Long Term Care (LTC): How to Complete MIPT Form (M-11)

In order for a Medicaid Income Pension Trust (MIPT) to be established, a completed MIPT form (M-11) (08MA023E) must be completed, signed, and kept in the case record.

The trustee and the financial institution must be given copies of the completed MIPT form.

The first thing to be entered is the person’s name or client that the MIPT is established for. Enter the name in the blank Medicaid income Pension Trust of. The name will autofill for Article Ⅱ and Article Ⅶ.

Next, enter the date the MIPT is to be established. This is the date the trust document is completed.

Then enter the name of the settlor, which is the person who establishes the trust and can be the client, a legal guardian, a Power of Attorney individual, or the client’s Medicaid authorized representative. This will auto-populate the “Settlor” block of in the Signatures section.

Article Ⅰ:
Enter the name of the client.


Article Ⅴ:
Enter the name of the Trustee.

This is the name of the person responsible to manage the account. This will auto-populate the “Trustee” block in the Signatures section.

Article Ⅷ.
One of the options must be chosen by the Settlor.

These are directives on what to do with the remaining trust property (if any). The amount paid out by OHCA for claims is due to them first. If anything is left over, and the client is alive; it goes to them as the primary beneficiary.

  • If the client is deceased, the Trustee must know what to do with remaining trust property.
  • If the client has a will, then the first box should be marked.
  • If there is no will, the second boxed should be marked.
  • If the ‘other box’ is checked – a description would be needed on how the remaining trust property is to be distributed.

Article Ⅺ.
Alternate Trustee

(if applicable – name of individual who will take responsibility in the event that the trustee will be unable).The name will autofill for the second line.

The notarized signatures of the settlor and the trustee are entered.

Schedule A
Attachment to Medicaid Income Pension Trust of:

The top section is for entering the monthly amount that is to remain in the trust and the effective date.

In the following example the MIPT amount (established in December 2020) was $200 monthly. The amount changed to $220 monthly for the year 2021.


MIPT Amount Example 1
Amount that must remain in trust every month Effective Date
$220.00 01/2021


The bottom section is for entering the accumulated amount for each year and also the total.

In the following example, the $200.00 is for the one month December 2020. The amount for 2021 is $220 monthly for 12 months = $2640. Then the $200 from 2020 is added for a total of $2840.00. That is the amount (from this example) that should be in the MIPT or minus the 3% if trustee takes the compensation.

MIPT Amount Example 2
Balance in account before trustee fee Effective Dec 31 of
$200.00 2020
$2840.00 2021


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