Paying for care and protecting what you leave

Most of us picture a long life at home: the garden, the dog's afternoon walk, coffee with a neighbor. Planning for care is not about expecting the worst. It is about knowing who pays for help if you ever need it, and what happens to the house you hoped to leave.

This guide walks through how long-term care gets paid for and how Medicaid's rules work, with Washington as the worked example. It also covers guarding against people who would take advantage, and what professional helpers charge. Every post in our Money, Medicaid and fees series is summarized and linked here.

What counts as long-term care?

Long-term care is help with everyday life over months or years. Think bathing, dressing, eating, getting in and out of a chair, or keeping track of medications. It can happen at home, in an adult day program, in assisted living or in a nursing home.

Most of it is not medical care at all. That one fact explains why so many people are surprised by who pays for what. For a broader look at planning ahead, see our guide to long-term care planning.

The four ways long-term care gets paid for

Here is the big picture before the details. Most people use more than one of these over time.

Washington also has a public program, WA Cares, covered below. It is a fifth source for many working Washingtonians.

Savings and income come first

For most people, care starts out paid from their own pocket. Retirement accounts, Social Security, a pension and the value of a home all play a part. That is simply how the system is built: the public programs step in later, and only under their rules.

This is also where planning matters most. A clear financial power of attorney lets someone you chose pay the caregiver, sell the car or refinance the house if you can't. Without one, your family may need a court before they can touch your accounts.

Long-term care insurance

Long-term care insurance is a private product you buy ahead of time. It pays toward care that its contract describes, up to a daily amount and a total limit. What it costs depends on your age, health and the benefits you choose, and you usually have to qualify medically when you apply.

Our post on what long-term care insurance costs explains how the price is built. Think of the age you buy, the daily benefit, how long benefits last and inflation protection.

It also covers what to ask before you sign. It does not recommend a product; it shows you how to compare them.

In Washington, assets protected by a qualified long-term care partnership plan are exempt from estate recovery (DSHS 14-454). Partnership plans are a kind of long-term care insurance. If you are shopping, ask whether a plan qualifies.

What Medicare pays for, and what it doesn't

This is the most common surprise. Medicare.gov says it plainly: "Medicare doesn't pay for long-term care" (Medicare.gov). Help with bathing, dressing and eating, when that is all you need, is yours to pay.

Medicare does pay for skilled nursing facility care in limited cases. You generally need a hospital inpatient stay of at least three days in a row first, and you must need daily skilled care (Medicare.gov).

Even then, it is short. Here is how Part A shares the cost in 2026, from Medicare.gov:

Two things trip people up. Time spent "under observation" or in the emergency room does not count toward the three days. And once you stop needing skilled care, Medicare stops paying, even if you still need help every day.

WA Cares, if you have worked in Washington

Washington is the first state with a public long-term care insurance program. WA Cares benefits became available on July 1, 2026 (WA Cares Fund).

Most Washington workers contribute automatically from their paychecks, and contributions began July 1, 2023. In 2026 the full lifetime benefit is $36,500, and it grows with inflation (WA Cares Fund). People born before 1968 can earn partial benefits, $3,650 for each year they contributed (WA Cares Fund).

To use it, you must need help with three or more daily activities for at least 90 days. Bathing, eating and managing medications are among them (WA Cares Fund).

It pays for things like in-home personal care, home-delivered meals, home modifications and adult day services. It helps, though $36,500 is a lifetime total, so it is one piece of the picture.

Medicaid: help once savings are spent

Medicaid is a joint federal and state program, and each state runs its own version. In Washington it is called Apple Health, run by the Health Care Authority. The Department of Social and Health Services (DSHS) collects estate recovery (DSHS 14-454).

Medicaid pays for nursing home care and for home and community-based care for people who qualify medically and financially. The financial rules are strict. In Washington, the resource limit for a single person getting long-term care is $2,000 (WAC 182-513-1350).

Some things do not count toward that limit, and married couples have separate protections for the spouse who stays at home. Those details vary by state and change over time. This is a place where a local elder law attorney earns their fee.

What does "spend-down" mean?

"Spending down" is the everyday phrase for paying for care from your own savings until what is left falls under Medicaid's limit. It is not a penalty or a trick. It is how most people move from paying privately to Medicaid paying.

Our post on the Medicaid spend-down explains what kinds of spending are allowed along the way, and what counts toward the limit. It also covers how your income still goes toward the cost of care once Medicaid starts. It uses Washington's rules as the worked example.

The five-year look-back

When you apply for Medicaid long-term care, the state looks back five years. It checks for anything you gave away or sold for less than it was worth.

In Washington the window is 60 months, set out in WAC 182-513-1363. Other states apply their own version of the rule.

If the state finds a gift inside that window, it does not take the money back. Instead, it delays Medicaid.

In Washington, the total of the gifts is divided by the statewide average daily private cost of a nursing home. The result is the number of days Medicaid won't pay (WAC 182-513-1363).

There are exceptions. Washington allows some transfers without penalty, such as gifts to a spouse or to a child who is disabled. A home can sometimes pass to a child who lived there and provided care, under specific conditions.

Our post on the Medicaid look-back period walks through how the window is counted and the common exceptions. It also explains why the timing of a gift matters.

Medicaid estate recovery: can the state take the house?

This question frightens people more than it should, so here is the plain version.

Federal rules require states to seek repayment from some estates. This applies to people who were 55 or older when Medicaid paid for their nursing home or home care (Medicaid.gov). Repayment is collected after death.

In Washington, the law is RCW 43.20B.080, and repayment is handled by the DSHS Office of Financial Recovery. For recovery, Washington counts property that passes outside a will too, such as non-probate assets and life estates (DSHS 14-454).

If you are in a nursing home and not expected to return, a lien can come earlier. It ends if you go home.

Recovery is delayed while any of these people survive you (DSHS 14-454):

• Your spouse.
• A child under 21.
• A child who was blind or disabled at the time of your death.
• An heir for whom DSHS approves an undue hardship delay, for example when recovery would leave them with nowhere to live.

Our post on Medicaid estate recovery explains which costs are included and which are not. It also covers how liens work on a home, and how heirs ask for a hardship delay. If your executor receives a letter from the state, that post is the place to start.

Protecting your savings, legally

Some planning to protect savings is entirely legitimate. Some is not, and some simply backfires because of the look-back. The difference is often timing, and whether the plan was made well before care was needed.

Our post on how to protect assets from Medicaid, legally lays out the tools people talk about. These include planning more than five years ahead, certain trusts, protections for a spouse at home, and written caregiver agreements.

It explains how each works in general terms. It is not a recommendation, and every one of these tools needs a lawyer in your state.

A revocable trust is useful for many reasons, such as avoiding probate and letting a trustee step in if you can't manage. Whether any trust affects Medicaid depends on its terms and your state's rules, so ask a lawyer before counting on one.

Who pays the bills when you can't?

Paying for care is one job. Actually paying the bills is another: the electric company, the property tax, the caregiver's invoice. If you are in the hospital for three weeks, someone has to do it.

That is the job of the agent named in your power of attorney for finances, or the trustee of your trust. Some people also hire a daily money manager for routine paperwork while they are well.

Our post on daily money managers explains what they do and how they usually charge. It also covers what they can't do without legal authority. The American Association of Daily Money Managers says most of its members bill by the hour (AADMM).

Protecting against financial exploitation

Most people who handle an older person's money do it honestly. Still, the risk is real, and it often comes from someone close. Washington law defines financial exploitation as the improper use of a vulnerable adult's money or property for someone else's benefit (RCW 74.34.020).

The Consumer Financial Protection Bureau publishes guides for people managing someone else's money. They set out four duties: act in the person's best interest, manage money carefully, keep it separate and keep records (CFPB). Those same duties are a good checklist for anyone you name.

Simple steps help a great deal:

• Name your financial agent and trustee in writing, so nobody has to improvise.
• Choose a fiduciary (someone legally required to act in your interest and follow what you wrote) who keeps records.
• Name a backup, so one person is never the only check.
• Keep a list of your accounts with someone you trust, not just in your head.

In Washington, concerns about a vulnerable adult can be reported to DSHS Adult Protective Services at 1-877-734-6277 (DSHS). Our post on elder financial exploitation covers the warning signs, common scams, and what to do if you think it is happening.

What do professional fiduciaries and trust companies charge?

If you name a professional in one of your roles, you will want to know how they are paid. The honest answer is that it depends on the role and the firm. Here are the structures, with the law that governs each in Washington.

For a sense of what a published trust company schedule looks like, here is one example, not a typical figure. Members Trust Company, offered through a North Carolina credit union, publishes its schedule.

It lists a $250,000 account minimum and a tiered annual fee starting at 1.25% on the first $1 million. Minimum annual fees start at $2,500, and its corporate executor fee is 5% of probate assets (SECU Trust Services fee schedule). Other firms price differently, so always ask for the schedule in writing.

Our post on trust company fees explains percentage fees, minimums and extra charges. It also lists the questions to ask before you name one. For executors specifically, see how much an executor gets paid.

How Kinly's fees work

Kinly is a membership, not a percentage of your assets. It is $999 a year for one person or $1,499 a year for a couple (pricing).

That includes your care plan, four legal documents written for your state, and a team on call around the clock. It also includes Trella Trust Company, named in whichever of the four roles you choose.

Sometimes the trust company actually steps in and does work, such as paying bills while you are in the hospital. That work is charged by the hour.

You always see the rates before anything starts. How it works has the details.

If Medicaid ends up paying for your care

This is the part of planning people often don't ask about, because it feels far away. But it matters when you choose who stands behind your plan. Most paid services end when the payments do.

The Kinly Lifetime Promise has two parts (the promise). First, Kinly never re-checks your health, age or memory at renewal.

Second, after two years of membership, if you spend down to the point where Medicaid is paying for your care, Kinly stops billing you. The membership continues, the documents stand, and the number still gets answered.

That second part is meant for exactly the situation this page describes. Your care plan, and the people authorized to carry it out, stay in place.

When a parent's plan lands on you

Many readers come to this page for someone else. If you are an adult child helping a parent, two posts in this series are written for you.

Our post on caring for aging parents is a practical list of what to put in place now. That means powers of attorney, a health care directive, and a list of accounts and doctors. It also suggests talking about wishes while it is still easy.

Our post on caregiver burnout is for when the load has already landed. It talks about sharing the work among siblings, paid help and respite care. It also covers handing some roles to a professional, so you can go back to being a daughter or son.

A quick checklist

If you want one place to start, this list covers the essentials. Tick off what you have.

1. Know what you would use first to pay for care: savings, income, home equity, long-term care insurance or WA Cares.
2. Have a durable financial power of attorney, with a backup agent named.
3. Have a medical power of attorney and a health care directive.
4. Keep a list of accounts, insurance, doctors and medications where someone you trust can find it.
5. Before giving away money or property, remember the five-year look-back.
6. Ask any professional you might name for their fee schedule in writing.
7. Decide who checks on whoever handles your money.

The posts in this series

Here is every post in our Money, Medicaid and fees series, in one place:

• Long-term care insurance cost: what drives the price and how to compare offers.
• Medicaid spend-down, explained: how savings are used before Medicaid pays.
• The Medicaid look-back period: the five-year window and its exceptions.
• Medicaid estate recovery: what the state can recover after death, and what it can't.
• How to protect assets from Medicaid, legally: the planning tools and their limits.
• Daily money managers: help with bills and paperwork.
• Elder financial exploitation: warning signs and how to protect yourself.
• Trust company fees: what professional trustees charge and why.
• Caregiver burnout: sharing or handing off a parent's care.
• Caring for aging parents: what to set up now.

When you are ready to think about who should act for you, our guide to choosing professional help compares the options side by side.

Common questions

Does Medicare pay for a nursing home?

Only for a short stay of skilled care, usually after at least three days as a hospital inpatient. In 2026, days 1 to 20 cost $0 after the deductible, and days 21 to 100 cost $217 a day. After day 100 you pay everything. Medicare does not pay for ongoing help with daily life.

How much can I have and still get Medicaid for long-term care in Washington?

For a single person, Washington's resource limit for long-term care is $2,000, under WAC 182-513-1350. Some things are not counted, and a spouse at home has separate protections. Other states set their own limits, so check your state's rules.

Can I give my house to my children to qualify for Medicaid?

A gift made within five years before you apply can delay Medicaid for a period based on its value. Washington allows some home transfers without penalty. Examples include a spouse, a disabled child, or a child who lived there and provided care, under specific conditions. Talk to an elder law attorney before transferring a home.

Will the state take my house after I die if Medicaid paid for my care?

It may seek repayment from your estate, including your home, if you were 55 or older when Medicaid paid for long-term care. In Washington, recovery is delayed while a spouse, a child under 21 or a blind or disabled child survives you. Heirs can also ask for an undue hardship delay.

What happens to my Kinly membership if Medicaid starts paying for my care?

After two years of membership, if you spend down to the point where Medicaid is paying for your care, Kinly stops billing you. The membership continues, your documents stand, and the number still gets answered.

Sources

• Medicare.gov: Long-term care
• Medicare.gov: Skilled nursing facility care
• Medicaid.gov: Estate recovery
• Washington DSHS: Estate Recovery, Repaying the State for Medical and Long-Term Services and Supports (DSHS 14-454, rev. 03/2026)
• Washington Health Care Authority: Apple Health (Medicaid)
• WAC 182-513-1350: Long-term care resource standards
• WAC 182-513-1363: Transfer of assets and the 60-month look-back
• RCW 43.20B.080: Recovery of medical assistance from estates
• RCW 74.34.020: Definitions, including financial exploitation
• RCW 30B.24.010: Trust company fee determination
• RCW 11.48.210: Personal representative compensation
• RCW 11.130.105: Guardian and conservator compensation
• WA Cares Fund: Benefits now available (July 1, 2026)
• WA Cares Fund: Covered benefits
• WA Cares Fund: Qualifying for benefits
• Washington DSHS: Report concerns involving vulnerable adults by phone
• Consumer Financial Protection Bureau: Guides for managing someone else's money
• American Association of Daily Money Managers: FAQs
• SECU Trust Services (Members Trust Company) fee schedule, April 2024