What a Florida Qualified Income Trust Actually Says

Irrevocable income trusts, qualified income trusts, Miller Trusts, and d4B trusts all mean the same thing. They refer to a trust created to work around Florida Medicaid's income limit. As of January 2026, a Florida Medicaid applicant can have no more than $2,982 per month in gross income from all sources. Mine runs about fifteen pages, and clients reasonably ask why a document that does one narrow job needs to be that long. The short version is that most of those pages exist to satisfy Medicaid, not you. The document names the parties, makes itself irrevocable, restricts what the trustee may deposit and spend, names the state as the first beneficiary at death, and plans for a trustee who cannot serve. This article walks through each of those pieces in plain English.

The income cap counts everything before any deductions for health insurance, Medicare, or other expenses, including Social Security, pensions, 401(k) and IRA distributions, and investment income. Our article on the income sources Florida long term care Medicaid counts covers what falls in and what does not. The cap also changes every January, because it is pegged to 300 percent of the federal benefit rate, which moves with the annual Social Security cost of living adjustment.

Where the Qualified Income Trust Sits Among Medicaid Trusts

A point worth clearing up first, because it causes real confusion. A qualified income trust is not a special needs trust. Both are exception trusts authorized by the same federal statute, 42 U.S.C. Section 1396p(d)(4), which is why practitioners refer to them by subsection as d4A, d4B, and d4C trusts. They are different instruments that solve different problems, and using one where the other belongs will not work

The practical takeaway is that depositing an asset into a Miller Trust does not shelter it, and a Miller Trust does nothing for SSI eligibility. If assets rather than income are the obstacle, you are looking at a special needs trust or a pooled trust instead. For a fuller comparison, our overview of the third party special needs trust explains how the funding source changes the analysis entirely.

The Qualified Income Trust in Plain English

If someone earns more than the income cap and wants to qualify, Florida provides a legal workaround in the qualified income trust. You go to an elder law attorney or Medicaid attorney to discuss drafting one. Your Medicaid planning lawyer gathers some basic information and produces the trust document. Other elder law attorneys may have Miller Trust documents that run a bit longer or shorter, but the general concepts will be virtually identical. Here is what those pages are doing.

The whereas clauses and the title

The trust typically opens with whereas clauses. These state the intent of the qualified income trust, which in this case is only for the purpose of holding income and never assets. Next come the key names and definitions. The title of the trust matters more than it looks, because it is what the bank will rely on when opening an account in the name of the Miller Trust.

The key players

The document names the settlor, sometimes called the grantor, meaning the person creating the trust. If you are the one seeking Medicaid, you will usually be the settlor, though the Department of Children and Families also authorizes the applicant's spouse to establish the trust.

The Miller Trust then names the primary beneficiary, meaning the Medicaid applicant. That is usually the same person as the settlor, but it need not be. If the beneficiary has a guardian, for instance, the guardian might be the settlor establishing the trust for the benefit of the person seeking eligibility.

The first page also names the initial trustee, or co-trustees if more than one. The trustees are the people in charge of the trust. One rule catches families off guard here. The trustee cannot also be the beneficiary.

The last key party is the Florida Department of Children and Families, which must be named as the primary beneficiary upon the death of the Medicaid recipient. That is not a drafting preference. It is a statutory condition of the trust working at all.

Why it has to be irrevocable

Another essential component is that the trust be irrevocable. A qualified income trust can only be used for a very limited purpose in order to be valid in the eyes of Medicaid and DCF. The document limits the trustee on what they can and cannot deposit, and what they can and cannot withdraw. If the applicant is not receiving Medicaid benefits, or stops receiving them, the trustee is given broader discretion over how to use the funds in the account.

How the trustee may spend the money

Any trust is essentially an instruction manual for the trustee, explaining what they can and cannot do. A qualified income trust is no different. It explains how the trustee is to spend the money held within the trust for the benefit of the beneficiary. In a Miller Trust, the trustee must spend the money on the health or medical expenses of the beneficiary.

In a nursing home context, that means all of the income in the trust goes to the facility, less the $160 personal needs allowance and a very limited number of other expenditures such as Medicare supplement premiums. Our overview of the Institutional Care Program covers how patient responsibility is calculated.

In an assisted living facility, or for someone receiving care at home, the funds must be spent on health care or medical expenses the beneficiary incurs, such as extra home health aide hours or the portion of the assisted living bill Medicaid does not cover.

What happens after the Medicaid recipient dies

The trustee has to follow strict rules about the money in the account after the Medicaid recipient passes away. First, the Florida Department of Children and Families, and any other state where the recipient received Medicaid benefits, must be notified. Those agencies then submit claims for reimbursement up to the amount of benefits they paid. Only after DCF has been repaid in full can the remaining money be distributed to other beneficiaries, typically family members.

Out of an abundance of caution, the trust names those secondary beneficiaries. Realistically, there is a very small likelihood of anyone but the state receiving anything, because a properly run qualified income trust tends not to accumulate money. Other than the $160 personal needs allowance and a few enumerated expenses such as health insurance premiums, the recipient's income comes into the account and immediately flows back out to the nursing home as patient responsibility. This is separate from Medicaid estate recovery, which reaches probate assets rather than trust funds.

What happens if the trustee cannot serve

The trust sets out the procedure for removing a trustee whose capacity is called into question, and anticipates what happens if the trustee can no longer serve for any other reason. There may be a named successor trustee, essentially a trustee on deck who has no power now but is willing and able to step into the role. The document can also provide a procedure for the settlor to name a new trustee if the initial and successor trustees are all unavailable.

There are other provisions, but those are the major points. Every clause in the document exists to satisfy a Medicaid requirement, which is why a trust that does one narrow job still runs fifteen pages.

Key Takeaways

• Irrevocable income trust, qualified income trust, Miller Trust, and d4B trust all describe the same instrument.
• A qualified income trust is not a special needs trust. Both come from 42 U.S.C. 1396p(d)(4), but a QIT holds income only and does nothing for SSI.
• The trust must be irrevocable, and the trustee cannot be the beneficiary.
• The Florida Department of Children and Families must be named primary beneficiary at death, and is repaid before any family member receives anything.
• Trust funds may be spent only on the beneficiary's health or medical expenses, which in a nursing home means nearly everything goes to the facility.
• A properly run QIT holds almost nothing, since income flows in and back out each month, which is why the payback rarely matters in practice.

Frequently Asked Questions

Q. Is a Miller Trust the same thing as a qualified income trust?

A. Yes. Irrevocable income trust, qualified income trust, Miller Trust, and d4B trust are all names for the same instrument. The d4B label comes from the subsection of federal law that authorizes it, 42 U.S.C. Section 1396p(d)(4)(B).

Q. Is a qualified income trust a type of special needs trust?

A. No, though they are related. Both are exception trusts under 42 U.S.C. Section 1396p(d)(4). A special needs trust under d4A can hold income and assets and works for both SSI and Medicaid. A qualified income trust under d4B holds income only and does not help with SSI. Putting assets into a Miller Trust does not shelter them.

Q. Can I be the trustee of my own Miller Trust?

A. No. The trustee cannot also be the beneficiary. Typically a spouse, adult child, or another trusted person serves as trustee, and the document names a successor in case that person cannot continue.

Q. Why must Florida be named as a beneficiary of my Miller Trust?

A. Federal law requires it as a condition of the trust working. The Department of Children and Families must be named primary beneficiary at death and is repaid up to the amount Medicaid paid for your care before anything passes to family. In practice these trusts hold very little, since income flows through each month.

Q. What can the money in a qualified income trust be spent on?

A. Only the beneficiary's health or medical expenses. In a nursing home, nearly all of it goes to the facility as patient responsibility, less the $160 personal needs allowance and a few items such as Medicare supplement premiums. At home or in assisted living, it covers medical costs such as extra aide hours or the part of the bill Medicaid does not pay.

Q. Why is the Miller Trust document so long if it does one simple thing?

A. Because nearly every clause exists to satisfy a Medicaid requirement rather than to serve you. The document has to name the parties, make itself irrevocable, restrict deposits and distributions, name the state as first beneficiary, and plan for trustee succession. Leave out any one of those and the trust may fail its purpose.

Have Someone Walk You Through the Trust Before You Sign It

If you are holding a Miller Trust document and none of it makes sense, that is a normal reaction, and it is worth having someone walk you through it before you sign or fund anything. The document only works if it is drafted to Medicaid's specifications and then operated correctly month after month, which is where most problems actually arise. A good first step is to gather award letters and statements for every source of monthly income you receive, since the correct transfer amount depends on the total, and the income cap changes every January. Bring that along with any trust document you already have, and our Florida Medicaid planning attorneys will confirm whether the trust says what it needs to say and calculate what belongs in it each month. For further clarification you can always speak with your own elder law attorney, and if you do not have one, schedule a consultation with our Florida elder law team by telephone or in person, anywhere in the state.