Florida Qualified Income Trusts (Miller Trusts): How They Work and How to Fund One

A Qualified Income Trust (QIT), also called a Miller Trust, is an irrevocable trust that lets a Florida Medicaid applicant whose gross monthly income is over the income cap qualify for long-term care anyway. For 2026 the cap is $2,982 a month (DCF Appendix A-9). Each month, the income over the cap goes into a separate trust bank account. The trust pays toward the person's care, and whatever is left when the person dies goes to the State, up to what Medicaid paid.

The trust is a simple document. Running it correctly every month is the hard part, and that is where most QIT cases go wrong.

Who Needs a Qualified Income Trust

Florida is an income cap state. For nursing home Medicaid (the Institutional Care Program, or ICP), the Statewide Medicaid Managed Care Long-Term Care waiver for home and assisted living care, and PACE, an applicant's gross income cannot be more than 300% of the SSI federal benefit rate. One dollar over and the applicant is ineligible, no matter how large the nursing home bill is. The QIT is the fix the law provides (ESS Policy Manual 1840.0110; 42 U.S.C. § 1396p(d)(4)(B)).

The test uses gross income, not the deposit that lands in the bank. Social Security is the usual trap. If Medicare Part B is withheld from the check, the gross benefit is higher than the deposit, and the gross figure is what DCF counts. A parent whose bank statement shows $2,800 from Social Security can easily be over the cap once the premium is added back. Pull the Social Security award letter and every pension statement before deciding whether a trust is needed.

The QIT rule covers ICP, institutional hospice, the home and community-based waiver, and PACE. It does not cover Community Hospice. VA benefits have their own rules, and some VA payments are left out of the cap test. Our guide to VA aid and attendance and Florida Medicaid walks through them.

What the Trust Must Say

DCF treats a trust as a qualified income trust only if it meets four requirements (ESS 1840.0110):

1. It was established on or after October 1, 1993, for the benefit of the individual.
2. It is irrevocable.
3. It holds only the individual's income: Social Security, pensions, and other income.
4. It provides that the State receives the balance in the trust at the individual's death, up to the total Medicaid paid on the individual's behalf.

Put any of the person's savings in the account, or anyone else's money, and it stops being a qualified income trust. DCF sends every income trust to its Circuit Legal Counsel for approval before the application is finished.

The trust has to be signed and dated, but it does not need witnesses (Appendix A-22.1, Step 1). It can be signed by the applicant, the applicant's spouse, or someone with legal authority to act for either of them (Step 4). That last category is where families get stuck. An agent under a power of attorney can create a trust only if the document specifically grants that power and the principal signed or initialed next to it (§ 709.2202(1)(a), Fla. Stat.). Many older powers of attorney don't. If the POA lacks that power and the parent can no longer sign, the choices narrow to the spouse signing or a guardianship.

How Funding Works Every Month

The trust needs its own bank account. Each month, enough income has to go into that account in the month it is received to bring the income left outside the trust under the cap, and it must happen every month Medicaid is needed (ESS 1840.0110). DCF's reviewing guidelines are blunt: income cannot be excluded until it is placed into the trust, and "trusts cannot be funded retroactively" (Appendix A-22.1, Step 2).

That means one missed or short deposit costs that month's Medicaid long-term care coverage. There is no catch-up deposit. Funding also starts before the State approves the trust; DCF expects deposits while the trust is still under legal review.

Social Security should not be sent straight to the trust account. The Social Security Administration generally will not approve direct deposit to an irrevocable trust where the beneficiary is not the trustee, because it treats that as an assignment of benefits (SSA POMS GN 02402.060). The arrangement that works: all income direct-deposits to the person's own checking account, and one automatic recurring transfer moves the trust amount to the QIT account at the same bank, timed after the last check of the month arrives.

The trustee also has to give DCF quarterly statements showing each month's deposits.

How Much Goes In

The legal minimum is the gross income over the cap. The right amount depends on where the person receives care.

Nursing home. Nearly all of the person's income goes to the facility as patient responsibility anyway. Depositing all income, or at least the full patient responsibility, keeps one clean payment path from the trust to the nursing home.

At home or in assisted living (the waiver). Do not deposit everything. Money in a QIT can be paid only to third parties for the person's benefit. Anything paid to the person counts as their income (ESS 1840.0110), so the trust cannot hand money back for rent, food, or utilities. Deposit the minimum plus a small cushion, or the patient responsibility if that is higher, and leave the rest in checking where the person can live on it.

Recheck the amount every January, when Social Security cost-of-living increases and new Medicare premiums arrive, and after any change in benefits or care setting. A deposit that was right last year can be short this year.

What the Trust Pays, and Patient Responsibility

A QIT does not reduce what the person pays toward care. It changes whether the person is eligible. DCF counts all income, inside the trust and out, when it computes patient responsibility, the monthly amount the person contributes to the cost of care (ESS 1840.0110, item 7).

Patient responsibility is gross income minus, in order, a personal needs allowance, any allowance for a community spouse or dependents, and uncovered medical expenses such as health insurance premiums (ESS 2640.0117). The personal needs allowance depends on the setting (ESS 2640.0118):

• Nursing home: $160 a month.
• At home on the waiver or PACE: 300% of the federal benefit rate, the same figure as the income cap. Only people over the cap, which means people with a QIT, have a patient responsibility at home.
• Assisted living on the waiver or PACE: the facility's basic monthly rate for three meals a day and a semi-private room, plus 20% of the federal poverty level.

The trust pays the patient responsibility to the nursing home, or to the provider the Medicaid plan designates, or to the PACE organization. It can also pay a community spouse's income allowance and health insurance premiums. Because the rules differ so much by setting, a plan built for a nursing home will misfire at home or in assisted living.

The Mistakes That Cost Coverage

The same few errors show up again and again:

• Using the net Social Security deposit instead of the gross benefit. The trust is sized wrong from the first month.
• A missed or short month. No retroactive funding means that month is lost.
• Direct-depositing Social Security into the trust account. SSA can reject it, and payments stall.
• Depositing all income in a home or assisted living case. The money is trapped in the trust and the person cannot pay rent.
• Letting checking build up. Income not spent in the month it arrives becomes an asset the next month. A slow buildup in the person's own account can push them over the $2,000 asset limit and end eligibility at renewal.
• A balance growing in the trust. In a nursing home case it usually means patient responsibility is not being paid. In a home case it usually means the deposit is too large. Either way, it goes to the State at death.

When the Person Dies

The trustee pays what remains in the trust, up to the total Medicaid paid, to the State's Medicaid program before anyone else receives anything. The trust ends there; it is not an inheritance vehicle.

Getting the Trust Set Up and Running

A licensed Florida attorney drafting the trust matters more than it sounds. DCF's own guidelines presume that a trust prepared by a licensed attorney was signed with proper authority (Appendix A-22.1, Step 4). The drafting is the short part of the job. The work that keeps coverage in place is getting the income figures right, setting the deposit for the care setting, and writing down a monthly routine the trustee can follow.

That is what our QIT Review does. Our firm checks the income and bills against your documents and gives you a written report: whether a trust is needed, the deposit to make, the estimated patient responsibility, which account pays each bill, and the steps to follow each month. If you need the trust drafted, our flat fee is $1,250, and it includes the full QIT Review. If you already have a trust, the review alone is $250, and it is credited toward the drafting fee if you later engage us to prepare the trust. To start on the trust, schedule a consultation.

Further reading: Carl Zacharia's book Florida Long-Term Care and Medicaid covers Qualified Income Trusts alongside the asset rules, the community spouse protections, and the five-year lookback.