In select states, the well spouse refuses to contribute — Medicaid must cover institutionalized spouse, may sue later.
In New York and Florida (limited use), the community (well) spouse can execute a Spousal Refusal declining to contribute income/assets toward the ill spouse's care. Medicaid MUST provide benefits regardless. The state has a right to sue the refusing spouse but recovery is often negotiated at 50–70% discount, or waived at second death. Especially powerful when combined with retitling assets to the community spouse before application.
Click Generate advisory deep dive for mechanics, IRC citations, a step-by-step execution plan, a worked numeric example on your profile, costs, risks, and this-week actions.
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.
Wartime-era veterans (or surviving spouses) needing help with ADLs get up to $2,795/mo tax-free — stacks with Medicaid.
Written contract paying an adult child market rate for caregiving spends down assets without Medicaid transfer penalty.
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.