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MS DOM HCBS Income Trust Document

EP&P/Appendix A-9-1

Revised July 2017

MISSISSIPPI DIVISION OF MEDICAID

HOME AND COMMUNITY BASED SERVICES WAIVER (HCBS) 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, Settlor's other assets have been exhausted by the expenses of the Settlor's care, and;

WHEREAS, the principal purpose of this Trust is to receive all income payments due Settlor, including Social Security benefits, retirement benefits, interest, dividends, or other income, and to allow the Trustee to expend for the benefit of the Settlor each month an amount equal to no more than $1.00 less than the then current Medicaid limit, with any excess income to be retained as a part of the Trust. WITNESSETH:

This _________________________Income Trust Agreement is entered into between _____________________, "Settlor", and ______________, "Trustee", who agree as follows: (A) The Trustee shall place all income due the Settlor into the Trust, and the Trustee shall hold such income under the following terms and conditions:

1) Trustee shall distribute to the Settlor, or for Settlor’s benefit, any amounts allowed by the Division of Medicaid, but the total amount distributed each month shall not exceed an amount equal to $1.00 less than the then current Medicaid income limit.

2) At the time of each review of the Settlor’s Medicaid eligibility (at least annually) while this trust is in existence, the Division of Medicaid will notify the Trustee of the amount that should be accumulated in the trust.