In addition to the death of a client there are other circumstances in which the MIPT needs to be dissolved. The most common are:

• The client’s home sells, or a lump sum payment is received, and the client becomes ineligible
• The client’s income decreases below the categorically needy standard
• There is a change of trustees, the MIPT must be dissolved and a new one established.

You must follow the MIPT Checklist below prior to submitting a request for MIPT Dissolution.

Please calculate all years that the MIPT was to be funded from certification forward. If a review was not completed during the PHE years, please attempt to verify the income. If unable to get the actual amount of the pension or other income, please use the best information available as well as the EDHL and EDOL screens to get the actual Social Security amount. Please document in your memo if the account was underfunded or overfunded due to incorrect funding during the PHE.

Please staff with your supervisor before requesting submission. After staffing with your supervisor, the following memo below can be copied and e-mailed by the supervisor to AFS.HRMS@okdhs.org by the supervisor when an MIPT is dissolved.

TO:  Adult & Family Services
Attn: HR&MS

FROM: Mary Smith, SSSII
Oklahoma County 55C

DATE: January 6, 2023

RE:  Phillip Doe
H123456

Please dissolve the Medicaid Income Pension Trust for Mr. Doe. This is being requested effective 02/01/21 because: state reason here, which could be death, closure of case because of lump sum payment & client no longer eligible, client’s income decreases to below the categorically needy standard or change of payee.

His trust was located at Arvest Bank, 3800 N. Lincoln, Oklahoma City, OK 73126, account number 123456-088 and the current balance is $________. Total required = $24,442.00 minus the 3% trustee fee of $733.26, which makes the total amount owed to OHCA = $23,708.74.

2018: Gross income $3095 – 2250 = $845 (funded for Nov.) $845 x 2 = $1690 – $50.70 (3% trustee fee) = $1639.30

2019: Gross income $3181-$2313 = $868. (Jan-Sept) x 9 = $7812 – $234.36 (3% trustee fee) = $7577.64

2019: Gross income $3181 – $2349 = $832 (Oct – Dec) x 3 = $2496 – $74.88 (3% trustee fee) = $2421.12

2020: Gross income $3232-2349 = $883. (Jan-Dec) x 12 = $10596 – $317.88 (3% trustee fee) = $10278.12

2021: Gross income $3273 – $2349 = $924. (Jan-Feb): $924 x 2 = $1848 – $55.44 (3% trustee fee) = $1792.56

The trustee is Joe Citizen and his/her is 1 N Main St, Indio, OK 77777. Please find a copy of the MIPT trust document as well as the most current bank statement available attached.

Trustee must be made aware when the MIPT is dissolved, they will receive a letter from OHCA requesting the amount that should be in the trust.

Check List

Supervisors: Please check the following has been completed or included before sending the request to HRMS@okdhs.org for MIPT dissolution:

• The reason and effective date the MIPT needs dissolved.
• The gross monthly income for each year benefits were received listing the exact months and the years to be funded.
• Complete copy of the most current bank statement showing account balance (include all pages) and the complete account number along with the name and address of the financial institution.
• The name and address of the trustee.
• Signed, notarized copy of all pages of the original MIPT/M-11 that were signed at the time the MIPT was established.
• Copy of the Schedule A document that was updated at least annually. Use the actual Schedule A form that lists all years the trust was funded, which is a part of the M-11 document.
• Copy of POA/Guardianship documents if there is a Guardian or a Power of Attorney for the client.
• Address any discrepancies, such as start date of the trust that differs from the trust document or reason why the trust may be underfunded, etc.