. TRANSFER OF ASSETS IN THE MEDICAID PROGRAM 
A CASE STUDY IN WASHINGTON 
STATE 
RICHARD P. KUSSEROW 
INSPECTOR GENERAL 
o A 1-09-88-0 1340 
MAY 1989  EXECUTIVE SUMMARY 
PURPOSE 
This study examned whether asset shelters
, including property transfers, playa
signficant role in qualifyng people for Medicaid long-term care 
benefits in the
State of Washington. 
BACKGROUND 
The Tax Equity and Fisca Responsibilty Act of 1982 
(TEFR) 
placed very strict
lits on the tranfer of 
assets within 2 years of application for the 
purpose of
qualifyng for Medicad. Nearly al States 
have adopted these restrictions and
enforce them with varyng degrees of intensity. The Consolidated Omnbus Budget 
. Reconciation Act of 1985 (COBRA) 
furter strengthened limitations on the use of 
trsts to shelter assets and income. The Medicare Catastrophic Coverage Act of 
1988 (MCCA) made tranfer of 
assets restr tions mandatory. 
Aggregate data.indicate that more than 
hal of the nation s nursing home costs are
paid privately "out-of-pocket." Most observers assume that asset shelters do not play 
an important role in long-term care 
fuding, that "Medicaid requires
impoverihment" and that the availabilty of 
Medicaid nursing home benefits does
not impede the development of other options to finance long-term care. 
In contrast, a recent Offce of Inspector General 
Medicaid Estate Recoveries. 
study, 
found that (1) Medicaid eligibilty staff 
thoughout the country report widespread
asset 
shelterig by applicants and their attorneys, (2) many legal shelters are
avaiable in the law, regulations and policy and (3) Medicaid nursing home 
recipients frequently die with signficant estates that pass unencumbered to 
noncontributing heirs. The Office of 
Inpector General will conduct a national 
inspection of Medicaid asset shelters to 
determne their impact on States other than
Washington. 
MAJOR FINDINGS 
The elderly and their familes transfer or shelter )ar 
e amounts ofrnonev and 
property to Qualify for Medicaid in Washin 
ton State. 
Fifty-eight percent of the Washington Mediciaid nursing home cases that were 
initially denied assistance because they exceeded the resource eligibilty threshold 
became eligible within a few months by transferring or sheltering their 
 ssets.  ...  --  ---. " ---_.. . .. - -- - - . - ---:-'- --...  '- . "
Advice on how to Qualifv for Medicaid nursin~ horne 
benefits is \\idelv available: 
abuse is common. 
The expeiiswho counsel 
MecIicaid applicants to shelter assets include private
attorneys, legal servces lawyers
, social servce agencies, the Medicaid agency staff
some nursing homes staff and private counselors. We found anecdotal evidence of 
concealment, fraud and financial abuse of the elderly for the purpose 
of qualifying
for Medicaid long-term care benefits. 
RECOMMENDATIONS 
. The Washington State Deparment of Social and Health Servces should 
well as nonexempt .asset values and (2) verify and
(1) document exen:pt 
set crfsl?  sit 
. Because-this casstudy empircally coroborates our earlier
, more
anecdotal Medicaid Estate Recoveries. 
, findings  we repeat the
recomI mdations from that report here. (See "
Recommendations" for 
- the detailed-proposals.
(1) ChirigeMedicaid ru1es.to permt famlies to retain and 
manage
propert while their elders receive long-term care. 
(2) Strengthen the tranfer of assets rules so that people 
canot give 
away propert to qualify for Medicaid. 
(3) Requie a legal instrument as a condition of Medicaid eligibilty to 
secure propert owned by applicants and recipients for later recovery.
(4) Increase estate recoveries as a nontax revenue source for the
Medicaid program while steadfastly protecting the personal and 
propert rights of recipients and their families.  . (

TABLE OF CONTENTS 
Page 
EXECUTIV SUMMAY 
INTRODUCTION 
FINDINGS 
CAE REVIEW-- THE ELDERLY AN THIR FAMIES
TRSFER OR SHELTER LAGE AMOUNTS OF MONEY MTI
PROPERTY TO QUALIF FOR MEDICA IN WASHIGTON
STATE 
INRVIEW REULTS--
ADVICE ON HOW TO QUALIF FOR
AMEVDAICIALIDE N; USING HOME BENEFIS IS WIELY
ABUSE IS COMMON 
ELDER LAW IS GROWIG 
THE LEGAL ARSENAL IS DIVRSE 
LEGAL SERVICES ATTORNYS OFFR ADVICE 
SOCIA SERVICE AGENCIE PROVIE REFERRA 
ASIlGTON'S MEDICAI 
AGENCY HELPS PEOPLE 
SHELTER ASSETS

NUSING HOME REPREENTATI 
CONCUR 
FRUD AN FIANCIA 
ABUSE WERE COMMON THEMES 
RECOMMENDATIONS 
BIBLIOGRAHY 
APPENDICES 
APPENDIX A: METHODOLOGY 
APPENDIX B: SAMPLE CASES 
APPENDIX C: ASSET 
DISPOSITIONS BY TYPE OF ASSET  .- --- 
. (  - ! . ' , " 
INTRODUCTION 
The objective of this study was to document the extent to which private resources 
are consumed, tranferred or otherwse 
sheltered to qualify for Medicaid nursing
home benefits in the State of Washington. We selected Washington because of a 
State law--the Deccio Amendment--which permits unlimited transfer of assets 
between spouses for the 
purose of qualifng for Medicaid. 
Stories alegig that r-eople with large incomes and assets are able to qualify for 
Medicaid long-term. ca.ehefitsby "
gamng the system
" have been common for
years.. In  ! e  BU5iness. Weekwrote:  The same people who rely on
tax planng and makellseof every loOhole in 
the tax laws to build up their
assets...can use the same techniques to keep them--and 
stil qualify for Medicaid.
Business Week,  l23) Generally, however
, information about transfer of assets
and other shelters 
' has been aneoooraL- - -
To determne the actual 
extent to which Washington State residents can legally
preserve income and assets and stil 
qualfy for Medicaid long-term care benefits
examined a random sample of nursing home beneficiaries over the age of  , we 
were initially denied eligibility for assistance 65 who
, but were later approved. Appendix A
describes our methodology. 
The background, legislative history and programmatic significance of the Medicaid
tranfer of assets" rules were examned in the 
Offce of Inspector General' 
s (OIG)
June 1988 national program inspection entitled 
 Medicaid Estate Recoveries 
publication of that report, the Medicare Catastrophic Coverage Act of  . Since

1988
(MCCA) became law (PL 100-
360). The MCCA tightened Medicaid eligibility
criteria in some respects and loosened them in others. 
For example, transfer of asset
restrictions were extended from 2 years to 
30 months, but the treatment of income
and resources was liberalized substantially to protect community spouses. \Ve 
completed this study before MCCA became law. Nevertheless
, our findings and 
Title 74 ofthe Revised Code of the State of 
Washington provides at 74 
09.532  A person is
ineligible for medica asistance...
if the person knowigly and 
\vilfully assigns or transfers cash or
other resources at less than fair market value..
.for the purpose of qualifying or continuing to
qualify for such medical cae 
withi 2 years preceding the date of application for such care:
Provided that for the 
purose of qualifyng for such cae...this section shall not prohibit 
voluntaty transfer or assignment between spouses  thG,
" (Emphasis added.) According to the 
conference commiuee report (synopsis as of 
April 9, 1981): 'This bil is needed to tighten 
law to prevent people from defrauding the Medicaid program by transferring large assets up the 
immediately prior to applyig for assistance." An earlier version of the bill limitcd intcrspousal
transfers to $175 00 for the principal residence and $15 00 
cash. The final version of the law
did not contain these limits.  recommendations are not materially affected by the new law
, but rather point to
further enhancements along the lines begun 
in MCCA. 
As a result of this inspection case study of Washington State
, the Offce of Inspector
General will conduct a national inspection of Medicaid asset shelters to determine 
(1) their fical impact in other States
, (2) the availabilty and distribution of
information on legal asset shelters and (3) the extent of concealment
, fraud and 
financial abuse of the elderly to qualfy for Medicaid.  FINDINGS 
The elderly and their familes 
CASE REVIEW:  transfer or shelter large
amounts of money and property to qualiy for Medicaid in 
Washington 
State. 
We originally selected a sample of 360 
cases; however, only 198 met our study
criteria. Al 198 were intially denied eligibilty--
114 Or 5: . 6 percent were approved
for Medicaid nursing home benefits within a few months. Most 
of these
(73 percent) were denied intially because of 
excess or improperly transferred assets
but quickly reapplied and qualified 
havig 
successfully resolved the resource
problem. The box insert 
below highlights a few examples. Appendix B provides
more examples and further details. 
SAMPLE CASES 
Case #12: Transferred $153 500 to adult children using an irrevocable trust. 
Cae #41: Used $50 000 to payoff a note on the famly home which is exempt. 
Case #114: Removed applicant 
s name from bank accounts and certificates of 
deposit (totaling $206 
363) and from the famly residence ($40 
000). 
Case #245: Tranferred propert with 
an assessed value of $433 
000 to the well
spouse. lito quali the incompetent for medical assistance benefits... 
according to the court order. 
Of the 114 subsequently approved cases
, 88 or 77.2 percent reported that they
possessed liquid assets at or before the time of their initial denial totaling S 1 
and averaging $19  690, 160
206 per case. Thirt-six cases or 31.6 
percent had home equity
totaling $1 522 
837 and averaging $34 610. Eighteen cases or 15. 
8 percent had other
real property totaling $751 
822 and averaging $41 768. Finally, 45 cases or 39.
percent had other assets totaling $269 
436 and averaging $5 987 per case. In total
we found that 100 
cases or 87.7 percent possessed 1 or more of these assets totaling 
234 255 and averaging $42 343 per case. 
How could these people have qualified for public 
assistance so quickly? Clearly,
much of what they owned
, such as homes, automobiles and life insurance policies
were at least partially exempt from Medicaid 
eligibility resource limits. A large
portion of their assets must have been disqualifyng, however 
l\ of the 
cases were initially denied eligibilty.  , because  . ( 
In aU four categories of assets, interspousal transfers account for the protection of
more assets than any other known form of disposition.2 InterspousaI transfers 
explain 68. 1 percent of liquid assets disposed, 46. 0 percent of disposed residence
value, 73.4 percent of other real 
propert and 35.1 percent of other assets. This
finding is not surprising given the "
Deccio" exemption of such transfers in
Washington State. Other 
tyes of disposition are much less signficant and account
for too little of the total assets to be analyzed confdently by 
tye of asset. Appendix 
C contains the raw findings by 
tye of asset. 
Some interesting observations emerge when we examine total assets by 
tye of

dispositicn (Table 1). Interspousal tranfers account for 59.
0 percent of total assets 
but only 15.8 percent of the cases. It appears that a few people are saving most of 
the money under ths 
eligibilty exclusion. 
Cases 
TABLE 1. ANALYSIS 
 OF TOTAL ASSETS BY TYPE  OF DISPOSITION
PercentD isposed Amounts
Type Of Disposition  No. 
Amount 
SHELTED  Percent
ASSETS 
Tranerred to Spouse 
15.  $2,498,246  59. 
TraneCrred to AdAult Chidren  
Retaied as Exempt  46,078  10. 
61.4  454 246  10.
OSubtoTtal  HER
CONSUMD FOR NUSING  85*  74.  412 570  80.
UHOMNE  KOWN 456  440.. 329 332 
TOTAL 23  112 054
NO ASSETS TO DISPOSE 14 20.2  380 299
0* $4, 
114. 100. 255 100.
These colum are not additive. Each cae could dipose of each 
which creates a duplicate count. The " tye of aset by different methods
total" of 114 represents all unduplicated approved 
caes. The
dollar figues are not afected by duplication, because they acce to 
the diposition categories
regardless of cae source. 
The category "consumed for nursing home care" means the assets were used to pay
for care in the maner commonly referred to as spend down of resources. Although 
spend down accounted for only a small percentage of total dollar dispositions
, it
touched over 40 percent of the people in the sample. This finding agrees with an 
observation in our earlier work on Medicaid estate recoveri 
s. People with large
assets who are accustomed to consulting attorneys and accountants can preserve 
their holdings by obtaining good professional advice
, whereas people with modest 
Case record documentation for the sample was frequently incomplete. We often were unable to 
determie the disposition of an asset. The tye of asset disposition was shown as unkown
whenever this occurred.  :-.
. . 
savings often lose what little they have to nursing home costs before they learn the 
ins and outs of Medicaid eligibility. 
Monthly income of Medicaid nursing home reci 
because most of 
it must be contributed toward their cost of  fients is important 
care. Data for May 1988 indicate that
the average recipient in Washington State costs 
$1692 per month to maintain in a
nursing home. Recipient income 
contributes $438 or 25. 
9 percent. Table 2 shows
the sources and amounts of income in the 
114 approved cases which were initially
denied. These cases 
contained 151 sources of income at $440 per source. 
None had
investment income. 
Al investment grade assets apparently were sheltered or
commmed to qualify for assistance. Average income per case was 
$583 per month
but incomes ranged fr.om$25 per month for 
15 private pensions to $477 per month
for 107 Social-Secuty benefidaries.: 
INCOMcSOURCES1=OR APPROVED CASES

TABLE  2. . 
Income Sourc  NoC.a s  TJ'I9oonttha9lyl A mount
Percent 
Average 
Soci S-ecurty. .  107 93. 671 
Veteran Beriefits  15 p.  $50563 $477
Raioad Retement  445
Other Governent 
Benefits 
432  429
Private Pensions 
13.  834  256
Totallocome Sources  ISI 
66,499  440
Total Cases 
114  100.  $66 499  $583 
Because caes may have more than one income source, their percentages do not add to 100 percent 
and the average total per 
cae exceeds any component average. 
Our fidings on recipient income in Washigton further disagree with general
beliefs concernng spend down. National data on nursing home costs for 
1986 
indicate that 50.9 percent or $19.4 bilion was paid by private individuals without the 
help of insurance. This high out-of-pocket cost is cited frequently as evidence that
the public is spending down their life 
savings in private pay nursing home status
before becomig impoverished and qualifg for Medicaid. The out-of-
pocket
figure is derived, however, by adding all known payment sources (e.  , Medicaid
Medicare, private insurance, etc.) and subtracting the total from total nursing home
costs nationally. The remainder is presumed to represent direct costs to private 
individuals. In Washington State, however
, a considerable portion of this
out-of-pocket" cost is really the contribution of personal income to the cost of 
care
of Medicaid recipients. This is money that recipients would have spent for normal 
living expenses even if nursing home care were unnecessary. It does not represent 
spend down of an estate. 
Some exclusions exist, however, such as a $25 per month personal needs allowance
, a spous
allowance in some cases; money spent for third party insurance coverage
, etc.  : "
Because comparable data State-
by-State are not av ilable, we cannot say what
proportion of Washington 
s out-of-pocket costs can be explained in this manner.
We do know, however, that patient contributions to cost of care in Washington for 
May 1988 were 34.9 percent of the amount contributed by Medicaid. The 
comparable figure for an 8-month period in neighboring Oregon State was 
percent. If such  31.2
figures are representative of the 
large proportion of out-of- tyical situation nationally, then a

pocket costs can be explained in this manner. 
PROJECTIONS 
Our 16.8 percent sample yielded $4 
234 255 in total assets among 114 originally
denied, but subsequently approved, Medicaid nursing home cases. Projected to the 
universe of our sampled population, the full year figure in 
Washigton is
$27 495 162. This is.14.3 percent oftotal Medicaid nursing home benefits in the
State for 1986. This figure does not take into account assets sheltered by (1) the 
majority of Medicaid recipients who were already on assistance when we conducted 
the study, (2) individuals in the nonapproved category who may end up on assistance 
while stil sheltering assets or (3) people who have not applied yet. 
Advice on how to qualiy for Medicaid nursing
INTERVIEW RESULTS: 
home benefits is widely available; abuse Is common. 
We intervewed 32 persons 
who give professional advice on Medicaid long-term
care eligibilty. We asked 
them about the people who seek their advice
, the
infonnation they provide
, the sources of their funding and the techniques used to
shelter or divest assets. Our intervews 
involved five categories of respondents:
private attorneys
, legal servces attorneys
, social workers, Medicaid representatives
and others. 
ELDER LAW IS GROWING 
Elder law deals with all aspects of laws that affect older people. 
Estate planning,
which traditionally emphasized what happens to property after death
, focuses
increasingly on planng for incapacity during life. One of the most important
objectives of elder law is to help the elderly and their families take full advantage of 
available public long-term care funding sources. Medicaid is by far the biggest 
4 Thus, according to the November 26 such 
source.
, 1987  New York Times  A new
breed of legal specialist is advising elderly people how to protect 
their financial 
Medicaid paid 415 percent of total nursing home 
costs in 1986 compared to 6, 1 percent from
Medicae 
and- al other public sources.  , ( 
...
assets, maxmize eligibility for Medicaid 
and avoid being impoverished by the high
cost of health care, especially nursing homes. 
The Washington State Bar Association has sponsored continuing education seminars 
on elder law. Training materials for one course advised that: 
there is no dollar limit on how much can be transferred. 
Nor are
there any time limits or requirements. An 
il spouse can transfer all of
his/her5 intere)st in propert to the well spouse on one day and the next
day make application for medicaid. 
Milions of dollars in resources 
can be tranferred or hundreds of dollars. (Thompson and Wechsler 
pps. 4-
A staf diector of the-Amerca Bar Asocition's Commssion . 
on Legal.Problems
for the Elderly said-th semar5-on'elder.law have now' been offered in every State
in the country. Five years ago 1hese courses were available in only a few States. 
We intervewed seven.attmeyswho actively 
practice health
, disabilty or elder law.
They counel:an average 
eight eiderly people per'month . 
ter  :of ' on how to qualify for
Medicaid long  care benefits while preservng assets and income. 
Their
Medicaid clients own an average of $140 
000 in assets of which $55 
000 is home
equity. Although rare
, some caes involve sum up to 
$1 milion. With certain
qualifcations, the attorney
s said that 95 to 1O0 percent of these assets can be 
rved while qu 
gfor M  aid. Clients were referred t  hes ' attorneys by
many sources, including hospital discharge planers
, social workers, welfare
caseworkers, medical doctors, other attorneys and clients or as a result of public
speakg 
engagements with 
retiee groups. 
When we asked how elder law attorneys help their clients qualify for Medicaid 
, we
received a wide range of anwers. 
But one response encompassed everyhing we
were told: 
SAMPLE MEDICAID ELIGIBII,TY PLAN BY AN ELDER LAW ATIORNEY 
I do everyhig from the begig including al of the paperwork. For a fee of $950
, I guarantee
eligibilty 
withi 30 days. Income makes no diference. I have never see  a cae with too much income
to qual, because the couple s income is split in hal to qualify. Washigton is a 
income State. I change the ownership of al property  spend down of
homes, residences and other real property,  includig life insurance policies, car titles, mobile
ban accunts, certifcates of deposit, stocks, government
or private bonds, and anythig else. Property tranfers go from the il to the well 
spouse. If the client is
competent, I do a Power of Attorney to establih authority for the transfers; otherwse
, I do a
guardianhip and we get the court to order the tranfers. If a contract or 
deed of trust is involved, I do
an assignent so that the income becomes separate to the well spouse. I help them buy burial plots 
and other exempt property. I search the Code of Federal Regulations for al possible "
set-asides." I
help the family obtain the necessar documentation
, verications, and signatures from banks, the Social
Security Administration, other private and government pension plans
, etc. I even go to the nursing
homefor the patient's signature if necessary. Finally, I fill out the Medicaid application and go to the 
eligibility intervew with the family. I have been doing 
thi for 2 and 1/2 years and it is 90 percent of my
practice. I fell into it by accident taking referrals from the local legal servces agency 
same thing I do, but for free, under a Federal grant.  which does the - ( , '
Several attorneys said they provide free informational hand-outs on Medicaid 
eligibility and on how to qualify while 
preservng income and assets. They also refer
clients who are unable or unwillng to pay their fees to the legal 
Some observed that qualifyng for Medicaid  services agency.
is so easy that people do not always
need professional help. 
The Legal Arsenal Is Diverse 
We asked about specific techniques to qualify people for Medicaid nursing home 
benefits while preservng assets and/or income. By far the most 
common procedu: e
recommended without exception by 
each of the respondents, was interspousal
tranfers as permtted under the 
Deccio amendment. Statutory 
exclusions such as
the home exemption are universaly known and 
used. Other techriques mentioned
include: 
(1) trusts, including revocable
, irevocable; craven, two pot and other 
variations;
(2) purchase of exempt assets such as homes
, home funishings
, color televisions
and other personal propert;
(3) lie estates, wherein permanent 
ownership is sold or given away while the
right to use the propert is retaied; ,
(4) joint tenancy with right of survvorship;
(5) divorce;
(6) relocation from other States to take advantage of Washington
s lenient
eligibilty and transfer of assets 
rules;
retu; 
(7) intent to 
(8) gifts, gift plans and estate plan.1Jng;
(9) durable power of attorney and guardians 
hips which allow others to dispose of
a sick elder s assets; and 
(10) miscellaneous techniques such as care contracts or nonsupport suits.
One respondent said 
There are probably another 10 sheltering 
techniques;
everyhing has been tried at one time or another.
" Some respondents expressed
concern about the new limits on asset 
tranfers in the MCCA. One volunteered 
however, that "people will just 
fid more creative solutions for hiding or disposing
assets in a legal way. 
Legal Services Attorneys Offer Advice 
Elderly people and their families
, who need legal advice to protect assets and qualify
for Medicaid, do not have to rely only on attorneys in commercial pructice. \Ve 
spoke to representatives of three organizations which provide free guidunce. 
Evergreen Legal Servces spends $60 000 per year to assist people to
qualify for Medicaid of which 90 percent is federally-
funded.from the 
Senior Citizens' Act.  - - -
, - :. 
. ,--.-  .".'. - ....--   -.-_-..  .-...."   .. -.-.   .--" :-.,:.   .-_ '-'' -:_.---...  ."--:. : -. _: -----.  -. -- -. - -  - -- ..- .:.-.   --...   .:-..:    -:-_  :. "..  --:---. - .-"  --=---..-..:  _:- :.. .. - 
. Gonzaga University Legal Assistance runs a Senior Citizens Law Project 
which uses law students to counsel the elderly on Medicaid eligibility and 
transfer of assets. Funding, which is part Federal 
Area
, comes from the

Agency on Aging, the law school and the Legal Servces Corporation. 
Senior Rights counsels 20 or 30 people per 
month on transfer of assets to 
qualify for Medicaid. United Way 
provides the funding. 
Legal servces attorneys recommended the same asset sheltering techniques 
enumerated by their colleagues in private practice. Two of them also 
have private
Medicad practices 
helping. an average of six people per month preserve a home and
$100 000.. Their publicly fuded clients usualy have fewer assets (e. 
, a home and
$10,000 or.Iess:):-:-
.. b . 
.. 0..

Social SeNiceAgencies Provide Referrals 
Social seIVceagencies .are one step removed from the legal exercise of structuring 
qual 
assets to.  peopJ.forMedkaid: Although they provide simple advice on
sheltering resources, their main function in this arena is to refer anyone with 
propert to a private or legal servces attorney. 
We intervewed eight representatives 
from a varety of agencies including the Red
Cross Aid to Agig Program the Foundation for the Handicapped, Harborvew
Hospital, the Kig County Prosecutor s Offce and the King County Division of
Aging (the loca Area Agency on 
Aging). 
These agencies counsel 895 clients per month on senior issues including Medicaid 
eligibilty and legal referrals. They reported the average 
assets of clients seeking
Medicaid eligibilty at $34 000, not counting homes. The agencies are well 
publicized and often refer famlies to each other. A few of their servces are 
highlighted: 
. The Foundation for the Handicapped manages elderly clients
' assets. 
They purchase room furnshings, clothing, television sets
, stereos, chairs
etc., with a client's assets to assure his comfort in the nursing home while 
simultaneously qualifyng him for Medicaid benefits. 
. Harborvew Hospital staff counsel 5,000 elderly patients per year. They 
complete and submit Medicaid applications for everyone they think is 
eligible. 
. The King County Division of Aging annually spends approximately 
$2 milion dollars (half Federal) to assist 2 200 elderly people. Medicaid
eligibilty counseling is an important part of the servce
, including
referrals to legal servces.  Although referrals are their main contribution
, some Medicaid counseling is quite
sophisticated  For example: "We do suggest to the elderly that if they have brothers 
or sisters to whom they want to leave estates, they should direct the estate into 
trust instead of leaving it directly through a will. Otherwse
, the sibling might lose
Medicaid eligibilty. 
Washington s Medicaid Agency Helps People Shelter Assets 
We intervewed five representatives of the Department of Social and Health 
Servces (DSHS)-- Washington s single State Medicaid agency. They included
expert on eligibilty  determation, trsts and 
policy, eligibilty  adult protective
servces. 
Medicaid staff routinely advise 
applicats with excess assets to exbaust their 
resources or consult an attorney. Individual eligibilty workers may 
suggest specific
asset protecton techniques--
it' s okay to tranfer resources to a spouse" or "intent to
return is so liberal, DSHS does not even question it. II The box insert below 
highlghts some examples from 
caes in our sample. A private attorney told us the
help an applicant receives depends 
entiely on the "luck of the draw" among
caseworkers. One kid of eligibilty worker ''believes hisjob is to help qualify
people for assistance...the other kid says 'go away and stop ripping off the system. 
Supervsors and workers are very aware of asset shelters. They cited the same 
technques listed by private and public attorneys. A financial servces specialist
, who
monitors cases handled by eligibilty workers
, said that 98 percent of married
applicants have tranferred at  ban 
least a  account. "Most retired couples coming on 
for the fist time have at least $10 000. Some have so much we don 
t know how 
much they have." One case had four single-spaced 
listing transferred
tyed pages 
assets. Another respondenttold us 
20 percent of applications begi with excess 
resources ranging up to $100,000. A third said, "Te idea to spend it on a spouse
long-term cae costs 
never ares." In fact some of the largest asset shelters are
done to qualif for Washington 
s home and community-based care program
(COPES)--not because care is needed, but to obtai the peripheral benefit of drug
reimbursement. 
Approximately 2 or 3 percent of Washington 
s Medicaid nursing home caseload
involves trusts. A staff attorney told us she reviews one trust case per month 
averaging $100,000 to $200,000. She also does personal injury settlements which 
although they do not usually affectthe elderly, do involve Medicaid long-
term care. 
These settlements are much higher, involving lump sums and annuities of $1.5 to 
$3.0 millon. Although people have these assets, ' They stil want Medicaid to pay all  .. - _. - , "

medical costs." The trusts have very precise 
language. They quote the Federal laws
. and regulations, including the Consolidated Omnbus Budget Reconciliation Act 
(COBRA) of 19855 which was supposed to make trusts 
much less effective as
Medicaid shelters. The language in the 
trusts is "virtually identical. There is no
doubt the private attorneys are sharng notes.
" Sample trusts are passed out at
lawyers' semiars. Although the Attorney General' s offce tries to attack the trusts 
they have had little success. Admstrative law judges reportedly are reluctant to
challenge truts set up.through Superior Court, and the Health Care Financing 
Administration (HCF A) has not provided the 
necessary guidance on interpreting
the COBRA Medicaid Qualifg 
Trust Law. 
Nursing Home Representatives Concur 
We talked to several nursing hOIe-
adminitrators and private long-term care 
counselors. Representatives of the nursing home industry 
confrmed the widespread 
use of interspousal and gther tranfers. TJy said trustS, intent to return
commngling of assetS?-and gift, .such' as deeding over the house or vacation
proper to-the chiken;a:e eommIt 
Each said that Medicaid eligibilty staff and
other social workers counel people on how to tranfer assetS while qualng for
Medicaid. 
Fraud and Financial Abuse Were Common Themes 
Nearly everyone we intervewed knew of people who either misrepresented their 
qual 
financial situation to  for Medicaid or were expropriated by others and forced 
onto public assistance. For example
, one attorney told us that clients ask: "Wil I get
caught? Do they (i.e., Medicad staf check and verify what I tell them? Do they
prosecute?" A nursing home 
admitrator said  10 percent of the people we see
involve a little bit of di wash." Often, however, the perpetrator is not a Medicaid
applicant or recipient, but rather a frend
, relative or unrelated third 
part with a
pecuniary interest in the infrm elder's 
estate. 
Financial abuse of the, elderly, according to study respondent 
, is "commonplace
bigger than anyone:t i1,""rife." We heard many stories about people forced onto 
Medicaid when theirincome or resources were taken. For example: 
. A dean of admissions and his CPA son "took grandma s Cadilac and 
rental houses. 
42 V.  1396a(k) 
C.
Commingling of asts is the practice of mig the income or assets of a nursing home patient
(especially Social Security income) with those of the personal representative so that money is lost 
which should pay the costs of cae.  Children became payees for their parents' income and then refused to pay 
the nursing home. 
. The son of an Alzheimer s patient neglected to report $65 
mother "intended him to have the money.  000 because
 his
. A contractor fraudulently sold $40 000 of remodeling to a frail old
woman went banpt
, and was allowed by the Bankptcy 
Court to pay
back 5 cents on the dollar. 
Although governent 
assumes the cost of care in such cases, detection
, enforcement
and recovery are very diffcult. Usualy, there is no hard proof. 
Often the victim is
incompetent or wi not testify against a loved one.  RECOMMENDATIONS 
RECOMMENDATION # I--
DOCUMENTATION OF LEGAL SHELTERS 
FINDING: During 
1 year, 57.6 percent of Medicaid nursing home applications
denied in WashiIigton State were on assistance within a few months. 
87.7 percent originally possessed liquid assets Of these cases

, homes, other real property, and other
assets totaling $27.5 millon or 14.3 percent of the State s annual Medicaid nursing
home budget. To 
qualif themselves for 
public assistance 8 percent of these 
ccaseas trasnfeerreds 59.. rcent of the assets to spouses; Co,n 1v5e.rsely, only 7. 
0 p. 

of the origialy  3ilable  ets were spent down for care by 40.4 percent o8f  ptheerc ent
RECOMMENDATION: The Washington State Medicaid agency 
should: 
improve case record documentation to assure that asset values and 
dispositions are recorded in al cases and 
. implement an information storage and retrieval system to measure the 
impact of interspousal tranfers, trusts, purchase of exempt assets and
other shelters on the availabilty of Medicaid resources for poor people. 
IMPACT: These improvements will enable State and Federal 
officials to determine
the full extent and impact of shelters. 

The following findings and recommendations are 
Medicaid Estate
Recoveries, with minor alterations to reflect  repeated from 

changes in the Medicare Catastrophic
Coverage Act. 
RECOMMENDATION #2--
ELIGIBILITY AND TRETMENT OF 
RESOURCES 
FINDING: Some HCF A, 
SSI and State Medicaid policies promote 
retention of
assets during Medicaid eligibilty while others encourage precipitous liquidation of 
property with concomitant losses in value. Assets retained by recipients
, in the 
absence of estate recovery programs, pass unencumbered to .heirs at the
the taxayers.  expense of

Assets liquidated, sheltered or concealed to obtain eligibility 
as a long-tenn care funding resource also. Incapacitated elderly people are are lost 
sometimes financially abused by people who want to take their property, while at the 
same time, qualifyng them for Medicaid nursing home benefits. 
RECOMMENDATION: Change Medicaid rules to permit families to retain and 
manage propert while 
their elders receive long-term care. Specifically: 
Eliminate SSI "intent to return" rules as they apply to Medicnid long-term
care recipient  Reinstate and broaden the "bona fide effort to sell" exemption. 
. Allow Medicaid recipients to retain more income-
producing property
such as "contracts of deeds" or rental homes. 
Require agreement to liens and estate recoveries as a condition of 
Medicaid eligibilty for people with propert. 
Encourage State Medicaid programs to protect recipients and their 
propert from financial exploitation through conservatorships
, legal 
representation and propert management when necessary. 
IMPACT: Ths policy would ease the financial impact of catastrophic long-term care 
costs on the elderly and their famlies
, giving them time to cope with the problem. 
Total Medicaid COSt$ would decline as estate recoveries increase. 
RECOMMENDATION #3--TRASFER OF ASSETS 
FINDING: Despite (1) 
alost unversal State implementation of the TEFRA
authority to restrict tranfers 
of assets for the purose of obtaining Medicaid
eligibilty and (2) mandatory tranfer of assets restrictions required by MCCA,
people are stil able to give away, or otherwse shelter, propert to qualify for
assistance. This may be done by using the legal "loopholes" recommended in law 
journal arcles or by deceit and concealment. 
RECOMMENDATION: Strengthen the 
tranfer of assets rules so that people
cannot divest themselves of propert to qualify for Medicaid. Specifically: 
. Improve State verication of propert and transfers. 
Clarfy that the "tranfer of assets" restrictions apply to all property 
including that which is, or would be, exempt from eligibilty
determnation. 
Exressly prohibit the transfer of property to spouses and other 
dependents which is permitted under current law. 
Extend the current  3D-month  look-back" period to 5 or more years. 
. Have HCFA publish regulations on transfer of assets. 
IMPACT: More property will be retained by 
recipients to reimburse Medicaid for
their cost of care after they and their dependents are no longer in need.  ~~~
, "
RECOMMENDA TI ON #4--
LIENS 
FINDING: State Medicaid 
programs need to track property owned by recipients
and ensure that it is not transferred or otherwse disposed before recovery of 
Medicaid benefits can be accomplished. Liens achieve these objectives most 
efficiently. While permtting liens 
TEFR 
placed so many qualifications on their
use that only two States have employed liens to secure 
propert for recovery of
benefits correctly paid.

RECOMMENDATION: Require a legal instrument as a condition of Medicaid 
eligibilty to secure 
propert owned by applicants and re( 'pients for later recovery.
Specifcally: 
I\ake-1ie  or som her form of encubrance
, a condition of eligibilty
so that the recipient's interest in any propert 
solely or jointly owned will
inure, up to the cost of care paid by Medicaid
, to the Medicaid program 
when neither  . recipient nor dependents need the property 
further. 
. Promote home equity conversion by using liens 
voluntary mortgages
opeh 
ended irortgages" arid aCC01mts receivable to let people extract
their equities gradualy whie they 
receive assistance. 
IMPACT: Mandatory liens would 
secue the State and Federal Governent'
investment 
a.T1d permt Medicaid recipients to retain needed property while 
receivig highly expensive, but essential
, care. 
RECOMMENDATION #5--
ESTATE RECOVERIES 
FINDING: Less than half of the States pursue Medicaid estate recoveries for 
benefits correctly paid. Of those 
which do, a few are very effective
, but most are not.
The HCF A and State Medicaid managements place little emphasis on retention of 
recipient propert or estate recoveries. The TEFRA authority for estate recoveries 
as for liens, is only voluntar. Many State staff believe that 
TEFRA limitations
hobble estate recoveries without safeguarding legitimate recipient interests. 
RECOMMENDATION: Increase estate recoveries as a nontax revenue source for 
the Medicaid program while steadfastly protecting the property rights of recipients 
and their dependents. Specifcally: 
. Make estate recovery programs mandatory like other forms of third party 
liabilty. 
Provide technical assistance on estate recoveries
, so that States can
implement them quickly and 
easily to generate an immediate cash flow
for the Medicaid program. 
. Promote awareness of the importance of real property ownership and 
estate recoveries for Medicaid funding.  . Allow estate recovery of benefits received before age 65. 
Permit estate recovery in cases of joint tenancy with right of survvorshi p, 
Require spousal and dependent recoveries upon death or seniority (of a 
minor child). 
IMPACT: Based on Oregon 
s experience--even under current restrictive laws 
reguations and policies--estate recoveries can recoup 5.2 percent of Medicaid
nursing home costs, 5.0 percent of Medicaid payments to people over age 65 and 
1.7 pecent of total Medicaid vendor payments. With enhanced legal authorities and 
greater programatic emphasis, the contribution of estate recoveries to Medicaid' 
program resources could be truy 
staggering.  , "  ,,  ""
, ", " , ", ', ". .
BIBLIOGRAPHY 
Comments: The Effect of Asset 
Transfers on Medicaid Eligibility,
University of Pennsylvania Law Review 
Vol. 129, April 1981 , pps. 882-910. 
American Bar Association, "
Doing Well by Doing Good: Providing Legal 
Services
to the Elderly in a Paying Private Practice 
" Commssion on Legal Problems of the
Elderly, Washington, D.
C., 1985. 
Carlucci, Timothy N.  e Asset Transfer Dilemma: Disposal of Resources and 
87.  TP_
QuaIificatioD'for'  edicad- sistance  Drake Law Review 
369- Vol. 36, 1986 , pps.
Davis, Clayton, "Solving Common Problems in Long-
Term Care and Medicaid
Financial Eligibility, 
The Alabama Lawver 
Volume 46, Number 6, November 
1985. 
Deford, Gil  Medicaid liens, Recoveries
, and Transfer of Assets after 
TEFRA"
Clearinghouse Review 
June 1984. 
Delbaum, Charles M.  Financial Planng for Nursing Home Care: Medicaid 
Eligibilty Considerations,"  Ohio State Bar Association Report, 
Volume 57, Number
, April 2, 1984, pps. 372-381. 
Donahue, Patrick H.  Medicad and Long-Term Institutional Care for the Victims 
of Catastrophic Disabling Iless," 
 Journal of the Kansas Bar Association 
Vol. 56
September/October 1987, pps. 26-35. 
Driner
, Paul  Medicaid' s Unhealthy Side Effect: The Financial Burdens on
At-Home Spouses of IntitutionaIed 
Lovola UniversitY Law Journal 
Recipients," 
Vol. 18, Sprig 1987, pps. 1031-52. 
Duncan, Glen, "Public Attitudes About Contingency Planning for Long-
Term Care
Needs," Beverly Foundation
, July 1986. 
Dunn, Donald H., editor  Easing the Burden of Nursing Home Costs 
Business
Week No. 2883, March 11
, 1985, pps. 123-4. 
Dussault, Wiliam L.E.  Chapter Two: Plannng for 
Property, Probate & Trust Mid- Disabilty," in  1985 Real
Year Meeting and Seminars (Prohate & Trust
Materials, Volume II), 
Washington State Bar Association
, Seattle, Washington, 1985. 
Ferreira, Louis A., "A Medical Assistance Overvew for the Attorney Advising an 
Elderly Client in Idaho 
Idaho Law Review  Vol. 24, 1987 , pps. 485:497.  , "  , "

, ," " , " , "
Greenfield, Peter and Barbara A. Isenhour 
Medicaid for Nursing Home Care:
Some Estate Planng Considerations 
Washington State Bar News 
Number 6 Volume 40
, June 1986. 
Health Care Financing Administration, Region X 
Medicaid Transfer of Assets
Seattle, Washington, October 24
, 1985. 
Hereford, Russ and Bruce Spitz 'Tranfer of Assets: State Practices
Options " unpublished, prepared for the Medicaid Cost Containment,  CIssoumems asnsdion
State of Connecticut, December 
1983. 
National Health Law Program (Roger 
Schwar), "New COBRA Legislation Adopts
Many Changes in Medicad and Other Health Programs 
Clearinghouse Review
Volume 20, Number 3, July 1986. 
National Senior Citizens Law Center 
Medicaid Transfer of Assets Update: 
HHS
Tries to Control the Hydra, 
Clearin~house Review 
October 1982
,pps. 431-433. 
Offce of Inspector General 
Medicaid Estate Recoveries. 
national program
inspection No. OAI-
09-86-00078, June 1988. 
Payne, John B., Jr.  Medicaid Asset and Divestment Policy, 
Michigan Bar Journal
January 1987.

Rowland, Don, "Diviion of 
The Journal of the Kansas 
Assets: A Status Report" 

Bar Association. Vol. 55, No.  , September/October 1986
, pps. 4
Sabatino, Charles P.  An Advocate s Primer on Long-Term Care Insurance
Clearinghouse Review 
Special Issue
, Summer, 1986. 
Simon, Mitchell M.  Estate Planng and 
Resource Maxmization for the Elderly:
Medicaid Considerations 
New Hampshire Bar Journal. 
Volume 25, Number 2
Januar 1984, pps. 101-108. 
Talis, Wiliam G., "Medicaid as an Estate Plannng Tool 
Massachusetts Law
Review 
Spring 1981, pps. 89-94. 
Thompson, Karen Marie and Barbara J. Wechsler 
Special Legal Problems of
Senior Citizens: An Overvew for the Family Law Practitioner 
Need
to Know: Family Law (Spring Family Law Section Round Robin"  iSn e\mVheni narsY)a u 
Washington State Bar Association
, Seattle, Washington, 1988. 
United States Code
, Congressional and Administrative News, 97th 
Congress--Second Session--1982, Legislative History (Public Laws 97-
146 to 97-248)
Volume 2, St. Paul, Minnesota, West Publishing Company.  - .. - ... _. " " . '.
" "
APPENDIX A

METHODOLOGY 
Background 
We focused the study sample on cases at the point of application for Medicaid 
assistance and determnation of eligibilty. We 
reasoned that cases initially denied
but later approved for assistance
, would yield the most transferred or sheltered 
assets. We sampled only for such cases. 
This method overlooked 
al assets sheltered by everyone already on Medicaid. For
example assets sheltered by.people who.successfuy:avaiI  g th 
the
counselig and advice discused in the "Intervew Results
" section of this report were
not measured. Such people qualifed immediately 
for Medicaid and, therefore
could not have fallen into our sample of denied and subsequently approved cases. 
The total ainOunt of-assets tr  ferr  cLand shelte,red by the Medicaid nursing home
population in Washington State is left to the reader 
s inerence and to future study. 
Sample Selection 
Washington s Medicaid agency provided a vald random sample of recipients over
the age of 65 who were initially denied eligibilty for nursing home assistance
, but
were later approved. Based on data 
provided earlier, we originally estimated the
universe of 
anual denied caes at 3000. We anticipated that 75 to 85 percent of
these caes would have reapplied and qualified 
for Medicaid by the time of our case
record reviews. Based on 
preinpection research, we expected approximately half of
the subsequently approved cases to have 
divested or otherwse sheltered personal
and/or real propert to achieve eligibilty. Given these parameters
, a sample of
358 cases would have yielded a 
confdence level of 90 percent and precision of 
10 percent. We actaly selected a sample of 360 cases. Unfortunately, only 
198 cases met the study criteria because the State was unable to provide a "
clean
sample. A total of 162 cases had to be dropped for a variety of reasons including 
deceased  nonnursing home 
under age 65 " etc. Adjusting for a sampling period
of 11 months instead of a year (July 1987 through May 1988) and for a factor of 
45 percent dropped  ases, the actual universe from which we sampled was reduced 
to 1182 cases.

Our 16.
8 percent sample yielded $4 234 255 in total assets among 
114 originally
denied, but subsequently approved
, Medicaid nursing home cases. Projected to the
universe of our sampling population
, the comparable figure in the \Vashington State
Medicaid nursing home caseload would be $25 
203 898. This, however, is an
ll-month figure. Ifwe add a 
month to estimate an annual total
, we get $27 495 162.
Thus, projecting from our sample
, approximately $27.5 milion in assets were
sheltered or consumed to qualify.  Methodological Caveats

(1) Because our review followed the sampling period by only a few weeks
, other
cases within the sample probably have been or will be approved after our review. 
Since they are not reflected, our findings are conservatively low. 
(2) Sixteen of the 36 homes owned by sample recipients had no values reported in
the case record. Because homes are usualy exempt
, their values often are not
recorded. To estimate the total value of 
home equity in the sample
, we assigned the
average value of the 20 homes with values recorded to 
the 16 without values

recorded. Total values in the 
text, char and 
tables reflect this extrapolatic n. 
(3) Other real 
propert values were extrapolated by the same methodology used for
home values. Sixeen of the 
18 other properties had values recorded in the case
record.  -..-... - --....... .. "_. ' - . ." . -" .. . -.",. :... _. ,
APPENDIX 8

SAMPLE CASES

Case #12: Tranferred $153,
500 to sons with an irrevocable trust on November 25

1986. Denied assistance October 5
, 1987. Case reconsidered
, approved briefly and
then closed. This case ilustrates the State 
s efforts to defeat trust shelters. 
Case #41: Denied August 17, 1987. Applicant and spouse separately held liquid 
assets of $235,
000. The applicant used $50 000 of his $80 000 to payoff a note on the
couple s home. Some of 
hi "emainig $30 000 was evidently used to pay for care
but the case record is unclear. Insurance in the amount of $8000 
was transferred to
the wife. The.casewas' appr.oved September. 14  1987..... , 
Case #114: Denied December 
18, 1987. Disqualifyng bank accounts and 
certificates of deposit were in the applicant'
s and spouse s names. The applicant
name was removed from the ban 
accounts and certificates of deposit (totaling 
$206 363) and the famy residence ($40 000) as of December 1987. The case was
approved for nursing home cae on February 1
, 1988. 
Cae #193: Denied August 18, 1987. A home valued at $84 
900 was transferred to
the spouse by quitclaim deed on July 2
, 1987. Personal effects of $15 000;
automobiles worth $5,775, and liquid assets of $222 
865 were transferred to the 
spouse with a Durable Power of Attorney dated April 14
, 1986. The assignment of
assets document cites the "Deccio Amendment" (RCW 74.09.532) by saying that it 
expressly allows the tranfer of propert from one spouse to the other for the
purposes of qualifyng for medical assistance from the state to pay for full time 
residential care and servces in a medically supervsed residential care facilty.
" The
case was approved on October 20, 1987 
with an effective date of July 1, 1987. 
Case #245: Denied September 17 
1987; reapplied and approved on 
October 1
1987. Propert with an 
assessed value of $433,000 was'transferred to the spouse on
June 26, 1987 by court order. The purpose of the court order was "
to cause all bUt 
000 of the incompetent' s assets to be transferred to the incompetent 
s husband
(spouse), to qualify the incompetent for medical assistance b 
nefits under RC\V 
74.09.532 (Deccio Amendment)." The applicant also owned and transferred
propert in another county for which we do not have an assessed value. In addi tion 
the applicant had 9 ban 
accounts, including two in banks outside the United States.
\Ve were able to find the value of only one of these accounts which was $12 
952.
The guardian for this case was given the 
following advice by the eligibilty worker:
Our state offce in Olympia 
has recently changed the way we look at resources of
husband and wife. Now, even if there has been a court approved gift of all property 
and the bank account stil has both names on it
, we will count one-half as being
available to our client. For this reason you 
may want to remove (applicant 
s) name
from all bank accounts, deeds, trust accounts, stocks, etc. and reapply.  Case #263: Denied February 16
, 1988, but approved March 1 , 1988. A half interest
in a home worth $33 
100 and $149 000 in liquid assets were transferred 
to the
spouse. The quitclaim deed for the 
residence explained: ' 
The Grantor (name of
Medicaid applicantJ; for and in consideration of love and affection; conveys and quit 
claims to (name of spouseJ all interest in the following described real estate.
" The
case record also contained a letter from Metropolitan 
Savings and Loan which said:
This letter is to inform you that 
as of today, Februar 18, 1988, the (Medicaid
applicant) has no legal claim to any funds held with Metropolitan 
Savigs and Loan.

The account number (XJ has been closed. The funds in the aforementioned account 
have been tranferred to account 
number (YJ in the name of (the spouse 
individual account with sole ownership of said funds.  J as an
TRUST CASES 
In addition to our sample of nursing home cas 
, we originally intended to analyze
examples of trut cases. We expected, based on 
preinpection findings
, to be able to
obtai such examples by requestig them when we visited the local community
servce offces tb conduct our cae record reviews. Unfortunately, the Medicaid 
agency does not have a  identi 
sytematic way to  trust cases. We had to rely on the
memory of eligibilty workers. Most of the Caes identified 
Were not Medicaid cases

or the trust docuent did not have a list of assets attached. Therefore
, we dropped
the analysis of specic trst caes from this report. Narative 
analysis and anecdotes
of trust issues are found in the "
Intervew Results" section of 
this report. This
analysis is based on our 
intervew with the trst specialist in the Department of
Social and Health Servces 
s Offce of Attorney General.  .:  --,  ":: .:  . '-"  . ----------
',  -_:::. '" 
APPENDIX C 
ASSET DISPOSmONS BY TYPE OF 
ASSET 
Tables C-l through C-4 indicate the 
disposition of the four categories of resources
reviewed. The reader 
s attention is directed to the fact that the detailed breakdowns 
of residential and other real 
propert disposition are extrapolated to reflect
estimated values for properties the value of which were unreported. 
of 
TABLE C-1: DISPOSITION COF LalasUIeD AsS SETS IN 
TDy isposition  APPROVED CASES
Disposed Amounts 
No. Percent Amount Percent Average
Tranerred to Spouse .. ,  15 13.2% $1  per Case
Tranferred to Adult Clidten '---'3 28"  33.3 210511,,552010 .6 18.811. 9%   1$30706768
, 1. 
Consumed for Nursing Home Care  0 22148,503 8. 750
621 18. 3 91
RUetaniekd aos wExemnpt-.
 ':: 16:- 14.  908
17 14.9 166, 414
Total 
015 . 9.
No Liquid Asets tAo Dispsoset  s,. . 26 22.
 766
160 
114 100.0% . $1 
Cases with Liquid  88 77.2% $1,696900, 160 1010O.( J.% $14 826 
$19 
TyTAeBL E Co-2f: D ISCPOaSITsIOeN OsF R ESIDENCES IN APPROVED CASES*
Disposition 
Disposed Amounts 
No. Percent  Percent Average
UTrannferErkedxo toe wSmpoupnset   181  79..07%  2$760A70mo,u7n0t 4 46.60%  3$633per  Case
Retaied as  487 17.0 39 700
4.4 198256 13.7 36 436
Tranferred to Adult Chidren  3.5 147408 9. 651
Total  728 
Consumed for Nursing Home Care 3 2.46.4  91162 73. 4 3222852
Other  78  254 6. 546
No Residence to Dispose 
085
68.4
114 100.0% $1,522 837 100.00%% $1 3 
Cases with Residences 36 31.6% $1  358
522 837 100,
* This table includes actual values of residences when available and average v$4a2l,u3e01s
for homes which had no value recorded in the case record.  of 
TABLE C-3: DISPOSITION 
OF OTHER REAL PROPERTY 
Cases 
IN APPROVED CASES'"
TDy isposition 
N5o .4 P.ercent ADmisopousnetd  Amounts  Average
Tranferred to Spouse  4% $551436Pe rcent per Case 
Other 2 1.8 89
Tranferred to Adult Chidren 7 6.  770 1173.. 4  $110 287 
Exempt  62,36 
UCRoentasiuenmd eadsk  for oNurswing Honme  Ca1re 21  1 ..98  2' 502805  8.3  885 
9 7 3.4  12,643
2.0
965 1.
No Other Real Propert to Dispose 96 84.  965 
114 
Total 
10().% 
Cases with ether Real Propert  $751,822  100.  595
to Dispose 
15.  $751,822  100.  $41 768 
. Th  act 
table includes  vaues for other rea 
propert when avaiable and average values if no
propert value was recor ed in the cae record. 
of 
Case 
TABLE C-4: DISPOSITION OF 
OTHER ASSETS IN APPROVED CASES
TDy isposition 
Disposed Amounts 
No. Percnt Amount P5e1rc.e5nt  Average
Retaied as ESxepmoputs e5 8  9 $13853  per Case
5 45.0.  1 18
TUTrraanne.snrererdrke tod  to o Awdult 1Cnhid re1n  2  1.198.  -8  8251944,5085  73.5.. .0923 . 11 8
 02$2 9,9147
Consumed for Nursing Home Care 700
Total  9 8007356   3 3.
Other 45  063 
No Other Asets to Dispose  800
39.5 
16149 1 00. 
Caes with Other Asets  $269 436  100.  $2,33
60.5%  $29 436  100. 
. In thi cae
, the asets were tranerred to nonrelatives.