Can 401K money be protected from Medicaid by turning into an annuity-monthly payments?

Yes, indeed it should be possible to convert the 401(k) assets to an immediate annuity that meets the "Medicaid annuity" rules. Each month, a fixed amount is payable to the annuitant, and is counted as income for Medicaid eligibility purposes. But the retirement asset itself will NOT be counted as an asset, assuming the annuity meets the rules. Note also that in some states IRAs and 401(k)s are exempt from being counted at all, for Medicaid eligibility purposes, (though in some states only for a spouse in the community vs the spouse in the nursing home) so be sure to check that out, first!

Caregiver9 - I'm assuming that your ? is about your doing something with your $ to get your joint assests to be within MA medicaid limits so your spouse can qualify for Medicaid. Is that it? If so, here's my suggestions.
NH Medicaid when it's for a widow / widower is pretty straightforward.... They gotta be impoverished & show the need for skilled nursing care. It's a buttrash of paperwork but imo can totally be a DIY by thier DPOA son or daughter of they have been involved in thier life. But for couples & thier Community Spouse situation - which it sounds like is your situation - its much much more complex. You need a NAELA level elder law atty as what is likely needed to b done will never ever be a DIY. Plus your focus will be so much on just dealing with day to day caregiving you won't have time or ability to do the mental math needed.

That being said, here's some things to look into now so that when you meet with your NAELA atty your more informed:
- doing a SPIA. Single premium immediate annuity done for you (not your wife). For NH Medicaid, your income does not enter the equation. But your assets do as they are viewed as joint. So if there is a way to convert assets to income stream for you it's a good move. But as Medicaid is involved for your bride, it will need to be Medicaid compliant product. Normally I hate hate hate annuities as they seem to be often sold at totally inappropriate terms to gullible, fearful elders. But a Medicaid compliant SPIA is a very unique insurance product. There is someone on this site who did this for himself as his wife had early onset dementia and now has been in a facility for years & his SPIA has been a good thing. So let's say that your state has CS max assets at $ 118k but you all have $ 300k in assets. The 182k becomes the SPIA which pays income to you that is done within actuarial tables & with state medicaid as the beneficiary (so Medicaid compliant). If you are somewhat on the younger side, it could well be that you outlive the annuity (like it has a 10 year payout). These type of annuities are speciality underwriting, so NOT to be done by your old insurance guy or a FA who isn't familiar with medicaid. Comprende?
- also you will need to get all your old legal reviewed & probably changed. Most couples have each other as thier life insurance beneficiary. Bad bad idea if one is on medicaid. Why? Well cause if you predecease her, that insurance $ will take her off medicaid. & who will deal with this for her?? So your beneficiary designations will liklely need to be all changed. Really the atty will know what needs to be done.
- you want to get the maximum CSRA / MMNA. I think of these as like alimony for the CS. If you have still a mortgage, heavy RX & medical costs for you, or other expenses that drain your $, thevatty can file for CSRA / MMNA for you that diverts your brides monthly income to go to you instead of being paid to the NH as her SOC (share of cost). Community spouse resource allowance. Monthly maintenance needs assessment.
Yeah it's not a DIY.

Medicaid does not expect the CS to themselves become impoverished but how to do this best needs savvy NAELA insight. AND done before she ever applies for Medicaid. Why? Cause for couples Medicaid usually does a snapshot day that your finances are fixed to. So if you need to move $ into a SPIA, pay off a mortgage, trade in 2 cars to buy 1 newer more dependable car (Medicaid allows 1 car only exempt), etc all needs to be done before the application submitted.

Really find a NAELA & set up an appointment. Good luck!

You do understand that the income from the annuity will be counted as income when they calculate your "share of cost" for Medicaid payment for long term care - the primary reason for changeover from 401K to annuity is to help move your assets below the Medicaid threshhold to qualify but it doesn't "protect the income from seizure". If you are worried about protecting money for a spouse still in the community, consult a lawyer that is experienced preferably certified in elder care and Medicaid in your state. If you have enough money to be concerned about protecting it from Medicaid, the money you pay a lawyer to create trusts, etc. will be wise investment. You want to do these things sooner rather than later as Medicaid will "look back" five years to see what kinds of transfers were made. For the record, Medicaid doesn't seize your assets. It requires that you pay money that you have available for care to the facility and caregivers that provide you aid. If you have money to private pay at a facility, that may get a Medicaid bed available to transition into at the time you need it more quickly. Many assisted living facilities do NOT take Medicaid. Some memory care facilities do not take Medicaid. So a lawyer that knows the in's and out's of the system is worth every penny.