A Conversation with Elder Law Attorney Cary Moss of Sawyer & Sawyer, P.A.
Key Takeaways
- Medicare does NOT cover long-term nursing home care — Medicaid does, if you qualify. These are two very different programs with very different rules.
- Florida nursing home costs range from $10,000 to $18,000 per month. Without planning, these costs can devastate a family’s finances.
- Many assets are already exempt under Florida Medicaid rules — including your home, retirement accounts, and your car — which means most people have more options than they realize.
- Medicaid planning mistakes (such as giving money to children, adding them to accounts, or acting on advice from other states) can make things significantly worse. Work with a Florida elder law attorney.
- It is almost never too late to do something. Even in a crisis, a comprehensive Durable Power of Attorney unlocks powerful legal options to protect your assets.
Introduction
Few conversations cause more anxiety for Florida families than the prospect of a loved one needing long-term nursing home care. The financial stakes are enormous, the rules are confusing, and the advice circulating among friends and family is often just plain wrong.
That’s exactly why estate planning and elder law attorney Cary Moss of Sawyer & Sawyer, P.A. breaks it all down in this two-part conversation — covering everything from what nursing home care actually costs in Florida today, to the legal strategies that can protect your life savings, to the mistakes that can make a difficult situation even worse.
Sawyer & Sawyer, P.A. serves families throughout Orange, Lake, Osceola, and Seminole Counties, including Orlando, Winter Park, Windermere, Winter Garden, Dr. Phillips, and Horizon West. Cary Moss has been practicing elder law and Medicaid planning for over 27 years and has guided hundreds of families through what can feel like an impossible situation.
The message she returns to again and again: you have far more options than you think.
The Sticker Shock of Nursing Home Costs in Florida
Cary Moss: Part of the issue is people assume Medicare is going to cover a good portion of the long-term care. So when they learn that Medicare’s not going to pay for it, and then they find out from the facilities what the private-pay costs actually are, it is quite a sticker shock.
When Cary started practicing 27 years ago, nursing home costs in Florida averaged $6,000 to $8,000 per month. Today, she’s seeing rates starting around $10,000 per month on the low end — and as high as $18,000 per month, often for a shared room, not a private one.
For married couples, that financial pressure is compounded: one spouse is in a facility at $18,000 a month while the other continues to pay everyday living expenses at home. The fear of financial devastation — of spending down everything they’ve saved together — is very real.
Medicare vs. Medicaid: Two Very Different Programs
One of the most common sources of confusion Cary encounters is the mix-up between Medicare and Medicaid. They sound similar, but they work very differently — especially when it comes to paying for nursing home costs.
Cary Moss: Medicare is a federal health insurance program for people typically 65 and older. Medicaid, on the other hand, covers medical costs for individuals with limited income and resources — and it can, if you’re eligible, cover long-term care costs. Medicare does not cover long-term care costs. That’s a source of a lot of misinformation.
Medicaid is a joint federal-state program, and in Florida there are two primary long-term care programs. The one most families often hear about is the Institutional Care Program (ICP), which covers nursing home care for those who need skilled nursing. Once someone is approved for Medicaid under ICP, they pay a “patient liability” amount each month — based on their gross income, minus a few allowable deductions — and Medicaid covers the rest of the nursing home cost.
Those deductions include a $160/month personal needs allowance (for clothing, hygiene, and personal items), supplemental health insurance premiums, and — for married applicants — a Community Spouse Income Allowance so the at-home spouse can maintain their household.
The Myths That Can Cost You Everything
Perhaps the most damaging myth Cary hears is: “Medicaid is going to take all my assets.”
Cary Moss: Medicaid’s not going to take your assets. Medicaid just is not going to approve benefits until you’ve met the financial criteria to qualify. It’s not a taking — it’s a qualification threshold.
Just as harmful is the belief that “I have too much money, so I’ll never qualify.” The key distinction in Medicaid planning is between exempt assets (which don’t count against eligibility) and countable assets (which do). Many people are surprised to learn how much they can legally keep.
A common question: “Are you hiding assets?” The answer is an emphatic no. Every strategy is fully disclosed to the Medicaid office. The goal is legal recharacterization — moving assets from countable to exempt categories under the rules — not concealment.
Finally, advice from friends or family in other states is often inapplicable and sometimes actively harmful. Every state has its own Medicaid rules, programs, and planning options. Florida’s are often more favorable than most — but only if you know them.
What Assets Can You Actually Keep? Exempt vs. Countable
When Cary sits down with a new client, one of her first tasks is categorizing everything they own into exempt or countable columns. Here’s how the major asset categories break down in Florida:
- Your home (homestead): Exempt up to $750,000 in equity. If a spouse still lives there, the home is exempt regardless of value — even a $3 million home.
- Retirement accounts (IRA, 401k, 457, etc.): If the account owner converts from an annual RMD to monthly distributions, the principal value of the account becomes exempt. This applies to both the Medicaid applicant and the community spouse.
- One vehicle: Exempt.
- Pre-paid funeral and cremation contracts: Exempt, as long as they’re irrevocable.
- Cash, savings, investments, and savings bonds: Countable — these are typically what require the most planning.
- Life insurance with cash value: If the combined face value of all policies exceeds $2,500, the cash value counts as a countable asset. (Term and group employer policies are treated differently.)
- Real estate other than the homestead: Countable, though rental properties may be exempt in some circumstances.
Two Paths: Pre-Planning vs. Crisis Planning
There’s no such thing as starting too early when it comes to Medicaid planning. But there is such a thing as starting too late — which is why understanding both planning paths matters.
Cary Moss: Some people want to do pre-planning — they’re not going to wait for a crisis to happen. For those individuals, we use an irrevocable Medicaid Asset Protection Trust. Moving assets into that trust starts the clock ticking on the five-year lookback. Once you get five years and a day, those assets are 100% protected, assuming the trust has been drafted correctly and administered properly during that time.
She generally finds the “sweet spot” for this kind of planning is somewhere in the mid-70s to early 80s, depending on the client’s health, assets, and family dynamics.
For those facing a crisis — a sudden hospitalization, a diagnosis that’s escalating quickly — crisis planning is still very much available. A comprehensive Durable Power of Attorney is the linchpin:
Cary Moss: I have had people come see me at the beginning of a month, and assuming we have proper legal documents in place, we’ve done that as quickly as a month if we have to. The issue that prevents us from doing something like that is someone who doesn’t have a Durable Power of Attorney and has already lost capacity. That gets us into a guardianship proceeding — which takes time and puts the outcome in the hands of a judge.
Legal Strategies for Protecting Your Assets
The specific tools available depend on whether you’re dealing with a single individual or a married couple. Here’s an overview of what Cary commonly uses:
- Personal Care Contract (for singles): A legal contract that allows the Medicaid applicant to pre-pay a trusted adult child or family member for future caregiving services — advocacy, bill-paying, oversight, coordinating with facility staff. The lump sum is calculated based on projected hours, an hourly rate, and Medicaid’s life expectancy tables.
- Home improvements: Countable cash can be used to repair or upgrade the exempt homestead (new roof, HVAC, etc.).
- Irrevocable pre-paid funeral contracts: An exempt way to use countable assets.
- Intra-family loan (married couples): The community spouse makes a lump-sum loan to a trusted adult child, repaid monthly — removing it from the countable asset column.
- Single Premium Immediate Annuity (married couples): Converts a lump sum into a monthly income stream for the community spouse.
- IRA conversion to monthly distributions: For both spouses — converting from annual RMD to monthly distributions makes the principal value exempt under Medicaid rules.
Common Mistakes — and the Red Flags That Signal Bad Advice
Some of the most heartbreaking cases Cary encounters involve families who tried to protect themselves without legal guidance — and made things significantly harder in the process.
Cary Moss: I have families come in where they’ve already started giving away assets to protect them. That’s going to be a problem for Medicaid eligibility — especially in a crisis — because Medicaid looks back five years to see if there’s been any gifts or transfers. And if the money’s already gone, we can’t reverse it.
She also sees families who private-paid for far too long because they simply didn’t know Medicaid planning existed. One client paid privately for 18 months — spending around $50,000 — before hearing through word of mouth to call Cary. By then, the options had narrowed considerably.
Other common mistakes and red flags to watch for:
- Believing divorce is necessary to protect assets. In Florida, this is almost never the case — but it’s advice that circulates from friends in other states.
- Adding children to bank accounts, investment accounts, or real estate. Medicaid attributes all funds in a jointly-held account to the applicant unless the child can prove they contributed their own money. There are also significant tax consequences, including a lower cost basis for the child when they later inherit.
- Misusing special needs trusts. There are many types — and most don’t work the way people think. A pooled special needs trust requires a payback to the state at death. A D4A self-settled special needs trust is only available to those under age 65. Poorly drafted trusts are common when non-specialists attempt this work.
- Relying on advice from other states, financial advisors, or internet searches. Florida’s rules are unique. What worked for a friend in Ohio may be completely inapplicable — or actively harmful — here.
A Real Success Story: Relief in the Middle of a Crisis
Cary shares a recent case that illustrates what proper Medicaid planning can actually look like in practice:
Cary Moss: A wife came in with her sister, who was a former client of mine. The wife and her husband were in their 80s. He’d been diagnosed with Parkinson’s and needed full-time care. The kids were out of state, she’d been the sole caregiver, and she was exhausted — and scared. She’d heard all the things from friends and family, and she was convinced she was going to be financially devastated.
When Cary reviewed their situation, the picture shifted quickly. The homestead was exempt. The husband’s IRA — over a million dollars — could be converted to monthly distributions, making the principal exempt. The wife’s smaller IRA could be handled the same way. The car was exempt. The remaining cash and investments were addressed through a loan to a trusted son.
Cary Moss: When she left my office, there were a lot of tears — because it was such a relief. She said, ‘I can do this. This is very manageable.’ And now she was comfortable making the decision she’d been putting off: placing him in a facility, knowing she wasn’t going to bankrupt herself. Those are the moments that are the best for me.
Why the Durable Power of Attorney Is the Foundation of Everything
Among the estate planning documents that matter most for Medicaid planning, the Durable Power of Attorney (POA) stands alone. Without a strong one, many planning strategies simply cannot be executed.
Cary Moss: I always tell people: if you do nothing else with me, we’ve got to have a good power of attorney in place. Assuming you’ve got people you trust in your life, we can solve a lot of problems — as long as we have the authority to do so.
The problem: many people have an outdated POA (predating Florida’s major 2011 statutory overhaul), one they printed from the internet, or one missing the critical “enhanced powers” — which must be specifically initialed to be valid.
These enhanced powers give the agent elevated authority that Cary relies on every day for Medicaid planning, including:
- The ability to create trusts — including Qualified Income Trusts, which are required when a Medicaid applicant’s income exceeds Florida’s monthly cap (currently ~$2,982). Florida is an income cap state, meaning one dollar over the limit technically disqualifies the applicant without this trust in place.
- Authority to change beneficiary designations on life insurance and retirement accounts — catching problems before they become irrevocable.
- Self-dealing provisions: If the agent is also a beneficiary (very common among adult children), they need explicit POA authority to execute transactions that name themselves — such as signing a Lady Bird deed that lists themselves as a remainderman. Without this provision, title companies can challenge the transaction.
Coordinating Medicaid Planning with Your Estate Plan
Getting someone approved for Medicaid is only half the picture. What happens next — especially if the community (well) spouse dies first — requires careful estate planning coordination.
Cary Moss: A traditional ‘I love you’ will — everything to my spouse, then to the kids — can inadvertently knock the Medicaid recipient off benefits if the well spouse dies first and assets flow back to them. Now we’re starting all over again.
The solution is a Spousal Supplemental Needs Trust built into the well spouse’s will. If the well spouse dies first, assets flow into this trust rather than directly to the Medicaid recipient. Benefits stay intact. The trust pays for supplemental needs Medicaid doesn’t cover. And when the recipient eventually passes, the remaining assets go to the family — not to the state.
Cary also recommends reviewing your plan regularly: every three to five years for general estate planning, and annually if you have an irrevocable Medicaid Asset Protection Trust. For clients already on Medicaid, her firm’s ongoing support program monitors annual recertifications, income changes, reporting to DCF, and any adjustments to patient liability after hospitalizations.
How to Start the Conversation — and What to Expect
For many families, the hardest part is simply getting started. These are emotional topics: aging, loss of independence, money, and family dynamics all collide at once.
Cary Moss: Most seniors of this generation have worked hard, lived frugally, and genuinely want to pass something on to their children and grandchildren. So it’s actually an easy conversation to have with them — because they’re like, ‘I really want to make sure I can leave something for my kids.’ Starting from that premise makes the rest of the conversation feel collaborative, not frightening.
When you’re ready to reach out to a Florida elder law attorney, here’s what to expect:
- An intake call where staff will assess whether it’s a crisis or a pre-planning situation.
- If it’s a crisis: a quick intake meeting with Cary’s Medicaid paralegal, Kathy. Bring financial information — income, assets, any transfer history — along with all current estate planning documents.
- If it’s pre-planning: a direct meeting with Cary to discuss irrevocable trust planning and long-term strategy.
- In all cases: Cary will review the existing POA and estate planning documents first — because those determine what planning options are even available. Sometimes that’s the most urgent step, before anything else is done.
Worried About Nursing Home Costs? Let’s Talk.
If you or a loved one is facing long-term care decisions in Orange, Lake, Osceola, or Seminole County — including Orlando, Winter Park, Windermere, Winter Garden, Dr. Phillips, or Horizon West — attorney Cary Moss at Sawyer & Sawyer, P.A. can help.
Whether you’re planning ahead or facing a crisis today, you have more options than you think. Don’t wait until it’s too late to protect what you’ve worked for.
Call us: 407-909-1900
Schedule online: sawyerandsawyerpa.com/contact-us/
Sawyer & Sawyer, P.A. | Orange, Lake, Osceola & Seminole Counties | Estate Planning, Elder Law, Medicaid Planning, Special Needs Planning & Probate
