Medicaid and Long-Term Care Planning: Who Does What, and Why the Three Professionals Have to Agree
A long-term care plan has a legal layer, a money layer and an eligibility layer. Three kinds of professionals each own one. Most households hire one of them and assume the other two are covered.
What types of professionals handle Medicaid, long-term care and retirement income planning, and who do I call first?
Three: an elder law attorney, who drafts the trusts, deeds and powers of attorney, designs any spend-down and files the Medicaid application; a financial adviser, who models what a care event does to retirement income and which accounts fund it; and a Medicaid planner, a specialist in eligibility rules who usually comes from one of the first two backgrounds and hands the rest to someone else. If a care event is likely within five years, call the attorney first, because the look-back period and the legal structures come first. If you are still years out, start with a fee-only fiduciary adviser who builds the income plan and brings the attorney in for the documents. Either way, the three have to be working from the same plan.
Who does what.
Each professional owns one layer and leaves the others to someone else. The table is the whole article in miniature.
| Professional | Handles | Usually does not handle | Hire when |
|---|---|---|---|
| Elder law attorney | Trusts, deed transfers, powers of attorney, spend-down design, the Medicaid application, appeals | Investments, retirement income sequencing, tax path, the spouse's income after the event | A care event is likely within the look-back window, or documents need drafting |
| Financial adviser (registered investment adviser) | What a care event does to income; which accounts fund it, in what order, with what tax result; what the at-home spouse lives on; coordination with the attorney and CPA | Legal documents, the application, eligibility determinations | Years before any event, so funding is planned inside the income plan rather than improvised |
| Medicaid planner (often a designation held by one of the above) | Eligibility rules in detail, asset and income tests, timing of applications | Whichever layer their underlying profession does not cover | A complex eligibility question that the attorney or adviser flags |
Elder law attorneys are the only one of the three licensed to draft the legal structures, and a Medicaid application is a legal filing with consequences if it is wrong. Many hold the Certified Elder Law Attorney designation from the National Elder Law Foundation. Most do not manage investments or build retirement income plans, and they will say so.
Financial advisers, including registered investment advisers, focus on investments, income and the tax path, and a meaningful share never raise long-term care at all. The ones who do treat the care event as a scenario inside the income plan: what it costs, which accounts pay, what the surviving or at-home spouse lives on for the years that follow. That is the layer the attorney does not model.
Medicaid planner designations are issued by private boards, not by a regulator; FINRA notes that it does not approve or endorse any credential. A planner who came from elder law can draft; one who came from financial planning can model; neither does both. Ask what the planner will hand to someone else, and verify the designation with the issuing body.
Where the layers conflict.
Each layer changes the others. Done separately, they contradict.
Medicare does not pay for custodial long-term care, so until Medicaid eligibility is reached the cost comes from savings and income. The median cost of nursing home care is a multiple of a typical retired household's annual income, which is why the funding question belongs inside the income plan rather than beside it: the plan has to say in advance which accounts pay, in what order, and what the spouse at home lives on while they do.
Now the conflicts. A trust the attorney drafts changes which assets the adviser can draw from and when. A deed transfer starts a look-back clock and may change the tax basis the CPA is counting on. An account the adviser retitles may no longer match the estate documents. A beneficiary designation on an IRA overrides the will the attorney wrote. A long-term care policy the adviser recommends has premiums that change the income schedule, and a hybrid policy has an estate effect the attorney needs to know about. None of these is a mistake by any one professional. They are mistakes of coordination, and they are caught only when the three are looking at the same plan.
New Hampshire and Massachusetts apply the look-back the same way in principle, reviewing transfers in the sixty months before application, with details that differ and change. Confirm any figure or exception with NH DHHS, MassHealth or an elder law attorney before acting; nothing here is legal advice. Because the rules shift by state, ask whether a professional works in both states every week.
Questions that sort the professionals quickly.
The answers tell you which of the three you are talking to, and who else you will need.
Who models the income plan, and who drafts the trust or deed?
If the same person claims both, ask which license covers which. If neither is named, you have found the gap.
Are you paid only by client fees, and are you a fiduciary at all times?
A fee-only registered adviser answers both in one sentence. An insurance-licensed professional recommending a care policy has a different answer, and should give it.
Will you work directly with my attorney and my CPA?
Coordination is the product. A professional who will not pick up the phone to the other two is one layer working alone.
What happens to the plan if one spouse needs care?
The answer should include what the other spouse lives on, in numbers, for the years after.
Will I deal with the same person in year ten?
Care planning runs for decades. Continuity matters more here than in almost any other engagement.
Which states' rules do you work with every week?
New Hampshire and Massachusetts, for most households in this area. An answer that names one state is an answer.
Litchfield households often arrive at this question with a parent already in care and their own planning not yet started. The town sits between Nashua and Manchester along the Merrimack River, and many of its pre-retirees are managing a parent's care in one of those cities while still working at employers along Route 3. For Litchfield residents, financial advice on this question means retirement income planning that runs the care scenario early, with an elder law attorney brought in before the look-back clock matters. KBR Retirement & Investment Solutions serves Litchfield from Londonderry, about twenty minutes east on Route 102, and by video.
Choosing by your biggest gap.
Timing decides the order.
If a parent or spouse already needs care, or an application is plausible within five years, the elder law attorney comes first: the look-back period and the legal structures are the binding constraint, and the adviser's job is to make the income plan fit around what the attorney can and cannot do. If you are still years out, the fee-only fiduciary adviser comes first, because the funding question is an income-plan question and the attorney's documents are drafted to match a plan that already exists. In both cases, keep the two in contact. A deed may no longer match the income plan. An account beneficiary may contradict the estate documents. Catching that is the point of having the three layers agree.
The money layer, coordinated with the other two.
An independent, fee-only registered investment adviser in Londonderry, New Hampshire.
KBR Retirement & Investment Solutions, LLC is the second professional in the table: a registered investment adviser, paid only by its clients, that sells no products and so has no reason to prefer a care policy over self-funding or the reverse. Bernie Ross, in financial services since 1997, is the only person who advises clients. The care scenario is modeled inside the income plan, with the funding order, the tax result and the at-home spouse's income worked through, and the work is coordinated with your elder law attorney so that titling and beneficiary designations match the estate documents, and with your CPA so the tax path holds. Medicaid and long-term care planning describes the service; estate and legacy planning covers the documents side; registration and the current Form ADV are linked from Disclosures.
Common questions.
Can a financial advisor help with Medicaid planning, or do I need an attorney?
Both, for different parts. An elder law attorney drafts the trusts, deeds and powers of attorney, designs any spend-down and files the application; that is legal work an adviser should not do. A financial adviser models what a care event does to retirement income, which accounts would fund care and in what order, what the spouse at home lives on, and how the attorney's structures affect taxes and estate goals. The failure mode is each working alone.
What is the Medicaid five-year look-back period?
When you apply for Medicaid long-term care benefits, the state reviews asset transfers made in the previous sixty months. Transfers for less than fair value during that window can trigger a penalty period of ineligibility. The rule and its exceptions are applied by New Hampshire DHHS or MassHealth and interpreted by elder law attorneys; confirm any specific figure or exception with them before acting. This is not legal advice.
Does Medicare cover long-term care?
No. Medicare covers a limited period of skilled nursing or rehabilitation after a qualifying hospital stay. It does not pay for custodial care, the help with daily activities that most long-term care actually is. That gap is funded by personal savings and income, by long-term care insurance or a hybrid policy where one exists, or by Medicaid once eligibility rules are met.
When should I start Medicaid and long-term care planning?
Years before a care event, because the look-back period rewards early decisions and because the funding question belongs inside the retirement income plan from the start. If a parent or spouse already needs care, or an application is likely within five years, the attorney comes first. If you are still years out, the income plan comes first and the attorney is brought in for the documents.
How does a fee-only advisor coordinate Medicaid planning with retirement income advice?
By running the care scenario inside the income plan: which accounts pay, in what order, with what tax result, and what the surviving or at-home spouse lives on for the years after. The adviser then works with the elder law attorney so that account titling and beneficiary designations match the estate documents, and with the CPA so the tax path holds. A fee-only adviser has no product reason to prefer insurance over self-funding or the reverse.
What this connects to.
Medicaid and estate legacy planning in southern NH
Why a care event and an inheritance draw on the same assets, and how the two are planned together.
What is estate and legacy planning?
The five documents, who does what, and how probate works in New Hampshire.
Six retirement income planning mistakes pre-retirees make
Including the long-term care gap most households leave unfunded.
About the author
Bernie Ross is the founder of KBR Retirement & Investment Solutions, LLC, an independent, fee-only registered investment adviser in Londonderry, New Hampshire. He has worked in financial services since 1997 and personally handles the planning and services every client relationship. Read more about Bernie.
This article is general information and is not personalized investment, tax or legal advice. It does not consider your individual circumstances. Consult your CPA or attorney on tax and legal matters. Advisory services are offered through KBR Retirement & Investment Solutions, LLC, a registered investment adviser. Registration does not imply a certain level of skill or training. See Disclosures.
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