Ohio Miller Trust 2026: Qualified Income Trust (QIT) Setup

An Ohio Miller Trust lets a long-term-care Medicaid applicant qualify when countable monthly income exceeds Ohio's 2026 Special Income Limit of $2,982.1 Over that cap, an applicant isn't income-eligible under the SIL; Ohio's rule lets them place income in the trust to bring countable income down to it, though any income kept outside the trust still counts.2 That cap applies whether you need Medicaid to pay for nursing facility care or home and community-based services (HCBS) waiver services like PASSPORT, the Assisted Living Waiver, or the Ohio Home Care Waiver. Ohio uses an income cap for Long-Term Care Medicaid, not a spend-down (it ended its aged, blind and disabled spenddown in 2016), and the Special Income Limit (SIL) is set at 300 percent of the SSI Federal Benefit Rate.2,3 This guide explains what a Miller Trust is under federal and Ohio law, when you need one and when you do not, how to set it up correctly, how the monthly deposit-and-distribution flow works, how the trust differs across nursing facility Medicaid and the HCBS waivers, what happens to the trust on death under Ohio estate recovery, and the operational mistakes that cause QITs to fail at the County Department of Job and Family Services (CDJFS) desk.

Key Takeaways

• The Miller Trust is the income-only trust 42 USC 1396p(d)(4)(B) permits, implemented in Ohio at OAC 5160:1-6-03.2. It lets an applicant in an income-cap state qualify for Long-Term Care Medicaid even when their income exceeds the Special Income Limit, provided the income is routed through an irrevocable trust that meets the rule's terms.2
• Ohio's 2026 Special Income Limit (SIL) is $2,982 per month for a single applicant, calculated as 300 percent of the 2026 SSI Federal Benefit Rate (FBR) of $994 per month. Ohio's rule lets an applicant with countable monthly income above $2,982 set up a Miller Trust to bring countable income down to the SIL; it's an option, not a mandate, but income kept outside the trust still counts. Applicants at or below the SIL do not need one. Authority: OAC 5160:1-6-03.1.1,2
• The Miller Trust applies to LTC Medicaid, not all Ohio Medicaid. A QIT can establish eligibility only for someone who is eligible for Medicaid long-term care services and subject to patient liability. If you need aged, blind or disabled (ABD) Medicaid for medical coverage only, a QIT can't help, and Ohio no longer offers an ABD spenddown: it ended on August 1, 2016, when Ohio became a 1634 state.3
• The trust must be irrevocable and hold only the applicant's own income, plus any interest the trust earns, in an account whose title clearly identifies it as a QIT account in the applicant's name.2
• Trust funds are paid out in the order Ohio's rule sets, within 30 days of when the income goes into the QIT account: a personal or maintenance needs allowance for the applicant, a maintenance allowance for a spouse (and family dependents) where applicable, health care costs, and up to $15 a month for bank, attorney and other trust administration costs unless ODM approves more. The trust doesn't shield income from the cost of care: everything placed in it still counts toward the monthly patient liability.2
• The county needs proof the trust is real and running. The executed trust document, proof the QIT account was opened, the required monthly deposit amount and verification of the monthly deposits go in with the application, and ODM Form 10193 is the state's QIT verification form for this. Deposit records are checked again at each annual renewal.2
• Ohio's 60-month look-back still applies separately. A Miller Trust does nothing about gifts or other transfers of assets made in the 60 months before the baseline date, which OAC 5160:1-6-06 presumes improper and OAC 5160:1-6-06.5 penalizes with a restricted Medicaid coverage period. Putting your own income into a QIT is not an improper transfer.4
• The trust must name the Ohio Department of Medicaid as the remainder beneficiary. It ends at the recipient's death, and what's left goes to ODM up to the total Medicaid paid on the recipient's behalf. That's a separate claim from Ohio estate recovery.2
• Have an Ohio elder-law attorney draft the trust. The rule's terms are specific, and income that isn't properly placed in a qualifying trust still counts, so a trust that misses one can leave the applicant over the limit while the family pays out of pocket.2

Why Ohio uses an income cap in the first place

States handle long-term-care applicants with higher incomes in one of two broad ways. Some run a medically needy program that lets an applicant over the income limit qualify by spending the excess on medical bills, a process called spend-down. Others set a hard income ceiling, the Special Income Limit (SIL), and those are called income-cap states. Social Security's list of state Medicaid programs records Ohio as a 1634 state and shows no medically needy program for aged, blind and disabled people.3

Ohio is an income-cap state for Long-Term Care Medicaid. The choice is implemented at OAC 5160:1-6-03.1, which sets the LTC income limit at 300 percent of the federal SSI Federal Benefit Rate. The 2026 SSI FBR is $994 per month, so the 2026 Ohio LTC SIL is $2,982 per month for a single applicant.1

The hard ceiling creates a common problem. Combined with even modest pensions, IRA required minimum distributions, or part-time work, many applicants have gross monthly income above $2,982 without being remotely wealthy.1 Without a workaround, these applicants would not be income-eligible under the SIL, even though they cannot afford Ohio nursing facility care, which the CareScout (Genworth) 2025 Cost of Care Survey puts at a median of roughly $9,186 per month for a semi-private room and $10,389 per month for a private room.5 The federal Miller Trust exception at 42 USC 1396p(d)(4)(B) was Congress's solution. By routing income through a qualifying irrevocable trust, the applicant gains eligibility while the state still captures any trust balance at death through the remainder beneficiary designation.2

Ohio implements the federal exception at OAC 5160:1-6-03.2, as amended effective October 12, 2026, which sets out the state's specific requirements for a QIT. Income that isn't placed in a qualifying QIT account counts toward the limit, so a trust that misses the rule's terms doesn't bring the applicant under it.2

When you need an Ohio Miller Trust and when you do not

The simple test is whether the applicant's countable monthly income exceeds the 2026 SIL of $2,982, since countable income is what Ohio's rule measures against the cap.1 Countable income is the applicant's own income, such as Social Security, a pension, annuity payments, retirement-account distributions or wages. Some payments are excluded under federal and Ohio rules, so confirm the countable figure with your county Department of Job and Family Services or an elder-law attorney before deciding on a trust.

Applicants below the SIL do not need a Miller Trust. If countable monthly income is $2,982 or less, the applicant meets the SIL income test without one (the resource rules and clinical eligibility still apply separately, and a monthly patient liability is still owed toward the cost of care).1 Setting up a Miller Trust when it is not required is not wrong, but it adds complexity and cost without benefit.

Applicants above the SIL can use a Miller Trust to bring countable income down to the SIL for any of the following Medicaid pathways:2

• Nursing facility (institutional) Medicaid under OAC 5160:1-6
• PASSPORT Waiver HCBS for older adults
• Assisted Living Waiver services
• Ohio Home Care Waiver services
• MyCare Ohio Waiver services
• Other Ohio HCBS waivers or PACE, where the participant is subject to patient liability6

Applicants who are NOT applying for LTC Medicaid generally do not use Miller Trusts. Two situations:

• ABD Medicaid for medical-only coverage. If the applicant needs Medicaid to cover doctor visits, prescriptions, and acute medical care but does not need NF or HCBS waiver services, a Miller Trust does not apply. Nor can the applicant spend down: Ohio ended its aged, blind and disabled spenddown on August 1, 2016, so an applicant in the community whose income is over the ABD limit can't spend excess income on medical bills to qualify. A working adult with a disability may have a route through the Medicaid Buy-In for Workers with Disabilities (Ohio WorkAbility); your county Department of Job and Family Services can say which category fits.1,3
• MAGI-based Medicaid for working-age adults. Modified Adjusted Gross Income (MAGI) Medicaid uses a different income method and has no SIL or Miller Trust mechanism.1

A related point of confusion is when an applicant is dual-eligible (Medicare + Medicaid) but only needs the wraparound Medicare Savings Program benefits without LTC services. In that case, no Miller Trust is needed. The Miller Trust is specifically a Long-Term Care Medicaid tool, not a general Medicaid tool.

How the Ohio Miller Trust works mechanically

A correctly structured Ohio Miller Trust has six structural elements that, if any is wrong, can cause the trust to be rejected. Ohio's QIT rule is OAC 5160:1-6-03.2, as amended effective October 12, 2026, and it sets four core requirements: the trust must be irrevocable, only the individual's own income may be deposited (plus interest the trust earns), the trust must terminate at the beneficiary's death with the remainder going to the Ohio Department of Medicaid (ODM), and disbursements are limited, in order and within 30 days of each deposit, to a monthly maintenance allowance for the beneficiary, a spousal or family allowance where applicable, health care costs, and up to $15 a month for trust administration unless ODM approves more.2

1. Irrevocable. The trust must be irrevocable, meaning once established it cannot be unilaterally revoked or modified by the grantor (the Medicaid applicant) to retrieve funds. Revocable trusts do not qualify under Ohio's QIT rule.2 The irrevocability is what gives the trust its legal effect for Medicaid purposes; the applicant has divested the qualifying income into a trust governed by federal and state rules rather than by their own discretion.

2. Established at a qualifying financial institution. The trust requires a dedicated bank account, separate from any personal checking or savings account. Ohio's rule requires the account title to clearly identify it as a QIT account in the applicant's name.2 Not every bank is set up to title an account this way, so ask before you go in. The account is typically titled along the lines of "[Applicant Name], [Trustee Name] Trustee, Qualified Income Trust under 42 USC 1396p(d)(4)(B)."

3. Trustee designation. A trustee must be named and willing to serve. The trustee is responsible for receiving the qualifying income each month, making the required distributions, maintaining records, and providing the bank statements that CDJFS will need to verify ongoing compliance. Who may serve, including whether the applicant can, is a point to settle with the drafting attorney rather than assume. Possible trustees include an adult child, a spouse (subject to specific care to avoid spousal-income complications), another close family member, a corporate trustee, or a professional fiduciary. The trustee should be reliable, organized, and accessible because the role is operational, not ceremonial.

4. Source-of-funds rules. Only the applicant's own income, plus interest the trust earns, can be placed into the trust.2 Non-qualifying funds (gifts from family, sale proceeds of personal property, inheritance, the community spouse's income, refunds of personal expenses) must not be deposited. Mixing them in, called comingling, breaks the rule's income-only requirement. Ohio's rule lets an applicant place some or all of their income in the trust, though income kept outside it still counts toward the limit, so the trust has to hold enough to bring countable income down to the SIL.3,2

5. Remainder beneficiary designation. Ohio's rule requires the trust document to provide that the trust ends at the beneficiary's death and that what remains then goes to the Ohio Department of Medicaid (or its successor), up to the total Medicaid paid on the beneficiary's behalf, with the trustee barred from paying other people or creditors first.2,3 Without this clause, the trust fails to qualify.

6. Specific Ohio language requirements. Beyond the federal structural elements, Ohio requires specific language in the trust document that aligns with OAC 5160:1-6-03.2.2 The language addresses the trustee's duties, the distribution waterfall, the irrevocability clause, the remainder beneficiary mechanics, and the prohibition on amendments.

The monthly deposit and distribution flow

Once the trust is established and CDJFS has verified it (typically through ODM Form 10193 submission), the monthly operational flow looks like this.

Each month, qualifying income is deposited into the trust account. Social Security is typically routed into the trust account by changing the direct deposit with Social Security. Pension payments are redirected to the trust account through the pension administrator. IRA distributions are routed to the trust account. The applicant signs the necessary authorizations once and the deposits then happen automatically each month.

The trustee distributes funds out of the trust in the order Ohio's QIT rule sets, within 30 days of when the income was deposited: the maintenance allowance, then a spousal or family allowance, then health care costs, plus up to $15 a month for trust administration unless ODM approves more.2

First: Maintenance needs allowance (the resident keeps a defined amount). For nursing facility residents, this is the Personal Needs Allowance (PNA): Ohio's 2026 NF PNA is $75 per month under OAC 5160:1-6-07.7 For HCBS waiver participants the kept amount is larger and is set by the waiver's post-eligibility rule rather than the NF PNA. For PASSPORT and the Ohio Home Care Waiver, the special individual maintenance needs allowance (SIMNA) is 65 percent of the SIL, which ODM publishes as $1,939 per month for 2026;6 for the Assisted Living Waiver, the assisted living waiver maintenance needs allowance (ALMNA) equals the full SSI FBR of $994 per month under OAC 5160:1-6-07.1.6 The figures by pathway are summarized in the table below. See /medicaid/ohio/personal-needs-allowance for the full breakdown.

Second: Community spouse income allowance. If the applicant is married and has a community spouse, the Community Spouse Monthly Income Allowance (CSMIA) under 42 USC 1396r-5 may apply. The community spouse can receive a portion of the institutionalized spouse's income to bring the community spouse up to a minimum income level. Ohio uses the federal Minimum Monthly Maintenance Needs Allowance (MMMNA), and its two figures are standards, not the ends of a sliding scale. The MMMNA is $2,705.00 per month, effective July 1, 2026, and the allowance is the amount by which it exceeds the community spouse's own income.1 The standard rises above that level for a spouse whose shelter costs run above the federal housing standard, $811.50 a month in Ohio and every state but Alaska and Hawaii, and $4,066.50 is the 2026 maximum standard, not an amount a spouse can simply ask for.8 It isn't an absolute limit, though: a fair hearing can set the allowance higher if the community spouse shows exceptional circumstances causing significant financial duress, and a court order for the spouse's support sets the allowance at no less than the ordered amount.1,8 The trust distributes the CSMIA to the community spouse.

Third: Medicare premiums and supplemental insurance. Health insurance premiums, including Medicare premiums such as Part B, Part D and Medigap, are allowable deductions, along with coinsurance, deductibles and copayments.7 The trust distributes the amount needed to pay these premiums.

Fourth: Allowable medical expenses not otherwise covered. Out-of-pocket medical expenses that Medicaid does not cover and that have not been reimbursed by other insurance can be deducted from the income available to pay the facility, subject to specific rules at OAC 5160:1-6-07.7

Fifth: NF income obligation or HCBS waiver income contribution. The remaining trust balance is paid to the nursing facility (for NF Medicaid recipients) as the patient liability obligation per 42 CFR 435.725, or to the appropriate party for HCBS waiver participants under 42 CFR 435.726 (the specific mechanism varies by waiver).7,6 The net effect is that the trust balance is paid out each month to bring the trust account to a near-zero balance.

No balance building up. Ohio's rule requires the distributions to be made within 30 days of when the income goes into the QIT account, so income shouldn't sit in the account from one deposit to the next.2 A balance that keeps growing is a sign the trust isn't being run the way the rule requires.

The amount the resident keeps before paying the facility or waiver depends on the care setting. The table below compares the 2026 maintenance allowance by pathway.7,6

In every pathway, Medicare and supplemental premiums and any applicable CSMIA are subtracted before the patient liability, and QIT administration fees of up to $15 per month, or a higher amount the agency approves, are an allowable deduction in the post-eligibility calculation.6

Real-world example: a single applicant entering a nursing facility

To make the mechanics concrete, consider Helen, age 79, a hypothetical applicant entering a Cleveland-area nursing facility in 2026. Her monthly income:

Helen's countable income exceeds the 2026 SIL of $2,982 by $818, so she isn't income-eligible unless she brings it down to the SIL, which is what a Miller Trust does.1 She and her daughter Karen (the proposed trustee) engage an Ohio elder-law attorney who drafts the trust using template language compliant with OAC 5160:1-6-03.2. The attorney also reviews Helen's 60-month lookback for any countable transfers and confirms that her asset position satisfies the $2,000 resource limit (her remaining $1,800 in checking is below the limit, and the attorney checks how her home is treated).1

Karen opens a trust account at a regional bank with the title "Helen Smith, Karen Smith Trustee, Qualified Income Trust under 42 USC 1396p(d)(4)(B)." Karen changes Helen's Social Security direct deposit to the trust account. The pension administrator is contacted to reroute pension payments. The IRA custodian is contacted to reroute RMDs.

With Helen's application, CDJFS receives ODM Form 10193 along with the executed trust document, proof the QIT account was opened, the required monthly deposit amount and the bank statement verifying the deposit.2 The trust is verified.

Each month thereafter, Karen as trustee distributes from the trust (PNA per OAC 5160:1-6-07):7

• PNA: $75 paid to Helen for personal use
• Medicare premiums: Part B premium plus any Part D and Medigap premiums (check the current-year amounts on medicare.gov)
• Community spouse allowance: Not applicable (Helen is single)
• Allowable medical expenses: None this month
• Patient liability to NF: Helen's gross income, minus PNA, minus the premiums above, is paid to the nursing facility

Karen makes these distributions within 30 days of each deposit, so no balance builds up in the account.2 Helen's Medicaid coverage continues. The nursing facility receives Helen's patient liability (her gross income after PNA and premium deductions) plus the Medicaid payment for the balance of the daily rate.

If at any point Helen's income changes (annual COLA, pension adjustment), Karen adjusts the distribution amounts accordingly and the trust continues to function. If Helen passes away, any final trust balance (typically minimal) goes first to ODM under the remainder beneficiary clause, up to the total Medicaid paid during her stay, before any other recipient.

How does a community spouse change the trust?

When the Medicaid applicant is married and the spouse is staying in the community (not also in NF or HCBS), spousal impoverishment rules at 42 USC 1396r-5 interact with the Miller Trust mechanics.

Income attribution. Under federal spousal impoverishment rules, while the institutionalized spouse is in the institution, none of the community spouse's own income is deemed available to the institutionalized spouse, and no MMMNA figure limits the community spouse's own income (which is a structural difference from the asset rules).1 If only the institutionalized spouse's income exceeds the SIL, only that income needs to be routed through the Miller Trust.

CSMIA distribution. Once the institutionalized spouse qualifies for Medicaid through the Miller Trust, the community spouse may be entitled to a Community Spouse Monthly Income Allowance to bring the community spouse's income up to the MMMNA, which is $2,705.00 a month from July 1, 2026 and reaches the $4,066.50 maximum standard only for a spouse whose shelter costs justify the increase. A fair hearing (on exceptional circumstances causing significant financial duress) or a court support order can set the allowance above that standard.1,8 The CSMIA is distributed from the institutionalized spouse's Miller Trust to the community spouse before the patient liability distribution to the facility.

CSRA (resources). Resources are addressed under separate Community Spouse Resource Allowance rules. For 2026, ODM lists a minimum CSRA of $32,532 and a maximum of $162,660. Those are standards that feed the federal calculation, not a cap on what the community spouse can keep: a fair hearing or a court order can set the allowance above $162,660, though at a hearing the state first treats the institutionalized spouse's available income as going to the community spouse (the "income first" rule).1,8 The Miller Trust does not address resources; the spousal impoverishment resource rules and the 60-month lookback handle asset eligibility separately.

Practical implication. Married applicants typically need both a Miller Trust for income above the SIL and careful spousal impoverishment planning for the assets and income coordination. This is one of the most complex areas of Ohio LTC Medicaid and is a primary reason married applicants should not attempt DIY Medicaid applications.

Miller Trusts and HCBS waivers (PASSPORT, AL Waiver, OHCW, MyCare)

A common misconception is that Miller Trusts are only for nursing facility Medicaid. They are not. HCBS waiver applicants whose countable income exceeds the SIL can use Miller Trusts too, but the distribution mechanics differ from NF mechanics, mainly in how much income the participant keeps before the patient-liability or waiver contribution.3

PASSPORT and the Ohio Home Care Waiver. Participants live in the community, not in a nursing facility, so there is no NF patient liability obligation. The Miller Trust distribution waterfall is structured around the special individual maintenance needs allowance (SIMNA), which is 65 percent of the SIL under OAC 5160:1-6-07.1 and which ODM publishes as $1,939 per month for 2026, far larger than the $75 NF PNA, plus Medicare and supplemental premium deductions, the CSMIA if applicable, and the post-eligibility income contribution to the waiver.6,7 The participant gets a written notice of the patient liability amount, and it explains how to request a hearing if they disagree.6

Assisted Living Waiver. Participants reside in a Medicaid-participating Residential Care Facility (RCF) and pay room and board from income. The Assisted Living Waiver maintenance needs allowance (ALMNA) equals the full SSI FBR, or $994 per month in 2026, under OAC 5160:1-6-07.1. Out of that $994, the RCF may charge room and board of no more than $944 per month ($994 minus $50) under OAC 5160-33-03, leaving the resident a $50 monthly personal cushion. That $50 cushion is lower than the $75 NF Personal Needs Allowance, not higher.6,7 After the ALMNA, Medicare and supplemental premiums, and any CSMIA, the remaining income is the resident's patient liability toward waiver services.

MyCare Ohio Waiver. Ohio's patient-liability rule treats a MyCare participant like the matching waiver: one living in the community keeps the $1,939 SIMNA, and one in an assisted living facility keeps the $994 ALMNA.6 The Miller Trust works the same way as for those waivers.

In all HCBS waiver cases, the Miller Trust is set up the same structural way (irrevocable, qualifying account, trustee, remainder beneficiary, Ohio-compliant language). What changes is the distribution waterfall during the monthly operation, reflecting the different post-eligibility income obligation rules for each waiver.

Setting up the trust: practical timeline

Setting up the trust takes some weeks even when everything goes smoothly. The sequence:

Delays can come from direct-deposit changes that take longer than expected, banks that hesitate to open Miller Trust accounts, errors in the trust document that require redrafting, and CDJFS reviewers who flag issues that need correction. Building in some buffer between trust setup and the Medicaid application start date is prudent.

Common drafting and operational mistakes

The defects that cause trouble, especially in do-it-yourself trusts:

Wrong trustee. Naming a person who is unable or unwilling to serve, or failing to address what happens if the trustee becomes unable to continue. The trust document should include a successor trustee clause.

Wrong account type. Using a personal checking account instead of a dedicated trust account, using an account title that does not clearly identify it as a QIT account in the applicant's name, as Ohio's rule requires, or using an account at a financial institution that does not recognize the structure.2

Revocability language. Including language that allows the grantor to amend or revoke the trust, which voids the qualifying structure, since Ohio's rule requires the trust to be irrevocable.2

Missing remainder beneficiary clause. Failing to designate the Ohio Department of Medicaid as the remainder beneficiary up to the total Medicaid benefits paid, as OAC 5160:1-6-03.2 requires the trust to terminate at death with the remainder going to ODM.2

Comingling of funds. Depositing non-qualifying funds into the trust account (gifts, the community spouse's income, inheritance, personal property sale proceeds). Only the applicant's own income, plus interest the trust earns, can go in.2

Retained balances. Failing to distribute funds within 30 days of each deposit, as Ohio's rule requires, so the account accumulates a balance over time.2 The trust is intended to be a flow-through account, not an asset accumulation account. Significant retained balances raise verification flags.

Incorrect distribution waterfall. Distributing trust funds to non-allowable purposes (gifts, ineligible relatives, the applicant's personal asset accumulation) instead of the disbursements Ohio's QIT rule allows.2

Failure to update for income changes. Not adjusting distribution amounts when Social Security has a COLA, when pensions change, or when allowable deductions change. Stale distribution structures can cause the patient liability calculation to be wrong, which the facility will eventually flag.

Improper trustee record-keeping. Failing to retain bank statements, distribution records, and correspondence that documents trust operation. CDJFS verification at the initial application and at annual redeterminations requires these records.2

Confusion with revocable living trusts. Some families confuse Miller Trusts with revocable living trusts used for probate avoidance. These are completely different instruments. A revocable living trust is not a QIT, because the QIT must be irrevocable, and it provides no LTC Medicaid eligibility benefit.2

What happens to the trust when the recipient dies?

The remainder beneficiary clause means that any balance left in the Miller Trust at the recipient's death is owed to Ohio Medicaid, up to the total Medicaid paid on the recipient's behalf. Ohio's QIT rule at OAC 5160:1-6-03.2 requires the trust document to say so.2

How much is typically left in the trust at death? If the trust is operated correctly, with each deposit paid out within 30 days, little should be left.2 A large balance suggests the trustee wasn't paying out the deposits, which itself is a compliance issue during the recipient's life.

Trust remainder vs broader estate recovery. The Miller Trust remainder recovery is separate from Ohio's broader estate recovery under Ohio Revised Code 5162.21. Ohio elects expanded estate recovery: it recovers from both probate and non-probate assets, including property that passes by joint tenancy, survivorship, life estate, or living trust, for recipients age 55 or older and for the permanently institutionalized of any age.2 That broader recovery waits, though, while a surviving spouse is living or there is a surviving child under 21 or blind or permanently and totally disabled; a surviving spouse delays recovery but doesn't cancel it, and the under-21 protection ends when the child turns 21. For a permanently institutionalized recipient, the home is also protected while either of two relatives still lives there: a sibling who lived there for at least a year before admission and ever since, or a son or daughter who lived there for at least two years before admission and ever since and whose care delayed the move (documented with a level-of-care assessment, the physician's statement, and care records).2 The trust remainder is paid before any other distribution from the trust at death; the broader recovery, by contrast, reaches assets like the home if the recipient retained ownership. See /medicaid/ohio/estate-recovery for the full picture.

Practical impact. A trust run as a flow-through, not an accumulator, should leave little for ODM to take. The bigger estate recovery question is assets like the home, which Ohio's expanded recovery can reach.2

Appeals when CDJFS rejects a Miller Trust

If the CDJFS county caseworker rejects the Miller Trust for any reason, the applicant has appeal rights. The time limit for requesting a state hearing is set by OAC 5101:6-3-02.9 OAC 5160:1-6-03.2 spells out what the county needs to see: the executed trust document, proof the QIT account was opened, the required monthly deposit amount, and verification of the monthly deposits.2

A rejection can trace to the defects covered above: trust-document language problems (revocability or a missing remainder-beneficiary clause), account-titling errors, comingled funds, retained balances, or missing deposit verification or Form 10193.

Resolution paths:

1. Correct the defect. If the problem is in the trust document or how the account is run, the elder-law attorney can work with the county to identify it, amend the trust or the practice, and resubmit, which may be faster than a hearing.
2. Request a State Hearing if the defect is contested. You have 90 calendar days, counted from the day after the notice was mailed, and the request counts on the date the state or local agency receives it. You can ask orally, in writing, or electronically: call or write your county agency, or write to the ODJFS Bureau of State Hearings, PO Box 182825, Columbus, Ohio 43218-2825 (the request form can also be faxed to (614) 728-9574). Only you can make a request by phone; someone filing in writing for you needs your signed statement naming them as your representative.9 Keeping existing benefits at the prior level while the appeal runs is a separate, shorter clock: a recipient whose assistance or services will be reduced, stopped, or restricted should request the hearing within 15 days of receiving that notice, and even then continuation is conditional, not automatic.9

Practical guidance for families

The single most important piece of guidance for Ohio families approaching LTC Medicaid with income above the SIL is: engage an Ohio elder-law attorney before applying. A properly drafted Miller Trust is a modest cost next to even one month without Medicaid coverage. The CareScout (Genworth) 2025 Cost of Care Survey puts Ohio nursing facility care at a median of roughly $9,186 per month for a semi-private room and $10,389 per month for a private room, paid out of pocket until coverage is approved.5 A template trust that lacks the terms OAC 5160:1-6-03.2 requires won't bring countable income under the limit.2

Other practical guidance:

Plan early when possible. If the applicant is still in the community and the need for NF or HCBS care is foreseeable in the next year or two, plan the Miller Trust setup well before the application date. Last-minute trust setup during a hospital discharge crisis is operationally challenging.

Address the 60-month lookback separately. The Miller Trust does not resolve any transfer issues from the lookback period. If the applicant has made gifts to children or grandchildren, transferred property at less than fair market value, or otherwise disposed of assets within the 60-month look-back, which runs back from a baseline date tied to institutionalization or the waiver application, those transfers are presumed improper and are handled under the penalty rules at OAC 5160:1-6-06.5.4 A complete elder-law engagement addresses both income (Miller Trust) and assets (lookback, exemption planning) together.

Coordinate with the facility or case manager. The facility billing office, or the waiver case manager for home care, needs to know the trust structure to apply patient liability or the waiver contribution correctly each month.

Key statutes, rules, and authorities

The figures and rules in this guide trace to the following federal and Ohio authorities.2,1

• 42 USC 1396p(d)(4)(B) (federal Miller Trust authority)
• 42 USC 1396r-5 (spousal impoverishment, CSMIA, MMMNA, CSRA)
• 42 CFR 435.725 and 42 CFR 435.726 (post-eligibility income / patient liability, institutional and HCBS)
• OAC 5160:1-6-03.1 (Ohio Special Income Limit)1
• OAC 5160:1-6-03.2 (Ohio Qualified Income Trust rule)2
• OAC 5160:1-6-06 (improper transfers and the 60-month look-back)4
• OAC 5160:1-6-06.5 (restricted Medicaid coverage period for an improper transfer)
• OAC 5160:1-6-07.1 (HCBS waiver and PACE patient liability, SIMNA and ALMNA)6
• OAC 5160:1-6-07 (Personal Needs Allowance and post-eligibility income)
• OAC 5160:1-3-03.5 (ABD income standard; Ohio's ABD spenddown ended August 1, 2016)3
• OAC Chapter 5160-33 (Assisted Living Waiver)6
• OAC 5101:6-3-02 (time limit for requesting a state hearing)9
• Ohio Revised Code 5162.21 (Medicaid estate recovery)2
• ODM Form 10193 (Qualified Income Trust Verification)

Learn More

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The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.