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MS DOM LTC Income Trust Document
EP&P/Appendix A-8-1
Revised July 2017 MISSISSIPPI DIVISION OF MEDICAID
LONG-TERM CARE INCOME TRUST
THE ________________________________________ INCOME TRUST
WHEREAS, __________________________, hereinafter referred to as the Settlor, now has a monthly income that exceeds the current Medicaid income limits, and;
WHEREAS, the total monthly income received by Settlor is not sufficient to pay for expenses associated with long-term care services and related services, and;
WHEREAS, Settlor's other assets have been exhausted by Settlor's long-term care expenses, and;
WHEREAS, the principal purpose of this Trust is to receive all income payments due Settlor in excess of the Settlor’s cost of care, including Social Security benefits, retirement benefits, interest, dividends, or other income. The Settlor’s cost of care will be determined by the daily rate that Medicaid pays the nursing facility in which the Settlor resides. If the rate for the facility is less than the Settlor’s income, the excess income will be used to fund the income trust. If the rate for the facility is more than the Settlor’s income, the Settlor’s total income, less authorized deductions, will be paid to the nursing facility. Any income in excess of the Settlor’s cost of care will be retained as part of the Trust. Income cannot exceed the private pay rate for the nursing facility in which the Settlor resides. If total income is determined to be in excess of the private pay rate for a 31-day month for any month, Medicaid eligibility will be denied or terminated for the month(s) under determination. WITNESSETH:
This _________________________Income Trust Agreement is entered into between _____________________, "Settlor", and ______________, "Trustee", who agree as follows: (A) A portion of the Settlor’s income may be protected in the month of entry into long term care. When income protection is applicable, there is no cost of care payable to the nursing facility. However, income above the amount that is $1 less than the Medicaid institutional income limit is payable to the Division of Medicaid within 30-days after receipt of the notice issued by the Division of Medicaid approving eligibility. The approval notice will inform the Trustee of the amount payable.
(B) In all subsequent month(s) or if income protection for the month of entry does not apply, the Trustee shall place all income in excess of the Settlor’s cost of care into the Trust, and the Trustee shall hold such income under the following terms and conditions: