year, the Medi-Cal Share of Cost (SOC) reform outlined in ACWDL No. 23-31 is hereby revoked.” The reform “The reform was intended to increase the maintenance need level to 138% of the federal poverty level (FPL), effective January 1, 2025, contingent upon fiscal capacity and federal approval.” Instead, “Counties are to adhere to existing SOC guidelines located in ACWDL 89-58 and the Medi-Cal maintenance need will continue to be based on the Aid to Families with Dependent Children (AFDC) program payment levels.” |
| Colorado | Colorado’s income trust rule is written from both ends. Going in, the trust must consist of “A trust consisting only of the individual’s pension income, social security income, and other monthly income”. Coming out, the list is closed: “The only deductions from the monthly trust distribution to the Long Term Care institution are the allowable deductions”; and anything not distributed does not vanish, because “Any excess income which is not distributed shall accumulate in the trust.” |
| Connecticut | Connecticut calls it a spend-down, and the rule is that “When the amount of the assistance unit’s monthly income exceeds the MNIL, income eligibility for a medically needy assistance unit does not occur until the amount of excess income is offset by medical expenses. This process of offsetting is referred to as a spend-down.” What makes Connecticut different from most states is the unit of time: for the prospective period the state takes “The total amount of excess income for the entire six-month prospective period is offset by:” medical expenses; the whole six months at once, not each month on its own. The medically needy income limit is $851 a month for a one-person needs group, set at 159% of the cash-assistance payment standard, effective 03/01/2026. |
| Delaware | Delaware is the outlier in this series, and it is worth knowing before you do any arithmetic. Its long-term care income limit is “set at 250% of the Supplemental Security Income – SSI – standard”; not the 300% figure most states use. Above it, “they will need to establish a Miller Trust in order to qualify”. A calculation done on the usual 300% assumption will put a Delaware applicant on the wrong side of the line. |
| District of Columbia | The District writes the split into the rule. For people not receiving long-term care, “the Department shall use a one (1) month period to budget the individual’s spend down obligation”. For long-term care, “For the eligibility groups described in Subsection 9515.4 who are applying for or receiving long term care services and supports, the Department shall use a six (6) month period to budget the individual’s spend down obligation.” And the MNIL itself is defined by formula, not by a published table. |
| Florida | Florida’s qualified income trust rule lives at ESS Policy Manual passage 1840.0110, and it contains a step almost no other state has: an eligibility specialist does not decide whether your trust is valid. The manual directs that they “forward all income trusts to their Region or Circuit Program Office for review and submission to the Circuit Legal Counsel”. The timing rule is equally strict; the deposit must happen “must deposit sufficient income into the income trust account in the month in which the income is received” |
| Georgia | Georgia’s manual states the funding target with a precision no other state in this series matches. Properly funded “means that, at minimum, the difference between the specified state income cap (minus a dollar) and the applicant’s total income has been deposited”. Minus a dollar; the deposit has to take you strictly below the cap, not to it. And the deadline is absolute: the application is denied for any month in which a QIT was not both established and funded before the month ended. |
| Hawaii | Hawaii’s rule defines the arithmetic and then fixes the sequence. “An individual’s excess income is the countable income which exceeds the medically needy income standard for the household of applicable size.” Then: “Medical expenses incurred by an individual or financially responsible relative not subject to payment by a third party shall be deducted from the excess income in the following order:”; and premiums, deductibles and coinsurance come first. |
| Idaho | Idaho exempts an income trust from trust treatment under IDAPA 16.03.05 Section 872, and the rule carries a timing condition that decides cases: “Any income, placed directly into an income trust in the same calendar month in which received by the recipient, is not considered income to the individual for determining long-term care Medicaid eligibility.” Money that arrives in January and reaches the trust in February was your income in January. |
| Illinois | Illinois runs spenddown under the MANG rules, and long-term care gets its own clock: “A one month eligibility period is used for persons receiving long-term care services”. Income and excess resources are then “Nonexempt income and nonexempt resources over the resource disregard are applied toward the cost of care on a monthly basis”. |
| Indiana | Indiana runs a Miller Trust, and its policy says something almost no other state’s does: “The Miller trust described in this subsection can be revocable or irrevocable.” Most states require irrevocability on the face of the document. Indiana does not, for this trust, in this subsection. |
| Iowa | Iowa’s Medical Assistance Income Trust helps “People with income in excess of 300 percent of the Supplemental Security Income (SSI) benefit for one person”; but Iowa also puts a ceiling on it, and that is the fact most summaries omit. A person with a MAIT qualifies “only if the person’s total gross monthly income does not exceed 125 percent of the statewide average” for the type of facility or level of care they meet. Above that ceiling the trust does not rescue the application. |
| Kansas | Kansas answers a question most manuals leave open. An expense you paid with a loan or a card is not spent: “This provision includes instances in which the individual has taken out a loan to pay the expense or charged the expense on a credit card.” and “The unpaid portion of the loan or credit card balance attributable to the original medical expense shall be regarded as a due and owing expense which can be applied to spenddown.” |
| Kentucky | Kentucky puts the pathway in its own section of the regulation, headed “The Medically Needy Who Qualify Via Spenddown.” It is open to someone who “has sufficient income to meet the individual’s basic maintenance needs” but needs help with medical costs, and it has two conditions, not one. |
| Louisiana | A great deal of national material lists Louisiana as a Miller trust state. Louisiana’s own manual, issued March 04, 2026, says otherwise: “Effective July 1, 1997, Miller-Type or Qualifying Income Trusts are no longer applicable due to the re-implementation of a Title XIX Medically Needy Program.” They applied for exactly one year, “Thus, Miller-Type or Qualifying Income Trusts were applicable in Louisiana effective July 1, 1996 through June 30, 1997 due to the State’s termination of the Title XIX Medically Needy Program coverage plan.” |
| Maine | Maine calls the excess-income obligation a deductible and measures it against the Protected Income Level. One provision is easy to miss and can decide a case: “An individual in this situation receives Medically Needy coverage without first having to incur any medical costs.” |
| Maryland | Maryland does not use an income trust for this. It runs a spend-down under COMAR 10.09.24.10, and the regulation is precise about when coverage begins: “Spend-down eligibility is established for the remainder of the period under consideration on the day the incurred medical expenses” equal or exceed the excess income. Not the month, the day. Maryland also counts projected private cost-of-care obligations toward that total, which matters enormously for a nursing home applicant. |
| Massachusetts | Massachusetts puts its rule in statute rather than a policy manual, and it is short. Under General Laws chapter 118E, section 25, someone over the income exemptions “shall be liable to pay to the provider of medical care or service an amount which shall be equal to the excess income for a period of six consecutive months”. Six consecutive months is the period the statute itself fixes, and the liability runs to the provider of care, not to the state. |
| Michigan | Michigan’s manual states an instruction that reads like a rule of fairness: “The individual must be given the most advantageous use of their old bills (also known as incurred expenses).” And when expenses finally cover the excess, coverage starts “The day after the day the expenses equaled the excess income.” |
| Minnesota | Minnesota runs a spenddown, and it is one of the few states to say out loud that there is more than one kind: “There are many types of spenddowns, such as monthly spenddowns or six-month spenddowns.” It also answers the question everyone asks about old bills: “you can use old medical bills that have not been paid, but you cannot use other household bills” |
| Mississippi | Mississippi states a limit on its own income trust that most states leave unsaid: “If monthly income exceeds the private pay rate that the nursing facility charges for a 31-day month, it is not possible to qualify for Medicaid under an Income Trust.” The trust is not a route around any amount of income. If your monthly income is larger than what the nursing facility charges a private payer for a 31-day month, the trust cannot make you eligible. |
| Missouri | Missouri is unusually direct about the mechanics for the person paying. “If your income is above the limit to qualify for Missouri Medicaid (MO HealthNet), you may still be able to get MO HealthNet coverage if you agree to pay, or “spend down,” a certain amount each month.” And then: “When you’re approved for spend down, you will get an invoice in the mail.” “There are 3 ways you can meet your spend down:” |
| Montana | Montana states the choice inside the eligibility rule itself: coverage goes to clients “Eligibility is determined for medically needy clients who are expected to meet their monthly spend down (either with incurred medical expenses or through a cash option payment to the Department).” And the arithmetic is plain: “The spend down is equal to the difference between their ‘total countable income’ and the appropriate ‘medically needy income level (MNIL)’.” |
| Nebraska | Nebraska runs a Medically Needy programme with a share of cost, and it publishes a worked example rather than a formula. For a household of three with $1,000 a month: “Their share of cost comes from the MNIL for their household, $492, subtracted from their monthly income, $1,000, which then equals $508 as the share of cost.” The MNIL is the number the state subtracts from, and it varies by household size. |
| Nevada | Nevada calls it a Miller Type or Qualified Income Trust, and its manual states the failure mode in one sentence: “No resources may be used to establish or augment the trust. Inclusion of resources voids the exemption.” Not a penalty, not a cure period; the exemption is gone. And the trust does not shrink the bill: “The customer’s total available income regardless of whether or not deposited into the QIT is used to determine the customer’s share of the cost of care.” |
| New Hampshire | New Hampshire does not use the phrase “spend-down state” in its program name. It runs in and out medically needy medical assistance under He-W 878.01, and the rule hands the applicant a decision almost no other state gives: “The client may choose either a one or 6 month spenddown period when the department determines eligibility for in and out medically needy medical assistance, subject to the following provisions:”. The limit the excess is measured against is the protected income level, $888 a month for an assistance group of one. |
| New Jersey | New Jersey switched routes. “The State of New Jersey adopted the use of QITs effective December 2014.” and “The use of QITs will replace the Medically Needy eligibility program used for nursing facilities.” That is a structural change, not a tweak: the medically-needy spend-down that used to serve nursing facility applicants is no longer the path. People already on the old programme were protected; “Individuals receiving benefits through the Medically Needy program prior to the QIT effective date will be grandfathered.” |
| New Mexico | New Mexico does not say Miller trust or QIT. Its rule says income diversion trust, and 8.281.510 NMAC describes it as a reversionary instrument: “An income diversion trust is a reversionary trust”, and “The trust terminates upon the death of the beneficiary.” |
| New York | New York gives the programme a name of its own: “Here we will be referring to it as the Excess Income program.” “The amount your income is over the Medicaid level is called excess income.” The provision most people miss is that a single payment can cover a stretch: in the state’s example, “the paid amount of $360 can be used to meet your excess income for six months”. |
| North Carolina | North Carolina multiplies monthly excess income by the certification period and rounds it. Then it makes one blunt exception: “The inpatient hospital admission of an MAABD a/b (who does not have Medicare Part A coverage) is assumed to meet the deductible, regardless of length of stay or the ultimate amount of the charges.” |
| North Dakota | North Dakota does not say spend-down. Its chapter says recipient liability, and which income level applies turns on the setting: “The nursing care income levels established in the Medicaid state plan are applied to residents receiving care in a nursing facility”, while the medically needy levels apply to someone at home or in a specialized facility. |
| Ohio | Ohio’s rule is 5160:1-6-03.2, effective June 1, 2021, and it contains a trap worth knowing before you open the account. If more goes into the trust than comes out under the payout rules, “the excess income may be subject to penalties under the transfer of assets provisions as set forth in rule 5160:1-6-06.5”. An accumulating balance is not a harmless cushion in Ohio; it can be treated as a transfer. |
| Oklahoma | Oklahoma’s instrument has its own name; the Medicaid Income Pension Trust; which is why searches for “Miller trust Oklahoma” often come up short. Its policy defines a band, not a floor: the trust is for an individual who “has countable income above the categorically needy standard for long-term care (OKDHS Appendix C-1 Schedule VIII.B) but less than the average cost of nursing home care”. Income above the average cost of nursing home care is outside what the trust can fix. |
| Oregon | Oregon calls it an income cap trust (ICT). “It allows someone with too much income to qualify for Medicaid long-term care services.” The part that catches trustees is what happens afterwards: “you are required to pay back any medical benefits your loved one received, using any funds left in the ICT”. And the state is explicit that funeral and burial costs are not an exception; “Can I pay funeral or burial related expenses out of an income cap trust? No.” |
| Pennsylvania | Pennsylvania measures medically needy eligibility over half a year rather than a month: “For medically needy only (MNO) categories, the limit is $2,550 (semi-annual net income)”. And for long-term care it allows a deduction large enough to change most cases: “If your income exceeds 300 percent of the FBR limit, the anticipated cost of long-term care facility services for a 6-month period is an allowable medical expense deduction to reduce monthly income.” |
| Rhode Island | Rhode Island runs two different clocks and says so plainly. Community coverage is spent down “during a specified MN eligibility period of six (6) months”. For long-term care: “The MN eligibility period for LTSS is one (1) month.” |
| South Carolina | South Carolina states a timing rule that decides whether a month is covered: “Eligibility cannot be established prior to the month the trust document is signed”. There is no back-dating an income trust in South Carolina. The state also removes a common assumption about cost; “It is not required to use an attorney, but you may do so if you wish.” |
| South Dakota | South Dakota’s Medicaid income trust runs the money in a full circle, and the rule caps the return leg: the trustee must pay the beneficiary the amount paid in, but “the amount paid to the beneficiary may not exceed 300 percent of the maximum SSI standard benefit amount when added to the beneficiary’s other monthly income not paid into the trust”. Whatever is left goes to the facility. |
| Tennessee | Tennessee’s QIT rule carries a reporting duty that catches families off guard: “the trust itself is a third party medical resource and must be reported to the TennCare Third Party Liability Unit”. The trust is not only an eligibility device in Tennessee; it is a resource TennCare tracks. “A QIT is a trust that is created specifically for the purpose of becoming eligible for TennCare Long-Term Services and Supports (LTSS).” |
| Texas | Texas policy is current to “Revision 25-1; Effective March 1, 2025”, and it carries an exclusion worth checking before anyone drafts anything: although a QIT can overcome the special income limit for institutional and waiver care, “it is not available to people in Community Attendant Services (CAS) who are income ineligible”. For that programme the trust is simply not a route. |
| Utah | Utah’s rule states the sequence for retroactive and current months and leaves no room in it: “If an individual is determined eligible for past or current months, but must pay a spenddown or Medicaid Work Incentive (MWI) premium for one or more months to receive coverage, the spenddown or MWI premium must be met before Medicaid coverage may be provided for those months.” |
| Vermont | Vermont uses two words for two situations, and its own table of contents sets them side by side: “Six-Month Spend-down Period” and “One-Month Patient-Share Period”. The rules are titled “Spenddown, Patient Share, and Resource Transfer” |
| Virginia | Virginia’s medically needy spenddown has a sequencing rule worth knowing in advance: “Eligibility for a medically needy spenddown is only reviewed when an applicant has been found over income for full-benefit Medicaid” and meets all other requirements. It is what happens after an over-income finding, not something you apply for instead. And what it buys is bounded; applicants “have high medical expenses to enroll in time-limited Medicaid coverage” |
| Washington | Washington gives the applicant the choice, in the rule: “A person who applies for Washington apple health (WAH) and is eligible for medically needy (MN) coverage with a spenddown may choose a three-month or a six-month base period.” That choice changes the size of the obligation, because “A base period is a time period used to compute the spenddown liability amount.” |
| West Virginia | West Virginia defines the term in its own glossary; “The amount by which income exceeds the Medically Needy Income Level (MNIL) for the Period of Consideration (POC).”; and then instructs workers to pick the window in the client’s favour: “The specific months which will constitute the Period of Consideration (POC) based on the six-month POC that will most benefit the client.” |
| Wisconsin | Wisconsin sums months, not averages them: “Add together the excess income of the months in the deductible period. The result is the Medicaid deductible.” And for an institutionalised person it gives an instruction that is easy to get backwards: “Calculate the deductible by comparing his or her monthly income for each of the 6 months to the SSI-related medically needy income limit, not the institutional income limit.” |
| Wyoming | Wyoming’s rule is in Medicaid Rules Chapter 18, effective 06/16/2021. It frames the trust as an exception rather than a programme: “To qualify for an Income Trust exception the trust shall be treated in accordance with Section 1917(d)(4)(B)”, and then lists what the trust must be; irrevocable, and “Composed only of pension, Social Security, and other income” of the individual. |
Coverage, stated honestly: 51 of 51 jurisdictions.