Alaska Miller Trust / Qualified Income Trust (QIT)

ALASKA MILLER TRUST / QUALIFIED INCOME TRUST AGREEMENT

Before use: identify the drafter on every page of the final signed instrument as 7 AAC 100.604(b)(9) requires; confirm the applicant's income treatment and the department's current approval instructions.

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.

This Trust terminates upon a court order or the Settlor's death, whichever occurs first, as required by 7 AAC 100.610(4). Its remaining funds are handled under Article IV.

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
• Federal tax refunds (excluded from eligibility income and resources for 12 months under 26 U.S.C. § 6409 for federally funded benefit programs; keep outside this income-only Trust). Review other refunds under the applicable program rules.

2.3 Alaska Permanent Fund Dividend (PFD)

Federal SSI policy counts the PFD as income in the month received and as a resource if retained in later months. The Trustee shall not direct a PFD payment into this Trust unless DPA confirms in writing that the deposit is permitted for this applicant's Medicaid eligibility category. The Trustee shall follow DPA's written treatment of the payment.

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 100.610, the Alaska Cost-of-Care Amount (COCA) framework, and the post-eligibility treatment-of-income rules of 42 C.F.R. § 435.725 (nursing facility/institutional care) and 42 C.F.R. § 435.735 (HCBS waiver services):

1. Personal Needs Allowance (as published by DPA; current published amounts: $200/month nursing home; $1,396/month assisted living; $1,656/month living at home — confirm current figures with DPA at drafting, as these are adjusted periodically): $[__________]/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, proof of court registration, 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 — STATE REIMBURSEMENT FROM TRUST REMAINDER

4.1 State Medicaid Reimbursement

Upon termination at the Settlor's death, the Trustee shall pay the funds remaining in the Trust to the STATE OF ALASKA, DEPARTMENT OF HEALTH, up to the Medicaid benefits Alaska paid for the Settlor while this Trust existed, subject to allowable trust expenses under 7 AAC 100.608(a). If the Settlor received Medicaid in more than one state, the Trustee shall distribute the balance among those states in proportion to their Medicaid payments, as 7 AAC 100.608(b) requires. This Trust provision implements 42 U.S.C. § 1396p(d)(4)(B)(ii) and 7 AAC 100.608, independently of estate recovery under AS 47.07.055.

If a court terminates this Trust before the Settlor's death, the Trustee shall reimburse the State under 7 AAC 100.608(c) or place the corpus in another recognized Medicaid trust approved by DPA, as the court directs.

4.2 Payment Directions

The Trustee shall notify the Alaska Department of Health when this Trust terminates, obtain its current accounting and payment directions, and remit the amount owed under Section 4.1 before distributing any excess residue. Department contact and remittance details: [________________________________].

4.3 Excess Residue

If, after full satisfaction of all state reimbursement claims under Section 4.1, any Trust property remains, the remainder shall pass to:

[________________________________] (contingent beneficiary), OR if none survive, to the Settlor's estate for distribution under a valid will, or by intestate succession to the extent property is not effectively disposed of by will. AS 13.12.101(a).

4.4 Relationship to Estate Recovery

The surviving-spouse and child restrictions on recovery from an individual's estate in 42 U.S.C. § 1396p(b)(2) do not defer the State's right to the remainder of this qualifying income trust under § 1396p(d)(4)(B)(ii). The Trustee shall account for and pay the State's trust remainder claim under Section 4.1 before distributing any excess residue.

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 13.36.070 (trustee's general duty to administer the trust for the benefit of the beneficiaries) and AS 13.36.105–.109 (powers attached to the office of trustee). The Settlor may not serve as Trustee or exercise any ability, access, or authority to manage or control the Trust account under 7 AAC 100.604(b)(5). 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

At least 30 days before a change of Trustee or co-trustee, the serving Trustee shall send written notice to the Settlor, the Settlor's authorized representative if any, DPA, and the court where this Trust is registered. The successor shall supply DPA with appointment and contact details. If advance notice cannot be given because of death or incapacity, the successor shall promptly notify the same recipients and seek DPA's instructions.

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 proof of court registration) 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 REGISTRATION

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 Registration

The Trustee shall register this Trust with the Alaska court at the Trust's principal place of administration under AS 13.36.005. DPA treats a recognized Medicaid trust that is not registered with a court as invalid under 7 AAC 100.604(c)(1). The Trustee shall give DPA proof of court registration. The Alaska Department of Natural Resources Recorder's Office is a separate land-recording office and is not the court registration destination.

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 may petition the Alaska court with jurisdiction over this Trust for instructions or other appropriate relief concerning its administration or terms. The Trustee may seek the Alaska Division of Public Assistance's review of any Medicaid eligibility effect before relying on a change. AS 13.36.035(a); 7 AAC 100.604(b).

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 100.610, AS 13.36.070, 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 (2026 SSI 300% FBR = $2,982/month; adjusted annually — confirm current figure with DPA before filing): ☐ Income exceeds cap; QIT required.

Alaska PFD: ☐ DPA's written treatment obtained; deposit into Trust only if approved for this applicant.

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 registered with the Alaska court at its principal place of administration
☐ Proof of court registration 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 (not to be confused with § 1396p(d)(4)(A), the first-party/self-settled disability trust provision)
• 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 — Post-eligibility treatment of income, institutionalized individuals in SSI-criteria states (Alaska is an SSI-criteria state, not a § 209(b) "more restrictive" state, so § 435.733 does not apply)
• 42 C.F.R. § 435.735 — Post-eligibility treatment of income, HCBS waiver participants
• AS 47.07.020 — Alaska Medical Assistance Eligibility
• AS 47.07.055 — Alaska Medicaid Estate Recovery
• 7 AAC 100.600–.619 — Medicaid Treatment of Trusts (Article 11), including 7 AAC 100.610 (Qualifying Income Trust) and 7 AAC 100.606 (effect on financial eligibility)
• 7 AAC 100.604(b), (c) and 7 AAC 100.608 — approval contents, court registration and trust-remainder reimbursement
• AS 13.36.005 — court registration at the principal place of administration; Alaska DNR Recorder's Office (https://dnr.alaska.gov/ssd/recoff/) is a different agency
• SSA POMS SI SEA00830.510(C) (https://secure.ssa.gov/poms.Nsf/lnx/0500830510sea) — PFD counts as SSI income in the receipt month and as a resource if retained later
• 7 AAC 130 — HCBS Waiver Programs
• AS 13.36.070 — Trustee's general duty; AS 13.36.105–.109 — Trustee powers (Alaska has NOT adopted the Uniform Trust Code; AS 13.36.157 is Alaska's decanting/power-of-appointment statute and does not govern general trustee duties)
• Alaska Department of Health — Cost of Care Amount Recipients Guide (https://health.alaska.gov/media/d4ckcuxf/coca_recipients_guide_july2025.pdf) — confirm current edition at drafting
• Alaska DPA Qualifying Income Trusts Brochure (MED 23 / 06-3971); Alaska Legal Services Corporation, Medicaid Qualifying Income Trust (Miller Trust) FAQ (alaskalawhelp.org)
• SSA, SSI Federal Payment Amounts (ssa.gov/oact/cola/SSI.html) — source for the current 300% FBR income cap, which changes annually