Which States Use a Miller Trust?

California: no Miller Trust

California does not use a Miller Trust. Medi-Cal uses a Share of Cost instead: a resident of a Medi-Cal certified nursing facility pays their share of cost, the countable income above the Maintenance Need Level, to the facility, and Medi-Cal pays the difference between that share and the facility's daily rate.

Source: DHCS, Share of Cost guidance (rev. 2020) · California Department of Health Care Services (DHCS)

Connecticut: no Miller Trust

Connecticut does not use a Miller Trust. People whose income is above its Medicaid limits may still qualify by "spending down" the excess on medical bills, and a Medicaid-covered nursing home resident generally turns over their monthly income, less a personal needs allowance, to the home, with Medicaid paying the difference.

Source: Connecticut Office of Legislative Research, Report 2015-R-0215; DSS form W-1LTC · Connecticut Department of Social Services (DSS)

District of Columbia: no Miller Trust

The District of Columbia does not use a Miller Trust. An applicant for long-term care services whose income is over the Medicaid income standard may still become eligible through "Spend Down," which uses the person's medical bills to reduce the excess income.

Source: DHCF, Long-Term Care Services and Supports Spend Down notice · DC Department of Health Care Finance (DHCF)

Hawaii: no Miller Trust

Hawaii does not use a Miller Trust. Its medically needy spenddown rule sets no maximum income for an aged, blind, or disabled applicant: income above the medically needy standard becomes a spenddown amount, met by incurring medical expenses.

Source: Haw. Admin. Rules § 17-1730.1-11 (Medically Needy Spenddown) · Hawaii Department of Human Services, Med-QUEST Division

Illinois: no Miller Trust

Illinois does not use a Miller Trust. A nursing-home or supportive-living resident whose countable income is over the AABD medical standard becomes a spenddown case, and the facility's charges, counted at the private rate, are applied toward the spenddown.

Source: Illinois DHS Policy Manual PM 15-02-03-b, Nursing Home/Supportive Living Facility Spenddown · Illinois Department of Human Services / Healthcare and Family Services

Kansas: no Miller Trust

Kansas does not use a Miller Trust. A nursing-home resident's share of cost is called patient liability; when that share would be more than the cost of care, Kansas's Medically Needy spenddown applies, and nursing-facility charges up to the private rate count toward it.For home and community-based services, the share of cost is called the client obligation.

Source: KanCare, Share of Cost fact sheet; KEESM 7532 · KanCare (Kansas Department of Health and Environment)

Louisiana: no Miller Trust

Louisiana does not use a Miller Trust. A nursing-facility or ICF/IID resident whose income is over the Special Income Limit may qualify through the Long Term Care Spend-Down Medically Needy Program, which counts the projected monthly cost of facility care as a medical expense toward the spend-down.A parallel spend-down covers several home and community-based waivers (LDH Medicaid Eligibility Manual H-1050).

Source: LDH Medicaid Eligibility Manual H-1040, Long Term Care Spend-Down Medically Needy Program · Louisiana Department of Health (LDH)

Maine: no Miller Trust

Maine does not use a Miller Trust. A nursing-facility resident whose gross income is over MaineCare's categorically needy limit but below the facility's private rate for a semi-private room can qualify by meeting a deductible, which is met by incurring the facility's Medicaid or private rate.

Source: MaineCare Eligibility Manual, 10-144 C.M.R. ch. 332, Part 14 · Maine Department of Health and Human Services (MaineCare)

Maryland: no Miller Trust

Maryland does not use a Miller Trust. For a nursing-facility resident, Maryland compares available income, after allowable deductions, with the monthly cost of care: if income is less, the person is eligible and Medical Assistance helps pay toward that cost.

Source: Maryland Medical Assistance Manual, Section 1000 (Eligibility for Institutionalized Persons) · Maryland Department of Health

Massachusetts: no Miller Trust

Massachusetts does not use a Miller Trust. MassHealth sets no countable income limit for members in a long-term-care facility; instead the member pays part of their income to the facility each month as the "patient-paid amount," after deductions such as a personal-needs allowance.

Source: MassHealth Board of Hearings decision citing 130 CMR 520.009(A)(3) and 520.026 · MassHealth

Michigan: no Miller Trust

Michigan does not use a Miller Trust. Under its Group 2 Medicaid rules, someone with excess income is income-eligible for any month in which allowable expenses, including long-term care costs, equal or exceed the excess income; a nursing-home resident then pays a patient-pay amount toward care.

Source: MDHHS Bridges Eligibility Manual BEM 545 (MA Group 2 Income Eligibility); BEM 546 · Michigan Department of Health and Human Services (MDHHS)

Minnesota: no Miller Trust

Minnesota does not use a Miller Trust. For someone in a long-term care facility, Medical Assistance runs a long-term-care income calculation that sets an "LTC spenddown," the amount the person contributes from their income toward the cost of care.For the Elderly Waiver, a person with income above the special income standard and no community spouse can use the cost of their long-term care services to meet a medical spenddown (Eligibility Policy Manual 2.4.2.5).

Source: Minnesota Health Care Programs Eligibility Policy Manual 2.4.2.5 · Minnesota Department of Human Services

Montana: no Miller Trust

Montana does not use a Miller Trust. An otherwise eligible nursing-home resident is income-eligible, as categorically or medically needy, as long as their monthly nursing-home costs equal or exceed their monthly income; the amount they apply toward their care is calculated separately.

Source: DPHHS Medicaid manual ABD 013, Nursing Home Residents: Income · Montana Department of Public Health and Human Services (DPHHS)

Nebraska: no Miller Trust

Nebraska does not use a Miller Trust. Someone whose income is over Nebraska's limits can be eligible as medically needy with a share of cost; for a resident of a medical institution, a projection of institutional expenses establishes the medical need, and the share of cost is calculated from there.The same medically needy route applies to home and community-based services, using a hypothetical amount of services (477 NAC 25-003.02).

Source: 477 NAC Chapter 25, Budgeting for the Medically Needy, § 003.03 · Nebraska Department of Health and Human Services

New Hampshire: no Miller Trust

New Hampshire does not use a Miller Trust. An applicant for nursing facility care whose monthly gross income exceeds the nursing facility cap (300% of the maximum SSI benefit) is income-eligible as medically needy when their net income is at or below the monthly Medicaid nursing facility rate.For its home and community-based waivers (including Choices for Independence), applicants over the cap are medically needy when net income is at or below the protected income level, with a spend-down route above that (He-W 858.06).

Source: N.H. Admin. Rules He-W 858.05, Eligibility for Adult Category Medical Assistance Nursing Care · New Hampshire Department of Health and Human Services

New York: no Miller Trust

New York does not use a Miller Trust. New York Medicaid treats income above the Medicaid level as "excess income," which works like a deductible, and a nursing-home resident pays their Net Available Monthly Income (NAMI) toward the cost of care while Medicaid pays the rest.

For home-care Medicaid, New York uses a different mechanism for excess income: see the New York Pooled Income Trust guide.

Source: NYS DOH, Medicaid Excess Income ("Spenddown") Program; NAMI overview · New York State Department of Health

North Carolina: no Miller Trust

North Carolina does not use a Miller Trust. When a long-term-care applicant's gross income is above the facility's Medicaid rate, the county compares net income with the facility's private rate; at or below that rate the person is financially eligible, and the resident then pays a patient monthly liability toward care.

Source: NC Aged, Blind and Disabled Medicaid Manual MA-2270, Long Term Care Need and Budgeting · NC Department of Health and Human Services (NC Medicaid)

North Dakota: no Miller Trust

North Dakota does not use a Miller Trust. Its Medicaid program applies a "nursing care income level" to nursing-facility residents, and a member whose net income is above the Medicaid income level pays a monthly recipient liability, which works like a deductible, before Medicaid pays.Medically needy income levels also apply when someone screened as needing nursing care chooses home and community-based services (Eligibility Policy Manual 510-05-85-40).

Source: ND Medicaid Eligibility Policy Manual 510-05-85-40; Recipient Liability policy · North Dakota Department of Health and Human Services

Pennsylvania: no Miller Trust

Pennsylvania does not use a Miller Trust. A nursing-facility applicant whose income is above the special income limit can qualify through the Medically Needy Only spend-down, where the projected cost of care at the facility's private rate, for up to six months, counts toward the spend-down.

Source: 55 Pa. Code § 181.14, Eligibility under MNO-MA spend-down · Pennsylvania Department of Human Services, Office of Long-Term Living

Rhode Island: no Miller Trust

Rhode Island does not use a Miller Trust. Its Medically Needy pathway for long-term services and supports (formerly the Flexible Test of Income) lets someone with income above the federal benefit cap qualify when the projected cost of care at the private-pay rate absorbs their excess income.The pathway applies to both institutional and home and community-based settings (210-RICR-50-00-2).

Source: 210-RICR-50-00-2, Medicaid LTSS: Medically Needy Eligibility Pathway · Rhode Island Executive Office of Health and Human Services (EOHHS)

Utah: no Miller Trust

Utah does not use a Miller Trust. Nursing-facility residents pay a cost-of-care contribution from their income after allowed deductions, and Utah's medically needy programs let a person qualify by making a spenddown payment to reduce countable income.Some recipients on home and community-based waivers must spend down to the medically needy income limit (Utah Medicaid Policy Manual § 463).

Source: Utah Medicaid Policy Manual §§ 463 and 461 · Utah Department of Health and Human Services (Medicaid)

Vermont: no Miller Trust

Vermont does not use a Miller Trust. When a long-term-care applicant's gross income is above the Institutional Income Standard, the Department of Vermont Health Access works out a monthly spenddown that the cost of care can meet, and the person then pays a monthly patient share toward care.The same spenddown procedure applies in home-based waiver and enhanced residential care settings.

Source: DVHA, Long-Term Care Monthly Spenddown Procedures · Department of Vermont Health Access (DVHA)

Virginia: no Miller Trust

Virginia does not use a Miller Trust. An institutionalized applicant whose gross income is over the 300%-of-SSI limit is evaluated as medically needy instead, with the excess becoming a "spenddown liability" that the cost of facility care can meet.Some waivers differ: the CCC Plus Waiver allows either the 300% limit or the medically needy spenddown, but under the Community Living Waiver, medically needy individuals are not eligible and income over 300% of SSI makes a person ineligible (Medical Assistance Eligibility Manual M1440).

Source: Virginia Medical Assistance Eligibility Manual, Chapter M14 (M1460.600, M1460.410) · Virginia Department of Medical Assistance Services (DMAS)

Washington: no Miller Trust

Washington does not use a Miller Trust. A person in a medical institution whose gross income is above the special income level can qualify for institutional services under the SSI-related medically needy program.A medically needy path also exists for home and community-based waiver services (Washington Administrative Code chapter 182-515, section 1508).

Source: Washington Administrative Code chapter 182-513, section 1395 · Washington State Health Care Authority (Apple Health)

West Virginia: no Miller Trust

West Virginia does not use a Miller Trust. People with income over the 300%-of-SSI limit for nursing-home Medicaid may qualify if their monthly nursing care costs exceed the Medicaid Medically Needy Income Limit, and they then contribute income toward the cost of care.

Source: WV Bureau for Family Assistance, Medicaid for Long Term Care: Eligibility and Requirements · West Virginia Department of Human Services, Bureau for Family Assistance

Wisconsin: no Miller Trust

Wisconsin does not use a Miller Trust. An applicant with income over the institutional categorically needy limit can qualify as medically needy when their monthly need, which includes the private rate of the nursing home where they live, is greater than their income.

Source: Wisconsin Medicaid Eligibility Handbook 27.5.2 and 27.6 · Wisconsin Department of Health Services