In 1996, Sanford Okura, the founder of Okura & Associates, did some estate planning for his own mother, Kishiye Okura. She had suffered a stroke earlier, and was paralyzed on the right side of her body. She was not wealthy. She owned her home and some bank accounts. In analyzing his mother’s estate, Mr. Okura realized that the greatest threat to her estate was not estate taxes, because she did not have enough assets to be taxed by the estate tax. Probate would have been an inconvenience, but would cost only a few thousand dollars. He realized that the greatest threat to mother’s estate was potential nursing home costs. He was already specializing in estate planning, but then began his study of Elder Law. He devised an estate plan for his mother which would protect her home from Medicaid liens if she ever had to enter a nursing home.

Later, after suffering a second stroke, Kishiye Okura lived for a while with her son, then her daughter, then her son again. She then became so incapacitated that it became necessary to admit her into a nursing home. Sanford Okura applied for Medicaid for his own mother to pay the very expensive monthly nursing home bill. To his surprise, the Medicaid application was denied. The Medquest office claimed that an earlier transfer of assets by Kishiye Okura had created a penalty period which had not yet expired. Sanford rechecked his calculations and confirmed that the penalty period had expired, and that his mother’s application should have been approved. He asked the Medquest office to show him the table they used to calculate the value of the property interest which his mother had transferred. When he received a copy of their table, he discovered that they were using the wrong table! Mr. Okura had obtained his copy of the table directly from the Health Care Finance Administration, which was the agency of the federal government then in charge of the Medicaid program. He gave to the Medicaid eligibility worker a copy of the correct table. It was forwarded to the office in the Department of Human Services which writes and interprets the Hawaii Medicaid rules. They reviewed the table. The answer came back: they had made a mistake, and Kishiye Okura’s Medicaid application is approved. Mother died in 1998, but her legacy lives on. To Sanford’s knowledge, as a result of his own mother’s case, the Medquest offices throughout the State of Hawaii began using the correct table to perform the kind of calculations which were necessary for his mother’s Medicaid application.

Since then, Sanford and other attorneys at Okura & Associates have studied the complicated federal and state Medicaid laws much more carefully.  We have had other Medicaid applications which were initially denied by a Medicaid eligibility worker, but which were later approved after the denial was challenged by our law firm. We do not at all blame the Medicaid eligibility workers or the Medquest office that interprets the Medicaid rules. Their job is so difficult, the federal and state Medicaid laws are so complicated, and the workers are often so overworked, that it is understandable that they sometimes make mistakes.  We have found that most Medicaid workers take their jobs seriously and sincerely do their best under difficult circumstances.  When we use creative techniques to protect assets from nursing home costs and to qualify a client for Medicaid benefits, we try to work cooperatively with the Medicaid workers to show them why the technique is legal. We have a good relationship with a number of Medicaid workers, and try to work harmoniously with them. Occasionally, we have to disagree and appeal their decision.

Protection Of Assets From Nursing Home Costs

A study by the Kaiser Family Foundation in 2003 found that if you are 65 years of age or older, there is a 45% chance that you will spend some time in a nursing home. The study also found that the average nursing home stay is 2.4 years. The State of Hawaii in November 2008 determined that the average nursing home cost in Hawaii is $8,850 per month. That amounts to $106,200 a year. For the average nursing home stay of 2.4 years, the cost would be $254,880! This means that 45% of the population who are over 65 years of age, face potential nursing home costs of $254,880!

For the person who is not a multi-millionaire, the greatest threat to the estate is not probate. It is not estate taxes. The greatest threat is nursing home costs.

Okura & Associates specializes in protecting assets from nursing home costs. For a client who does not need to enter a nursing home right away, we use long range planning techniques to protect the home from Medicaid liens. For a client who is already in a nursing home or about to enter a nursing home, we use creative techniques to protect as much of the assets as possible, and to get the client qualified for Medicaid as soon as possible. We have had many clients marvel that we have been able to quickly get them qualified for Medicaid for nursing home costs, when they thought they would have to spend down their assets to almost nothing. We probably do more Elder Law planning to protect assets from nursing home costs than any other law firm in the State of Hawaii.

Call us to protect your assets from nursing home costs.

Medicaid and Nursing Home Costs Articles

Is Medicaid Going Away?

Is Medicaid Going Away?


Ethan R. Okura & Carroll Dortch

There has been a lot of political changes in the federal government over the past year. With a Republican president in office and a Republican majority in Congress, some people are concerned about losing the expansion of health care benefits that the Affordable Care Act (Obamacare) provided for. Recently, one of the most frequent questions that we are asked by our clients is: Will read more

Hawaii Real Property Tax Exemptions

Did you know that there are some exemptions that you can employ to save on your property taxes in Hawai‘i? One of the most commonly used exemptions is the real property tax exemption for homeowners. If you own a home in Hawai‘i, your property tax exemption is based on a variety of considerations regarding your intent to reside in the home. Some of these include:

1) You occupy your home for a minimum number of calendar days in a year — read more

Legislative Update: New Elder Care Laws Passed

Recently, the Hawaii State Legislature passed two bills that affect our elderly population and their health care. One was Senate Bill 534, the Kupuna Caregivers Act; the other was House Bill 1396, Relating to Community Care Foster Family Homes, both of which were signed into law by Governor Ige this session.

Kupuna Caregivers: One of the most difficult things that many people here in Hawaii face is trying to provide in-home care for their aging read more


Last month we talked about the different types of nursing homes and long-term care facilities available in Hawaii. We covered ARCH, Adult Foster Homes, and Nursing Homes. There are also assisted-living facilities, which we did not discuss, but which are an important component of elderly care. Assisted-living facilities are especially helpful for those who don’t have family members who can help them to stay read more


We have had hundreds of clients over the years who have gone to nursing homes to provide for their care as they aged. Some of them lived full, rich, engaged lives in the nursing home until the very end. Others suffered from severe physical disabilities or dementia that prevented them from actively interacting with the world as meaningfully as they would have liked. Clients often are confused by the different types read more