For most families, elder law and Medicaid planning in Long Island begins with a single shock: a private room in a Nassau or Suffolk County nursing home can run well over $15,000 per month, and unlike acute hospital care, Medicare pays for almost none of it after the first 100 days. The surprising part is what most people do not know — New York is one of the few states that still allows community Medicaid for home care with effectively no lookback in 2026, even as the institutional five-year lookback grinds on. That gap between the two programs is exactly where careful planning lives, and getting it wrong can cost a family their largest asset: the house.
What Elder Law and Medicaid Planning Actually Cover
Elder law is not a single statute; it is a practice area that braids together estate planning, public-benefits eligibility, guardianship, and long-term care strategy. On Long Island, the dominant concern is almost always how to pay for care without forcing a healthy spouse into poverty or selling a home that has been in the family for decades. Medicaid — administered in New York through the Department of Social Services in each county and governed federally and by state law — is the program that ultimately pays for long-term nursing care for the middle class, because Medicare does not and private long-term care insurance is comparatively rare.
There are two very different Medicaid programs, and conflating them is the most common mistake we see:
- Institutional (nursing home) Medicaid — pays for skilled nursing facility care. It carries the full 60-month (five-year) lookback on asset transfers.
- Community Medicaid — pays for home care, including the Consumer Directed Personal Assistance Program (CDPAP) and Managed Long Term Care. In 2026 a lookback for community-based care has been authorized in law but has been repeatedly delayed and is not being enforced, meaning transfers for home care can still be made without a penalty period.
Understanding which program a loved one needs — and planning years ahead so you are not forced to choose under pressure — is the entire point of working with an elder law attorney rather than reacting in a crisis.
The Cost of Long-Term Care on Long Island
Long Island consistently ranks among the most expensive care markets in the country, driven by high real estate and wages. While exact figures vary by facility, the order of magnitude is what matters for planning. Nursing home care commonly exceeds $180,000 per year, and even part-time home health aides add up quickly when care stretches across years rather than months.
| Care Setting | Who Typically Pays | Medicaid Program Involved |
|---|---|---|
| Skilled nursing facility (long-term) | Private pay, then Medicaid | Institutional (5-yr lookback) |
| Home health aide / CDPAP | Private pay, then Medicaid | Community (no enforced lookback in 2026) |
| Short-term rehab (first 100 days) | Medicare (with copays) | None |
| Assisted living | Mostly private pay | Limited (Assisted Living Program) |
The takeaway: assuming Medicare or a basic health plan will cover years of care is the single costliest miscalculation a Long Island family can make. Care is a long-term financial event, and it deserves long-term planning.
The Core Tool: The Medicaid Asset Protection Trust (MAPT)
The workhorse of elder law and Medicaid planning in Long Island is the Medicaid Asset Protection Trust, an irrevocable trust governed in part by New York’s Estates, Powers and Trusts Law (EPTL Article 7). When properly drafted and funded, assets placed in a MAPT — most importantly the family home — are no longer counted as available resources for Medicaid eligibility once the lookback period has run.
How a MAPT Works
You transfer assets (commonly the house and some investments) into the trust, naming someone other than yourself as trustee, typically an adult child. You can retain the right to live in the home for life and to receive trust income, but you give up access to the principal. That surrender of control is exactly why the assets stop counting. Critically, because you retain a life interest, the home generally keeps the STAR exemption and, when the property eventually passes to your beneficiaries, they receive a stepped-up cost basis — avoiding a large capital gains tax bill that an outright lifetime gift would trigger.
The Five-Year Lookback
For nursing home Medicaid, any uncompensated transfer into a MAPT (or to anyone) within 60 months of applying creates a penalty period during which Medicaid will not pay. The penalty is calculated by dividing the transferred amount by a regional rate set annually for New York. This is why the elder law mantra is simple: the best time to fund a MAPT is five years before you need care. A trust funded today protects the home completely once 2031 arrives — but a trust funded the week before a nursing home admission does little for institutional care.
Protecting the Healthy Spouse
One of the most reassuring features of New York Medicaid is the set of spousal protections, often discussed under the heading of “spousal impoverishment” rules. When one spouse needs institutional care and the other remains in the community, the law shields a meaningful portion of the couple’s assets and income for the spouse staying home.
- Community Spouse Resource Allowance (CSRA): the at-home spouse may keep a substantial protected amount of countable assets, with figures adjusted each year for 2026.
- Minimum Monthly Maintenance Needs Allowance (MMMNA): the community spouse is entitled to keep enough of the couple’s monthly income to meet a state-set floor.
- Spousal refusal: New York remains one of the states that still permits a “just say no” approach, where the community spouse declines to contribute their resources — a powerful, if technical, tool that should only be used with attorney guidance.
These protections mean a healthy spouse on Long Island is not destined to lose the house and savings simply because their partner enters care. But the rules are detailed and the numbers change yearly, so they reward planning rather than guesswork.
Long Island Scenarios
Scenario 1: The Widow With a Paid-Off Levittown Home
A 74-year-old widow in Nassau County owns her home outright, worth roughly $650,000, plus $200,000 in savings. She is healthy today. By funding a MAPT now with the home and a portion of her savings — keeping enough outside the trust for emergencies — she starts the five-year clock immediately. If she needs nursing care in 2032, the home is fully protected and passes to her children with a stepped-up basis, avoiding both a Medicaid claim and a capital gains hit.
Scenario 2: The Couple Facing a Sudden Diagnosis in Suffolk County
A husband suffers a stroke and needs immediate nursing home care; no advance planning was done. Here, crisis planning applies: the community spouse uses the CSRA, MMMNA, and potentially spousal refusal to retain assets, while a portion of the remaining funds may be converted into a Medicaid-compliant annuity. The outcome is not as clean as a five-year-old MAPT, but a skilled attorney can still protect a significant share of the estate even at the eleventh hour.
Scenario 3: Home Care Instead of a Facility
An 80-year-old in Huntington wants to age in place with a home health aide. Because community Medicaid has no enforced lookback in 2026, transfers can be structured to qualify for CDPAP relatively quickly — a flexibility that does not exist on the institutional side. This is the planning window many families do not realize is still open.
Planning is not about hiding money. It is about lawfully arranging your affairs years in advance so that a lifetime of work is not consumed by a few years of care.
Common Mistakes Long Island Families Make
- Gifting the house outright to the kids. This starts a lookback but forfeits the stepped-up basis and exposes the home to a child’s divorce, creditors, or bankruptcy. A MAPT achieves protection without those risks.
- Waiting for a crisis. The five-year clock cannot be sped up; every year of delay is a year of unprotected assets.
- Assuming a revocable living trust protects assets. It does not — assets in a revocable trust are fully countable for Medicaid. Only an irrevocable MAPT works.
- Ignoring the income side. Excess income can be sheltered through a pooled income trust, but only if you set one up correctly and on time.
- Naming the wrong people or skipping coordination with the will. Medicaid planning must align with your broader estate plan; understanding the duties an executor will eventually carry out helps you choose fiduciaries who can manage both the trust and the estate.
How This Fits Your Larger Estate Plan
Medicaid planning is one chapter of a complete plan, not the whole book. A MAPT should be coordinated with your will, powers of attorney, and health care proxy, and you should understand how assets will move through the Surrogate’s Court after death. On Long Island, probate runs through the Surrogate’s Court in Nassau or Suffolk County depending on the decedent’s residence. Because trust and estate disputes can arise — especially when an irrevocable trust changes who inherits — it is worth understanding how contested estates and will contests unfold before they ever happen. For a broader overview of how these pieces connect, our Long Island estate planning guide is a useful starting point.
When to Call an Attorney
Elder law is too unforgiving for do-it-yourself documents. The lookback rules, the annually changing spousal figures, the drafting required to keep STAR and the stepped-up basis intact, and the interplay between community and institutional Medicaid all demand professional drafting and timing. You should speak with an attorney well before a health crisis — ideally in your sixties or early seventies — and immediately if a loved one has just received a diagnosis that points toward long-term care. An experienced Long Island estate planning lawyer can run the five-year math, draft a MAPT that fits your family, and build a crisis plan if time is short.
The goal is straightforward: protect your home, protect your spouse, and qualify for the care you have already paid for through a lifetime of taxes — all while staying fully within New York law. In 2026, the planning window for both community and institutional Medicaid remains open. The families who act early are the ones who keep the house.
Frequently Asked Questions
How much does nursing home care cost on Long Island in 2026?
Long-term nursing home care in Nassau and Suffolk Counties commonly exceeds $15,000 per month, or more than $180,000 per year. Medicare covers only short-term rehab (up to 100 days with copays), so ongoing care is paid privately until Medicaid eligibility is reached.
What is the Medicaid lookback period in New York?
For institutional (nursing home) Medicaid, New York applies a 60-month (five-year) lookback on asset transfers. Uncompensated transfers within that window create a penalty period. As of 2026, the authorized lookback for community (home care) Medicaid has been repeatedly delayed and is not being enforced.
What is a Medicaid Asset Protection Trust (MAPT)?
A MAPT is an irrevocable trust, governed in part by New York’s EPTL, that holds assets such as your home so they no longer count for Medicaid eligibility once the five-year lookback has passed. You can keep the right to live in the home and receive income, but you give up access to principal.
Should I just give my house to my children instead?
Generally no. An outright gift starts a lookback but forfeits the stepped-up cost basis and exposes the home to your child’s divorce, creditors, or bankruptcy. A properly drafted MAPT protects the home while preserving the basis step-up and the STAR exemption.
Will Medicaid take my spouse's assets if I enter a nursing home?
No. New York’s spousal protections shield the community spouse through the Community Spouse Resource Allowance, the Minimum Monthly Maintenance Needs Allowance, and the option of spousal refusal. These rules let a healthy spouse keep a meaningful portion of assets and income.
Can I still plan if a loved one needs care right now?
Yes. Crisis planning uses spousal protections, Medicaid-compliant annuities, and other tools to protect a significant share of assets even without five years of advance planning. The results are stronger with early planning, but it is rarely too late to do something.
Does a revocable living trust protect assets from Medicaid?
No. Assets in a revocable trust remain fully countable for Medicaid because you retain control. Only an irrevocable Medicaid Asset Protection Trust removes assets from the eligibility calculation after the lookback period.
Which court handles estates after death on Long Island?
Estates are administered through the Surrogate’s Court in the county where the person lived — Nassau County Surrogate’s Court or Suffolk County Surrogate’s Court. Coordinating your Medicaid plan with your will helps avoid surprises and disputes in that process.
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