Wyoming Miller Trust / Qualified Income Trust (QIT)

WYOMING QUALIFIED INCOME TRUST (MILLER TRUST) AGREEMENT

TRUST CAPTION

ARTICLE I. ESTABLISHMENT AND PURPOSE

1.01 Creation. This Qualified Income Trust ("Trust") is created on [__/__/____] by [SETTLOR NAME] ("Settlor"), an individual residing in [__________] County, Wyoming, who is an applicant for or recipient of Medicaid long-term care benefits administered by the Wyoming Department of Health ("WDH").

1.02 Statutory Basis. This Trust is established pursuant to:

• (a) Section 1917(d)(4)(B) of the Social Security Act, 42 U.S.C. § 1396p(d)(4)(B);
• (b) Wyo. Stat. § 42-4-101 et seq. (Wyoming Medical Assistance and Services Act);
• (c) Wyoming Medicaid Rules, Chapter 18 — Medicaid Eligibility (promulgated by WDH under Wyo. Stat. § 42-4-104(a)(iv)); and
• (d) the Wyoming Uniform Trust Code, Wyo. Stat. § 4-10-101 et seq.

1.03 Purpose. The sole purpose of this Trust is to enable the Settlor to qualify for long-term care Medicaid (institutional care or a Wyoming Home and Community-Based Services waiver, including the Community Choices Waiver) under the Wyoming Medicaid special income limit equal to 300% of the SSI Federal Benefit Rate by diverting the Settlor's countable income into this Trust during the calendar month of receipt.

1.04 Income-Cap Recognition. The Settlor's gross monthly income exceeds the applicable Wyoming Medicaid special income limit. Without this Trust, the Settlor would be income-ineligible. The funds deposited into this Trust shall not be counted as available income for Medicaid eligibility determinations for the long-term care eligibility group.

ARTICLE II. IRREVOCABILITY

2.01 Irrevocable. This Trust is IRREVOCABLE, consistent with Wyo. Stat. § 4-10-410 and the federal requirements of 42 U.S.C. § 1396p(d)(4)(B). The Settlor expressly waives any right to revoke, rescind, amend, alter, modify, or terminate this Trust, in whole or in part, except as required to comply with applicable federal or Wyoming Medicaid law or by order of a court of competent jurisdiction.

2.02 No Power to Withdraw Corpus. Neither the Settlor nor any beneficiary other than the Residuary Beneficiary (the State of Wyoming) shall have any power to compel distributions from the Trust except as expressly authorized by Article V.

ARTICLE III. TRUST RES; FUNDING

3.01 Corpus. The corpus of this Trust shall consist solely of the Settlor's income, including accumulated income thereon. No resources of the Settlor or any other person shall be deposited into this Trust, except that nominal amounts (typically $10–$20) may be used to open the Trust bank account without invalidating the Trust.

3.02 Identified Income Sources. The following income source(s) shall be deposited into this Trust in full during the calendar month of receipt:

☐ Social Security retirement / disability benefits
☐ Pension: [_______________________________]
☐ Annuity: [_______________________________]
☐ VA benefits (excluding aid and attendance / housebound allowance)
☐ Railroad retirement
☐ Other: [________________________________]

3.03 Entire-Source Rule. For each income source identified above, the entire amount of that source must be deposited into the Trust during the month of receipt. Partial deposits of an identified source invalidate the Trust as to that month, except in the initial month of QIT establishment to the extent permitted by WDH policy.

3.04 Trust Account. The Trustee shall open and maintain a separate, dedicated bank account in the name of the Trust at a federally insured financial institution located in Wyoming. The Settlor's Social Security Number may be used as the Trust's taxpayer identification number, consistent with IRS guidance for grantor trusts.

ARTICLE IV. TRUSTEE

4.01 Initial Trustee. The initial Trustee shall be [TRUSTEE NAME], residing at [_______________________________________].

4.02 Successor Trustee. If the initial Trustee resigns, becomes incapacitated, dies, or otherwise ceases to serve, the successor Trustee shall be [SUCCESSOR TRUSTEE NAME].

4.03 Trustee Powers. Subject to the restrictions of this Trust, the Trustee shall have all powers granted to trustees under the Wyoming Uniform Trust Code, Wyo. Stat. §§ 4-10-815 and 4-10-816, exercised solely to carry out the limited distribution scheme of Article V.

4.04 Trustee Duties. The Trustee shall:

• (a) Receive and deposit the Settlor's identified income source(s) into the Trust account each calendar month;
• (b) Make distributions in the order and amounts required by Article V;
• (c) Maintain complete, contemporaneous accounting records and bank statements;
• (d) File any required fiduciary tax returns (the Trust is a grantor trust for federal income tax purposes);
• (e) Notify WDH of the Settlor's death within thirty (30) days; and
• (f) Provide an accounting to WDH upon request.

4.05 Bond. The Trustee shall serve without bond unless otherwise ordered by a court of competent jurisdiction.

ARTICLE V. DISTRIBUTIONS DURING SETTLOR'S LIFE

The Trustee shall make distributions each calendar month, in the following order of priority and only from funds deposited in that month (or accumulated income), strictly in accordance with the Wyoming Medicaid Rules and WDH policy guidance:

5.01 Personal Needs Allowance. Pay to the Settlor (or to the institution for credit to the Settlor's personal needs account) the monthly Personal Needs Allowance authorized by WDH.

5.02 Spousal Maintenance. Pay to the Settlor's community spouse, if any, the Minimum Monthly Maintenance Needs Allowance (MMMNA) and any incremental income allowance authorized by 42 U.S.C. § 1396r-5.

5.03 Family Allowance. Pay any Family Allowance authorized for dependent family members.

5.04 Health Insurance Premiums. Pay the Settlor's Medicare Part B premium, Medicare supplement premiums, and any other health-insurance premiums approved by WDH.

5.05 Incurred Medical Expenses. Pay non-covered medical expenses approved by WDH.

5.06 Applied Income (Patient Liability). Pay the remaining balance to the nursing facility or HCBS waiver service provider as the Settlor's patient liability / applied income toward the cost of care, in the amount calculated by WDH.

5.07 Trustee Compensation. Reasonable Trustee compensation and necessary trust administration expenses (e.g., bank fees) may be paid only to the extent permitted by WDH policy.

5.08 No Other Distributions. The Trustee shall make no other distributions during the Settlor's lifetime. Funds paid directly to the Settlor (other than the Personal Needs Allowance) or otherwise spent for the Settlor's benefit outside this priority list are countable income for Medicaid eligibility purposes.

ARTICLE VI. DEATH OF SETTLOR — STATE AS RESIDUARY BENEFICIARY

6.01 Mandatory State Payback. Upon the death of the Settlor, the Trustee shall, before any other distribution, pay to the State of Wyoming, through the Wyoming Department of Health, all amounts remaining in the Trust up to the total amount of medical assistance paid by Medicaid on behalf of the Settlor, as required by 42 U.S.C. § 1396p(d)(4)(B)(iii).

6.02 WDH Notification and Claim. The Trustee shall, within thirty (30) days of the Settlor's death:

• (a) Notify the WDH Division of Healthcare Financing and the Wyoming Medicaid Estate Recovery Program;
• (b) Request a statement of the total Medicaid benefits paid; and
• (c) Pay the State's claim from Trust assets before any other distribution.

6.03 Estate Recovery Coordination. This Trust's payback obligation is in addition to any rights the State may assert under the Wyoming Medicaid Estate Recovery Program under Wyo. Stat. § 42-4-206 et seq. and Wyoming Medicaid Rules Chapter 16 against the Settlor's probate estate.

6.04 Residual Distribution. After full satisfaction of the State's claim, any remaining Trust assets shall be distributed to:

[_______________________________________] (relationship: [_____________________])

or, if such person does not survive, to the Settlor's heirs at law determined under the Wyoming Probate Code, Wyo. Stat. § 2-4-101 et seq.

ARTICLE VII. PROHIBITED ACTIONS

7.01 The Trustee shall not:

• (a) Deposit any resource (as opposed to income) of the Settlor or any third party into the Trust, except nominal account-opening amounts;
• (b) Deposit only a portion of an identified income source;
• (c) Make any distribution that would render the Settlor income-ineligible;
• (d) Lend Trust assets to the Settlor or any third party;
• (e) Commingle Trust funds with the Trustee's personal funds or any other account; or
• (f) Use Trust funds for purposes not expressly authorized by Article V and applicable WDH policy.

ARTICLE VIII. TAX MATTERS

8.01 Grantor Trust. This Trust is a grantor trust under 26 U.S.C. §§ 671–679. All items of income, deduction, and credit shall be reported on the Settlor's individual income tax return. The Settlor's Social Security Number may be used as the Trust's taxpayer identification.

ARTICLE IX. GOVERNING LAW; CONSTRUCTION

9.01 Governing Law. This Trust is governed by the laws of the State of Wyoming, including the Wyoming Uniform Trust Code (Wyo. Stat. § 4-10-101 et seq.), and by applicable federal Medicaid law.

9.02 Federal Conformity. Any provision of this Trust that would disqualify it as a Qualified Income Trust under 42 U.S.C. § 1396p(d)(4)(B) or under the Wyoming Medicaid Rules shall be construed, reformed, or severed as necessary to preserve qualification.

9.03 Severability. If any provision is held invalid, the remaining provisions shall continue in full force and effect.

ARTICLE X. EXECUTION

EXECUTED on this [____] day of [_______________], [______], in [__________] County, Wyoming.

SETTLOR

TRUSTEE — ACCEPTANCE

The undersigned accepts appointment as Trustee and agrees to administer this Trust in accordance with its terms, 42 U.S.C. § 1396p(d)(4)(B), and the Wyoming Medicaid Rules.

NOTARIAL ACKNOWLEDGMENT — WYOMING

STATE OF WYOMING

COUNTY OF [______________________]

This instrument was acknowledged before me on [__/__/____] by [SETTLOR NAME], as Settlor.

____________________________________
Notary Public, State of Wyoming
My commission expires: [__/__/____]
(SEAL)

STATE OF WYOMING

COUNTY OF [______________________]

This instrument was acknowledged before me on [__/__/____] by [TRUSTEE NAME], as Trustee.

____________________________________
Notary Public, State of Wyoming
My commission expires: [__/__/____]
(SEAL)

SCHEDULE A — INITIAL FUNDING / IDENTIFIED INCOME SOURCES

Nominal account-opening deposit: $[______] (Settlor's resources or other party's funds; not gift income; not corpus).

Trust bank account information:

• Financial institution: [_______________________________]
• Account number: [____________________]
• Date account opened: [__/__/____]

EXECUTION CHECKLIST

☐ Confirm Settlor's gross monthly income exceeds the current Wyoming special income limit (300% SSI FBR)
☐ Confirm Settlor meets medical-necessity (NFLOC) and resource tests ($2,000 individual)
☐ Identify each income source that will be diverted (entire source — no fractional deposits)
☐ Confirm Settlor is applying for institutional Medicaid or a Wyoming HCBS waiver (Community Choices Waiver, DD waiver, etc.)
☐ Verify Settlor's capacity, or that Agent's Wyoming durable power of attorney expressly authorizes trust creation/funding
☐ Execute Trust before Settlor's first month of Medicaid coverage
☐ Open dedicated Trust bank account; nominal opening deposit only
☐ Notarize Settlor's and Trustee's signatures
☐ Submit signed Trust instrument and bank documentation to WDH eligibility worker
☐ Establish monthly deposit and applied-income payment workflow
☐ Calendar annual review of special income limit, CSRA, and WDH policy changes
☐ Provide copy to community spouse (if any) and successor Trustee

SOURCES AND REFERENCES

• 42 U.S.C. § 1396p(d)(4)(B) — Federal Qualified Income Trust authority
• Wyo. Stat. § 42-4-101 et seq. — Wyoming Medical Assistance and Services Act
• Wyo. Stat. § 42-4-104(a)(iv) — WDH rulemaking authority
• Wyoming Medicaid Rules, Chapter 18 — Medicaid Eligibility (controlling Wyoming Medicaid eligibility rule; includes the 300% SSI Federal Payment income standard for the long-term care eligibility group)
• Wyoming Medicaid Rules, Chapter 16 — Medicaid Estate Recovery
• Wyo. Stat. § 4-10-101 et seq. — Wyoming Uniform Trust Code
• Wyo. Stat. § 42-4-206 et seq. — Wyoming Medicaid Estate Recovery
• Wyoming Department of Health, Division of Healthcare Financing — Programs and Eligibility guidance
• Miller v. Ibarra, 746 F. Supp. 19 (D.N.M. 1990) — Origin of "Miller Trust"