Miller Trust (Qualified Income Trust): The 24 States That Require One in 2026

Most states let a person qualify for nursing-home Medicaid once their income is less than the cost of their care. Twenty-four states do not. In those states the test is a hard income cap, set in most of them at 300% of the federal SSI benefit: $2,982 a month in 2026 ($994 × 3). The cap counts only the applicant's own income; a spouse's Social Security or pension doesn't count toward it. A parent with $3,100 a month in Social Security and a pension is over the cap by $118, and without a trust they are denied, even though the nursing home charges three times their income.

The fix is a Miller trust, the common name for a Qualified Income Trust (QIT). It is named after Miller v. Ibarra, a 1990 Colorado case, and federal Medicaid law (42 U.S.C. §1396p(d)(4)(B)) requires income-cap states to allow it. Each month, income is deposited into a separate trust account: at least the amount over the cap, and in some states an entire income source, such as the whole pension check. Medicaid does not count income that goes into the trust when it checks the cap, so the applicant qualifies. The money is not shielded from the nursing home: it is paid back out toward the cost of care.

Three things are worth knowing up front. A Miller trust only deals with income; savings above the asset limit still have to be spent down or protected another way (see our spend-down guide). It has to be irrevocable. And when the person dies, whatever is left in the trust goes to the state, up to the amount Medicaid paid for their care.

The 24 states below apply a hard income cap to nursing-home Medicaid, and a Miller trust is the way to qualify above it. In many of them, including Florida, Nevada, New Jersey and South Carolina, the same trust also opens the state's home-care (HCBS) waiver. A few states use their own name for it, and a few add rules of their own, noted in the table.

In the other 27 states (including DC) there is no hard cap for nursing-home care: an applicant over the limit qualifies by paying their income, minus a small personal needs allowance, toward the cost of care. If your parent's state is in that list, you do not need a Miller trust for a nursing home, although some of those states still use an income cap, or a pooled trust, for home-care waivers. Each state's page has the details.

Take a widowed mother in Ohio entering a nursing home that costs $9,305 a month, the state median for a semi-private room. Her income is $3,400 a month: $2,100 from Social Security and $1,300 from a pension. That is $418 over Ohio's $2,982 cap, so without a trust she cannot qualify at all.

Her son, acting under her power of attorney, signs a Miller trust and opens a checking account in the trust's name. Each month the pension goes into that account. Ohio would accept just the $418 over the cap, but routing the whole $1,300 pension check is simpler and safer: it leaves a cushion when Social Security rises each January, and some states require a whole income source to go in rather than a partial amount, so check your state's instructions. With the pension in the trust, her countable income is no longer over $2,982 and she is eligible.

Then the money goes back out. Ohio lets a nursing-home resident keep a $75 personal needs allowance each month. After that and any health insurance premiums such as Medicare Part B, the rest of her income, including what passed through the trust, is paid to the nursing home as her share of cost (patient liability). Medicaid pays the nursing home the rest of its Medicaid rate, which is set by the state and is lower than the $9,305 private-pay price. The trust is a pass-through: nothing accumulates in it, and the family is not keeping the pension.

If she were married and her husband still lived at home, part of her income could instead go to him as a spousal income allowance before the nursing home is paid. That calculation is separate from the trust; our guide to how Social Security pays a nursing home walks through it.

Who signs it. The applicant can set up the trust if they are able to. More often an adult child signs as agent under a power of attorney. Check that the document gives the agent authority to create trusts; some older forms do not, and then a court-appointed guardian may be needed, which takes months.

The trustee and the account. The trustee is usually a family member; the applicant generally cannot be their own trustee. The trust needs its own bank account, separate from the parent's other accounts, and only income goes into it: never savings, the proceeds of a house sale, or anyone else's money. Kentucky requires the account to be at a Kentucky bank, and other states have their own small rules, so read your state's version. Because the trust is treated as the applicant's for tax purposes, the account is usually opened under their Social Security number; some banks ask for a separate tax ID (EIN) instead, so ask before opening it.

Templates. Several states publish a ready-made trust form or packet, including Alabama (its Form 262 QIT packet) and Wyoming (an Income Trust Packet given to applicants over the income standard). Indiana's FSSA has a page on establishing a Miller trust. Where the state supplies a form, many families use it without a lawyer; where it doesn't, or where there is also a spouse, savings or a house to plan around, an elder law attorney is usually worth it.

Timing. Medicaid generally will not cover months before the trust existed and was funded, so set it up as soon as it is clear your parent's income will be over the cap, ideally before the application goes in. Some states also cap how much income the trust can fix. In Oklahoma it works only up to $7,637 a month of income (from July 2026), and in Colorado total income must be below the regional private-pay nursing-home rate ($9,780 to $11,522 a month in 2026). South Carolina states there is no upper limit.

• Missing a deposit. Eligibility is checked month by month. A month in which the excess income was not put into the trust is a month the applicant is over the cap, and Medicaid can deny that month's care.
• Depositing too little. Income changes every January with the Social Security cost-of-living increase, and the cap changes too. Recheck the amount over the cap each year and whenever a pension changes.
• Putting savings in the trust. A Miller trust may hold only the person's income. Adding savings can disqualify the trust; savings are dealt with under the asset rules.
• Spending from the trust. Money in the trust is there to pay the allowed items: the nursing home's share of cost, the personal needs allowance, premiums, and in some states a small trustee or bank fee. Using it for anything else can be treated as a transfer under the look-back rules and cost the person their eligibility.
• Using the wrong state's form. Each state has its own required wording. A template from another state, or a generic one from the internet, can be rejected.
• Closing the account at death. The balance is owed to the state, up to what Medicaid paid. The trustee should notify the Medicaid agency rather than distribute it to family.