Texas Miller Trust (Qualified Income Trust) for Nursing Home Medicaid in San Antonio: How It Works (2026 Guide)

By San Antonio Senior Advisor Care Team · October 27, 2026

What a Texas Miller Trust (Qualified Income Trust) Does for Nursing Home Medicaid in San Antonio

A Texas Miller trust, officially called a Qualified Income Trust or QIT, is the tool that lets a San Antonio senior whose monthly income is a little too high still qualify for nursing home Medicaid. Texas is an income-cap state. To be financially eligible for Medicaid in a nursing facility, or for the STAR+PLUS Home and Community Based Services (HCBS) waiver, an applicant's gross monthly income must fall at or below the Special Income Limit, which Texas Health and Human Services (HHSC) sets at 300 percent of the federal SSI benefit rate. Effective January 1, 2026, the SSI rate is $994, so the Special Income Limit for an individual is $2,982 a month. A retired Kelly Field civilian employee with a $2,400 pension and $1,100 in Social Security, for example, has $3,500 in gross income and is over the cap by $518. Without a Qualified Income Trust, that person is simply ineligible, no matter how little money is in the bank and no matter how high the nursing home bill is.

The Miller trust fixes the problem with a simple legal mechanism. Each month, the amount of income above the cap (or the whole check from one source) is deposited into a special trust bank account. HHSC does not count income that flows into a properly drafted QIT toward the Special Income Limit, so the applicant becomes income-eligible. The money in the trust does not vanish; it is used to pay toward the cost of care. The trust exists so Texas can follow federal law, which since 1993 has allowed income-cap states to use these trusts, named after the Colorado case Miller v. Ibarra. For families in Bexar County, the practical point is this: a pension or Social Security check that is too large is not a reason to give up on Medicaid for a parent at a facility in Northeast San Antonio, the Medical Center or New Braunfels.

Who Needs a Qualified Income Trust in Bexar County: The 2026 Income and Asset Limits

Only people whose gross income exceeds $2,982 a month need a QIT. Gross means before Medicare Part B premiums, Medicare Advantage premiums, tax withholding or insurance deductions, so look at the award letter, not the bank deposit. Military retirees from JBSA-Lackland, JBSA-Randolph and Fort Sam Houston often land just over the line once military retired pay, Social Security and a survivor annuity are added together. A Qualified Income Trust does nothing about assets, however. Texas still applies a $2,000 countable resource limit for an individual and $3,000 for a couple, and the home is generally exempt only if the equity is under the 2026 limit of $752,000 and the applicant intends to return home or a spouse or dependent lives there.

When one spouse needs nursing home care and the other stays home in Alamo Heights, Helotes or the South Side, Texas spousal impoverishment rules also apply. For 2026 HHSC lets the community spouse keep a Spousal Protected Resource Amount of at least $32,532 and up to $162,660, and the community spouse can receive a monthly spousal allowance from the institutionalized spouse's income, capped at $4,066.50. The Miller trust works alongside those rules: the trust income can be used to fund the spousal allowance before the remainder goes to the nursing home. Because these calculations interact, families with a married parent should run the numbers carefully before the application is filed with HHSC's Medicaid for the Elderly and People with Disabilities (MEPD) program.

How to Set Up a Miller Trust in Texas: Template, Trustee and Bank Account

HHSC publishes a sample Qualified Income Trust form in Appendix XXXVI of the Medicaid for the Elderly and People with Disabilities Handbook, and many San Antonio families start there. The trust must be irrevocable, must contain only the applicant's income (never savings, home sale proceeds or other assets), and must name the State of Texas as the remainder beneficiary up to the amount Medicaid paid for care. The trustee is usually an adult child, the healthy spouse or the agent named in a durable power of attorney, and the trustee cannot be the applicant. If the applicant lacks capacity and no power of attorney authorizes creating a trust, a Bexar County probate court guardianship may be needed first, which is one more reason to have a statutory durable power of attorney signed early.

Next the trustee opens a separate checking account titled in the name of the trust, such as "Maria Garza Qualified Income Trust, Jose Garza, Trustee." Frost Bank, USAA, Broadway Bank and the local credit unions in San Antonio are all familiar with these accounts, though branch staff may need to see the signed trust document. Then the trustee must fund it every single month, in the same month the income is received. Many families redirect a pension or annuity payment by direct deposit straight into the QIT account; others transfer the excess from the senior's regular account on the day Social Security arrives. Missing a month can make the applicant ineligible for that month, which can leave a nursing home bill of $7,000 or more unpaid, so set up an automatic transfer and keep statements for HHSC reviews.

Where the Money Goes: Paying the Nursing Home from the QIT Each Month

Once Medicaid is approved, the trustee disburses the trust funds every month in a specific order. First comes the $75 monthly personal needs allowance that Texas lets a nursing facility resident keep for clothing, haircuts, phone service and other personal items. Next, the trustee may pay the spousal allowance to a community spouse and allowable costs such as health insurance premiums not covered by Medicaid. Whatever is left becomes part of the resident's applied income, the monthly copayment owed to the nursing facility. Medicaid then pays the facility the difference between that copayment and the Medicaid daily rate. A small trustee or bank fee may be allowed, but the trustee cannot use the money for gifts, the family's household bills or to build up savings.

Applied income is calculated by HHSC and shown on the approval notice, so the trustee should pay exactly that amount to the nursing home each month and keep a simple ledger. Facilities in San Antonio, from nonprofit communities such as Morningside Ministries to the many for-profit nursing homes near Methodist Hospital and Baptist Medical Center, have business office staff who track applied income closely, and a shortfall can trigger a discharge notice for nonpayment. If the account starts building a balance, ask the facility's business office or a Medicaid planner why; excess funds can cause trouble at renewal. When the resident dies, any balance in the QIT must first repay Texas, which is why the state is the named remainder beneficiary under federal law.

Getting Help with a Qualified Income Trust in San Antonio

Most families do not need to pay thousands of dollars to set up a Texas Qualified Income Trust, but they do need the details right. Free help starts with the Alamo Area Council of Governments (AACOG) Area Agency on Aging at (210) 362-5200 and aacog.com, whose benefits counselors can explain MEPD eligibility and refer you to legal aid. Texas RioGrande Legal Aid serves low-income seniors in Bexar County, and the Texas Health and Human Services website at hhs.texas.gov hosts the MEPD handbook and the QIT template. Nursing home social workers and business office managers at San Antonio facilities file dozens of Medicaid applications a year and can usually tell you whether a QIT is needed after a short look at the income letters.

An elder law attorney is worth the fee when there is a married couple with significant assets, a recent gift or transfer that could trigger a penalty under the five-year look-back, a parent who lacks capacity with no power of attorney, or income from many sources. Para familias que prefieren hablar en espanol, many AACOG counselors and San Antonio elder law offices are bilingual, and HHSC accepts Medicaid applications (Form H1200) in Spanish through YourTexasBenefits.com or by mail. Before you choose a nursing home, verify its license and inspection history on the HHSC Long-Term Care Provider Search at apps.hhs.texas.gov/HSPubDisclosure, and confirm the facility is Medicaid-certified so the trust you set up actually pays for care where your parent lives.

Sources

Talk to a free San Antonio advisor →

Common questions

What is the Miller trust income limit for Texas nursing home Medicaid in 2026?

The Texas Special Income Limit for 2026 is $2,982 a month for an individual, which is 300 percent of the $994 SSI federal benefit rate that took effect January 1, 2026. HHSC compares this cap to gross income, before Medicare premiums or taxes are taken out. If a San Antonio applicant's gross pension, Social Security, VA pension, annuity and other income add up to more than $2,982, they must place income into a Qualified Income Trust (Miller trust) to become income-eligible for nursing facility Medicaid or the STAR+PLUS HCBS waiver. If income is at or below $2,982, no trust is needed. The limit is adjusted each January when the SSI rate changes, so check the HHSC MEPD Budget Reference Chart (Appendix XXXI) for the current figure.

Does a Qualified Income Trust help if my parent has too much money in savings in San Antonio?

No. A Texas Qualified Income Trust only solves an income problem. It cannot hold savings, CDs, investment accounts, home sale proceeds or any other assets, and putting assets into a QIT can invalidate it. Texas still requires countable resources to be at or below $2,000 for an individual or $3,000 for a couple. Families with excess savings typically spend down on legitimate needs such as paying the nursing home privately, prepaying a funeral with an irrevocable funeral contract, repairing the home, or buying needed equipment. Gifts to children within the five-year look-back period can cause a Medicaid penalty period. A married couple may protect more through the 2026 Spousal Protected Resource Amount of up to $162,660. Talk to AACOG at (210) 362-5200 or an elder law attorney before moving money.

Who can be the trustee of a Miller trust in Texas, and can my parent sign it in a nursing home?

Any responsible adult other than the Medicaid applicant can serve as trustee, most often an adult child, a spouse, another relative or a trusted friend. The person creating the trust can be the applicant if they have the mental capacity to sign, or an agent acting under a durable power of attorney that authorizes creating trusts, or a court-appointed guardian. Many San Antonio residents sign QIT documents at a nursing facility, at Methodist Hospital or Baptist Medical Center before discharge, or at home with a notary. If a parent has advanced dementia and never signed a power of attorney, the family may need a Bexar County guardianship first, which takes weeks and adds cost. That is why advisors urge families to sign a Texas statutory durable power of attorney while a parent can still do so.

Can a Miller trust be used for assisted living or STAR+PLUS in Bexar County?

Yes, for the STAR+PLUS HCBS waiver. In Texas, the Special Income Limit and Qualified Income Trust rules apply to the STAR+PLUS Home and Community Based Services waiver as well as to nursing facility Medicaid. A San Antonio senior over $2,982 a month can use a QIT to qualify for STAR+PLUS HCBS services delivered at home or in a contracted assisted living facility, coordinated by a managed care organization such as Superior HealthPlan, Molina Healthcare, Amerigroup or UnitedHealthcare in the Bexar service area. Keep in mind the waiver does not pay for room and board in assisted living, so the senior still pays rent and meals from income, and HCBS waiver slots in Texas have historically involved an interest list. Ask AACOG or the MCO's service coordinator about current wait times before planning around it.

What happens to the money left in a Texas Qualified Income Trust when my parent dies?

Federal law requires a Qualified Income Trust to name the State of Texas as the primary remainder beneficiary. When the Medicaid recipient dies, any balance in the trust account must first be paid to HHSC up to the total amount Texas Medicaid paid for the person's care. Only funds left after that reimbursement can pass to family members named in the trust. In practice, a well-run San Antonio QIT holds very little at death because the trustee disburses the personal needs allowance and applied income every month. The trustee should notify HHSC and the bank, pay the final nursing home bill, and request instructions on the remainder. This is separate from the Texas Medicaid Estate Recovery Program (MERP), which can file claims against other parts of the estate.