Alaska Miller Trust / Qualified Income Trust (QIT)

ALASKA MILLER TRUST / QUALIFIED INCOME TRUST AGREEMENT

CAPTION

Trust Name: The [SETTLOR LAST NAME] Qualified Income Trust

Date of Execution: [__/__/____]

Borough or Census Area of Settlor's Residence: [________________________________], Alaska

ARTICLE I — ESTABLISHMENT AND PURPOSE

1.1 Establishment

I, [SETTLOR FULL LEGAL NAME] (the "Settlor"), of [________________________________], Alaska, hereby establish this irrevocable trust to be known as THE [SETTLOR LAST NAME] QUALIFIED INCOME TRUST (the "Trust"), and I appoint [TRUSTEE FULL LEGAL NAME] of [________________________________] as Trustee.

1.2 Statement of Purpose

The sole purpose of this Trust is to establish a Qualified Income Trust ("Miller Trust") within the meaning of 42 U.S.C. § 1396p(d)(4)(B) so that the Settlor may qualify for Long-Term Services and Supports Medicaid administered by the Alaska Department of Health, Division of Public Assistance ("DPA") under AS 47.07 and 7 AAC 100, including:

• ☐ Nursing Facility (Institutional) Medicaid
• ☐ Home and Community-Based Services (HCBS) Waiver under 7 AAC 130 (Adults with Physical and Developmental Disabilities; Alaskans Living Independently; Children with Complex Medical Conditions; Intellectual and Developmental Disabilities)
• ☐ TEFRA Medicaid
• ☐ Other: [________________________________]

1.3 Irrevocability

This Trust is IRREVOCABLE. The Settlor expressly waives any power to alter, amend, revoke, or terminate this Trust, except as may be required to conform this instrument to the requirements of 42 U.S.C. § 1396p(d)(4)(B), 42 U.S.C. § 1396a(a)(10)(A)(ii)(V), or any controlling rule or written directive of the Alaska Division of Public Assistance.

1.4 Income-Cap Findings

The Settlor's gross monthly income from all sources exceeds the 300% SSI Federal Benefit Rate cap applied by the Alaska Division of Public Assistance under 7 AAC 100, but is less than the private-pay cost of the nursing facility or community-based services for which the Settlor is applying. This Trust is therefore necessary to establish income eligibility for Alaska Long-Term Services and Supports Medicaid.

ARTICLE II — TRUST FUNDING

2.1 Permitted Trust Property

The Trust shall consist solely of the following categories of the Settlor's regularly recurring income:

• ☐ Social Security retirement, disability, or survivor benefits
• ☐ Federal, state (Alaska PERS / TRS), military, or private pension benefits
• ☐ Required Minimum Distributions from IRA or qualified plan (received as monthly income)
• ☐ Veterans Administration benefits (subject to VA assignment rules)
• ☐ Railroad Retirement benefits
• ☐ Annuity payments classified as income
• ☐ Alaska Permanent Fund Dividend — see Section 2.3 below
• ☐ Other regularly recurring income: [________________________________]

2.2 Property That Shall NOT Be Deposited

The following shall NEVER be deposited into the Trust, and any such deposit is void ab initio:

• Lump-sum payments, retroactive benefits, inheritances, gifts, settlement proceeds
• Resources or assets of any kind (bank accounts, CDs, real property proceeds)
• Income belonging to the Settlor's spouse or any third party
• Tax refunds (treated as resources, not income)

2.3 Alaska Permanent Fund Dividend (PFD)

The Alaska Permanent Fund Dividend is excluded from countable income for Medicaid eligibility under federal SSI rules and DPA policy and therefore shall not be deposited into this Trust. The PFD remains the Settlor's personal property and is treated as a resource subject to applicable resource limits.

2.4 Trust Bank Account

The Trustee shall open and maintain a separate, segregated bank account titled in the name of the Trust at an Alaska financial institution or other FDIC-insured institution acceptable to DPA. All Trust funds shall be held in that account, and the Trustee shall provide trust bank statements to the DPA caseworker as required.

2.5 Funding Mechanics

The Trustee shall arrange for direct deposit of the designated income source(s) into the Trust account. The Settlor authorizes the Trustee to execute any direct-deposit authorization, EFT instruction, or financial institution form necessary to effectuate funding.

ARTICLE III — DISTRIBUTIONS

3.1 Mandatory Monthly Distributions

The Trustee shall, in each calendar month and in the following order of priority, distribute Trust income consistent with 7 AAC 100, the Alaska Cost-of-Care Amount (COCA) framework, and the post-eligibility treatment-of-income rules of 42 C.F.R. § 435.725 and § 435.733:

1. Personal Needs Allowance (as published by DPA; 2025 amounts: $200/month nursing home; $1,396/month assisted living; $1,656/month living at home): $[__________]/month.

2. Community Spouse Monthly Income Allowance (if applicable) under 42 U.S.C. § 1396r-5(d): $[__________]/month to [COMMUNITY SPOUSE NAME].

3. Family Allowance for dependent family members: $[__________]/month.

4. Health Insurance Premiums (Medicare Part B, Part D, Medigap/Medicare Supplement, other health insurance).

5. Incurred Medical Expenses not subject to third-party payment.

6. Guardian / Conservator Fees (up to $100/month under current DPA policy).

7. Income Taxes owed by the Settlor.

8. Cost-of-Care Amount (COCA) payment to the LTSS provider as calculated by DPA.

3.2 No Discretionary Distributions

The Trustee shall have no discretion to accumulate income, retain income beyond the month of receipt, or distribute Trust income for any purpose other than those expressly authorized in Section 3.1 and consistent with 42 U.S.C. § 1396p(d)(4)(B).

3.3 Reporting Obligations

The Trustee shall report any change in the Settlor's income or living situation to the DPA caseworker within ten (10) days as required by Alaska DPA policy. The Trustee shall provide complete trust documents, court recording document, and current bank statements at each annual Medicaid redetermination.

3.4 Trustee Compensation

The Trustee shall serve ☐ without compensation OR ☐ for reasonable compensation not to exceed $[________]/month, payable from the Trust, only to the extent permitted by Alaska DPA policy.

ARTICLE IV — RESIDUAL BENEFICIARY / ESTATE RECOVERY

4.1 State of Alaska as Residual Beneficiary

Upon the death of the Settlor, all funds remaining in the Trust (the "Residual Trust Property") shall be paid to the STATE OF ALASKA, DEPARTMENT OF HEALTH, up to the total amount of medical assistance paid on behalf of the Settlor by the State of Alaska, in accordance with 42 U.S.C. § 1396p(d)(4)(B)(iii) and AS 47.07.055 (Alaska Medicaid Estate Recovery).

4.2 Recovery Payment Address

The Trustee shall, within thirty (30) days of the Settlor's death, notify and remit Residual Trust Property to:

Alaska Department of Health
Division of Public Assistance — Estate Recovery Unit
P.O. Box 110640
Juneau, AK 99811-0640

4.3 Excess Residue

If, after full satisfaction of the State of Alaska's claim, any Trust property remains, the remainder shall pass to:

[________________________________] (contingent beneficiary), OR if none survive, to the Settlor's estate under intestate succession per AS 13.12.101 et seq.

4.4 Surviving Spouse and Dependent Exceptions

Pursuant to 42 U.S.C. § 1396p(b)(2) and AS 47.07.055, no recovery against the Trust shall be enforced during:

• The lifetime of the Settlor's surviving spouse, [SURVIVING SPOUSE NAME, if any]; or
• The period during which any surviving child of the Settlor is under age 21, blind, or permanently disabled.

Recovery shall be deferred until the qualifying condition no longer exists.

ARTICLE V — TRUSTEE PROVISIONS

5.1 Trustee Independence

The Trustee shall act independently and shall owe a fiduciary duty solely to the lawful purposes of this Trust under AS 13.36.157 (Alaska trustee duties). The Trustee shall not be the nursing facility, HCBS provider, assisted-living home, or any agent thereof providing services to the Settlor.

5.2 Successor Trustee

If the named Trustee is unable or unwilling to serve, the following shall serve as Successor Trustee in the order listed:

1. [________________________________] of [________________________________]
2. [________________________________] of [________________________________]
3. An Alaska state-chartered or national bank's trust department designated by court order

The Trustee or Successor Trustee shall promptly file a Successor Trustee Appointment with the DPA caseworker as required by Alaska DPA policy.

5.3 Trustee Powers

The Trustee shall have only those powers necessary to receive income, maintain the Trust account, make the mandatory monthly distributions enumerated in Article III, report to DPA, and account to the State of Alaska. The Trustee shall not have the power to invest, lend, encumber, or commingle Trust assets.

5.4 Accounting and DPA Reporting

The Trustee shall maintain complete records of all deposits and disbursements and shall provide:

• Trust bank statements showing all deposits to DPA caseworker
• An accounting of all Trust expenditures upon DPA request
• Complete trust documents (executed instrument and court recording) at each annual Medicaid redetermination

5.5 Bond

☐ The Trustee shall serve without bond.
☐ The Trustee shall post bond in the amount of $[__________].

ARTICLE VI — DPA APPROVAL AND COURT RECORDING

6.1 Pre-Funding DPA Approval

Before funding this Trust, the Trustee shall submit a complete copy of this executed instrument to the appropriate DPA Adult Public Assistance Office (Anchorage, Mat-Su, Coastal, Fairbanks, or Southeast) for review and approval by a Medicaid Policy Specialist.

6.2 Court Recording

Following DPA approval, the Trustee shall record this Trust with the Alaska Court System (Recorder's Office for the appropriate Recording District) and shall deliver a copy of the recording document to the DPA caseworker.

6.3 Confirmation of Compliance

This Trust is intended to satisfy all requirements of 42 U.S.C. § 1396p(d)(4)(B) and Alaska DPA Qualified Income Trust policy. The Trustee is authorized and directed to take all steps necessary to maintain such compliance.

ARTICLE VII — GENERAL PROVISIONS

7.1 Governing Law

This Trust shall be governed by, and construed in accordance with, the laws of the State of Alaska, including the Alaska statutes governing trusts (AS 13.36), and the federal Medicaid statutes and regulations cited herein. To the extent of any conflict, federal Medicaid law shall control.

7.2 Severability

If any provision of this Trust is held invalid, the remainder shall remain in effect, and the invalid provision shall be reformed to the minimum extent necessary to comply with 42 U.S.C. § 1396p(d)(4)(B).

7.3 Spendthrift Clause

To the maximum extent permitted by Alaska law, the interests of the Settlor and all beneficiaries are subject to a spendthrift restriction and are not assignable or subject to claims of creditors, except as required to satisfy the State of Alaska's residual beneficiary claim under Article IV.

7.4 Reformation Authority

The Trustee is authorized to petition any Alaska Superior Court of competent jurisdiction, or the Alaska Division of Public Assistance, to reform this Trust to maintain compliance with 42 U.S.C. § 1396p(d)(4)(B) and Alaska Medicaid policy.

SIGNATURES

Settlor

Executed this [____] day of [__________________], 20[____], in [________________________________], Alaska.

____________________________________
[SETTLOR FULL LEGAL NAME], Settlor

Trustee Acceptance

I, [TRUSTEE FULL LEGAL NAME], accept the appointment as Trustee of THE [SETTLOR LAST NAME] QUALIFIED INCOME TRUST and acknowledge the fiduciary duties imposed by 42 U.S.C. § 1396p(d)(4)(B), 7 AAC 100, AS 13.36.157, and Alaska Division of Public Assistance policy.

____________________________________
[TRUSTEE FULL LEGAL NAME], Trustee

Date: [__/__/____]

NOTARIAL ACKNOWLEDGMENT

STATE OF ALASKA

[__________________] JUDICIAL DISTRICT

On this [____] day of [__________________], 20[____], before me, the undersigned Notary Public in and for the State of Alaska, personally appeared [SETTLOR FULL LEGAL NAME] and [TRUSTEE FULL LEGAL NAME], known to me (or satisfactorily proven) to be the persons whose names are subscribed to the foregoing instrument, and they acknowledged to me that they executed the same for the purposes therein contained, as their free and voluntary act.

In witness whereof I hereunto set my hand and official seal.

____________________________________
Notary Public in and for the State of Alaska

My Commission Expires: [__/__/____]

[NOTARY SEAL]

EXHIBIT A — SCHEDULE OF INCOME SOURCES

Income-Cap Verification (2025 SSI 300% FBR = $2,901): ☐ Income exceeds cap; QIT required.

Alaska PFD: ☐ Excluded from Trust (treated as resource per DPA policy).

EXHIBIT B — ALASKA QIT FILING AND APPROVAL CHECKLIST

☐ Attorney drafted Trust instrument
☐ Trustee identified (family member, friend, or Alaska bank trust department)
☐ Separate Trust bank account opened at Alaska financial institution
☐ Direct deposit of income source(s) authorized
☐ Draft Trust submitted to DPA Adult Public Assistance Office for review
☐ DPA Medicaid Policy Specialist approval obtained
☐ Trust recorded with Alaska Court System (Recorder's Office)
☐ Copy of recording document delivered to DPA caseworker
☐ Trust bank statements provided to DPA caseworker monthly (initial period) and at redetermination
☐ Successor Trustee Appointment on file with DPA
☐ State of Alaska designated as residual beneficiary
☐ Monthly distribution schedule documented (Personal Needs Allowance, premiums, COCA)
☐ Income or living-situation changes reported to DPA within 10 days

DPA CONTACT REFERENCE

• Anchorage Adult Public Assistance Office (Miller Trusts): (907) 269-6000
• Mat-Su Adult Public Assistance Office: (907) 376-3903 or 1-800-478-7778
• Coastal Adult Public Assistance Office: (907) 269-8950 or 1-800-478-4372
• Fairbanks Adult Public Assistance Office: (907) 451-2850 or 1-800-478-2850
• Southeast Adult Public Assistance Office: (907) 465-3537 or 1-800-478-3537
• DPA Long Term Care Coordinator (General Trust Questions): (907) 269-7880
• Specialized Medicaid Office: (907) 465-3347

SOURCES AND REFERENCES

• 42 U.S.C. § 1396p(d)(4)(B) — Qualified Income Trust safe harbor
• 42 U.S.C. § 1396a(a)(10)(A)(ii)(V) — 300% SSI special income level
• 42 U.S.C. § 1396p(b) — Estate recovery and exceptions
• 42 C.F.R. § 435.725, § 435.733 — Post-eligibility treatment of income
• AS 47.07.020 — Alaska Medical Assistance Eligibility
• AS 47.07.055 — Alaska Medicaid Estate Recovery
• 7 AAC 100 — Medicaid Eligibility (Division of Public Assistance)
• 7 AAC 130 — HCBS Waiver Programs
• AS 13.36.157 — Alaska Trustee Duties
• Alaska Department of Health — Cost of Care Amount Recipients Guide (July 2025) (https://health.alaska.gov/media/d4ckcuxf/coca_recipients_guide_july2025.pdf)
• Alaska DPA Qualifying Income Trusts Brochure (MED 23 / 06-3971)