Spousal Refusal: What It Is, How It Works, and Where It Applies

Spousal refusal is the name commonly given to a spouse living at home declining to make his or her assets or income available for the other spouse's nursing-home Medicaid. Whether a state accepts it depends on that state's own rules, and under 42 U.S.C. § 1396r-5(c)(3) two of the three situations in which the institutionalized spouse is not ineligible by reason of deemed resources involve the state's rights to support from the spouse at home.

Most people facing this question are married to someone who has just moved into a nursing home, or are an adult child watching a parent at home try to work out what will be left to live on. Somewhere in their reading, the phrase "spousal refusal" appeared as if it were a simple form that keeps the family's savings safe. The real picture is more conditional than that, and it turns on federal spousal-impoverishment law, the state's right to pursue support and the rules of the state where the application is filed.

What Spousal Refusal Means Under Federal Medicaid Law

Two terms come first. The institutionalized spouse, under 42 U.S.C. § 1396r-5(h)(1), is in general a person in a medical institution or nursing facility who is married to a spouse who is not, and does not include a person unlikely to meet that requirement for at least 30 consecutive days. The community spouse is the spouse of an institutionalized spouse. Spousal refusal is the name commonly given to the community spouse declining to make his or her assets or income available to the institutionalized spouse for Medicaid purposes; the statute does not use the term.

That refusal operates inside a larger federal structure. Congress built the spousal-impoverishment rules, now at 42 U.S.C. § 1396r-5, so that the at-home spouse is not left with little or nothing by the cost of the other spouse's care. The Centers for Medicare & Medicaid Services describes these rules on its Spousal Impoverishment page as protecting "a certain amount of the couple's combined resources" for the spouse at home.

Federal law sets minimum protections, chiefly a resource allowance and a monthly income allowance, explained below. Each state, though, runs its own long-term-care Medicaid program, and whether a particular state accepts a spousal refusal depends on that state's own rules. A refusal does not by itself establish eligibility in any state.

How the Spousal Impoverishment Rules Set the Stage

Under 42 U.S.C. § 1396r-5(c)(1), the state totals the value of resources in which either spouse has an ownership interest "as of the beginning of the first continuous period of institutionalization," and computes a spousal share equal to half that total. This snapshot is often called the resource assessment, and either spouse may ask the state to make it, with notice of the right to a fair hearing.

Only countable assets go into that total: assets Medicaid counts toward its eligibility limit. Exempt assets are not counted. Section 1396r-5(c)(5) excludes resources that federal SSI rules exclude. The home has its own limit: under 42 U.S.C. § 1396p(f), long-term-care coverage is barred when home equity exceeds a limit, unless a spouse, a child under 21 or a blind or disabled child lives in the home. Federal home-equity limits for 2026 are a minimum of $752,000 and a maximum of $1,130,000, effective January 1, 2026, per the CMS 2026 standards bulletin.

The community spouse resource allowance (CSRA) is the amount by which the greatest of the figures listed in 42 U.S.C. § 1396r-5(f)(2)(A) exceeds the resources otherwise available to the community spouse. Those figures include the lesser of the spousal share and a dollar cap that is indexed each year, and amounts set at a fair hearing or by a court order. The federal 2026 standards are a minimum of $32,532 and a maximum of $162,660, effective January 1, 2026. The minimum monthly maintenance needs allowance (MMMNA) is the monthly income level that the at-home spouse's income can be raised to. The community spouse monthly income allowance is the amount by which the MMMNA exceeds the at-home spouse's other monthly income, and it comes out of the institutionalized spouse's income only to the extent that income is made available to the at-home spouse (42 U.S.C. § 1396r-5(d)). The 2026 federal figure is $2,705 (Alaska $3,381.25, Hawaii $3,111.25), effective July 1, 2026, with a maximum of $4,066.50 effective January 1, 2026. A state's own figures apply from the dates that state sets.

Resources above the greatest of the figures in § 1396r-5(f)(2)(A) are the ones the rule treats as available to the institutionalized spouse, as explained next. That is where spousal refusal comes up. The site's page on Medicaid spend-down covers spend-down itself.

How Spousal Refusal Works in Practice

Deeming is the starting point. Deeming means Medicaid treats one person's assets as available to another. Under 42 U.S.C. § 1396r-5(c)(2), at the time of application, all resources held by either spouse are considered available to the institutionalized spouse to the extent they exceed the amount computed under subsection (f)(2)(A), "regardless of any State laws relating to community property or the division of marital property."

In a spousal refusal, the community spouse declines to make those assets or income available. Whether and how a state accepts that depends on the state's own rules.

The federal hook sits in 42 U.S.C. § 1396r-5(c)(3). It says the institutionalized spouse "shall not be ineligible by reason of resources" deemed available where the institutionalized spouse has assigned to the state any rights to support from the community spouse; or lacks the ability to sign an assignment because of physical or mental impairment, but the state has the right to bring a support proceeding without one; or the state determines that denial "would work an undue hardship."

The first two of those situations keep the state's rights to support from the community spouse in place, and the form, the process and how a state uses those rights depend on that state's own rules.

Which States Allow Spousal Refusal

Whether spousal refusal is accepted at all is a state question, answered by each state's own Medicaid program rules. Federal law supplies the framework in § 1396r-5(c)(3); what a particular state accepts, and in what form, depends on that state's own current rules.

The answer in one state does not carry over to another. A couple who owned property in two states, or a parent who moved to be near an adult child, can find that the state of application matters more than either of them expected. State rules also change through legislation, regulation and agency policy, so the current status in any state turns on that state's program as it stands when the application is filed. For the deepest state coverage on this site, see the pages on California Medi-Cal asset limits and Florida Medicaid planning.

The State's Right to Pursue the Community Spouse

Under § 1396r-5(c)(3), the institutionalized spouse is not ineligible by reason of the deemed resources where support rights have been assigned to the state; where the institutionalized spouse cannot execute an assignment because of physical or mental impairment but the state has the right to bring a support proceeding against the community spouse; or where the state determines that denial of eligibility would work an undue hardship.

A support proceeding against the community spouse is the kind of claim (c)(3)(B) names. How a state uses those rights depends on that state's own rules.

Section 1396r-5(c)(3) does not state an amount or limit for a support claim.

Estate recovery is a separate mechanism. It means the state recovers Medicaid costs from a deceased recipient's estate. Under 42 U.S.C. § 1396p(b)(1), states must seek this recovery for certain individuals, including those who were 55 or older when they received nursing facility services, home and community-based services and related hospital and prescription drug services; CMS's Eligibility Policy page lists the same services. Federal law delays recovery, but does not cancel it, while a surviving spouse, a child under 21 or a blind or disabled child survives. A support claim against a living community spouse and a claim against an estate are different things.

Spousal Refusal and the Look-Back Period

The look-back period is the window Medicaid reviews for gifts and other transfers for less than fair market value. Under 42 U.S.C. § 1396p(c)(1)(B)(i), the federal look-back is 60 months for transfers made on or after February 8, 2006, counted back from the date the person is institutionalized and has applied. A state's own look-back depends on that state's own rules.

A penalty period is a stretch of Medicaid ineligibility based on the uncompensated value of assets transferred. Under § 1396p(c)(1)(D)(ii), it starts on the later of the month of the transfer and the date the person is otherwise eligible and would be receiving institutional-level care, so a gift made four years ago and one made last month inside the look-back are penalized the same way.

Transfers between spouses are treated differently. Under 42 U.S.C. § 1396p(c)(2)(B)(i), a transfer to the applicant's spouse carries no transfer penalty. The institutionalized spouse can therefore move assets to the community spouse without starting a penalty period.

The site's overview of Medicaid crisis planning places this in the wider picture.

What Spousal Refusal Does Not Cover

Several limits are worth naming plainly. Section 1396r-5(c)(3) keeps the state's support rights in place in two of its three situations. Estate recovery after the Medicaid recipient dies is a separate matter, governed by 42 U.S.C. § 1396p(b) and each state's own rules. Whether a state accepts a refusal depends on that state's current rules, which can change.

The form a state uses, if any, how it enforces its support right and how it handles income depend on that state's current program rules.

This page does not cover Medicare, private long-term-care insurance or veterans' benefits. It also does not cover Medicaid programs other than long-term-care Medicaid, such as MAGI-based Medicaid for working-age adults, which CMS notes does not use an asset test.

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Spousal refusal sits where three sets of rules meet: the federal spousal-impoverishment allowances, the state's right to seek support from the spouse at home, and the particular state's program. For readers who are still sorting out whether the question is about Medicaid at all, the overview of what a Medicaid planning attorney does may be a gentler place to begin.

To request a consultation about your family's Medicaid and long-term-care options, contact Medicaid Asset Protection Group.