Written contract paying an adult child market rate for caregiving spends down assets without Medicaid transfer penalty.
Instead of gifting assets (which triggers 5-year lookback), an elder enters a written Personal Care Contract with an adult child (or other caregiver) paying market rate (e.g., $20–$30/hr) for documented services: transportation, meal prep, medication management, personal care. Because it's exchange for services (not a gift), no Medicaid transfer penalty. Child reports as SE income. Elder spends down toward Medicaid eligibility while family retains the money.
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Irrevocable income-only trust funded 5+ years before Medicaid application shelters home and assets from spend-down.
Transfer the primary residence to an adult child who lived there caregiving for 2+ years — no Medicaid transfer penalty.
In select states, the well spouse refuses to contribute — Medicaid must cover institutionalized spouse, may sue later.
Wartime-era veterans (or surviving spouses) needing help with ADLs get up to $2,795/mo tax-free — stacks with Medicaid.
Immediate irrevocable annuity converts spend-down assets into an income stream for the community spouse.
Ladybird deed transfers home at death with §1014 step-up, avoids probate, and doesn't trigger Medicaid transfer.
Post-65, HSA funds pay Medicare Part B/D/Advantage premiums + LTC insurance premiums tax-free.
Combo policies give LTC benefits if needed, death benefit if not — no 'use it or lose it' like standalone LTC.