Medicaid Estate Recovery by State: Aggressiveness Scorecard

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Disclaimer: This page is for general educational purposes only and is not legal advice. Medicaid estate recovery rules are state-specific and change. Always verify current rules with your state Medicaid agency and a qualified elder-law / estate-planning attorney before making decisions.

Estate Planning Data & Research → Medicaid estate recovery scorecard

A 50-state + D.C. policy scorecard comparing how far state Medicaid estate recovery policies go beyond the federal minimum, built only from government sources: federal law and the state-plan review published by MACPAC, the congressional advisory commission on Medicaid.

When a parent needs long-term care, Medicaid often becomes the payer of last resort. Federal law requires states to seek recovery from the estates of enrollees who were 55 or older when they got nursing facility care, home and community-based services, and related hospital and prescription drug services. States may choose to recover for other Medicaid services too, to use liens, and to define the estate more broadly than the probate estate (42 U.S.C. § 1396p(b)).

This scorecard turns the state-plan differences MACPAC documented into a 0–100 score (higher = more optional recovery tools in the state plan). It is a research synthesis, not a prediction of what will happen in any one family.

Related planning context: nursing home costs & quality by state, protecting a parent’s legacy beyond a revocable trust, and the Family Estate Guide home page for wills, trusts, and probate basics.

Download

State scorecard CSV (50 states + D.C., each MACPAC policy flag and the score)

Cite this page URL when reusing findings. Not a substitute for state Medicaid manuals or legal advice.

Key findings

Federal law sets the floor: for enrollees 55 and older, states must seek recovery for nursing facility care, home and community-based services, and related hospital and prescription drug services, and may choose to recover for other state plan services (42 U.S.C. § 1396p(b)(1)(B)).
In MACPAC’s review of 2020 state plans, 36 states (counting D.C.) recover for non-mandatory services for people 55 and older, and 26 impose TEFRA liens on real property.
Hardship protections vary. 36 state plans list an income-producing asset as a hardship criterion, but only 8 list a home of modest value.
Recovery is delayed while a surviving spouse is alive, and while there is a surviving child under 21 or a child who is blind or disabled (42 U.S.C. § 1396p(b)(2)).
MACPAC’s table reflects 2020 state plans (published March 2021). Some states have changed their rules since, so check current state policy.

Highest scores (this model)

Connecticut — 100.0/100
Massachusetts — 100.0/100
Illinois — 90.0/100
Missouri — 90.0/100

Lowest scores (this model)

Arkansas — 15.0/100
Louisiana — 15.0/100
Pennsylvania — 15.0/100
South Carolina — 15.0/100
Vermont — 15.0/100
Mississippi — 0.0/100
New Mexico — 0.0/100
Virginia — 0.0/100

A low score means the state plan MACPAC reviewed showed few optional recovery tools. It does not mean the state skips the federally required recovery.

Scorecard table

“Not in plan reviewed” means MACPAC marked the item as missing from the state plan copy it reviewed. That is not the same as “no.”

State	Score (0–100)	Confidence	Recovers non-mandatory services (55+)	TEFRA liens	Post-death lien	Hardship: income-producing asset	Hardship: home of modest value
Connecticut	100.0	high	yes	yes	yes	no	no
Massachusetts	100.0	high	yes	yes	yes	no	no
Illinois	90.0	high	yes	yes	no	no	no
Missouri	90.0	high	yes	yes	no	no	no
Maryland	85.7	medium	yes	yes	no	not in plan reviewed	not in plan reviewed
Arizona	85.0	high	yes	yes	yes	yes	no
Hawaii	85.0	high	yes	yes	yes	yes	no
Idaho	85.0	high	yes	yes	yes	yes	no
Ohio	85.0	high	yes	yes	yes	yes	no
Utah	85.0	high	yes	yes	yes	yes	no
Alabama	75.0	high	yes	yes	no	yes	no
Delaware	75.0	high	yes	yes	no	yes	no
Indiana	75.0	high	yes	yes	no	yes	no
Kansas	75.0	high	yes	yes	no	yes	no
Montana	75.0	high	yes	yes	no	yes	no
New Hampshire	75.0	high	yes	yes	no	yes	no
Wisconsin	75.0	high	yes	yes	no	yes	no
California	70.0	high	yes	yes	yes	yes	yes
Iowa	70.0	high	yes	no	no	no	no
Kentucky	70.0	high	yes	no	no	no	no
Nebraska	70.0	high	yes	no	no	no	no
New York	70.0	high	yes	yes	yes	yes	yes
North Dakota	70.0	high	yes	no	no	no	no
Oregon	70.0	high	yes	no	no	no	no
District of Columbia	65.0	high	yes	no	yes	yes	no
Georgia	65.0	high	yes	no	yes	yes	no
Nevada	65.0	high	yes	no	yes	yes	no
New Jersey	65.0	high	yes	no	yes	yes	no
Rhode Island	65.0	high	yes	no	yes	yes	no
Maine	57.1	medium	yes	no	no	not in plan reviewed	not in plan reviewed
North Carolina	55.0	high	yes	no	no	yes	no
Tennessee	55.0	high	yes	no	no	yes	no
Texas	55.0	high	yes	no	no	yes	no
Wyoming	55.0	high	yes	no	no	yes	no
Michigan	50.0	high	yes	no	yes	yes	yes
Oklahoma	50.0	high	no	yes	no	no	no
South Dakota	50.0	high	no	yes	no	no	no
Minnesota	45.0	high	no	yes	yes	yes	no
Washington	45.0	high	no	yes	yes	yes	no
West Virginia	45.0	high	no	yes	yes	yes	no
Florida	40.0	high	yes	no	no	yes	yes
Colorado	35.0	high	no	yes	no	yes	no
Alaska	30.0	high	no	yes	yes	yes	yes
Arkansas	15.0	high	no	no	no	yes	no
Louisiana	15.0	high	no	no	no	yes	no
Pennsylvania	15.0	high	no	no	no	yes	no
South Carolina	15.0	high	no	no	no	no	yes
Vermont	15.0	high	no	no	no	yes	no
Mississippi	0.0	high	no	no	no	yes	yes
New Mexico	0.0	high	no	no	no	yes	yes
Virginia	0.0	medium	no	no	no	not in plan reviewed	not in plan reviewed

How the score works

Score = weighted average of the items below from MACPAC Appendix 3C, Tables 3C-1 and 3C-2. Items marked missing from the plan are left out and the remaining weights are rescaled. Confidence is “high” when all five items are present and “medium” otherwise.

Recovers non-mandatory services for people over 55 (40%): yes raises the score.
TEFRA liens (20%): yes raises the score.
Post-death lien (10%): yes raises the score.
Hardship criterion: income-producing asset (15%): yes lowers the score.
Hardship criterion: home of modest value (15%): yes lowers the score.

Not scored: each state’s cost-effectiveness threshold (MACPAC Table 3C-3 quotes these from state plans, but they aren’t in a comparable format), and whether a state uses the expanded, non-probate estate definition (no complete government 50-state table).

What families usually ask next

Will Medicaid take the house? Recovery happens only after death, and not while a spouse survives or there is a surviving child under 21 or a child who is blind or disabled. State liens and expanded-estate rules can change the practical answer.
Does a revocable living trust stop estate recovery? Federal law lets states count assets passed through a living trust as part of the estate (42 U.S.C. § 1396p(b)(4)(B)). See Protecting Your Parents’ Legacy.
How do nursing-home prices affect spend-down? Compare state nursing home costs.

Related research: SSI’s asset limit and special needs trusts, on how a special needs trust interacts with means-tested benefits.

Related research: Medicaid nursing home days by state shows who pays for nursing home care in every state.

Related research: Medicaid dollars per older resident by state compares 2025 Medicaid benefit spending in every state (BEA).

Sources

Medicaid and CHIP Payment and Access Commission (MACPAC), Chapter 3: Medicaid Estate Recovery—Improving Policy and Promoting Equity, Report to Congress, March 2021, Appendix 3C, Tables 3C-1, 3C-2 and 3C-3 (review of 2020 state plans): https://www.macpac.gov/wp-content/uploads/2021/03/Chapter-3-Medicaid-Estate-Recovery-Improving-Policy-and-Promoting-Equity.pdf
42 U.S.C. § 1396p (liens, adjustments and recoveries), U.S. Code via GovInfo: https://www.govinfo.gov/content/pkg/USCODE-2023-title42/html/USCODE-2023-title42-chap7-subchapXIX-sec1396p.htm

Scorecard published September 17, 2026; rebuilt October 15, 2026 using government sources only (MACPAC 2021 review of 2020 state plans; 42 U.S.C. § 1396p). State plans may have changed since 2020. Editorial standards.