Florida Miller Trust / Qualified Income Trust (QIT)

FLORIDA QUALIFIED INCOME TRUST (MILLER TRUST)

(Irrevocable Income-Only Trust — 42 U.S.C. § 1396p(d)(4)(B) — Fla. Admin. Code r. 65A-1.702)

ARTICLE I — DECLARATION OF TRUST

1.1 Trust Creation. I, [FULL LEGAL NAME OF SETTLOR], of [CITY], [COUNTY] County, Florida (the "Settlor," "Grantor," and "Beneficiary"), hereby establish this Qualified Income Trust (the "Trust") on [__/__/____] under and pursuant to:

(a) 42 U.S.C. § 1396p(d)(4)(B) (federal safe harbor for Qualified Income Trusts);
(b) Fla. Admin. Code r. 65A-1.702 (ACCESS Florida Medicaid — Special Provisions) and Fla. Admin. Code r. 65A-1.7141 (SSI-Related Medicaid Trust Treatment);
(c) The Florida Trust Code, Fla. Stat. ch. 736.

1.2 Name of Trust. This Trust shall be known as the "[FULL LEGAL NAME OF SETTLOR] Qualified Income Trust dated [__/__/____]."

1.3 Purpose. The sole and exclusive purpose of this Trust is to enable the Settlor to establish and maintain Medicaid eligibility for long-term care services under the Florida Statewide Medicaid Managed Care Long-Term Care ("SMMC-LTC") program and/or institutional (nursing facility) Medicaid by diverting the Settlor's monthly income that exceeds the Florida Medicaid income cap (300% of the SSI Federal Benefit Rate) into this Trust in accordance with 42 U.S.C. § 1396p(d)(4)(B).

1.4 Trust is Irrevocable. This Trust is IRREVOCABLE. The Settlor expressly waives and disclaims any power to revoke, amend, modify, alter, or terminate this Trust except as required to maintain compliance with federal or Florida Medicaid law or as ordered by a court of competent jurisdiction.

1.5 No Resources; Income Only. Only income of the Settlor (including, without limitation, Social Security retirement and disability benefits, pension payments, annuity payments, Veterans Administration benefits, railroad retirement benefits, and any other recurring income) shall be deposited into this Trust. No countable resources, assets, or principal of the Settlor shall be transferred into or held by this Trust.

ARTICLE II — PARTIES

2.1 Settlor / Beneficiary.

• Name: [FULL LEGAL NAME OF SETTLOR]
• Date of Birth: [__/__/____]
• Social Security Number (last 4): xxx-xx-[____]
• Florida Medicaid ID (if assigned): [____________________]
• Address: [STREET], [CITY], FL [ZIP]

2.2 Trustee. The initial Trustee shall be:

• Name: [FULL LEGAL NAME OF TRUSTEE]
• Relationship to Settlor: [__________] (e.g., adult child, spouse, professional fiduciary, Florida bank or trust company)
• Address: [STREET], [CITY], [STATE] [ZIP]
• Telephone: [(___) ___-____]

2.3 Successor Trustee. If the initial Trustee resigns, dies, becomes incapacitated, or is otherwise unable or unwilling to serve, the successor Trustee shall be [FULL LEGAL NAME OF SUCCESSOR TRUSTEE], of [ADDRESS]. If no named successor is able and willing to serve, a successor shall be appointed by a Florida court of competent jurisdiction upon petition of any interested person.

2.4 Primary Remainder Beneficiary — Florida Agency for Health Care Administration. As required by 42 U.S.C. § 1396p(d)(4)(B)(iii) and Fla. Admin. Code r. 65A-1.702, the Florida Agency for Health Care Administration ("AHCA") is hereby designated the primary remainder beneficiary of this Trust, up to the total amount of medical assistance paid on behalf of the Settlor under the Florida Medicaid program (including, without limitation, SMMC-LTC, institutional Medicaid, and any home and community-based services waiver).

Notice to AHCA shall be sent to:
Agency for Health Care Administration
Medicaid Program Integrity / Estate Recovery
2727 Mahan Drive, MS #5
Tallahassee, FL 32308

2.5 Contingent Remainder Beneficiaries. After full satisfaction of AHCA's claim under Section 2.4, any remaining trust property shall be distributed as follows:

☐ To the Settlor's estate
☐ To: [FULL LEGAL NAME(S) OF CONTINGENT BENEFICIARY/IES] in the following shares: [____________________]
☐ Per stirpes to the Settlor's descendants

ARTICLE III — FUNDING OF THE TRUST

3.1 Income Subject to Trust. The following items of the Settlor's gross monthly income shall be deposited into the Trust bank account each month (check all that apply at funding):

3.2 Funding Method. The Trustee shall open a dedicated checking account in the name of "[FULL LEGAL NAME OF SETTLOR] Qualified Income Trust, [TRUSTEE NAME], Trustee" at a federally-insured Florida financial institution. All deposits required under Section 3.1 shall be made into this account each calendar month. No co-mingling with personal funds of the Settlor or the Trustee is permitted.

3.3 Monthly Funding Required. Funding of the Trust must occur every calendar month in which the Settlor is enrolled in Florida Medicaid long-term care. Failure to fund the Trust in a given month may result in loss of Medicaid eligibility for that month and recoupment of benefits.

3.4 No Resources. The Trustee shall not accept any transfer of resources (real estate, vehicles, bank accounts not constituting current-month income, securities, life-insurance cash value, or other countable assets) into the Trust. Any such transfer received in error shall be returned to the source within thirty (30) days.

ARTICLE IV — DISTRIBUTIONS DURING THE SETTLOR'S LIFETIME

4.1 Mandatory Disbursement Priority. The Trustee shall disburse the funds in the Trust each calendar month in the following order, consistent with Florida DCF / AHCA SMMC-LTC policy:

First — Personal Needs Allowance (PNA). To or for the benefit of the Settlor, the current Florida Medicaid Personal Needs Allowance for an institutionalized individual (currently $[____] per month; confirm current amount with DCF).

Second — Community Spouse Monthly Income Allowance. If applicable, the monthly maintenance needs allowance for the community spouse, [NAME OF COMMUNITY SPOUSE], as calculated and approved by DCF under 42 U.S.C. § 1396r-5.

Third — Dependent Family Allowance. If applicable, the monthly maintenance allowance for any dependent family member as authorized by DCF.

Fourth — Health Insurance Premiums and Approved Medical Expenses. Medicare Part B and Part D premiums, Medigap or supplemental insurance premiums, and other non-covered medical expenses approved by DCF.

Fifth — Patient Responsibility / Patient Pay Amount. To the nursing facility, assisted living facility, or SMMC-LTC managed care organization providing long-term care services to the Settlor, in the amount of the Settlor's patient responsibility as determined by DCF.

4.2 No Discretionary Distributions. The Trustee has no discretion to make distributions other than as enumerated in Section 4.1. Distributions to the Settlor in excess of the PNA, or to any third party other than as authorized in Section 4.1, are prohibited and may constitute disqualifying transfers.

4.3 Trust Account Balance. Consistent with Florida Medicaid policy, the Trustee should disburse all funds received in a given month within that month to the extent practicable. Any de minimis balance carried forward shall not exceed the amount reasonably necessary for bank fees and administrative reserve.

ARTICLE V — TERMINATION AND DISTRIBUTION ON DEATH OF SETTLOR

5.1 Termination Event. This Trust shall terminate upon the death of the Settlor.

5.2 Notice to AHCA. Within thirty (30) days of the Settlor's death, the Trustee shall provide written notice to the Agency for Health Care Administration, Medicaid Estate Recovery Program, at the address in Section 2.4, together with a copy of the Settlor's death certificate.

5.3 Payment to AHCA — Primary Remainder. Upon termination, the Trustee shall pay all funds then remaining in the Trust to AHCA, up to an amount equal to the total medical assistance paid on behalf of the Settlor under the Florida Medicaid program (including SMMC-LTC and any other Title XIX program), pursuant to 42 U.S.C. § 1396p(d)(4)(B)(iii) and Fla. Stat. § 409.9101.

5.4 Distribution of Excess. After AHCA has been paid in full, any remaining Trust property shall be distributed under Section 2.5.

5.5 Final Accounting. The Trustee shall provide AHCA, and any contingent beneficiary, a final accounting of all Trust receipts and disbursements within ninety (90) days of the Settlor's death.

5.6 Homestead Note. Nothing in this Trust affects the Settlor's homestead protections under Article X, § 4 of the Florida Constitution or Fla. Stat. § 732.4015; this Trust does not hold homestead property.

ARTICLE VI — TRUSTEE POWERS, DUTIES, AND ADMINISTRATION

6.1 General Powers. Subject to the limitations of this Trust and applicable federal and Florida Medicaid law, the Trustee shall have all powers conferred by Fla. Stat. ch. 736 necessary to administer this Trust, including the power to open and maintain a fiduciary bank account, to deposit income, to make the disbursements authorized in Article IV, to maintain books and records, to file tax returns, and to communicate with DCF and AHCA.

6.2 Standard of Care. The Trustee shall administer this Trust in good faith and with the care of a prudent fiduciary, consistent with Fla. Stat. § 736.0801 and § 736.0804.

6.3 Records and Reporting. The Trustee shall maintain complete records of all deposits to and disbursements from the Trust account and shall provide such records on request to DCF, AHCA, the Settlor, the Settlor's authorized representative, any guardian or agent under a durable power of attorney, and any contingent beneficiary.

6.4 Trustee Compensation. The Trustee shall serve ☐ without compensation / ☐ for reasonable compensation in the amount of $[__________] per month, subject to DCF approval as a deductible administrative expense.

6.5 Bond. The Trustee shall serve ☐ without bond / ☐ with bond in the amount of $[__________].

6.6 No Modification of Medicaid-Required Terms. No provision of this Trust may be construed or applied in a manner inconsistent with 42 U.S.C. § 1396p(d)(4)(B), Fla. Admin. Code r. 65A-1.702, or applicable DCF / AHCA policy. To the extent any provision is so inconsistent, it shall be deemed reformed to comply.

ARTICLE VII — MEDICAID PROGRAM ACKNOWLEDGMENTS

7.1 SMMC-LTC Acknowledgment. The Settlor acknowledges that this Trust is being established in connection with an application for Florida Medicaid long-term care benefits, which may be provided through the Statewide Medicaid Managed Care Long-Term Care ("SMMC-LTC") program administered by AHCA through contracted managed care plans, or through institutional (nursing facility) Medicaid.

7.2 Eligibility Determination by DCF. Eligibility for Florida Medicaid is determined by the Florida Department of Children and Families ("DCF") through the ACCESS Florida program under Fla. Admin. Code ch. 65A-1.

7.3 Estate Recovery Acknowledgment. The Settlor acknowledges that, upon the Settlor's death, AHCA has the right and obligation under 42 U.S.C. § 1396p(b) and Fla. Stat. § 409.9101 to recover from the Settlor's estate (including this Trust as the primary remainder beneficiary) the amount of Medicaid benefits paid on the Settlor's behalf.

7.4 No Asset Protection. The Settlor acknowledges that this Trust is not an asset protection vehicle, does not shield property from Medicaid eligibility determinations, and does not avoid estate recovery as to the funds held herein.

ARTICLE VIII — MISCELLANEOUS

8.1 Governing Law. This Trust shall be governed by the laws of the State of Florida and applicable federal Medicaid law.

8.2 Situs. The situs of this Trust is [COUNTY] County, Florida.

8.3 Severability. If any provision of this Trust is held invalid, the remaining provisions shall remain in full force and effect.

8.4 Spendthrift Provision. To the maximum extent permitted by 42 U.S.C. § 1396p(d)(4)(B) and Fla. Stat. § 736.0502, the interest of the Settlor in this Trust is subject to a spendthrift restriction; provided, however, that nothing in this Section shall limit AHCA's rights as primary remainder beneficiary or its right of estate recovery.

8.5 Counterparts. This Trust may be executed in counterparts, each of which shall constitute an original.

ARTICLE IX — EXECUTION

IN WITNESS WHEREOF, the Settlor and the Trustee have executed this Qualified Income Trust on the date first written above.

SETTLOR:

Signature: [____________________________________]
Printed Name: [FULL LEGAL NAME OF SETTLOR]
Date: [__/__/____]

TRUSTEE ACCEPTANCE:

The undersigned hereby accepts the office of Trustee of this Qualified Income Trust and agrees to administer it in accordance with its terms and applicable law.

Signature: [____________________________________]
Printed Name: [FULL LEGAL NAME OF TRUSTEE]
Date: [__/__/____]

WITNESSES

The foregoing instrument was signed in our presence by the Settlor (or by a person authorized to sign on the Settlor's behalf), who declared it to be the Settlor's Qualified Income Trust, and we, at the Settlor's request and in the Settlor's presence and in the presence of each other, hereunto subscribe our names as witnesses on [__/__/____].

NOTARY ACKNOWLEDGMENT

STATE OF FLORIDA
COUNTY OF [____________]

The foregoing Qualified Income Trust was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this [__] day of [__________], 20[__], by [FULL LEGAL NAME OF SETTLOR], who is ☐ personally known to me or ☐ produced [____________________] as identification, and by [FULL LEGAL NAME OF TRUSTEE], who is ☐ personally known to me or ☐ produced [____________________] as identification.

Notary Public Signature: [____________________________]
Printed Name: [____________________________]
Notary Commission No.: [__________]
My Commission Expires: [__/__/____]
(Notary Seal)

SCHEDULE A — INITIAL FUNDING SCHEDULE

Total Monthly Funding Estimate: $[__________]

Florida Medicaid Income Cap (300% SSI FBR) at Funding: $[__________]
Personal Needs Allowance at Funding: $[__________]

SOURCES AND REFERENCES

• 42 U.S.C. § 1396p(d)(4)(B) — Qualified Income Trust safe harbor
• 42 U.S.C. § 1396p(b) — Medicaid estate recovery
• 42 U.S.C. § 1396r-5 — Spousal impoverishment
• Fla. Admin. Code r. 65A-1.702 — ACCESS Florida Medicaid Special Provisions
• Fla. Admin. Code r. 65A-1.7141 — SSI-Related Medicaid Trust Treatment
• Fla. Stat. § 409.901 et seq. — Florida Medicaid Program
• Fla. Stat. § 409.9101 — Medicaid Estate Recovery Act
• Fla. Stat. ch. 736 — Florida Trust Code
• Fla. Stat. § 732.4015 — Homestead devise restrictions
• AHCA Statewide Medicaid Managed Care Long-Term Care (SMMC-LTC) program
• Florida Department of Children and Families (DCF), ACCESS Florida