Miller Trust in Nevada: How to Set Up a Qualified Income Trust for Medicaid

Nevada is a strict income-cap state for Medicaid long-term care. If your parent's gross monthly income exceeds $2,982 (the 2026 limit, set at 300% of the Federal Benefit Rate), they are disqualified from Institutional Medicaid and the Frail Elderly waiver — regardless of how few assets they have or how desperately they need nursing care. The Miller Trust, formally called a Qualified Income Trust (QIT), is the legal mechanism that solves this.

How the Income Cap Works

In "spend-down" states, applicants with excess income can pay the difference to the nursing home and still qualify for Medicaid. Nevada does not work this way. Here, one dollar over the $2,982 cap means total disqualification. There is no partial credit, no sliding scale.

This creates a cliff: a parent receiving $3,100 per month from Social Security and a small pension is ineligible for the same Medicaid nursing home coverage as someone receiving $2,900. The Miller Trust bridges this gap by routing the excess income through a dedicated, irrevocable trust account that Medicaid disregards for eligibility purposes.

What a Miller Trust Is

A Miller Trust is an irrevocable trust with a single purpose: receive income that would otherwise push the applicant over Nevada's Medicaid income cap. The trust:

• Must be established before the Medicaid application is approved (though it can be set up while the application is pending)
• Must name the State of Nevada as the primary remainder beneficiary — upon the trust holder's death, any remaining funds go to the state to reimburse Medicaid costs
• Must be an irrevocable trust — the applicant cannot dissolve it or redirect funds at will
• Must have a dedicated bank account that receives only the excess income deposits

Step-by-Step Setup

1. Determine the excess amount. Calculate gross monthly income from all sources — Social Security, pensions, annuities, VA benefits, rental income. Subtract $2,982. The difference is the amount that must flow through the Miller Trust each month.

2. Draft the trust document. The trust document must comply with 42 U.S.C. §1396p(d)(4)(B) and Nevada's implementing regulations. It must identify the grantor (your parent), the trustee (typically an adult child or trusted family member), and the State of Nevada as the remainder beneficiary. Many families hire an elder law attorney for this step, though the document itself is straightforward.

3. Open a dedicated bank account. The trustee opens a checking account in the name of the trust. This account receives the excess income deposit each month — not the full income, only the portion above $2,982.

4. Route income monthly. Each month, the excess income must be deposited into the Miller Trust account. In practice, many families direct the entire income into the trust account and then disburse allowable amounts — patient liability to the nursing home, the Personal Needs Allowance ($154/month), Medicare premiums, and any spousal maintenance — from the trust.

5. Submit trust documentation with the Medicaid application. The Division of Social Services (DSS) requires a copy of the executed trust document and proof that the dedicated bank account has been established.

Common Mistakes

Setting it up too late. The Miller Trust must exist when Medicaid eligibility is determined. If DSS processes the application before the trust is established, the application will be denied. Start the setup process as soon as long-term care becomes likely — do not wait for a hospital admission to force the issue.

Depositing funds from other sources. The Miller Trust can only receive the applicant's own income. Deposits from family members, gifts, or non-income sources contaminate the trust and can jeopardize eligibility.

Failing to make monthly deposits. Every month that income is not routed through the trust, the applicant is technically over the income cap and ineligible. Missed months can trigger a coverage gap.

Ignoring the remainder beneficiary requirement. Nevada requires the state to be named as the primary beneficiary upon the trust holder's death. A trust that names children or other heirs as primary beneficiaries does not qualify.

Cost and Complexity

An elder law attorney typically charges $500 to $1,500 to draft a Miller Trust in Nevada. Some legal aid organizations and Medicaid planning services offer assistance at reduced cost. The trust itself does not require court approval — it is a private document executed by the grantor and trustee.

The ongoing administrative burden is minimal: one monthly deposit, basic record-keeping, and an annual accounting if DSS requests one.

A Miller Trust builder template, income calculation worksheet, and DSS submission checklist are included in the Hospital-to-Home Nevada Toolkit.

See more Nevada guides →