Supplemental Needs Trusts:  A Malpractice Trap for the Unwary Plaintiff Attorney
©  2004
by:  Jay J. Sangerman


 Supplemental needs trusts can be an excellent planning tool for the receipt of funds from a medical malpractice or personal injury action.  By means of the supplemental needs trust, the amount of the award can be multiplied many times through the ability to retain Medicaid and Supplemental Security Income (SSI) benefits.  Therefore, the plaintiff's needs may be better met with a supplemental needs trust and the retention of such benefits, than solely upon reliance of the award itself.  Another benefit of the supplemental needs trust is that the plaintiff attorney may be able to settle an action, which otherwise the client would be unwilling to settle due to unreasonable settlement expectations.  Notwithstanding the benefits of supplemental needs trusts, improper planning related to supplemental needs trusts can expose the plaintiff attorney to the risk of malpractice.  This article is intended to highlight some of those risks, discuss the due diligence which the plaintiff attorney may deem necessary to undertake and offer suggestions for avoidance of potential legal malpractice.


 Under New York State and federal law, the following are the requisites for the creation of a supplemental needs trusts:

  • It may be established only for a person under the age of 65 years. 
  • The intended trust beneficiary must be disabled pursuant to section 1614(a)(3) of the federal social security act, i.e., unable to engage in gainful employment, or will be unable upon achieving the age of majority.
  • The trust must be created by a parent, grandparent, legal guardian, or court.  The individual cannot create the trust for him/herself, nor can the prospective trust beneficiary's attorney-in-fact create the trust for the beneficiary.  1
  • There can be no additional payments to the trust once the individual reaches age 65.
  • Upon termination of the trust, the state will receive all amounts remaining in the trust up to the total value of all medical assistance paid on behalf of such individual.
  • Introduction
  •  The analysis behind the planning for, and drafting of, the supplemental needs trust, and related issues, often can be complex.  2The issues discussed in this article are the following: 

  • 1. The Medicaid Lien
  • a. Is there a Medicaid lien against the lawsuit proceeds?  If so, did the plaintiff attorney review the Medicaid lien for a determination of those charges which may not be legally subject to a lien?  The results of a proper review of the Medicaid lien details can produce dramatically different results.
  • b. Has the Medicaid lien been negotiated to a final settlement or is the unpaid lien deferred until the termination of the supplemental needs trust?  What did the plaintiff attorney tell the client and represent in court?  What does the client understand regarding payment of the lien?
  • 2. The Medicare Lien: Retroactive and Prospective.
  • a. Is the plaintiff 65 years of age or over and, therefore, a recipient of Medicare?  If the plaintiff is under the age of 65, legally disabled, worked and entitled to Social Security Disability, the plaintiff will be eligible for Medicare within the next 24 months.
  • b. Did the recovery include payment for causally related future medical needs?  If so, there may be a need for a Medicare Set-Aside arrangement for the payment of future medical needs, whatever the size of the recovery and whatever the cause of action.  Set-Aside arrangements are not only required in Worker's Compensation actions.
  • 3. The Structured Settlement.

a. Did the plaintiff attorney discuss with the client the advantages and disadvantages of a structured settlement?  Are those discussions memorialized for the client and the court? 

  • b. Did the plaintiff attorney consider the immediate cash needs, namely, costs associated with the litigation, payment of liens, cash needs of the plaintiff including, but not limited to, the purchase of a residence and vehicle, specialized wheelchair and/or surgery not sufficiently available through the Medicaid program?  Has the Medicaid lien amount been determined in writing prior to the purchase of a structure?  Is there an appropriate amount of upfront cash in the structured  settlement proposal?  What are the federal and state income tax implications of the matter settling with a structure?
  •   c. Did the plaintiff consider the provisions of General Obligations Law 5-1700 and Internal Revenue Code Section 5891?  If so, can the plaintiff assign the structured settlement periodic payments?  Did the insurance underwriter consider, and receive, a rated age for the plaintiff and, if so, is it reasonable?  Did the plaintiff attorney adequately consider the form of the structured payments:  period certain, life only, life with a guarantee? 
  • d. Does the settlement agreement and/or infant's compromise order comply with the Social Security rules for the payment of a structure into a supplemental needs trust?
  • 4. The Supplemental Needs Trust.

  a. Should there be a supplemental needs trust?  Have the plaintiff attorney and client undertaken a sufficient analysis?  Was private health insurance considered?

  • b. What may be included in the "pay-back" to Medicaid upon the termination  of the trust?  Is the negotiated Medicaid lien merely deferred?  Does the client know this?  Will the local Medicaid district seek payment for all Medicaid paid during lifetime, including those Medicaid provisions required under federal and state mandated free education provisions, and not only as of the date of the establishment of the trust?  What are the potential costs associated with the supplemental needs trust?  What is the cost/benefit analysis?
  •   c. What if the plaintiff/trust beneficiary moves to another Medicaid district?  Will the supplemental needs trust which had been approved comply with the rules of another Medicaid district?
  • d. Does the supplemental needs trust include provisions for court protection for the beneficiary or is the use of the funds in the supplemental needs trust subject only to the Medicaid district?
  • The thesis of this article is that, in the absence of the above analyses, memorialized in writing, and preferably "on the record," the plaintiff attorney can be subject to claims for legal malpractice, even after having attained an excellent settlement or verdict.  The moment that the plaintiff learns that the supplemental needs trust will not comply with the Medicaid rules in the jurisdiction to which s/he wishes to move, it is the plaintiff attorney who will be called to account.  The moment that the plaintiff realizes that, although the settlement is large, there is insufficient cash to enable the purchase of a house for a period of years, it is the plaintiff attorney who will be called to account.  The moment the plaintiff learns that s/he was not offered, or adequately explained, the income tax advantages of a structured settlement, to which the plaintiff could have taken advantage, it is the plaintiff attorney who will be called to account.  And the moment that the heirs of the plaintiff learn of a "pay back" against the supplemental needs trust, far in excess of that anticipated, it is again the plaintiff attorney who will be called to account.  Therefore, the analysis of the medical malpractice or personal injury action goes far beyond settling or winning a favorable verdict.


1. Medicaid Lien.

 Prior to the settlement of the lawsuit, the plaintiff attorney should ascertain the amount of the Medicaid lien, if any.  If there is a settlement on the record, or informally agreed to, it should be contingent upon the settlement of the Medicaid lien.  If the Medicaid lien needs to be negotiated, there is a loss of incentive for the Medicaid district to negotiate the lien after a settlement.  New York State law is clear that Medicaid has a right to collect its lien against the proceeds of the lawsuit prior to the funding of a supplemental needs trust; however, the local Medicaid district cannot (i.e., should not) seek reimbursement for (i) payments not causally related to the injury or (ii) educationally related payments which are mandated by both the federal and New York State governments to be provided within a free education.

 The plaintiff attorney should request a Claims Detail Report ("CDR") from the Medicaid district which identifies every service provided by Medicaid.  By analyzing the individual entries, together with the summaries, it should be possible to determine whether the services provided are causally related to the injury.  The second level of scrutiny is to determine if, although the services are causally related, the Medicaid services were provided pursuant to federally and state mandated free education. 

 Under federal and New York State law, New York State is required to give each student a free education.  The mandated free education for a disabled person includes services which could be considered "quasi-medical," e.g., physical therapy, occupational therapy, speech therapy, leg braces and wheelchairs.  Medicaid cannot collect for the payment of such services as part of its lien against lawsuit proceeds.  3  Under the New York State Education Law 4100ff, a free education must be provided to every child.  The free education set forth in the Education Law provides for children as of age three.  Under the Individuals with Disability Act (IDEA), 20 USCA 1400ff and Public Health Law, Article 25, Title II, New York State is required to provide educational and developmental related services to infants and toddlers.  Section 1401 provides definitions for those provisions which states are required to provide at no charge and which are not subject to a Medicaid lien against settlement proceeds.  These services and provisions include, but are not limited to, assistive technology devices, e.g., leg braces and related services, e.g., speech, audiology, physical and occupational therapy and transportation. 

 In the absence of a review of the CDR, it is impossible to ascertain whether the lien asserted by the local Medicaid district is accurate.  Especially in cases where the plaintiff has received services through Early Intervention, preschool or the board of education, it is an important aspect for closure of the matter to review the CDR in order to determine the accuracy of the asserted Medicaid lien.

 As discussed below, it is important to consider both the amount of the Medicaid lien asserted and the total amount of Medicaid services provided during the plaintiff's lifetime.  It is possible that the Medicaid district will seek to assert a lien against the supplemental needs trust, upon its termination, for all Medicaid paid during the plaintiff's lifetime, including non-causally related Medicaid, as well as the remainder of any "reduced" or "compromised" Medicaid lien negotiated prior to the establishment of the supplemental needs trust.

II. The Medicare Considerations: Retroactive Lien and Prospective Payments.

A. Retroactive Lien.

  • Because Medicare had not actively pursued its liens until recently, it is easy for the plaintiff attorney not to consider whether there is a Medicare lien against the lawsuit proceeds.  If the plaintiff is over the age of 65 and received medical care, it is likely that Medicare paid for some of the causally related medical care.  If the under 65 years of age plaintiff had been employed prior to the cause of action and, as a result of the lawsuit is unable to engage in gainful employment, it is likely that the plaintiff has applied for, or is a recipient of, Social Security Disability payments.  Once an individual has been a recipient of Social Security Disability for a period of 24 months, plus a six month waiting period prior to receipt of Social Security Disability, the individual is eligible for Medicare.  In these foregoing instances, it is necessary to obtain the amount of the Medicare lien.  The plaintiff's attorney can be held liable to Medicare for the non-payment of the Medicare lien.  4

B. Prospective Needs and Payments.

 Plaintiff attorneys must also consider the plaintiff's prospective medical needs which are causally related to the injury.  Recovery funds may need to be "Set-Aside" for payment of these future medical needs.  Although such medical care ordinarily would be covered by Medicare, because of the plaintiff's personal injury or medical malpractice settlement, prospective causally related medical care may not be paid for by the Medicare program.  Pursuant to federal regulations, the plaintiff attorney, and anyone else involved in the lawsuit, can be held liable by Medicare for not having considered Medicare's interests in the lawsuit.

 If the recovery is a (i) Worker's Compensation (WC) action, (ii) a commutation case (intended to compensate individuals for future medical expenses), (iii) is in excess of $250,000.00 and (iv) the plaintiff is either a recipient of Medicare or has a “reasonable expectation” of Medicare enrollment within 30 months of the settlement, there must be consideration with Medicare for a "set-aside" of funds for future medical care which otherwise would be paid for by the Medicare program. 5  However, WC cases are not the only instance for set-aside arrangements.  In any action, whether WC or not, and no matter what the size of the recovery, there could be a need for a Set-Aside arrangement for future medical needs.  If funds are not "set-aside," then Medicare may preclude its payments pursuant to 42 CFR 411.46.  

 The Centers for Medicare and Medicaid Services (CMS) Regional Office will review a proposed settlement in WC cases, above the thresholds and criteria set forth above, including a Set-Aside arrangement and will give a written opinion on which the potential beneficiary and the attorney can rely, regarding whether the WC settlement has adequately considered Medicare’s interests per 42 CFR 411.46.  If requested, CMS might be willing to review other matters which are not WC and/or do not come within the above thresholds.

III. The Structured Settlement.

 A. The structured settlement can be a great tax planning tool, increasing the over-all benefit of the lawsuit proceeds.  Pursuant to Internal Revenue Code Section 104(a)(2), all payments from a structured settlement are income tax free, effectively increasing the value of the award.  Additionally, the structure may provide additional protection to the plaintiff in a bankruptcy proceeding.  6  The failure to consider a structure can impose upon the plaintiff attorney significant legal malpractice liability, as occurred in a matter in Texas.  Similarly, not designing the structure consistent with the plaintiff's needs, or not explaining both the positive and negative benefits of a structure, can similarly impose liability upon the plaintiff attorney.

 Whenever considering a structured settlement, plaintiff attorneys should consider the requirements, and implications, of Section 5-1700 of the New York State General Obligations Code and Section 5891 of the Internal Revenue Code.  Both statutes are developments of anti-factoring legislation, which are intended to protect plaintiffs from being influenced to sell or assign their structured settlement payments.  Furthermore, the statutes impose caution on the part of plaintiff attorneys both in the design of the settlement proceeds and in the provisions to be included in the documentation settling the matter, e.g., the settlement agreement and the infant's compromise order.

 Section 5-1700 of the General Obligations Law, known as the "Structured Settlement Protection Act," requires that the defendant disclose to the plaintiff, inter alia, the following:

  • The payment details as to the structure.
  • The amount of premium payable to the annuity issuer.
  • Whether any transfer of the payments is prohibited by the terms of the structured settlement.
  • A statement from the defendant that the plaintiff is advised to obtain independent professional advice relating to the legal, tax and financial implications of the settlement.
  • The Structured Settlement Protection Act describes the procedure required for the transfer of a structured settlement, including that the payments from a structured settlement cannot be transferred for consideration, i.e., factored, except upon order of a court of competent jurisdiction.  The plaintiff attorney is best protected if s/he informs the plaintiff of the transfer provisions set forth in the Act.  Equally important is the language of the settlement documents.  While the Structured Settlement Protection Act has certain restrictions upon the ease of the transfer of the structured settlement annuity, the Structured Settlement Protection Act is also permissive, i.e., setting forth a process whereby an application can be made to court to factor the structured settlement.  Case law holds that if the terms of the settlement documents prohibit such transfer, the settlement documents override the Structured Settlement Protection Act.  7
  •  Section 5891 of the Internal Revenue Code is similarly intended to place restrictions on the transfer of structured settlements.  Therefore, under the Internal Revenue Code, if the structure is transferred for consideration in the absence of a court order, there is a tax equal to 40% of the factoring discount imposed on the transferee on the transaction.  In New York State, the court order would need to be obtained pursuant to GOL 5-1700.

     Should the plaintiff decide to take the settlement as a structured settlement and have the settlement proceeds placed into a supplemental needs trust, then it is essential that the financial plan maintains Medicaid and SSI eligibility.  If the settlement documents, including the supplemental needs trust, are incorrectly drafted, the structure payments could be countable as income to the beneficiary for purposes of SSI and/or Medicaid eligibility.

      IV. The Supplemental Needs Trust.

      . Whether to establish a Supplemental Needs Trust.

     Not every case involving a disabled person requires a supplemental needs trust.  Every case, however, requires consideration of a supplemental needs trust.  The settlement may be large enough whereby the plaintiff's medical needs can be provided for without utilizing the Medicaid program, and without the restrictions the local Medicaid district may impose upon the use of the funds in the supplemental needs trust.  It is also possible that private health insurance, to which every resident of New York State is entitled without preexisting conditions 8, will be sufficient for the plaintiff's medical needs.  There is also the consideration of the pay-back provision in the supplemental needs trust.  Medicaid districts disagree as to the extent of the pay-back provision.  In a Medicaid district that requires a pay-back for all Medicaid provided during lifetime, the pay-back can be draconian, especially in the instance of an individual who had significant Medicaid benefits prior to the establishment of the supplemental needs trust, which amounts were neither causally related to the injury nor otherwise needed to be paid as a Medicaid lien from the lawsuit proceeds.

     The failure to recommend a supplemental needs trust can be cause for a malpractice claim, as occurred in a matter in Texas.  In the Texas case, neither the guardian ad litem, appointed by the court to consider the settlement and the manner in which the settlement should be paid, nor the plaintiff attorney, informed the plaintiff about the possibility of a structured settlement and/or a supplemental needs trust.  The legal malpractice claim settled and the insurance carriers for both attorneys paid settlement amounts.  The plaintiff attorney should inform the client of the advantages and disadvantages of both a supplemental needs trust and a structured settlement.  Such discussion should be memorialized.  In a matter in which either or both the structured settlement and/or the supplemental needs trust is not to be used, the fact of such discussion, and the client's decision, may be included in the court transcript, or in the compromise order.

      B. Drafting issues with a Supplemental Needs Trust.

     A form supplemental needs trust is available in Justice Leone's decision in In re Morales9  However, in the more than nine years since the Morales decision, there has been an opportunity to observe supplemental needs trusts administration and the problems that can develop from poor administration.  Since trust administration is governed by the provisions of the trust, careful drafting is extraordinarily important. 

      C. Need for Portability.

     Certain New York State Medicaid districts, and Medicaid districts in other states, have developed rules and guidelines for what may, and may not, be included in a supplemental needs trust, as has the Social Security Administration.  Unfortunately, many of these guidelines are informal and not available in printed form.  In New York State, there is no consistency among the counties for how a supplemental needs trust should be drafted.  Therefore, a trust that is drafted to meet the requirements of one New York State county may not be acceptable in another New York State county.  As a result, it is necessary to provide for portability among the provisions in a supplemental needs trust, so that the trust can be amended, as necessary, should the trust beneficiary move to another state or another county in New York State.

     The issue of "portability" was among the issues litigated in In re Cano. 10   In Cano, the plaintiff submitted a supplemental needs trust which included the opportunity to amend the trust.  The Department of Social Services of the City of New York objected, inter alia, to such provision.  The court upheld the trust provisions.  DSS argued that the only mechanism for amending a trust is the statutory provision found in Estates, Power and Trust Law Section 7-1.9.  The Cano court disagreed, stating:

  • T]he Court is constrained to agree with the plaintiffs that EPTL 7-1.9, which requires that amendment be consented to by the settlor and all those beneficially interested in the trust, is not capable of strict application to a trust established for the benefit of a party incapable of providing such consent.  Moreover, it would violate public policy to  permit a Supplemental Needs Trust to be construed in such a way as to prevent the family of a disabled person from moving freely to another state without jeopardizing the disabled's ability to receive entitlement payments.

     EPTL 7-1.9(a), the New York State statute for amending an irrevocable trust, states that an irrevocable trust can be amended by the creator of the trust upon "the written consent . . . of all the persons beneficially interested in a trust of property."  Therefore, if EPTL 7-1-9 were the sole avenue for amending an irrevocable trust, the trust could never be amended in a situation where (i) the beneficiary is an infant and/or mentally disabled 11 and/or (ii) the creator of the trust refuses to amend the trust or is deceased or mentally disabled.  12  As the plaintiff in Cano argued, EPTL 7-1.9(a) is a "savings statute" which controls only when the trust instrument does not provide for amendments to an irrevocable trust.  13  A properly drafted supplemental needs trust will provide for such amendments to the trust, beyond those provided by EPTL 7-1.9(a).  Without specific amendment provisions in the trust instrument, irrevocable trusts may not be able to be properly administered nor able to properly protect the interests of the trust beneficiary.
  • D. Court Control.

     In Cano, The Department of Social Services of the City of New York argued that the Court should not be involved in the administration of the trust, should not supervise or over-see the trust administration, but the Court should be involved if and only if The Department of Social Services of the City of New York  seeks to sue the trustee.  The Court responded:

  • The position of DSS with respect to its apparent belief that the Court should exercise no such oversight, except in response to applications brought by DSS, must be vehemently rejected.  Just as a Supplemental Needs Trust may not be used to abrogate or circumvent the protections of a guardianship, Matter of  Greenstein [Hope Graham] 195 Misc 2d. 628, it cannot be used to abrogate the Court's responsibility to its infant wards.  See DiGennaro v. Community Hospital of Glen Cove, 204 AD 2d 258 (Second Dept, 1994) [the Court approving a Supplemental Needs Trust must provide for Court approval of withdrawals by the Trustees, and require accountings to the Court on an annual or biannual basis].
  • The heart of the issue litigated in Cano was whether DSS should have de facto control of the trust administration, including how the trust funds should be utilized for the beneficiary.  DSS' interests in a supplemental needs trust can be adverse to that of the disabled trust beneficiary.  DSS' concern may be the preservation of its remainder interest, whereas the trust should have a balance between the interests of DSS and of the disabled trust beneficiary.  Without the protection of the court, the trust beneficiary's interests may not be protected.  For instance, should DSS object, or not consent, to certain purchases as a trust asset, or from the trust corpus, such as a house or a van, the payment for such items would be at the peril of the trustee, who would be subject to an action for surcharge, and possibly hesitant to make such purchases.  The Cano court stated:
  • Although the Court is sympathtic with the assertion that the Supplemental Needs Trust should not be micro-managed by the Court, there is a competing and superseding interest implicated herein, which is the Court's supervisory and protective role with respect to an infant plaintiff.  Valdimer v. Mount Vernon Hebrew Camps Inc., 9 N.Y. 2d 21. 
  • Court control can create greater opportunity for effective trust administration for the protection, and to the benefit, of the beneficiary.  Accountings to the court, and their review by the court, protects all concerned: the trustee, the beneficiary and DSS. 
  • Conclusion

     Supplemental needs trusts and related planning are important aspects in the planning for the placement of the proceeds from medical malpractice and personal injury recoveries.  As set forth in this article, such planning requires the same detailed attention by the plaintiff attorney as the litigation itself.  The opportunity to plan for the placement of tort proceeds with the use of supplemental needs trusts is only beginning its second decade and the law is still developing.  The interaction of the supplemental needs trust, the Medicaid and Medicare liens, and the structured settlement need to be considered in the planning for the settlement proceeds.  Inadequate planning can not only hurt the client, but can create the risk for legal malpractice

     Jay J. Sangerman's firm, Jay J. Sangerman, PLLC, is a boutique law firm which practices in the areas of trusts and estates and elder law.  The firm is listed in The Bar Register of Preeminent Lawyers published by Martindale-Hubbell.  A significant aspect of the practice is involved in assisting plaintiff and defense attorneys in case settlement through estate planning, including the use of supplemental needs trusts.  The firm practices in New York, Florida and New Jersey.  He is certified by the states of New York and Florida to present CLE programs on “Expediting a Settlement Through The Use of Supplemental Needs Trusts.”  Jay J. Sangerman is an Adjunct Assistance Professor of Estate Planning and Gift Taxation at New York University School of Continuing and Professional Studies. 


    1. Establishment of First Party Supplemental Needs Trust, N.Y.L.J., Outside Counsel, June 2, 2003, Vol. 229, pg. 1, col. 1.

    2. First Party Supplemental Needs Trusts: The Second Decade, N.Y.L.J., July 26, 2004, Vol. 17, pg. 9.

    3. See, e.g., Andree v. The County of Nassau, E.D.N.Y., N.Y.L.J., April 9, 2004, holding "that DSS's [sic] placement of a lien on settlement or personal injury awards received by a disabled student to pay for services that are mandated to be provided free of charge to such students is a violation of IDEA"; Hannah v. NYC Housing Authority, Supreme, Kings, N.Y.L.J, June 26, 2001.

    4. See U.S. v. Weinberg, U.S. District Court for the Eastern District of Pennsylvania, July 1, 2002.

    5. Medicare regulations at 42 CFR 411.46 state that:

       If a lump-sum compensation award stipulates that the amount paid is intended to compensate the individual for all future medical expenses required because of the work-related injury or disease, Medicare payments for such services are excluded until medical expenses related to the injury or disease equal the amount of the lump-sum payment.

    6. See, e.g., In re: Daniel F. Terrance, United States Bankruptcy Court, Northern District of New York.

    7. See, e.g., Matter of Emerald Funding Corp., N.Y.L.J. June 12, 2003, page 25, wherein the court held that it is the settlement agreement, i.e., the contract, which controls.

    8. New York State Insurance Law 3232(a) and 4318(a).

    9. N.Y.L.J., July 28, 1995, at 25, col. 1.

    10. DSS filed a notice of appeal in the Appellate Division, First Department and, thereafter, withdrew the appeal.

    11. See, e.g., In re Dodge, 25 N.Y.2d 273, 250 N.E.2d 849, 303 N.Y.S.2d 847 (1969) stating that the creator of the trust cannot amend or revoke the trust instrument due to the fact that infants are beneficially interested in the trust and that infants cannot consent.

    12. See, e.g., Werbelovsky v. Manufacturers Trust Company, 12 A.D.2d 793, 209 N.Y.S. 2d 564 (2nd Dep't 1961) in which the surviving settlor could not amend or revoke the trust because "[t]he trust instrument does not contain any power in a surviving settlor to revoke the trust;"  June Rosner v. Mildred Caplow, 90 A.D.2d 44, 456 N.Y.S.2d 50 (1st Dep't 1982), stating that a trust that did not contain any provisions for amendment, could only be amended pursuant to EPTL 7-1.9, which means that consent must be given by all settlors and all those beneficially interested in the trust.  Since one of the settlors was deceased, the trust could not be amended.

    13. See In re Joint Eastern and Southern Districts Asbestos Litigation, 878 F.Supp. 473 (E.D.N.Y. 1995) stating that the legislative history of New York Estates, Powers & Trusts Law 7-1.9 demonstrates that the statute was intended to enhance, not restrict, the modifiability of trusts. 


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