If you or a parent has retirement income above $2,982 per month in 2026 and you need Ohio Medicaid to pay for nursing facility care or HCBS waiver services like PASSPORT, the Assisted Living Waiver, or the Ohio Home Care Waiver, you almost certainly need a Qualified Income Trust, known in everyday usage as a Miller Trust. Ohio is one of about a dozen states that uses an income cap rather than a medically-needy spend-down for Long-Term Care Medicaid, and the Special Income Limit at 300 percent of the SSI Federal Benefit Rate is a hard ceiling. Without a properly drafted and properly operated Miller Trust, an applicant with even one dollar of gross monthly income above the cap is denied. This guide explains what a Miller Trust actually 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 interacts with nursing facility Medicaid versus HCBS waivers, what happens to the trust on death under Ohio estate recovery, and the operational mistakes that cause QITs to fail at the CDJFS desk.

By Brevy Care Team · Last verified May 11, 2026

Why Ohio uses an income cap in the first place

Federal Medicaid law gives states two basic options for Long-Term Care Medicaid income eligibility. Some states adopt the medically-needy option under 42 CFR 435.831, which lets applicants with income above a defined limit qualify by spending the excess on medical expenses each month, a process commonly called spend-down. Other states adopt the categorical Special Income Limit (SIL) option authorized at 42 USC 1396a(a)(10)(A)(ii)(V), which sets a hard income ceiling at up to 300 percent of the SSI Federal Benefit Rate. States that use the SIL approach are called income-cap states.

Ohio is an income-cap state for Long-Term Care Medicaid. The state policy choice was made decades ago and 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.

The hard ceiling creates an obvious problem. The median Social Security retired-worker benefit in Ohio runs in the $1,800 to $2,400 per month range. 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. Without a workaround, these applicants would be denied Medicaid because their income is too high, even though they cannot afford the $9,000 to $12,000 per month average cost of Ohio nursing facility care or the substantial cost of HCBS waiver services. 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.

Ohio implements the federal exception at OAC 5160:1-6-03.2, which sets out the state's specific requirements for QIT recognition. Miller Trusts that comply with both the federal authorizing statute and the Ohio implementing rule are recognized; trusts that fall short on either standard are not, and the applicant is treated as if no trust existed at all.

When you need a Miller Trust and when you do not

The simple test is whether the applicant's gross monthly income exceeds the 2026 SIL of $2,982. Gross income includes Social Security retirement and disability benefits (the full benefit before the Medicare Part B premium deduction), pension payments, annuity income that counts under Ohio's annuity rules at OAC 5160:1-6-06.1, VA non-improved pension benefits to the extent counted, IRA and 401(k) distributions, deferred compensation, wages from any employment, and rental income net of allowable expenses. It does not include income that federal law excludes from countable Medicaid income, such as VA Aid and Attendance for service-connected purposes under certain rules, food stamps, certain Native American income, or tax refunds.

Applicants below the SIL do not need a Miller Trust. If gross monthly income is $2,981 or less, the applicant qualifies for LTC Medicaid on income alone (asset and clinical eligibility tests still apply separately). Setting up a Miller Trust when not required is not wrong per se, but it adds complexity and cost without benefit.

Applicants above the SIL must use a Miller Trust for any of the following Medicaid pathways:

Applicants who are NOT applying for LTC Medicaid generally do not use Miller Trusts. The two most common situations:

  • ABD Spend-Down 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, the ABD Spend-Down at OAC 5160:1-3-04.1 is the right pathway. The applicant spends down monthly excess income on medical expenses; a Miller Trust does not apply.
  • MAGI-based Medicaid for working-age adults. Modified Adjusted Gross Income (MAGI) Medicaid under OAC Chapter 5160:1-4 uses a different income methodology entirely and does not have an SIL or Miller Trust mechanism.

The most common 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 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.

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 42 USC 1396p(d)(4)(B). 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. The account holder is the trust, not the applicant directly. The financial institution must be one that recognizes Miller Trust accounts and can open the account properly. Most major Ohio banks and credit unions will open these accounts, but some may require specific documentation or refer the request to a trust department. 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. The trustee cannot be the Medicaid applicant themselves; that would defeat the divestment structure. Common trustees are 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 qualifying income can be deposited into the trust. 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 qualifying and non-qualifying funds is a structural defect known as comingling and causes the trust to lose its qualifying status. Some practitioners advise depositing only the income that pushes the applicant over the SIL plus a buffer; others advise depositing all of the applicant's income for clean accounting. Both approaches can work if executed consistently; the key is that all funds in the trust must be qualifying income.

5. Remainder beneficiary designation. Federal law at 42 USC 1396p(d)(4)(B) requires that the State Medicaid program be named as the remainder beneficiary of the trust up to the total amount of Medicaid benefits paid during the recipient's lifetime. Ohio implements this through specific language in the trust document that designates the Ohio Department of Medicaid (or its successor) as the first remainder beneficiary. Without this clause, the trust fails to qualify. Any balance left in the trust at the recipient's death (whether from accumulated funds or interest) is owed to ODM up to the recovery cap.

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. The language addresses the trustee's duties, the distribution waterfall, the irrevocability clause, the remainder beneficiary mechanics, and the prohibition on amendments. Ohio elder-law attorneys maintain template language that has been refined against CDJFS verification standards; this is a major reason DIY templates frequently fail.

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 directly through SSA's direct-deposit system into the trust account using SSA Form 1199 (Direct Deposit Sign-Up Form) or its successor. 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 according to the federally-mandated waterfall:

First: Personal Needs Allowance (PNA). Ohio's 2026 PNA for nursing facility residents is $75 per month under OAC 5160:1-6-07. For HCBS waiver participants, the applicable PNA is different and is governed by the waiver-specific rules; for PASSPORT and the Ohio Home Care Waiver, the community-living maintenance allowance is significantly higher than the NF PNA. See /medicaid/ohio/personal-needs-allowance for the current allowance figures across pathways. The PNA gets distributed to the applicant for personal use (clothing, toiletries, haircuts, modest entertainment, small personal items).

Second: Medicare premiums and supplemental insurance. Medicare Part B premiums, Medicare Part D premiums, Medicare Supplement (Medigap) premiums, and certain other health insurance premiums are allowable deductions. The trust distributes the amount needed to pay these premiums.

Third: 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 ensure the community spouse maintains a minimum income level. Ohio's 2026 Minimum Monthly Maintenance Needs Allowance (MMMNA) range is $2,643.75 to $4,066.50. The trust distributes the CSMIA to the community spouse.

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.

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 435.726, or to the appropriate party for HCBS waiver participants (the specific mechanism varies by waiver). The net effect is that the trust balance is paid out each month to bring the trust account to a near-zero balance.

Month-end balance. The trust account should be empty or nearly empty at month-end. Any residual balance carries over but should be small. Significant retained balances at month-end raise red flags during CDJFS verification and can indicate that the trust is not being operated correctly. The general practice is to time distributions so that the account zeros out within a few days of the income deposits.

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

To make the mechanics concrete, consider Helen, age 79, who is entering a Cleveland-area nursing facility in 2026. Helen receives:

  • Social Security retirement: $2,200/month gross
  • Teachers Retirement System of Ohio pension: $1,400/month gross
  • IRA required minimum distribution: $200/month (averaged)

Total gross monthly income: $3,800.

Helen's gross income exceeds the 2026 SIL of $2,982 by $818, so she needs a Miller Trust. 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; her home is exempt while she has intent to return).

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 submits SSA Form 1199 (the direct deposit form) to reroute Helen's Social Security to the trust account. The pension administrator is contacted to reroute pension payments. The IRA custodian is contacted to reroute RMDs.

CDJFS receives ODM Form 10193 along with the trust document and the first month's bank statement showing the deposit and distributions. The trust is verified.

Each month thereafter, Karen as trustee distributes from the trust:

  • 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

The trust account zeros out by month-end. 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.

Married applicants and the community spouse interaction

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 and OAC 5160:1-6-04 interact with the Miller Trust mechanics.

Income attribution. Under federal spousal impoverishment rules, only income paid in the name of the institutionalized spouse counts toward their income for Medicaid eligibility. The community spouse's own income is not counted against the institutionalized spouse, and the community spouse can retain their own income without limit (which is a structural difference from the asset rules). 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 (2026 range: $2,643.75 to $4,066.50). 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. The 2026 CSRA range in Ohio is $32,532 to $162,660. 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 gross income exceeds the SIL also need Miller Trusts, but the distribution mechanics differ from NF mechanics.

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 community-living maintenance allowance (which is higher than the NF PNA), Medicare and supplemental premium deductions, the CSMIA if applicable, and the post-eligibility income contribution to the waiver. The specific waiver contribution amount is calculated by the AAA case manager based on the participant's income and the waiver's cost share rules.

Assisted Living Waiver. Participants reside in a Medicaid-participating Residential Care Facility and have a room and board obligation that they pay from income. The Miller Trust distribution covers the AL Waiver PNA (higher than NF PNA, but lower than community-living amounts), Medicare and supplemental premiums, CSMIA if applicable, and then the room and board contribution to the RCF. The AL Waiver mechanics are at OAC Chapter 5160-33.

MyCare Ohio Waiver. For dual eligibles enrolled in MyCare who are receiving PASSPORT, OHCW, or AL Waiver services through MyCare absorption under OAC 5160-58-04, the Miller Trust functions the same way as for the underlying waiver. The MyCare carrier coordinates the service delivery, but the income trust and patient liability calculations follow the underlying waiver rules.

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

The Miller Trust setup process typically takes one to three weeks if everything goes smoothly. The sequence:

Step 1: Engage an Ohio elder-law attorney. The attorney evaluates whether a Miller Trust is needed, identifies any 60-month lookback issues that need to be addressed separately, and reviews the asset position. If a Miller Trust is appropriate, the attorney drafts the trust document using template language compliant with OAC 5160:1-6-03.2 and the relevant federal authority. Cost: typically $500 to $2,500 depending on complexity, attorney rate, and any related spousal impoverishment or estate planning work.

Step 2: Identify the trustee. The trustee should be available, organized, and willing to take on the monthly administrative duties. The trustee signs the trust document and accepts the trustee role.

Step 3: Open the trust bank account. The trustee takes the trust document to a bank or credit union and opens a separate dedicated account in the trust's name. Some banks require seeing the trust document and may have specific requirements; the elder-law attorney can recommend banks that routinely handle Miller Trust accounts. Cost: typically $0 to $50.

Step 4: Reroute qualifying income. The trustee submits the necessary forms to reroute Social Security (SSA Form 1199), pension payments, IRA distributions, and any other qualifying income sources to the trust account. SSA changes can take 30 to 60 days; pension administrator changes typically take one to two billing cycles.

Step 5: First-month operation. Once income arrives in the trust account, the trustee makes the first month's distributions (PNA, premiums, CSMIA, patient liability or waiver contribution). Bank statements document the flow.

Step 6: CDJFS verification. The applicant or their elder-law attorney submits the trust document, the trustee designation, and the first one to three months of bank statements to CDJFS, accompanied by ODM Form 10193 (QIT Verification). The county caseworker reviews the trust for compliance with OAC 5160:1-6-03.2 and federal requirements. If approved, the Medicaid application can proceed (or, for already-eligible recipients adding LTC services, the trust is added to the file).

Step 7: Ongoing compliance. Each month, the trustee continues the deposit-and-distribution cycle. Bank statements are retained for annual reassessment and any future audits. If income changes, distribution amounts are adjusted.

Common timeline obstacles include SSA 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 two to four weeks of buffer between trust setup and the Medicaid application start date is prudent.

Common drafting and operational mistakes

The CDJFS rejection rate for DIY Miller Trusts is high. The most common defects:

Wrong trustee. Naming the applicant as their own 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, titling the account in the applicant's name rather than the trust's name, or using an account at a financial institution that does not recognize the structure.

Revocability language. Including language that allows the grantor to amend or revoke the trust, which voids the qualifying structure under 42 USC 1396p(d)(4)(B).

Missing remainder beneficiary clause. Failing to designate the State of Ohio Medicaid program as the first remainder beneficiary up to the total Medicaid benefits paid.

Comingling of funds. Depositing non-qualifying funds into the trust account (gifts, the community spouse's income, inheritance, personal property sale proceeds). The account must be funded only with the applicant's qualifying income.

Retained month-end balances. Failing to distribute funds out of the trust each month, so the account accumulates a balance over time. 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 federally-defined waterfall.

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.

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 does not qualify under 42 USC 1396p(d)(4)(B) for Medicaid income trust purposes and provides no LTC Medicaid eligibility benefit.

Estate recovery interaction

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 benefits paid during the recipient's lifetime. This is a federal requirement under 42 USC 1396p(d)(4)(B) and is enforced through specific Ohio procedures.

How much is typically left in the trust at death? If the trust is operated correctly with monthly zero-out distributions, the balance is usually small (a few hundred dollars or less). Larger balances suggest that the trustee was not zeroing out the account, which itself is a compliance issue during the recipient's life.

Trust remainder vs probate estate recovery. The Miller Trust remainder recovery is separate from Ohio's broader probate estate recovery under Ohio Revised Code 5162.21. The trust remainder is paid before any other distribution from the trust at death. Probate estate recovery, in contrast, targets assets that pass through the probate estate (which can include the home if the recipient retained ownership). See /medicaid/ohio/estate-recovery for the full estate recovery picture.

Practical impact. For most recipients, the trust remainder recovery is small in absolute dollars because the trust should be operated as a flow-through, not an accumulator. The bigger estate recovery exposure is usually the recipient's home, not the trust remainder.

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 applicable rule is the State Hearings procedure at OAC 5101:6-7-01.

Most common rejection reasons:

  • Trust document language defects (revocability, missing remainder beneficiary, non-compliant Ohio language)
  • Account titling issues
  • Comingling of funds in the bank statements
  • Retained balances at month-end
  • Wrong trustee structure
  • Missing or incomplete Form 10193 submission

Resolution paths:

  1. Correct the defect. Most rejections are correctable. The elder-law attorney works with the county to identify the specific defect, amend the trust or the operational practice, and resubmit. This is faster than appealing.
  2. File for an informal county-level review before going to State Hearing if the defect is procedural and can be addressed with additional documentation.
  3. Request a State Hearing within 90 days of the adverse notice if the defect is contested. File at 1-866-635-3748, by mail, or through CDJFS. Aid pending hearing is available if filed within 15 days and the application was previously approved before this denial.

The most common practical outcome is correction, not litigation. State Hearings on Miller Trust rejections are uncommon because the structure is well-defined and a properly drafted, properly operated trust generally satisfies verification standards.

Frequently Asked Questions

No. Miller Trusts are required only for Long-Term Care Medicaid applicants whose gross monthly income exceeds the Special Income Limit (2026: $2,982 per month for a single applicant). Applicants below the SIL do not need a Miller Trust. Applicants applying for ABD medical-only coverage use the ABD Spend-Down at OAC 5160:1-3-04.1 rather than a Miller Trust. MAGI-based Medicaid applicants do not use Miller Trusts at all.

No. The applicant cannot serve as their own trustee. The trustee must be a different person (typically a spouse, adult child, other family member, professional fiduciary, or corporate trustee). The trust structure depends on the applicant having divested their qualifying income into a trust governed by a separate fiduciary, which is structurally inconsistent with the applicant also being the trustee.

If the Medicaid recipient's circumstances improve to the point that LTC Medicaid is no longer needed, the trust can be wound down. The applicant stops depositing future income into the trust, the trustee distributes any remaining balance per the trust terms (first to ODM up to the recovery cap, then to other beneficiaries as the trust document specifies), and the trust terminates. Because the trust is irrevocable, you cannot simply dissolve it and recover the funds for personal use; the remainder rules apply. The income that was previously routed through the trust resumes normal direct payment to the recipient.

The Miller Trust addresses income above the SIL. Asset spend-down (technically, spending assets down to the resource limit of $2,000) addresses the asset side of eligibility. These are separate eligibility tests that operate independently. If both income and assets exceed the limits, you need both a Miller Trust for income and a strategy to bring assets below the resource limit (asset spend-down on permissible items, exempt asset designation, irrevocable trust planning for assets where appropriate, and so on).

Only within the federally-allowed distribution waterfall. The applicant's PNA is paid out of the trust and can be used for any personal purpose. Medicare and supplemental insurance premiums are allowable. Allowable medical expenses not otherwise covered are allowable. The CSMIA goes to the community spouse and can be used for their general expenses. After these required distributions, the remaining funds go to the NF (for institutional Medicaid) or to the appropriate waiver income contribution (for HCBS). Trust funds cannot be diverted to gifts, ineligible relatives, the applicant's accumulation of new assets, or non-allowable purposes.

Attorney drafting typically costs $500 to $2,500 depending on attorney rates, geographic area, complexity, and any bundled estate or spousal impoverishment planning. Bank account fees are typically minimal or zero. Ongoing trustee duties take a few hours per month and can be handled by a family member without additional cost; professional or corporate trustees charge fees that vary widely. Many elder-law attorneys offer flat-fee Medicaid packages that include the Miller Trust setup along with the application, asset planning, and CSMIA/CSRA analysis.

Most major Ohio banks and credit unions will open Miller Trust accounts, but some require specific documentation, some refer the request to a trust department, and a few decline entirely. The elder-law attorney can recommend banks that routinely handle Miller Trust accounts in your area. Common providers in Ohio include large regional banks (Huntington, Fifth Third, Key, PNC) and many community banks and credit unions. If the first bank declines, try another; the issue is usually institutional preference, not legal.

Income changes are common. Social Security has annual COLA adjustments. Pensions may have COLA adjustments. IRA distributions change. The trustee updates the monthly distribution amounts to reflect the new income, recalculating the PNA (which does not change with income), the Medicare premium deductions (which can change), the CSMIA (which is recalculated when the community spouse's situation changes), and the patient liability or waiver contribution (which absorbs the rest). The trust structure does not need to be redrafted for income changes; only the operational amounts change.

Yes. Miller Trusts apply to all LTC Medicaid pathways, not just NF Medicaid. PASSPORT, the Assisted Living Waiver, the Ohio Home Care Waiver, the MyCare Ohio Waiver (LTSS portion), and DODD waivers when used at institutional level of care all require Miller Trusts for applicants above the SIL. The distribution waterfall is adjusted to reflect the waiver's specific income contribution rules rather than the NF patient liability rules, but the structural elements of the trust are the same.

The National Academy of Elder Law Attorneys (NAELA) Ohio Chapter maintains a directory. The Ohio State Bar Association Lawyer Referral Service can refer you to elder-law specialists in your area. Pro Seniors Cincinnati at 1-800-488-6070 offers free legal assistance for older adults in the Cincinnati area and referrals statewide. Ohio Legal Aid operates regional offices and has elder-law capacity. Most elder-law attorneys offer initial consultations to scope the work and provide a flat-fee estimate.

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. The cost of a properly drafted Miller Trust (typically $500 to $2,500) is small compared to the cost of one or two months of denied Medicaid coverage during which the family pays $9,000 to $12,000 per month out of pocket for nursing facility care or substantial out-of-pocket cost for HCBS. DIY Miller Trust templates from internet sources frequently fail CDJFS verification because they lack the specific Ohio language required by OAC 5160:1-6-03.2 or miss federal structural elements required by 42 USC 1396p(d)(4)(B).

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 dispositioned assets in the 60 months before application, those issues need to be addressed through the transfer penalty rules at OAC 5160:1-6-06.5. A complete elder-law engagement addresses both income (Miller Trust) and assets (lookback, exemption planning) together.

Coordinate with the facility or AAA. Nursing facilities and AAA case managers see Miller Trusts every week and can often connect families with elder-law attorneys they have worked with successfully. The facility billing office and the AAA case manager need to know the trust structure to apply patient liability or waiver contribution correctly each month.

Key statutes, rules, and authorities

Key phone numbers and contacts

  • Ohio Medicaid Consumer Hotline: 1-800-324-8680 (LTC Medicaid questions, Miller Trust general guidance, county caseworker connection)
  • County Department of Job and Family Services (CDJFS): locate your county office at jfs.ohio.gov (file LTC Medicaid application with Miller Trust documentation, ODM Form 10193 submission)
  • Pro Seniors Cincinnati: 1-800-488-6070 (free legal help for older adults including Miller Trust review, statewide referrals)
  • Ohio Legal Aid: ohiolegalhelp.org (free legal services for low-income Ohioans, elder-law assistance)
  • Disability Rights Ohio: 1-800-282-9181 (free legal services for adults with disabilities, including Miller Trust and waiver eligibility)
  • National Academy of Elder Law Attorneys (NAELA) Ohio Chapter: naela.org (directory of elder-law specialists)
  • Ohio State Bar Association Lawyer Referral Service: ohiobar.org (statewide elder-law referrals)
  • Ohio Senior Hotline (Area Agency on Aging): 1-866-243-5678 (PASSPORT and HCBS Miller Trust coordination, AAA case management)
  • Long-Term Care Ombudsman: 1-800-282-1206 (NF and HCBS quality issues, advocacy for Medicaid recipients)
  • Social Security Administration: 1-800-772-1213 (direct deposit redirect to Miller Trust account via SSA Form 1199)
  • Ohio Department of Job and Family Services Bureau of State Hearings: 1-866-635-3748 (file appeal if Miller Trust is rejected by CDJFS)

This guide reflects Ohio Medicaid policy and federal Miller Trust authority in effect as of May 2026. Income limits, asset limits, and rule citations may change with annual SSI COLA adjustments and ODM rule revisions. Verify current figures with the Ohio Department of Medicaid and engage a qualified Ohio elder-law attorney before establishing or operating a Miller Trust.

Find personalized help navigating Ohio Medicaid and Miller Trusts at brevy.com.

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Brevy Care Team

Expert eldercare guidance from Brevy's team of healthcare professionals and researchers.