Title: Fournier v. Secretary of Executive Office of Health & Human Services
Citation: N/A
Docket Number: SJC-13059
State: Massachusetts
Issuer: Massachusetts Supreme Court
Date: July 23, 2021

NOTICE:  All slip opinions and orders are subject to formal 
revision and are superseded by the advance sheets and bound 
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error or other formal error, please notify the Reporter of 
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SJC-13059 
 
PATRICIA A. FOURNIER, personal representative,1  vs.  SECRETARY 
OF THE EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES. 
 
 
 
Worcester.     April 7, 2021. - July 23, 2021. 
 
Present:  Budd, C.J., Gaziano, Lowy, Cypher, Kafker, Wendlandt, 
& Georges, JJ. 
 
 
Medicaid.  MassHealth.  Trust, Irrevocable trust, Power of 
appointment.  Fiduciary. 
 
 
 
 
Civil action commenced in the Superior Court Department on 
September 5, 2018. 
 
 
The case was heard by Susan E. Sullivan, J., on a motion 
for judgment on the pleadings. 
 
 
The Supreme Judicial Court on its own initiative 
transferred the case from the Appeals Court. 
 
 
 
Julie E. Green, Assistant Attorney General, for the 
defendant. 
 
Lisa M. Neeley for the plaintiff. 
 
Patricia Keane Martin, Clarence D. Richardson, Jr., & C. 
Alex Hahn, for Massachusetts Chapter of the National Academy of 
Elder Law Attorneys, amicus curiae, submitted a brief. 
 
Martin W. Healy, Thomas J. Carey, Jr., Ryan P. McManus, & 
Paul M. Cathcart, for Massachusetts Bar Association, amicus 
curiae, submitted a brief. 
 
1 Of the estate of Emily Misiaszek. 
2 
 
 
 
GEORGES, J.  Four years ago, in Daley v. Secretary of the 
Exec. Office of Health & Human Servs., 477 Mass. 188, 203 
(2017), we raised -- but did not answer -- the question whether 
a trust settlor's reservation of a limited power of appointment 
to appoint trust principal to a nonprofit or charitable entity 
over which the settlor has no control, contained within an 
irrevocable trust established by the settlor, could render the 
assets held in the trust "countable" for purposes of determining 
the settlor-applicant's eligibility for Medicaid long-term care 
benefits.  Specifically, we instructed MassHealth2 to consider, 
in the first instance, whether there were "any circumstances," 
see 42 U.S.C. § 1396p(d)(3)(B)(i), in which the settlor-
applicant could use his limited power of appointment to appoint 
 
2 MassHealth is the State-administered Medicaid program in 
Massachusetts, and it was established "pursuant to and in 
conformity with the provisions of" the Federal Medicaid Act 
(act).  G. L. c. 118E, § 9.  If a person meets the Federal 
financial eligibility requirements for Medicaid under the act, 
then MassHealth may not deny the person long-term care benefits.  
See G. L. c. 118E, § 9 ("provided that such persons meet the 
financial eligibility requirements of [the act], . . . long-term 
care services shall be available to otherwise eligible persons 
whose income and resources are insufficient to meet the costs of 
their medical care as determined by the financial eligibility 
requirements of the program").  "In order to qualify for 
Medicaid in Massachusetts, MassHealth requires that '[t]he total 
value of countable assets owned by or available to' an 
individual applicant not exceed $2,000."  Daley, 477 Mass. at 
191-192, quoting 130 Code Mass. Regs. § 520.003(A)(1) (2014). 
3 
 
the trust principal to a nonprofit or charitable nursing home 
for the purpose of paying for his care.  Daley, supra. 
This case picks up where Daley left off.  While both were 
living, the plaintiff, Emily Misiaszek,3 and her husband created 
an irrevocable trust, the corpus of which includes their home.  
The terms of the trust grant Misiaszek, during her lifetime, a 
limited power of appointment to appoint all or any portion of 
the trust principal to a nonprofit or charitable organization 
over which she has no controlling interest.  After Misiaszek 
applied for and was denied MassHealth long-term care benefits, 
the Massachusetts Office of Medicaid's board of hearings (board) 
affirmed MassHealth's determination that the home was a 
countable asset, concluding that Misiaszek ostensibly could use 
her limited power of appointment to appoint portions of the 
home's equity, included as part of the trust principal, to the 
nonprofit nursing home where she resided as payment for her 
care.  Misiaszek then sought judicial review of the board's 
decision, and a Superior Court judge reversed the board's 
ineligibility determination. 
 
3 Although the trust was self-settled by both Misiaszek and 
her husband, the husband predeceased her well before she applied 
for MassHealth benefits and before this litigation commenced.  
Accordingly, we refer to Misiaszek, who initially commenced this 
action but died during the pendency of this case, as the 
plaintiff and sole self-settlor of the trust.  Currently, 
Misiaszek's daughter, Patricia Fournier, is the named plaintiff 
as personal representative of Misiaszek's estate. 
4 
 
We conclude that under the terms of her trust, Misiaszek's 
limited power of appointment does not allow her, in any 
circumstance, to appoint the trust principal for her benefit, 
and thus the trust principal is not "countable" for purposes of 
determining her eligibility for MassHealth benefits.  
Accordingly, we affirm the judgment of the Superior Court and 
remand the case for further proceedings consistent with this 
opinion.4 
Background.  We first provide an overview of the Medicaid 
framework and our decision in Daley, both of which provide 
important context for our analysis.  We then summarize the 
relevant facts and procedural posture of this case. 
1.  Medicaid framework.  "Medicaid is a cooperative Federal 
and State program that 'provides medical assistance to low 
income persons based on financial need.'"  Guilfoil v. Secretary 
of the Exec. Office of Health & Human Servs., 486 Mass. 788, 789 
(2021), quoting Rudow v. Commissioner of the Div. of Med. 
Assistance, 429 Mass. 218, 221-222 (1999).  As we have noted 
previously, the Medicaid eligibility requirements "often 
[require] applicants to 'spend down' or otherwise deplete their 
resources to qualify for Medicaid long-term care benefits when 
 
4 We acknowledge the amicus briefs submitted by the 
Massachusetts Chapter of the National Academy of Elder Law 
Attorneys and the Massachusetts Bar Association. 
5 
 
they enter a nursing home."  Daley, 477 Mass. at 192.  Through 
the practice known as "Medicaid planning," however, individuals 
with "significant resources devise strategies to appear 
impoverished in order to qualify for Medicaid benefits."  Lebow 
v. Commissioner of the Div. of Med. Assistance, 433 Mass. 171, 
172 (2001).  "One such strategy is to transfer assets into an 
inter vivos trust, whereby funds appear to be out of the 
individual's control, yet generally are administered by a family 
member or loved one."  Id. 
To limit the practice of Medicaid planning and to preserve 
scarce public resources, Congress in 1993 amended the act to 
include what is known as the "any circumstances" test, which 
applies when determining an applicant's eligibility for Medicaid 
benefits.  See Cohen v. Commissioner of the Div. of Med. 
Assistance, 423 Mass. 399, 405-406 (1996), cert. denied sub nom. 
Kokoska v. Bullen, 519 U.S. 1057 (1997).  With respect to an 
irrevocable trust, the act provides that "if there are any 
circumstances under which payment from the trust could be made 
to or for the benefit of the individual, the portion of the 
corpus from which, or the income on the corpus from which, 
payment to the individual could be made shall be considered 
resources available to the individual."  42 U.S.C. 
6 
 
§ 1396p(d)(3)(B)(i).5  MassHealth has promulgated a regulation 
that implements the "any circumstances" test.  See 130 Code 
Mass. Regs. § 520.023(C)(1)(a) (2014) ("Any portion of the 
principal or income from the principal . . . of an irrevocable 
trust that could be paid under any circumstances to or for the 
benefit of the individual is a countable asset"); 130 Code Mass. 
Regs. § 520.023(C)(1)(d) (2014) ("The home or former home of a 
nursing-facility resident or spouse held in an irrevocable trust 
that is available according to the terms of the trust is a 
countable asset"). 
In essence, "[t]he effect of the ['any circumstances'] test 
is that if the trustee is afforded even a 'peppercorn of 
discretion' to make payment of principal to the applicant, or if 
the trust allows such payment based on certain conditions, then 
the entire amount that the applicant could receive under 'any 
state of affairs' is the amount counted for Medicaid 
eligibility."  Daley, 477 Mass. at 193, citing Cohen, 423 Mass. 
at 413.  Importantly, though, we have stressed that "the 
principle of actual availability . . . has served primarily to 
prevent the States from conjuring fictional sources of income 
 
5 "The relevant MassHealth regulation defines an irrevocable 
trust as 'a trust that cannot be in any way revoked by the 
grantor,' . . . and adopts the same 'any circumstances test.'"  
Guilfoil, 486 Mass. at 791, quoting 130 Code Mass. Regs. 
§ 515.001 (2013).  The parties do not dispute that the Misiaszek 
trust is an irrevocable trust. 
7 
 
and resources by imputing financial support from persons who 
have no obligation to furnish it or by overvaluing assets in a 
manner that attributes nonexistent resources to recipients."  
Daley, supra at 202, quoting Heckler v. Turner, 470 U.S. 184, 
200 (1985).  See Heyn v. Director of the Office of Medicaid, 89 
Mass. App. Ct. 312, 314 (2016) ("The resulting law reflects a 
compromise, with . . . strict requirements governing the extent 
to which assets must be made unavailable to the settlor in order 
to avoid being treated as 'countable assets' for purposes of 
Medicaid eligibility.  Nonetheless, it is settled that, properly 
structured, [irrevocable] trusts may be used to place assets 
beyond the settlor's reach and without adverse effect on the 
settlor's Medicaid eligibility"). 
In short, for trust principal to be considered countable 
under the "any circumstances" test, the terms of the trust must 
give the applicant a direct path to reach or benefit from the 
trust principal.6 
 
6 We also have emphasized that "if the amounts that may be 
paid to the Medicaid applicant come only from the income of the 
trust, those income payments do not render the principal of the 
trust available as an asset; rather, they are treated as income 
that may affect the amount of Medicaid benefits to be received 
but not the applicant's eligibility for such benefits" (emphases 
in original).  Daley, 477 Mass. at 194, citing Guerriero v. 
Commissioner of the Div. of Med. Assistance, 433 Mass. 628, 632 
n.6 (2001).  Thus, while article 2.1 of the irrevocable trust at 
issue here empowers the trustee to pay Misiaszek income from the 
trust as the trustee deems appropriate, these amounts, actual or 
potential, do not factor into our analysis. 
8 
 
2.  Daley.  In Daley, 477 Mass. at 189, we considered the 
MassHealth eligibility of two individuals who had established 
irrevocable trusts.  As relevant here, one of those plaintiffs, 
Lionel Nadeau, together with his wife, deeded their home to an 
irrevocable trust (Nadeau trust) in return for nominal 
consideration and named their daughter as sole trustee.  Id. at 
196-197.  Save for two exceptions, the terms of the Nadeau trust 
required the trustee to hold the principal until the termination 
of the trust, which was to occur either upon Nadeau's death or 
when the trustee, in her sole discretion, determined that the 
trust should be terminated.  Id. at 197.  One of the exceptions 
granted Nadeau a limited power of appointment, which permitted 
him, as the settlor of the trust, to appoint the trust principal 
to a nonprofit or charitable organization over which he had no 
controlling interest.  Id.  The terms of the Nadeau trust also 
granted Nadeau "the right to use and occupy any residence that 
may from time to time be held" by the trust.  Id. 
The question before us in Daley was whether Nadeau's 
retention of the right to reside in and enjoy the use of the 
home held in trust rendered the home a "countable" asset under 
the act's and MassHealth's "any circumstances" test, such that 
MassHealth could consider the full value of the trust principal 
in determining Nadeau's eligibility for MassHealth benefits.  
Id. at 189.  We answered the question in the negative, 
9 
 
concluding that the right of a settlor of an irrevocable trust 
to reside in a home held in trust as one of the trust assets is 
equivalent to a distribution of income of the trust, and not the 
principal, because the trustee had neither the obligation nor 
the power to sell the home and furnish the proceeds to Nadeau in 
any circumstance.  Id. at 202-203.  Thus, MassHealth's decision 
to count the home's equity as part of its eligibility 
determination for Nadeau amounted to "'conjuring [a] fictional' 
resource (the applicant's home) by 'imputing financial support' 
from a person who has no authority to furnish it (the trustee)."  
Id., quoting Heckler, 470 U.S. at 200. 
In our remand instructions to MassHealth, we suggested it 
was "appropriate for MassHealth to consider," in the first 
instance, whether it was possible for Nadeau to use his limited 
power of appointment to use the trust assets to pay a nonprofit 
organization for his care, and whether such a possibility fits 
within the "any circumstances" test.7  Id. at 203.  Notably, 
after the case was remanded to MassHealth, the board ultimately 
concluded that Nadeau's limited power of appointment did not 
render the home a countable asset for MassHealth eligibility 
 
7 Unlike with Misiaszek, the skilled nursing home that 
Nadeau resided at was not operated by a nonprofit or charitable 
organization.  See Daley, 477 Mass. at 203.  Accordingly, we 
remanded the case to MassHealth so it could consider what was 
then a hypothetical circumstance. 
10 
 
purposes because the terms of the trust instrument did not 
permit him to exercise the limited power for his benefit.  See 
Office of Medicaid Bd. of Hearings App. No. 1408634, at 13 (Mar. 
5, 2018).  MassHealth did not appeal from the board's decision 
in Nadeau's case. 
3.  Misiaszek trust.  The trust at issue here is nearly 
identical to the Nadeau trust we considered in Daley.  In 
December 2002, Misiaszek and her husband, both of whom now are 
deceased, established an irrevocable trust (Misiaszek trust).  
They appointed their daughter, Patricia Fournier, as trustee.8  
On the same date as the trust was created, Misiaszek and her 
husband deeded their home and primary residence to the trust for 
no consideration.  From the time the trust was formed until the 
day she entered a skilled nursing facility, Misiaszek lived in 
the home, as permitted by the terms of the trust. 
The parties' dispute centers on a handful of the trust's 
provisions.  Article 1.2 provides that the purpose of the trust 
is "to manage [Misiaszek's] assets and to use them to allow 
[Misiaszek] to live in the community as long as possible."  
Article 2.1 provides that Misiaszek is entitled to payments of 
trust income from the trustee, which are to be made solely in 
the trustee's discretion.  The trust instrument defines "income" 
 
8 Fournier was and continues to be the sole trustee of the 
Misiaszek trust. 
11 
 
as "net income and accumulated income not added to principal, 
and does not include capital gain."  Article 2.1 further 
provides that "[e]xcept as provided in paragraph 2.2 below, the 
principal shall be held until the termination of this trust." 
Importantly, article 2.2 grants Misiaszek a limited power 
of appointment over the trust principal.  Specifically, the 
provision states that, during her lifetime, Misiaszek 
shall have the power to appoint from time to time, by an 
instrument in writing by [herself] or by [her] legal 
representative, all or any part of the trust property then 
on hand to any one or more charitable or non-profit 
organizations over which [she has] no controlling interest, 
whether or not organized for a purpose specified in section 
170(c) of the Internal Revenue Code of 1986, but excluding 
any [F]ederal, [S]tate, or local government or any sub-
division, department, or agency thereof."9 
 
In addition, article 3.1 provides that the trust shall terminate 
upon either Misiaszek's death or a determination by the trustee, 
in her sole discretion, that the trust should be terminated.  In 
either case, article 3.2 directs the trustee to "[p]ay the 
remaining principal and undistributed income in equal shares to 
[Misiaszek's] children with their issue to take by right of 
representation."  Finally, article 4.9 provides that "[a]ll 
powers and discretion given to [Misiaszek's] trustee are 
 
9 As we discuss infra, neither party disputes that article 
2.2 grants Misiaszek a "limited" (as opposed to a "general") 
power of appointment. 
12 
 
exercisable only in a fiduciary capacity, in accordance with 
reasonable discretion." 
4.  Procedural history.  In May 2017, following her 
admission to a skilled nursing facility, Misiaszek applied for 
and was denied MassHealth benefits.10  MassHealth determined that 
Misiaszek was ineligible because the equity of the home held in 
the trust exceeded MassHealth's $2,000 eligibility ceiling by 
over $160,000.  Misiaszek appealed to the board, which affirmed 
MassHealth's denial of her application.  The board subsequently 
agreed with MassHealth's conclusion that article 2.2 rendered 
the trust corpus countable, because it seemingly permitted 
Misiaszek to appoint the trust principal to a nonprofit nursing 
facility to pay for her long-term care. 
Misiaszek then sought review of the board's decision in the 
Superior Court pursuant to G. L. c. 30A, § 14, and moved for 
judgment on the pleadings, which the judge subsequently allowed.  
The judge determined that the board's reliance on Daley was 
misplaced because Daley did not purport to address the contours 
or scope of Nadeau's limited power of appointment, but instead 
only instructed MassHealth to consider the issue in the first 
instance.  The judge also noted that, in Nadeau's particular 
 
10 Misiaszek's husband predeceased her.  While the record is 
unclear as to when the husband died, the board hearing officer 
found that he died prior to when Misiaszek moved to a skilled 
nursing facility and applied for MassHealth benefits. 
13 
 
case, the board on remand ultimately reversed MassHealth's 
denial of Nadeau's application, finding there was "no evidence 
that if [Nadeau] were to move to a non-profit organization that 
the non-profit nursing facility would be allowed to or required 
to use the trust principal for the appellant's benefit or care."  
Because there is "no substantive difference between [a]rticle 
2.2 of [the Misiaszek] trust and the article considered in 
[Daley]," the judge concluded that the hypothetical transfer 
contemplated by the board and MassHealth would be ineffective as 
a matter of law, and thus "does not constitute circumstances 
under which payment from the trust could be made to or for the 
benefit of [Misiaszek]." 
MassHealth timely appealed from the judge's order granting 
Misiaszek judgment on the pleadings to the Appeals Court.  We 
then transferred the case on our own motion. 
Discussion.  1.  Standard of review.  "In reviewing 
administrative agency decisions, we give 'due weight to the 
experience, technical competence, and specialized knowledge of 
the agency, as well as to the discretionary authority conferred 
upon it.'"  Springfield v. Department of Telecomm. & Cable, 457 
Mass. 562, 567 (2010), quoting G. L. c. 30A, § 14 (7).  "We 
exercise de novo review of legal questions, however, and we must 
overturn agency decisions that are not consistent with governing 
law."  Bulger v. Contributory Retirement Appeal Bd., 447 Mass. 
14 
 
651, 657 (2006), citing Plymouth v. Civil Serv. Comm'n, 426 
Mass. 1, 5 (1997).  The specific issue in this case -- whether 
Misiaszek's limited power of appointment renders the value of 
the trust corpus a countable asset for purposes of determining 
her MassHealth eligibility -- is a question of law, and thus is 
subject to de novo review.  See Guilfoil, 486 Mass. at 793 ("At 
issue here –- whether the entire interest in a property 
transferred to a nominee trust is a countable asset in a 
MassHealth eligibility determination where the trustee retains a 
life estate in the real property -- is a question of law"). 
In addition, "[t]he interpretation of a written trust is a 
matter of law to be resolved by the court."  Ferri v. Powell-
Ferri, 476 Mass. 651, 654 (2017).  "The rules of construction of 
a contract apply similarly to trusts; where the language of a 
trust is clear, we look only to that plain language."  Id.  It 
is "a 'fundamental principle of Massachusetts law' that trust 
instruments be construed to 'ascertain the intention of the 
testator from the whole instrument, attributing due weight to 
all its language . . . and to give effect to that intent unless 
some positive rule of law forbids.'"  Pierce v. Doyle, 442 Mass. 
1039, 1040 (2004), quoting Dana v. Gring, 374 Mass. 109, 117 
(1977). 
2.  Limited power of appointment.  MassHealth argues that 
the plain language of article 2.2 of the Misiaszek trust 
15 
 
"contains no language barring transfers of principal to or for 
the benefit of Misiaszek," and thus permits her to exercise her 
limited power accordingly.  Its contention is that Misiaszek 
could "enter a nursing facility with an express promise to pay 
for her care through [her limited] power of appointment," or she 
could incur a debt to the facility and then subsequently appoint 
trust principal to the nursing facility to pay the debt.  
MassHealth further argues that this permissible exercise of 
Misiaszek's limited power is corroborated by article 1.1, which 
states that the purpose of the trust is to "allow [the 
Misiaszeks] to live in the community as long as possible." 
We are not persuaded because MassHealth's hypothesized 
appointment is not permitted under established principles of 
trust and property law.  Neither party disputes that article 2.2 
grants Misiaszek a limited power of appointment, which allows 
Misiaszek to appoint trust principal "to any one or more 
charitable or non-profit organizations over which [she has] no 
controlling interest . . . ."  By definition, a "limited power 
of appointment" is a power that "restricts to whom the estate 
may be conveyed; esp[ecially], a power by which the donee can 
appoint to only the person or class specified in the instrument 
creating the power, but cannot appoint to oneself or one's own 
16 
 
estate."  Black's Law Dictionary 1417 (11th ed. 2019).11  The 
persons or entities to whom an appointment is authorized 
collectively are known as the class of "permissible appointees."  
See Restatement (Third) of Property:  Wills and Other Donative 
Transfers § 17.2 (2011). 
Our cases long have understood that, with respect to 
limited powers of appointment, the class of permissible 
appointees is restricted to the class of persons or entities 
specifically named in the limited power, and does not include by 
implication the donee of the limited power.  See, e.g., 
Fiduciary Trust Co. v. First Nat'l Bank of Colo. Springs, Colo., 
344 Mass. 1, 5 (1962), citing Restatement (First) of Property 
§ 320 (1940) ("The power of appointment given to Francis under 
the Trust, however, was not a general testamentary power but a 
special or limited testamentary power of appointment. . . .  He 
could, in fact, appoint only to his widow and his issue"); 
 
11 In contrast to a "limited" or "special" power of 
appointment, a "general" power of appointment is "[a] power of 
appointment by which the donee can appoint -- that is, dispose 
of the donor's property -- in favor of anyone at all, including 
oneself or one's own estate . . ." (emphasis added).  Black's 
Law Dictionary 1417 (11th ed. 2019).  See Florez v. Florez, 441 
Mass. 1004, 1005 (2004) (general power of appointment would give 
donee "the power to distribute the remaining trust assets in her 
will to whomever she chooses").  The distinction between the two 
is important for estate tax purposes, as assets subject to a 
"general" power of appointment are considered those of the donee 
and thus may be reached by the donee's creditors.  See Shawmut 
Bank, N.A. v. Buckley, 422 Mass. 706, 712 & n.11 (1996), citing 
State Street Trust Co. v. Kissel, 302 Mass. 328, 335 (1939). 
17 
 
O'Brien v. Massachusetts Catholic Order of Foresters, 220 Mass. 
79, 81 (1915) (donee possessed limited power of appointment, 
thus "[h]e was limited in making the appointment to his widow, 
children, relatives or dependents").  See also Fleet Nat'l Bank 
v. Mackey, 433 Mass. 1009, 1009 (2001) ("Richard has a limited 
power of appointment that enables him to designate the person or 
persons -- other than himself, his estate, his creditors, or 
creditors of his estate -- to whom the res of trust B is to be 
distributed on his death").  Accordingly, Misiaszek, as the 
donee of the limited power, cannot exercise the power to appoint 
any portion of the trust principal directly to herself.12 
Similarly, the donee of a limited power of appointment may 
not circumvent the constraints on the power by appointing trust 
principal to a permissible appointee for the purpose of 
benefitting himself or herself.  In Pitman v. Pitman, 314 Mass. 
465, 467 (1943), the settlor of the trust at issue granted her 
son a testamentary limited power of appointment to appoint the 
trust assets to the descendants of the son's grandmother.  
Later, as part of a divorce settlement, the son agreed to assign 
to his former wife a portion of his interest in the trust, or, 
 
12 MassHealth appears to concede this point in its reply 
brief, stating that an appointment of trust principal to a donee 
of a limited power of appointment, "by definition, is not 
permitted . . . because [the power] is limited to specified 
permissible appointees." 
18 
 
in the alternative, to appoint the trust principal to his 
daughters.  Id. at 467-468.  The son expressly stated that the 
purpose of the arrangement was to discharge his obligation to 
pay alimony to his former wife under the divorce agreement.  Id. 
at 468.  The son executed a will exercising his limited power of 
appointment in favor of his daughters, and he specifically 
referenced the divorce agreement in his will.  Id. 
We held that the son's attempted exercise of his limited 
power of appointment in his will was invalid.  We reasoned that 
the son could not validly assign any of his interest in the 
trust assets to his former wife in the divorce agreement because 
his interest was governed by the special power of appointment 
created by his mother's trust, and his former wife "was not one 
of the objects of the power."  Id. at 476.  In other words, the 
former wife was not a descendant of the grandmother, and thus 
was not within the limited power's class of permissible 
appointees.  With respect to the will itself, we concluded that 
the son could not exercise his testamentary power of appointment 
in favor of his daughters because, even though his daughters did 
fall within the class of permissible appointees, the son's 
motivation for exercising his limited power -- namely, to 
benefit himself by satisfying his contractual obligations to his 
former spouse -- was contrary to the settlor's intent in 
19 
 
creating the trust, which was to benefit the grandmother's 
issue.  Id. at 477.  Specifically, we explained: 
"The exercise of the [limited] power [of appointment] was 
not a thing of barter or bargain, and there is a fraudulent 
exercise of a power not only where the donee acts corruptly 
for a pecuniary gain but where he acts primarily for his 
own personal advantage or that of a third person who is a 
non-object of the power and thereby abuses the power which 
the donor conferred on him." 
 
Id. at 476.  Therefore, we held that the son's attempted 
exercise of his limited power of appointment "constitute[d] an 
abuse of the power and render[ed] its exercise ineffectual."  
Id. at 477, citing Restatement (First) of Property § 353 (1940). 
 
MassHealth argues that Pitman is distinguishable because 
"[w]here the donor and the donee [of a limited power of 
appointment] are the same person," as here, "there is no need to 
protect the donor-donee from her own actions."  The problem, 
however, is that the court in Pitman made no such distinction.13  
Moreover, the Restatement (Third) of Property, which subsumed an 
 
13 The section  of the Restatement that the court in Pitman 
cites in its holding, see Pitman, 314 Mass. at 477, states, in 
relevant part: 
 
"Where an appointment is made to an object in 
consideration of a benefit conferred upon or promised 
to a non-object[,] an element is injected into the 
motivation of the power which is foreign to the intent 
of the donor in creating the power for the benefit of 
the objects.  Therefore, to whatever extent the 
appointment is induced by such a motive, it is 
ineffective." 
 
Restatement (First) of Property § 353 comment a (1940). 
20 
 
earlier provision cited by the court in Pitman, see Reporters' 
Note to Restatement (Third) of Property:  Wills and Other 
Donative Transfers § 19.16 (2011), similarly does not turn on 
the identity of the donee of the limited power: 
"An appointment to a permissible appointee is ineffective 
to the extent that it was (i) conditioned on the appointee 
conferring a benefit on an impermissible appointee, (ii) 
subject to a charge in favor of an impermissible appointee, 
. . . [or] (iv) in consideration of a benefit conferred 
upon or promised to an impermissible appointee . . . ." 
 
Restatement (Third) of Property:  Wills and Other Donative 
Transfers § 19.16 (2011).  Simply put, the court in Pitman was 
concerned not with who possesses the limited power of 
appointment, but rather with how the limited power is used with 
respect to the terms of the trust.14 
 
Furthermore, we are unpersuaded that the terms of the 
Misiaszek trust must expressly bar Misiaszek from exercising her 
limited power of appointment for her own benefit, as MassHealth 
contends.  MassHealth does not cite, nor are we aware of, any 
Massachusetts case that has imposed such a rigid requirement on 
the construction of a trust.  On the contrary, "a provision 
 
14 MassHealth also cites a New York statute that prohibits 
donees of testamentary powers of appointment from entering into 
contracts during their lifetime binding the exercise of their 
power.  See N.Y. Est. Powers & Trusts Law § 10-5.3(a).  We find 
the New York statute to be inapposite here.  Indeed, MassHealth 
does not cite, and we are not aware of, any analogous 
Massachusetts statute or case that distinguishes between 
exercises of a limited power of appointment based on the 
identity of the donee or powerholder. 
21 
 
making trust principal available to persons other than the 
grantor does not by its nature make it available to the 
grantor."  Heyn, 89 Mass. App. Ct. at 318.  It generally is 
accepted that "[t]he donor may define the permissible appointees 
of a nongeneral power by exclusion, by inclusion, or by a 
combination of the two. . . .  If they are defined by inclusion, 
the donor lists the persons to whom a valid appointment can be 
made."  Restatement (Third) of Property:  Wills and Other 
Donative Transfers § 19.15 comment d (2011).  Article 2.2 
defines the class of permissible appointees by inclusion, 
specifically by referencing "any one or more charitable or non-
profit organizations over which [Misiaszek has] no controlling 
interest" as objects of the appointment power.  Accordingly, the 
absence of express language prohibiting Misiaszek from 
exercising her limited power for her benefit does not in turn 
permit Misiaszek to do so. 
Construed as a whole, the terms of the Misiaszek trust 
reflect Misiaszek's intent to benefit from the income of the 
trust, while generally preserving the principal for her children 
and their issue upon the termination of the trust.  MassHealth 
correctly notes that the stated purpose of the trust, according 
to article 1.2, is to "manage [Misiaszek's] assets and to use 
them to allow [Misiaszek] to live in the community as long as 
possible."  This purpose is directly advanced by two subsequent 
22 
 
trust provisions.  First, article 2.1 provides that the trustee 
"may pay on [Misiaszek's behalf] as much of the income of the 
trust as it shall determine in its sole and non-reviewable 
discretion to be necessary for [Misiaszek's] care and well-
being" (emphasis added).  Second, article 2.3 provides that 
Misiaszek "shall have the right to use and occupy any residence 
that may from time to time be held in trust hereunder."  Indeed, 
the board hearing officer found that from the time when the home 
was deeded to the trust in 2002 until she moved into a nursing 
home and applied for MassHealth benefits in May 2017, Misiaszek 
continued to reside in the home in accordance with this 
provision.  As we held in Daley, 477 Mass. at 203, this right to 
reside in the home held in trust does not render the home itself 
countable as an asset for purposes of determining Misiaszek's 
MassHealth eligibility.  The same applies to any income payments 
Misiaszek was to receive from the trust -- such payments "may 
affect the amount of Medicaid benefits to be received but not 
the applicant's eligibility for such benefits" (emphasis in 
original).  Id. at 194, citing Guerriero v. Commissioner of the 
Div. of Med. Assistance, 433 Mass. 628, 632 n.6 (2001), and 130 
Code Mass. Regs. § 520.026 (2013). 
Elsewhere, the terms of the trust impose clear limitations 
on how the trust principal may be disposed of or distributed.  
Article 2.1 provides that, except by way of Misiaszek's limited 
23 
 
power of appointment to nonprofit or charitable organizations 
under article 2.2, the "principal shall be held until the 
termination of this trust," which, under article 3.1, is to 
occur either upon Misiaszek's death or at the trustee's sole 
discretion that the trust should be terminated.  At such time, 
article 3.2 directs the trustee to "[p]ay the remaining 
principal and undistributed income in equal shares" to 
Misiaszek's children or their issue, as beneficiaries of the 
trust. 
Taken together, the terms of the Misiaszek trust only 
permit Misiaszek to live in the home during her lifetime, to 
receive payments of trust income, and to make charitable 
contributions to organizations in which she has no interest.  
She is not permitted to receive any distribution of trust 
principal from the trustee, and the termination of the trust is 
contingent on events beyond her control.  We do not discern from 
the trust language any intent for Misiaszek to benefit 
personally from any distribution of the trust principal.15 
 
15 To underscore this point, the terms of the Misiaszek 
trust stand in stark contrast with those of the trust at issue 
in Petition of Estate of Braiterman, 169 N.H. 217 (2016) 
(Braiterman), a case cited by MassHealth.  In Braiterman, the 
New Hampshire Supreme Court similarly considered whether assets 
held in an irrevocable trust were countable in determining the 
settlor-applicant's eligibility for Medicaid benefits.  Id. at 
218.  As in this case, the applicant in Braiterman held a 
limited power under the trust -- there to appoint the trust 
principal to any one or more of her children, who together 
24 
 
"In determining the meaning of a contractual [or trust] 
provision, the court will prefer an interpretation 'which gives 
a reasonable, lawful and effective meaning to all manifestations 
of intention, rather than one which leaves a part of those 
manifestations unreasonable, unlawful or [of] no effect.'"  
Ferri, 476 Mass. at 654-655, quoting Siebe, Inc. v. Louis M. 
Gerson Co., 74 Mass. App. Ct. 544, 550 n.13 (2009).  Applying 
Pitman and § 19.16 of the Restatement (Third) of Property (2011) 
to this case, we construe the trust at issue as providing that 
Misiaszek, as the donee of the limited power of appointment, may 
not exercise the power for her benefit by appointing the trust 
principal to a permissible appointee, such as a nonprofit 
nursing home, on the condition that the trust principal be used 
to pay for Misiaszek's long-term care.  As in Pitman, such an 
appointment would be motivated to benefit an impermissible 
 
constituted the class of permissible appointees.  Id. at 219-
220.  Unlike the Misiaszek trust, however, the Braiterman trust 
contained express language permitting the trustee, in the event 
the applicant's Medicaid benefits were jeopardized, to terminate 
the trust and distribute the trust principal to the appointees.  
Id. at 220.  As expressed in the terms of the trust, the 
settlor's "hope" was that the appointees would "supplement the 
income and the governmental benefits and services to which the 
[applicant] may be entitled."  Id.  The New Hampshire Supreme 
Court relied on this language to conclude that the trust assets 
were countable, as the plain terms of the trust "evince[d] the 
applicant's general intent that Trust disbursements be used for 
her benefit."  Id. at 227-228.  The Misiaszek trust does not 
contain any analogous provision; on the contrary, the terms of 
the Misiaszek trust evince Misiaszek's clear intent to place the 
trust principal out of her reach. 
25 
 
appointee -- in this case, both the donor and the donee of the 
limited power -- and thus would be ineffective as a matter of 
law as a "fraudulent exercise of [the] power."  Pitman, 314 
Mass. at 476.16  This constraint on Misiaszek's limited power is 
further evidenced by the plain terms of the trust, which state 
that the principal is to be held until the termination of the 
trust, at which time that principal is to be distributed to 
Misiaszek's children or their issue.  Accordingly, we conclude 
that the terms of the Misiaszek trust do not, under any 
circumstances, allow Misiaszek to exercise her limited power of 
appointment over the trust principal for her benefit, including 
 
16 MassHealth argues that "[S]tate law principles do not 
necessarily control the [F]ederal law analysis of Medicaid 
eligibility."  To the extent MassHealth's contention is that 
State trust and property law do not factor into our analysis, 
this argument is misguided.  We routinely have looked to 
established principles of trust and property law for guidance 
when applying the Federal "any circumstances" test for Medicaid 
eligibility.  See, e.g., Guilfoil, 486 Mass. at 800 (applying 
principles of property law to conclude that "the retention by an 
applicant of a life estate in his or her primary residence [held 
in trust] does render the property a countable asset" for 
Medicaid eligibility determination); Guerriero, 433 Mass. at 
632-633, citing Restatement (Second) of Trusts (1959) ("there 
were no remaining circumstances in which the trustee retained 
discretion to pay out principal to" settlor for purposes of 
determining settlor's eligibility for MassHealth benefits).  
Because the Medicaid program is, by design, a partnership 
between the Federal and State governments, "Congress did not 
pass a [F]ederal body of trust law, estate law, or property law 
when enacting Medicaid.  It relied and continues to rely on 
[S]tate laws governing" the operation of trusts for purposes of 
determining an applicant's eligibility for Medicaid benefits.  
Lewis v. Alexander, 685 F.3d 325, 347 (3d Cir. 2012), cert. 
denied, 568 U.S. 1123 (2013). 
26 
 
by appointing the trust principal to a nonprofit or charity-run 
nursing home for the purpose of paying for her care. 
3.  Fiduciary duties.  In addition, we conclude that the 
terms of the Misiaszek trust do not permit Misiaszek to exercise 
her limited power of appointment for her benefit because doing 
so would require the trustee to violate her fiduciary duties to 
Misiaszek's children as the ultimate beneficiaries of the trust 
principal. 
It is well-established that "a trustee holds 'full legal 
title to all property of a trust and the rights of possession 
that go along with it.'"  Ferri, 476 Mass. at 660, quoting 
McClintock v. Scahill, 403 Mass. 397, 399 (1988).  See Welch v. 
Boston, 221 Mass. 155, 157 (1915) ("It is one of the fundamental 
characteristics of trusts that the full and exclusive legal 
title is vested in the trustee").  Despite holding a limited 
power of appointment, Misiaszek cannot herself disburse the 
trust principal because she no longer holds legal rights to the 
home held in trust.  Practically speaking, then, Misiaszek would 
need to rely on the trustee to effectuate the appointment by 
having the trustee disburse the trust principal to the 
permissible appointee.17  Thus, in order for Misiaszek to appoint 
 
17 MassHealth does not contest this point, as it 
acknowledges in its reply brief that "it might be necessary for 
the [t]rustee to take some action to implement Misiaszek's 
exercise of the power of appointment" (emphasis in original). 
27 
 
any portion of the trust principal to a nonprofit nursing home 
as payment, the trustee "literally and figuratively" would need 
to write the check to facilitate the appointment.18 
This act, however, would violate the trustee's fiduciary 
duties to Misiaszek's children as the ultimate beneficiaries of 
the trust principal.  Article 4.9 states that "[a]ll powers and 
discretion given to [the] trustee are exercisable only in a 
fiduciary capacity, in accordance with reasonable discretion."  
In addition, the trustee is required by the Massachusetts 
 
 
18 The parties dispute whether this action by Misiaszek 
would constitute a "power to direct" under G. L. c. 203E, § 808, 
added by St. 2012, c. 140, § 56.  See note 19, infra 
(application to existing trusts).  That statute provides, "A 
person who holds a power to direct is presumptively a fiduciary 
who is required to act in good faith with regard to the purposes 
of the trust and the interests of the beneficiaries."  G. L. 
c. 203E, § 808 (c).  A "power to direct" refers to a power the 
settlor grants to a person other than the trustee with respect 
to the administration of the trust.  See A.M. Hess, G.G. Bogert, 
& G.T. Bogert, Trusts and Trustees § 138 (rev. 2d ed. Supp. 
2020).  This individual, commonly known as a "trust director," 
can be given powers "to direct the trustee in acts of 
investments, distributions, and borrowing and lending money," or 
even "the power to remove and replace the directed trustee or 
amend the trust instrument."  Id.  Notwithstanding the dearth of 
case law interpreting this statute, we note that the terms of 
the Misiaszek trust do not grant Misiaszek any express power to 
"direct" the trustee.  Indeed, article 2.2 states that Misiaszek 
may exercise her limited power "by an instrument in writing by 
[herself]."  Rather, Misiaszek would rely on the trustee, as a 
practical matter, to effectuate her appointment, as it is the 
trustee who holds legal title to the trust assets.  Accordingly, 
we agree with MassHealth that G. L. c. 203E, § 808 (c), does not 
apply here. 
28 
 
Uniform Trust Code19 to "administer the trust solely in the 
interests of the beneficiaries."  G. L. c. 203E, § 802 (a).  See 
G. L. c. 203E, § 801 ("Upon acceptance of a trusteeship, the 
trustee shall administer the trust in good faith, in accordance 
with its terms and purposes and the interests of the 
beneficiaries" [emphasis added]).  "If the trustee violates any 
duty to a beneficiary, the trustee will be liable for 'breach of 
trust.'"  Guerriero, 433 Mass. at 632, citing Restatement 
(Second) of Trusts § 201 (1959).  Because an appointment of the 
trust principal to a nonprofit or charitable nursing home as 
payment for Misiaszek's care would be solely for Misiaszek's 
benefit, and Misiaszek herself is an impermissible appointee, 
the trustee would not be able to effectuate the appointment 
without exposing herself to civil liability for violating her 
fiduciary duties to Misiaszek's children.  These concerns 
further underscore our conclusion that the plain terms of the 
Misiaszek trust neither intend for nor permit Misiaszek to 
exercise her limited power of appointment for her benefit as 
contemplated by MassHealth. 
 
 
19 The Massachusetts Uniform Trust Code (MUTC) took effect 
July 8, 2012.  See St. 2012, c. 140.  Pursuant to its enabling 
legislation, except as otherwise provided, the MUTC's provisions 
"apply to all trusts created before, on or after the effective 
date" of the act.  Matter of the MacMackin Nominee Realty Trust, 
95 Mass. App. Ct. 144, 149 (2019), quoting St. 2012, c. 140, 
§ 66 (a) (1). 
29 
 
Conclusion.  For the foregoing reasons, we affirm the 
judgment of the Superior Court. 
 
 
 
 
 
 
 
Judgment affirmed.