The Medicaid planning handbook

What this book actually teaches

Alexander Bove's handbook addresses one of the most consequential financial planning gaps facing American families: the interaction between long-term care costs, Medicaid eligibility rules, and personal asset protection. Bove, an estate planning attorney, wrote the book after watching families discover — too late — that nursing home costs could exhaust a lifetime of savings in months, and that Medicaid eligibility rules are complex enough to require planning years in advance to navigate legally.

The book opens with the core arithmetic problem: nursing home costs at time of writing averaged $25,000-$40,000 per year (figures now dramatically higher), Medicare covers only a short rehabilitation period rather than custodial care, and most private long-term care insurance did not yet exist in accessible form. For families without substantial assets, Medicaid is the only available payer — but Medicaid eligibility requires spending down assets to very low thresholds, with look-back rules that scrutinize transfers made in prior years. The family that gives assets to children six months before a nursing home admission and expects to qualify for Medicaid will find the transfer counted against them.

Bove's framework for planning centers on understanding what Medicaid counts as an "available resource" and what it does not. The primary residence, a vehicle, personal property, and certain prepaid funeral arrangements are typically excluded from countable assets under federal rules (with state variations). A "community spouse" — the well spouse who is not in the nursing home — is entitled to keep a Community Spouse Resource Allowance (CSRA), which Bove explains how to calculate and maximize. The strategy chapters walk through how careful planning around these rules, done early enough, can protect assets legally without violating Medicaid regulations.

The trust chapters are the book's most technically detailed. Bove distinguishes between revocable living trusts (which do not protect assets from Medicaid because the grantor retains control) and irrevocable trusts structured to meet Medicaid rules (which can protect assets but require giving up control and must be created before the look-back period). He covers Medicaid-qualifying annuities, spousal refusal strategies (available in some states), and the difference between income-cap states and medically needy states — a distinction that changes which strategies apply.

State variation is a persistent theme. Medicaid is jointly administered by federal and state governments, and while federal law sets minimums, states vary significantly in look-back periods (at time of writing; the Deficit Reduction Act of 2005 later standardized many rules), spousal protections, estate recovery rules, and income standards. Bove consistently warns readers that state-specific advice from a licensed elder law attorney is essential before implementing any strategy.

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About Alexander A Bove

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