Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 103 - Resources › Chapter 5 - Trust Provisions › Rule 23-103-5.18 - Income Trust Legal Forms

Current through June 25, 2024
A. The Long Term
				Care Income Trust Agreement will be discussed and provided to the long term
				care client subject to an Income Trust.
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.
WITNESSETH:
This _________________________ Income Trust Agreement is
				  entered into between _____________________ , "Settlor", and ______________ ,
				  "Trustee", who agree as follows:
(A)
				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:
(1) Trustee shall retain the
				income in excess of the Settler's cost of care in the Income Trust
				Account.
(2) At the time of each
				review of the Settlor's Medicaid eligibility (at least annually) while this
				trust is in existence, if the Settlor's income exceeds the cost of care, the
				Division of Medicaid will notify the Trustee of the amount that should be
				accumulated in the trust. The Trustee will then be requested to make payment of
				this amount to the Division of Medicaid up to the total amount expended by the
				Division of Medicaid on behalf of the Settlor that has not previously been
				repaid to Medicaid. Failure to make the requested payments may result in the
				loss of Medicaid eligibility for the Settlor.
(3) This trust will terminate upon the death
				of the Settlor; when the Settlor's Medicaid eligibility is terminated; when the
				Settlor's income no longer exceeds the current Medicaid income limits; or when
				the trust is otherwise terminated. At that time, any income amounts accumulated
				in the trust shall be paid over to the Division of Medicaid, State of
				Mississippi, up to the total amount expended by the Division of Medicaid on
				behalf of the Settlor that has not previously been repaid to Medicaid