Long-term care costs can consume lifetime savings in months or years, leaving families financially devastated. Nursing home care averages $100,000 annually or more depending on location and care level. Without planning, most people must spend down their assets to qualify for Medicaid coverage, the primary payer for long-term care in the United States.
Our friends at Hirani Law help families implement strategies that protect assets while positioning clients for Medicaid eligibility when needed. A trust lawyer experienced in Medicaid planning can structure your assets to preserve wealth for your spouse and children while accessing government benefits for care costs.
The Long-Term Care Cost Reality
According to the U.S. Department of Health and Human Services, about 70% of people over 65 will need some form of long-term care during their lifetimes. This care includes nursing homes, assisted living facilities, memory care units, and in-home services.
Medicare doesn’t pay for long-term custodial care. It covers only short-term skilled nursing or rehabilitation following hospitalization. Most long-term care costs fall on individuals and families until they qualify for Medicaid or exhaust their resources.
Private long-term care insurance provides one solution, but policies are expensive and contain numerous limitations. Many people cannot afford premiums or don’t qualify due to pre-existing conditions. This leaves Medicaid as the primary option for most middle-class families facing extended care needs.
Understanding Medicaid Eligibility
Medicaid is a means-tested program. To qualify, you must have limited income and assets. In most states, individuals can keep no more than $2,000 in countable assets. Married couples face different rules protecting the healthy spouse while the other spouse needs care.
Not all assets count toward Medicaid limits. Exempt assets include your primary residence up to certain equity limits, one vehicle, personal belongings and household goods, prepaid burial arrangements, and certain life insurance policies. These exemptions let you retain some property while qualifying for benefits.
Income limits also apply, though Medicaid planning addresses income issues differently than asset concerns. Many people have low enough income to qualify but too many countable assets.
The Five-Year Look-Back Period
Medicaid reviews all asset transfers made during the five years before you apply for benefits. Transfers for less than fair market value trigger penalty periods during which Medicaid won’t pay for your care.
The penalty period is calculated by dividing the amount of improper transfers by your state’s average monthly nursing home cost. If you gave away $200,000 and your state’s average monthly cost is $8,000, you face a 25-month penalty period.
This look-back period makes planning ahead important. Last-minute transfers after needing care create lengthy penalty periods when you must somehow pay for care without assets or Medicaid assistance.
Asset Protection Strategies
Strategic planning well before needing care provides the most options. Transferring assets more than five years before needing Medicaid means those transfers don’t trigger penalties. However, giving away everything creates different problems if you need resources before requiring long-term care.
Effective planning approaches include:
- Transferring assets to irrevocable trusts
- Converting countable assets to exempt assets
- Purchasing Medicaid-compliant annuities
- Spending down on exempt items and improvements
- Strategic gifting within penalty rules
Each strategy involves tradeoffs between protection, control, and timing. What works for one family might be inappropriate for another based on health status, financial situation, and family dynamics.
Irrevocable Medicaid Trusts
Irrevocable trusts remove assets from your ownership, making them non-countable for Medicaid purposes after the five-year look-back period expires. You cannot serve as trustee or retain the ability to revoke the trust, but you can receive income from trust assets.
These trusts protect real estate, investments, and other property while eventually qualifying you for Medicaid. Your home can stay in the trust, you can continue living there, and it remains protected from nursing home costs.
The main disadvantage is loss of control. You cannot access principal, sell assets without trustee consent, or change beneficiaries after creating the trust. This irrevocability requires confidence that you’re ready to relinquish direct control over these assets.
Spousal Impoverishment Protections
When one spouse needs nursing home care, federal law protects the healthy spouse from complete financial devastation. The community spouse can retain the primary residence, one vehicle, and a portion of the couple’s joint assets.
The Community Spouse Resource Allowance lets the healthy spouse keep approximately $148,000 to $154,000 in 2024, depending on state rules. Amounts above this limit must be spent down before the institutionalized spouse qualifies for Medicaid.
Income protections also exist. The community spouse can retain all income in their own name plus receive some of the institutionalized spouse’s income if needed to meet a minimum monthly maintenance needs allowance.
Converting Countable To Exempt Assets
Smart spending can reduce countable assets while improving your life or protecting family interests. Paying off your mortgage converts cash into home equity, which is exempt. Making needed home repairs or modifications uses countable funds for exempt property improvements.
Purchasing a more expensive exempt vehicle, replacing outdated appliances, or buying new household furnishings converts countable cash into exempt personal property. Prepaying funeral and burial costs removes money from countable assets while addressing inevitable future expenses.
These conversions must reflect fair value. You cannot pay your son $50,000 for a vehicle worth $20,000. But legitimate purchases at market value strategically reduce countable assets.
Medicaid-Compliant Annuities
Immediate annuities can convert countable assets into income streams meeting Medicaid requirements. These annuities must be irrevocable, non-transferable, actuarially sound, and name the state as remainder beneficiary after death.
The annuity provides income that might be used for the community spouse’s benefit or to pay the institutionalized spouse’s care costs until Medicaid eligibility is established. This strategy works well in specific circumstances but requires careful structuring to avoid disqualification.
Caregiver Agreements
Adult children who provide care for parents can be compensated through written caregiver agreements. These agreements document services provided and establish fair compensation rates based on market values for similar services.
Payments under caregiver agreements reduce countable assets while keeping money in the family. The agreements must be in writing before care begins, specify services and compensation clearly, and reflect reasonable market rates.
Caregiver agreements won’t work for services family members typically provide without compensation. But extensive care, medical assistance, household management, and other demanding services can qualify for paid arrangements.
Half-a-Loaf Strategy
Some families use gifting strategies that trigger penalty periods but preserve assets for family members. You might gift half your assets to children and use the remaining half to pay for care during the resulting penalty period.
This approach requires careful calculation to ensure remaining assets cover care costs during the penalty period. If you run out of money before the penalty expires, you have neither assets nor Medicaid coverage.
Life Estate Deeds
Transferring your home while retaining a life estate removes the property from your countable assets after five years while letting you live there for life. You maintain the right to live in the home but cannot sell it without the remainder beneficiary’s consent.
Life estates create property tax benefits in some states and can protect homes from Medicaid estate recovery. However, they complicate property transactions and might create capital gains tax issues for beneficiaries.
Early Planning Advantage
The earlier you plan, the more options you have. Planning at age 60 or 65 provides flexibility that disappears at age 80 when health issues are imminent. Early planning lets you transfer assets, establish trusts, and position yourself for eventual Medicaid eligibility while maintaining resources for current needs.
Crisis planning after a stroke or dementia diagnosis offers fewer options and often results in higher asset loss than advance planning would have prevented.
Professional Guidance Necessity
Medicaid planning involves federal regulations, state-specific rules, and complex strategies with significant consequences. Mistakes can disqualify you from benefits, trigger unnecessary penalty periods, or result in losing more assets than proper planning would have cost.
We work with families regularly to implement Medicaid planning strategies appropriate for their situations. Long-term care costs shouldn’t destroy everything you’ve worked to build, and proper planning protects both your care needs and your family’s financial security. Whether you’re planning decades ahead or facing more immediate concerns, take action now to develop a strategy that preserves your legacy while preparing for potential care needs.
