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You are so right. This is a combination State and Federal program and the State's own rules are the deciding factors in care.
In NYS, all retirement account are non-countable assets for Medicaid, but they must be in payout status (which makes the income available).
There is also "spousal refusal".
It is yet another reason why consultation with a CELA lawyer who understands your state's Medicaid regs is so important.
Makes me understand better why, when I had a brief consult with an estate attorney after my mom left me a bit of money, she said it was better to use that money to live on and put nearly all my salary into my retirement accounts. It saved me a lot on taxes at the time but also ended up with those funds being non-countable.
like some states are very pro-property rights and these tend to allow for a waiver of elders income to be used for a period of time on the elders property or the state allows for Enhanced Benefit Deeds aka Lady Bird Deeds, or Testamentary Trusts, or other types of Trusts & Deeds allowed which are outside the reach of the attempted recovery. Some states do not allow for a proactive Tefra type of lien placement on the elders property, instead it’s an after death claim against the estate which then can get probate laws (like as to how claims are required to be done or the opening / closing aspects of probate) and property rights all interacting. Some states take a very loose interpretation of allowing a home that has the address as a business or a huge HUGE property that’s obstensibly a ranch to be totally outside of recovery.
its all all so state specific. No 1 system fits all ever.
https://www.google.com/search?q=in+what+states+are+retirment+accounts+non+countable+for+medicaid&oq=in+what+states+are+retirment+accounts+non+countable+for+medicaid&aqs=chrome..69i57.40096j0j4&client=ms-android-tmus-us-revc&sourceid=chrome-mobile&ie=UTF-8
:-)