SAGE: Advocacy & Services for LGBT Elders
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Spousal Impoverishment Protections Initiative

Medicaid serves as the single largest payer of long-term care in the United States, which is often necessary for older adults and people with disabilities who need institutional or in-home health services. Medicaid qualification rules include a series of “spousal impoverishment” protections that aim to prevent a healthy spouse from having to give up a family home or retirement savings, and live in poverty, in order to qualify his/her spouse for Medicaid. Married same-sex couples are now on equal footing with their heterosexual counterparts. Many coupled, LGBT, elders, however, remain unmarried for a variety of reasons. Those who are unmarried, may have access to some spousal impoverishment protections depending on the state in which they live.

Early Advocacy and 2011 Breakthrough

In 2009, SAGE, Lambda Legal and The National Gay and Lesbian Task Force began advocating with the Centers for Medicare and Medicaid Services (CMS) to issue guidance that extends the same spousal impoverishment protections to same-sex partners. In June 2011, before the nationwide freedom to marry ,CMS notified states that they are empowered to treat same-sex couples the same as married heterosexual couples when it comes to protection from "spousal impoverishment" under Medicaid. Thus, the responsibility for extending these protections rested with state advocates. Read the CMS guidance.

Original Research

Medicaid qualification rules vary across states, as do the related laws, regulations and sub-regulatory guidance of each state. Further, some states have broad relationship recognition laws, while many others have less recognition, even constitutional amendments forbidding marriage and civil unions for same-sex partners. Read recent research from The Williams Institute at UCLA School of Law explaining how states can implement these protections.

In New York State

SAGE successfully issued guidance in October 2011 to New York State on how it could extend spousal impoverishment protections in SAGE's home state, and a month a later, Governor Andrew Cuomo announced that these protections would be extended to same-sex partners in New York. The information about the extended real estate protections—Medicaid liens, estate recovery and transfer of asset rules—was made official in a letter sent from the New York Office of Health Insurance programs in November 2011. Read SAGE's White Paper on spousal impoverishment protections in New York.

To learn more about the Spousal Impoverishment Protections Initiative, please contact Aaron Tax, Director of Federal Government Relations, SAGE, at

SAGE would like to thank the Gill Foundation for their generous support of this initiative.

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