Medicaid crisis planning in Florida: what families can still do after a nursing home admission

Many admissions start with a hospital stay and a Medicare-covered rehab stay. Medicare may cover up to 100 days in a skilled nursing facility, with a daily coinsurance of $217 for days 21 through 100 in 2026 (Medicare.gov), but coverage often ends sooner, when the person no longer needs daily skilled care. Medicare can’t stop coverage just because the person has stopped improving. Skilled care needed to keep them from getting worse can still qualify (Jimmo v. Sebelius settlement). After that, the bill is private pay until Medicaid starts.

Two DCF rules set the pace. Institutional care coverage can begin the first day of the month of admission, but not before the month of application (ESS Policy Manual 0640.0506; 0640.0509). And a person who meets the limits on any day of a month is eligible for that whole month (1640.0405). In practice, a plan finished on the 28th of a month may cover the whole month, while waiting until the 2nd of the next month may cost a month of private pay. At $10,000 or more a month, that's often the single largest number in the case.

Married couples usually have the most room. Two different steps matter. First is the snapshot, also called the resource assessment: DCF adds up both spouses' countable assets as of the start of the first continuous period of institutionalization (42 U.S.C. 1396r-5(c)(1)). That snapshot sets the spouse's share, the CSRA, up to $162,660. Second is the asset test in the month of application, after any spend-down: the couple's combined countable assets must then be no more than the CSRA plus $2,000 (ESS Policy Manual 1640.0314.01). The home, one car and household goods are generally excluded in addition.

Tools often considered for the amount over the line:

Transfers to the spouse. Interspousal transfers are allowable and carry no penalty (ESS Policy Manual 1640.0609.05). After approval, the CSRA assets still in the patient's name should be moved to the spouse before the next renewal (1640.0610). A community spouse annuity. When the at-home spouse buys an annuity within the look-back, it isn't a transfer if it names the Agency for Health Care Administration (AHCA) as primary beneficiary (after a minor or disabled child, if any) and is actuarially sound for the spouse's age. A revocable or assignable annuity is counted as an asset (ESS Policy Manual 1640.0609.03). Because income generally belongs to the spouse whose name is on the check (42 U.S.C. 1396r-5(b)(2)), the payments help the spouse at home without counting against the patient. A fair-hearing CSRA increase. If the CSRA wouldn't generate enough income to raise the spouse at home to the $2,705 minimum, a hearing officer may raise it (1640.0314.01). Federal law requires the patient's available income to be counted first (42 U.S.C. 1396r-5(d)(6)). Our guide to the spouse's income allowance walks through the numbers.

Spending money on fair-value purchases or paying a valid, enforceable debt is allowable (ESS Policy Manual 1640.0609.05). Families commonly look at:

paying the nursing home bill, credit cards, medical bills and taxes; repairs or improvements to the home, if it's excluded; replacing an unreliable car; an irrevocable prepaid funeral and burial arrangement, which DCF treats as a purchase (1640.0609.05); clothing, hearing aids, dentures, a wheelchair or other items the person needs.

Keep receipts. DCF reviews bank statements, and unexplained withdrawals may be treated as transfers.

If a child or other relative provides care, a written personal services contract can pay them fair market value for services going forward. DCF looks at the value, frequency and duration of the services and wants documentation of how the value was set (ESS Policy Manual 1640.0614.04). Payment for care already given without an agreement is often treated as a gift. Our personal services contract guide covers drafting, and paying a family caregiver covers the family side.

A single person can't shelter assets with a spouse, so a common approach is to gift part of the savings and use the rest to pay for care during the penalty that the gift creates. The kept portion is usually converted to income through a Medicaid-compliant annuity (1640.0609.03) or a promissory note that is actuarially sound, has equal payments with no balloon, and can't be forgiven (ESS Policy Manual 1640.0609.08). Our promissory note guide explains the note rules.

This works because of when the penalty starts. For transfers since November 1, 2007, it begins on the later of the first day of the transfer month or the date the person would otherwise be eligible, which requires an application and meeting every other rule (ESS Policy Manual 1640.0619). Partial months count as days (1640.0618).

A gift made without a plan to cover the penalty can leave a parent with no way to pay the nursing home. DCF's undue hardship exception is narrow and requires a doctor's documentation of endangerment (ESS Policy Manual 1640.0617). An annuity sold as "Medicaid-friendly" with surrender charges, a balloon payment or the wrong beneficiary may be counted as an asset or treated as a transfer. A power of attorney without gifting, trust or annuity powers may stop the plan. Florida requires certain powers to be separately initialed (Fla. Stat. 709.2202), and without them a guardianship may be the only route. Missing the application month, or missing a DCF request for documents, can cost coverage. Our guide to after the Medicaid application covers deadlines.

No option can promise approval. DCF decides each case on its documents.