An Ohio Miller Trust lets a long-term-care Medicaid applicant qualify when gross monthly income exceeds Ohio's 2026 Special Income Limit of $2,982. Without one, an applicant over that cap is denied; with one, the over-cap income routes through the trust and eligibility is restored. 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 rather than a medically-needy spend-down for Long-Term Care Medicaid, and the Special Income Limit (SIL) at 300 percent of the SSI Federal Benefit Rate is a hard ceiling. 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 authorized by 42 USC 1396p(d)(4)(B) and implemented in Ohio at OAC 5160:1-6-03.2. It is a federal Medicaid exception that lets applicants in income-cap states qualify for Long-Term Care Medicaid even when their gross income exceeds the Special Income Limit, provided income is routed through a properly structured irrevocable trust.
  • 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. Applicants with gross monthly income above $2,982 must use a Miller Trust to access Long-Term Care Medicaid. Applicants below the SIL do not need one. Authority: OAC 5160:1-6-03.1.
  • The Miller Trust applies to LTC Medicaid, not all Ohio Medicaid. If you are applying for ABD Medicaid for medical coverage only and not for nursing facility or HCBS waiver services, you use the ABD Spend-Down at OAC 5160:1-3-04.1 instead; Miller Trusts are not the right tool for ABD-only coverage.
  • The trust must be irrevocable, established at a qualifying financial institution, and use a separate dedicated trust account. Monthly qualifying income (Social Security, pension, annuity payments, IRA distributions used to qualify) gets deposited into the trust account each month and then flowed out per a defined distribution waterfall.
  • Trust funds are distributed each month in a federally-defined order to the applicant's Personal Needs Allowance (PNA), Medicare premiums and supplemental insurance, community spouse income allowance if applicable, the applicant's NF income obligation or HCBS waiver income contribution, and finally any allowable medical expenses not otherwise covered. The trust account should be empty or nearly empty at month-end; retained balances at month-end cause technical failures and ineligibility.
  • CDJFS verification uses ODM Form 10193 (QIT Verification). The trust document and the monthly bank statements are reviewed for compliance. Miller Trusts can be rejected for wrong trustee, wrong account type, missing remainder beneficiary language, comingling of non-qualifying funds, or retained month-end balances.
  • Ohio's 60-month lookback period at 42 USC 1396p(c)(1) still applies separately. Setting up a Miller Trust does not address the lookback issue, which targets asset transfers and is enforced through the transfer penalty rules at OAC 5160:1-6-06.5.
  • The Miller Trust must name the State of Ohio Medicaid program as the remainder beneficiary under 42 USC 1396p(d)(4)(B). Any balance left in the trust at the death of the Medicaid recipient is owed to Ohio Medicaid up to the total amount of Medicaid benefits paid during life. This interacts directly with Ohio estate recovery but is distinct from probate estate recovery.
  • Engaging a qualified Ohio elder-law attorney to draft the trust is strongly recommended. DIY templates frequently fail at CDJFS verification, and a rejected trust can mean weeks or months of denied Medicaid coverage during which the family pays out of pocket.

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 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.

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. Without a workaround, these applicants would be denied Medicaid for excess income, 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. 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, effective June 1, 2021, 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 an Ohio 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 (A&A) 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 it is not required is not wrong, 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 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, effective June 1, 2021, 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 to a monthly maintenance allowance for the beneficiary, a spousal or family allowance where applicable, and health care costs.

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: 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. 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 income maintenance needs allowance (SIMNA) is 65 percent of the SIL, which is $1,938.30 per month in 2026; 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., The figures by pathway are summarized in the table below. See /medicaid/ohio/personal-needs-allowance for the full breakdown.

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 bring the community spouse up to a minimum income level. Ohio uses the federal Minimum Monthly Maintenance Needs Allowance (MMMNA) range of $2,705.00 to $4,066.50 for 2026. 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.

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.,

Care setting What the resident keeps (2026) Authority What the rest pays
Nursing facility $75/month Personal Needs Allowance OAC 5160:1-6-07 Patient liability to the nursing facility
PASSPORT or Ohio Home Care Waiver $1,938.30/month (SIMNA, 65% of the $2,982 SIL) OAC 5160:1-6-07.1 Post-eligibility income contribution to the waiver
Assisted Living Waiver $994/month (ALMNA, equal to the SSI FBR); room and board capped at $944 ($994 minus $50) OAC 5160-33-03; OAC 5160:1-6-07.1 Patient liability toward waiver services after room and board
MyCare Ohio (LTSS) Follows the underlying waiver (NF, PASSPORT, OHCW, or ALW) OAC Chapter 5160-58 Same as the underlying pathway

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 are an allowable deduction in the post-eligibility calculation.

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:

Income source Gross monthly amount
Social Security retirement $2,200
Teachers Retirement System of Ohio pension $1,400
IRA required minimum distribution (averaged) $200
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 per OAC 5160:1-6-07):

  • 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.

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 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: $2,705.00 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, mainly in how much income the participant keeps before the patient-liability or waiver contribution.

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 income maintenance needs allowance (SIMNA), which is 65 percent of the SIL, or $1,938.30 per month in 2026 under OAC 5160:1-6-07.1, 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. The specific waiver contribution amount is calculated by the Area Agency on Aging (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 (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., 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. 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:

1
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 a few hundred to a few thousand dollars, depending on complexity, attorney rate, and any related spousal impoverishment or estate planning work.

2
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.

3
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: usually little or nothing.

4
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.

5
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.

6
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).

7
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 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.

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.

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 benefits paid during the recipient's lifetime. This is a federal requirement under 42 USC 1396p(d)(4)(B), carried into Ohio's QIT rule at OAC 5160:1-6-03.2, and 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 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. 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. 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. A QIT that meets OAC 5160:1-6-03.2 generally clears verification, so most rejections are document defects rather than substantive denials.

Rejections usually trace to the same defects covered above: trust-document language problems (revocability or a missing remainder-beneficiary clause), account-titling errors, comingled funds, retained month-end balances, a wrong trustee structure, or a missing or incomplete Form 10193.

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

Does Ohio require Miller Trusts for all Medicaid applicants?

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.

Can I be my own trustee?

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.

What happens to the Miller Trust if I get better and no longer need Medicaid?

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.

Do I still need a Miller Trust if I am also doing spend-down on assets?

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).

Can the Miller Trust pay for non-medical expenses?

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.

What does a Miller Trust cost to set up and maintain?

Attorney drafting typically costs a few hundred to a few thousand dollars, 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.

Do all Ohio banks open Miller Trust accounts?

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.

What if my income changes after the trust is set up?

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.

Can I use a Miller Trust if I am applying for HCBS waiver services rather than nursing facility care?

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.

Where do I find an Ohio elder-law attorney?

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. A properly drafted Miller Trust costs a few hundred to a few thousand dollars, small compared to the cost of one or two months of denied 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. 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

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

Ohio Medicaid Consumer Hotline Answers LTC Medicaid questions, gives general Miller Trust guidance, and connects you to your county caseworker. 1-800-324-8680
County Department of Job and Family Services (CDJFS) Files your LTC Medicaid application with the Miller Trust documentation and ODM Form 10193; locate your county office online. jfs.ohio.gov
Pro Seniors Cincinnati Free legal help for older adults, including Miller Trust review, with statewide referrals. 1-800-488-6070
Ohio Legal Aid Free legal services for low-income Ohioans, with elder-law assistance. ohiolegalhelp.org
Disability Rights Ohio Free legal services for adults with disabilities, including Miller Trust and waiver eligibility questions. 1-800-282-9181
National Academy of Elder Law Attorneys (NAELA) Ohio Chapter Directory of Ohio elder-law specialists who draft Miller Trusts. naela.org
Ohio State Bar Association Lawyer Referral Service Statewide referrals to elder-law attorneys. ohiobar.org
Ohio Senior Hotline (Area Agency on Aging) Coordinates PASSPORT and HCBS Miller Trust setup and AAA case management. 1-866-243-5678
Long-Term Care Ombudsman Advocacy on NF and HCBS quality issues for Medicaid recipients. 1-800-282-1206
Social Security Administration Redirects your Social Security direct deposit to the Miller Trust account via SSA Form 1199. 1-800-772-1213
ODJFS Bureau of State Hearings File an appeal if CDJFS rejects your Miller Trust. 1-866-635-3748

Learn More

MedicaidOhio Medicaid Eligibility & Income LimitsOhio Medicaid 2026 income and asset limits across the MAGI, ABD, and long-term-care pathways: the $2,982 income cap, the $2,000 asset limit, and Miller Trusts. MedicaidOhio Medicaid Pay-In Spend-DownHow Ohio's pay-in spend-down works in 2026: the OAC 5160:1-3-04.1 authority, the three monthly options, and how the pay-in pathway differs from a Miller Trust. MedicaidOhio Medicaid Asset Spend-DownOhio Medicaid asset spend-down explained: the $2,000 countable-asset limit, assets you keep, lawful conversions, and how to avoid a 5-year look-back penalty. MedicaidOhio Medicaid Transfer Penalty & LookbackOhio Medicaid 60-month lookback in 2026: the $7,787 APPR penalty divisor, exempt transfers, the caregiver-child exception, and the DRA-2005 start-date rule. MedicaidOhio Medicaid Spousal ImpoverishmentOhio spousal impoverishment in 2026: CSRA $32,532-$162,660, MMMNA $2,705.00-$4,066.50, CSMIA income diversion, snapshot date, and HCBS waiver coverage. MedicaidHow to Apply for Ohio MedicaidHow to apply for Ohio Medicaid: the application channels, form ODM 07216, the 60-month look-back, processing timelines, retroactive coverage, and how to appeal.

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

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.

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Brevy Care Team

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