Medicaid Planning for Married Couples:
CSRA, Spousal Protections & Asset Strategies

Section 1: The Spousal Impoverishment Problem

Medicaid long-term care has one brutal design flaw for married couples: a spouse who needs nursing care typically must spend down nearly all marital assets before Medicaid pays a dollar. Without federal protections, the at-home spouse — still living, still paying bills, still decades from death — could be left with almost nothing while their husband or wife receives care.

Congress addressed this in 1988 with the Medicare Catastrophic Coverage Act, which established the spousal impoverishment protections still in effect today. These rules guarantee the community spouse (the at-home spouse) a minimum share of assets and a minimum monthly income, regardless of what Medicaid requires the institutionalized spouse to contribute.

The protections are substantial — but they are not automatic. You have to know them, invoke them correctly, and in many cases actively plan to maximize them. Families who don’t plan often leave tens of thousands of dollars on the table. Families who do plan can protect six figures in assets while still qualifying for Medicaid.

Section 2: The Community Spouse Resource Allowance (CSRA)

The Community Spouse Resource Allowance (CSRA) is the cornerstone of Medicaid spousal protection. It defines how much of the couple’s combined countable assets the at-home spouse gets to keep after the other enters a Medicaid-covered facility.

How the CSRA Is Calculated

The CSRA is determined through a process called the snapshot. Medicaid looks at the couple’s combined countable assets on the date the institutionalized spouse first enters a medical institution continuously for 30 days (the “snapshot date”). This is not necessarily the Medicaid application date — it’s often earlier, which matters for couples who moved from hospital to rehabilitation facility to nursing home.

From that combined total, each state applies its CSRA formula:

• Flat maximum states simply set the CSRA at the federal maximum ($154,140 in 2026), regardless of what the couple owned.
• Percentage states set the CSRA at 50% of combined countable assets on the snapshot date, subject to a minimum floor and the federal maximum cap.

After the CSRA: What the Institutionalized Spouse Keeps

Once the community spouse’s CSRA is set aside, the institutionalized spouse must spend down their remaining assets to $2,000 before Medicaid coverage begins. Assets above $2,000 in the institutionalized spouse’s name are considered available for care costs. This is why planning — particularly shifting assets into the community spouse’s name before the snapshot — matters so much.

Section 3: CSRA Limits by State — IL, WI, IN, OH, MI

The five-state region covered by Willwright includes both flat-maximum states and one percentage state. Here are the 2026 CSRA rules for each:

Illinois, Wisconsin, Ohio, and Michigan all use the flat maximum CSRA. This means the community spouse keeps $154,140 regardless of total assets — even if total joint countable assets were only $80,000 (in which case the community spouse keeps everything above the institutionalized spouse’s $2,000 limit).

Indiana uses the 50% formula. If a couple has $200,000 in combined countable assets, the community spouse keeps $100,000 (50%). If they have $340,000, the community spouse keeps $154,140 (the cap). If they have $50,000, the community spouse keeps $25,000 — but not less than the $30,828 federal minimum.

Section 4: The Minimum Monthly Maintenance Needs Allowance (MMMNA)

Assets are only half the picture. The Minimum Monthly Maintenance Needs Allowance (MMMNA) protects the community spouse’s income. Once one spouse enters a Medicaid facility, their income is directed largely toward the cost of care. The MMMNA ensures the at-home spouse retains enough monthly income to live on.

How the MMMNA Works

Medicaid first counts the community spouse’s own income (Social Security, pension, annuities, etc.). If that income falls below the MMMNA floor, the community spouse can receive a Community Spouse Monthly Income Allowance (CSMIA) — a portion of the institutionalized spouse’s income redirected to make up the shortfall.

In 2026, the federal MMMNA floor is $2,555/month. If the community spouse has income below $2,555, they receive an allowance from the institutionalized spouse’s income until they reach $2,555. The federal maximum — the most a community spouse can receive via CSMIA — is $3,853.50/month.

Excess Shelter Allowance

The MMMNA can be increased above the floor if the community spouse has high housing costs. If the community spouse’s rent, mortgage, property taxes, homeowner’s insurance, and utilities exceed a standard shelter deduction (approximately $767.25/month in 2026), the MMMNA can be bumped up accordingly — but not above the federal maximum of $3,853.50/month.

Section 5: Income-First vs. Resource-First States

When the community spouse’s income falls below the MMMNA, states differ sharply on how they close the gap. This distinction — income-first vs. resource-first — can mean a difference of tens of thousands of dollars in how much the at-home spouse keeps.

Why Resource-First Can Be a Significant Advantage

In an income-first state, Medicaid says: “We’ll give the community spouse the institutionalized spouse’s Social Security check first. If that’s not enough, then we’ll talk about more assets.”

In a resource-first state like Indiana, Medicaid says: “We’ll calculate how many assets the community spouse needs to generate the MMMNA as investment income, and we’ll set the CSRA at that amount.” This can push the CSRA well above the standard calculation — sometimes dramatically so for couples with limited income but significant assets.

Section 6: The Division of Assets — Step by Step

When a married couple applies for Medicaid long-term care, the asset division process follows a specific sequence. Understanding each step helps you identify where planning can intervene.

1. Snapshot date identified. Medicaid establishes the date the institutionalized spouse first entered a hospital or care facility continuously for 30+ days. All assets on that date are counted.
2. Combined countable assets tallied. All countable assets in both spouses’ names are added together. Exempt assets (home, car, personal property) are excluded.
3. CSRA calculated. The community spouse’s allowance is determined using the state’s formula (flat maximum or 50%).
4. Institutionalized spouse’s spend-down calculated. Combined assets minus CSRA minus $2,000 equals the spend-down amount required before Medicaid begins.
5. Income assessment. Each spouse’s income is identified. The MMMNA is applied to determine how much of the institutionalized spouse’s income flows to the community spouse vs. toward care costs.
6. Ongoing monthly payment calculated. The institutionalized spouse’s income minus the CSMIA (if any) minus a personal needs allowance (typically $30–$60/month) equals their monthly contribution toward nursing home costs. Medicaid covers the rest.

Section 7: 6 Strategies to Maximize the At-Home Spouse’s Assets

Spousal impoverishment protections set a floor. These strategies can raise the ceiling. All are legal. Most require professional guidance to execute correctly.

Section 8: The Medicaid Application Process for Married Couples

Applying for Medicaid when one spouse is married differs meaningfully from single applicant cases. Here’s what to expect:

Documents You’ll Need

Both spouses’ financial records are required, not just the institutionalized spouse’s. Gather:

• 5 years of bank statements for all accounts (both spouses)
• Investment and retirement account statements (5 years)
• Property tax records and deed for the home
• Life insurance policies (for cash value assessment)
• Both spouses’ Social Security award letters
• Pension and annuity statements
• Records of any gifts, transfers, or large expenditures in the past 5 years
• Documentation of any irrevocable trusts or prepaid funeral contracts

Community Spouse Assessment Interview

Many states allow the community spouse to request a Community Spouse Resource Assessment before or at the time of the Medicaid application. This assessment formally establishes the snapshot date, tallies countable assets, and sets the CSRA — giving the couple a clear picture of how much must be spent down before Medicaid begins. Requesting this assessment early prevents disputes later.

Estate Recovery and the Surviving Spouse

Federal law bars Medicaid estate recovery while the community spouse is alive. The state cannot place a lien on the marital home or recover costs during the community spouse’s lifetime. However, after both spouses have died, the state may seek recovery from the estate for care costs paid on behalf of the institutionalized spouse. Strategies like the MAPT, Lady Bird deed, or life estate can protect the home from estate recovery — see our Medicaid estate recovery guide for the full picture.

Frequently Asked Questions