This section is designed to assist Lesbian, Gay, Bisexual and Transgender (LGBT) individuals in understanding their unique needs and special considerations when planning for future care needs. The information should be seen as a supplement to the overall site content. It takes into consideration laws, programs and services that may impact LGBT individuals and couples and their planning process, including:
- Laws and regulations that differ from state to state that should affect your decisions
- Resources from Lambda Legal, an organization whose mission is to protect the civil rights of LGBT individuals. They have a webpage that details laws and policies in each state that protect LGBT individuals that you may find useful
- An article by Services and Advocacy for LGBT Elders (SAGE) titled "LGBT Older Adults: Facing Legal Barriers to Caring for Loved Ones" that provides great information about LGBT caregivers
- Health Disparities Impacting LTC
Many LGBT individuals experience health disparities throughout their lives. While health issues in anyone's younger years may lead to the need for long-term care later in life, limited research shows that health disparities can have a major impact on some LGBT individuals, and this should be taken into account in planning for future long-term care needs. Below are categories of disparities and our current understanding of how they impact LGBT individuals.
Barriers to Health Care Access
LGBT Adults are:
- Less likely to have health insurance coverage
- More likely to delay or not seek medical care
- Facing barriers to access as older adults due to isolation and a lack of culturally competent providers. One study found 13% of older LGBT adults were denied or provided inferior health care.
- More likely to delay or not get needed prescription medications
- More likely to receive health care services in emergency rooms
- Fail to receive screenings, diagnoses and treatment for important medical problems. 22% of LGBT older adults do not reveal sexual orientation to physicians. In some states health care providers can decline to treat or provide certain necessary treatments to individuals based on their sexual orientation or gender identity.
- Particularly distressed in nursing homes. One study indicates elderly LGBT adults face distress from potentially hostile staff and fellow residents, denial of visits from partners and family of choice, and refusal to allow same-sex partners to room together
Negative Impact on Physical and Mental Health and Well-Being
Societal biases are taking a toll on LGBT adults. They are:
- Less likely to report having good health than their heterosexual counterparts
- More likely to have cancer
- More likely to suffer psychological distress
- More likely to require medication for emotional health issues
- Lesbian and bisexual women are less likely to receive mammograms and are more likely to be overweight or obese.
- 41% of LGBT adults age 50 + have a disability
- Transgender adults are much more likely to have suicide ideation
More Likely to Engage in Risky Behavior
- LGBT adults are more likely to have problems with alcoholism
- Older lesbians are significantly more likely to engage in heavy drinking
- LGBT adults are more likely to smoke cigarettes
- Gay men are at higher risk of HIV and other STDs, especially among communities of color
Research also indicates that if you live alone, you're more likely to need paid care than if you're married or single and living with a partner. Important implication for LGBT individuals: data shows that people living alone are more likely to need paid long-term assistance. Planning is particularly important for such individuals.
Among LGBT elders, many singles and couples are estranged from their families of birth, normally the largest source of support when long-term care is needed. Many in the LGBT community are reliant on "families of choice" for their support. As defined by the National Resource Center on LGBT Aging, these are diverse family structures that:
- Are usually created by LGBT people, immigrants, and racial or ethnic minorities
- Include but are not limited to, life partners, close friends, and other loved ones not biologically related or legally recognized
- Are the source of social and caregiving support
- Provided a tremendous amount of support to gay men during the early years of the AIDS epidemic
- Tend to be from the same age cohort
- For the aging LGBT population, this may mean that many in their families of choice are also in need of support and services and therefore may not be available to provide the level of support needed.
A major question often faced by those needing long-term care is "Do you have family members who will provide care?" Whether you have a family of choice, family of origin, or both to assist you in the event you need long term supports and services, plan ahead with your ‘family' now and begin to talk with your loved ones to develop a plan of care.
- Participant Directed Services
Regardless of race, ethnicity, sexual orientation or gender identity, individuals want to have choices and control over the decisions made about their long-term care. Many publicly funded programs provide Participant Directed Services for those who choose it. Some things to consider:
- Be sure to check if one's chosen provider is culturally competent to work with LGBT individuals, their partners and their family of choice
- LGBT adults may want to work with LGBT service organizations or culturally competent mainstream aging organizations to identify providers that are competent to meet their needs
Finding individual or agency providers competent to work with LGBT individuals and families may prove difficult for some. In addition to working with local LGBT organizations or inclusive mainstream aging providers, LGBT individuals may want to use the resources of the National Resource Center on LGBT Aging for additional information and assistance. This web-based clearinghouse contains a number of valuable resources and hopes to add a new section highlighting LGBT-friendly services.
- Housing, Financial, Legal Matters
Whether they are looking for supportive services in their current home or looking for new housing with supportive services, LGBT individuals and couples need to ensure that services or housing providers are inclusive and culturally competent to work with LGBT families.
A new and growing option is LGBT elder housing. It's limited in availability now, but more of these residences designed specifically for the needs of the LGBT aging community are springing up across the U.S.
For more information on housing and supportive services, including LGBT specific housing, go to the National Resource Center on LGBT Aging at www.lgbtagingcenter.org
Continuing Care Retirement Communities (CCRC)
Not all CCRCs are the same, and not all are LGBT competent:
- Since LGBT individuals or same-sex couples may be treated differently depending on the CCRC, it's important to research the facility thoroughly before making a decision.
- As noted above, you may want to consider retirement housing with services designed for LGBT older adults.
Due to the lack of uniformity in state and federal laws, the financial implications for LGBT couples—even those who are legally married—are very different than for heterosexual married couples. Consider that:
- In states that allow it, having a legally recognized partnership (domestic partnership, civil union, marriage, etc.) increases your chances of maximizing insurance and financial benefits.
- However, as long as the Defense of Marriage Act (DOMA) remains the law, you have very limited access to federal partner benefits.
- There are over 1,000 Federal laws in which marriage status is a consideration. These laws confer rights, protections, and benefits to opposite-sex married couples.
- Under DOMA, partners in same-sex unions cannot receive a wide range of federal benefits, including Social Security survivor benefits, federal tax benefits and federal employee health and retirement benefits.
- Although some states allow gay and lesbian couples to marry, the majority of states don't recognize marriages between same-sex partners
- In other states, same-sex couples can register as domestic partners, but under most Federal laws, this makes no difference in terms of benefit eligibility.
- Same-sex couples, whether unmarried, married, or registered as domestic partners, are not permitted to enjoy most of the federal marriage benefits provided to opposite-sex married couples. Plan accordingly.
Planning for long-term care can be complicated and filled with pitfalls. That's why having legal documents that clearly define your relationship and individual interests, and clearly express your wishes, is of particular importance to members of the LGBT community.
Regardless of whether you are in a domestic partnership, marriage or other legal relationship, you should still be prepared with a Power of Attorney for Health or Property, a will, and any other legal documents that clearly state your wishes
- Paying for Long-Term Care - Public & Private
Applying for Medicaid
Medicaid regulations related to long-term care include a series of "spousal impoverishment protections" that prevent a healthy spouse from losing a primary residence or savings in order to qualify a spouse for Medicaid. In most states these protections don't apply to same-sex couples. However:
- States have received guidance from the Centers for Medicare and Medicaid Services on how they can extend the spousal impoverishment protections to same-sex couples.
- The intent of this guidance is to encourage additional states to recognize that same-sex couples have the same need for spousal protections.
- SAGE (Services and Advocacy for LGBT Elders) has produced a guide to help the LGBT community understand Medicaid and spousal impoverishment, including estate recovery, and the implications for same-sex couples.
GOOD TO KNOW
The National Resource Center on LGBT Aging has an excellent section on "Medicaid and the LGBT Community: Paying for Long-Term Care" that we recommend you read. It provides in depth coverage on what LGBT individuals and couples should look for in applying for Medicaid.
Older Americans Act Programs
Older Americans Act (OAA) programs are available to adults aged 60 and older. There are no specific financial eligibility criteria for OAA services, though Congress has directed that they generally be targeted for low-income, frail seniors, minority older adults, seniors living in rural areas and other older adults of greatest social need. Additionally:
- Not all providers of aging services funded through the OAA are inclusive and culturally competent.
- Check with LGBT friends and acquaintances to see if they have any suggestions.
- Your local LGBT community center may be helpful in steering you toward inclusive providers.
- The National Resource on LGBT Aging has a special section for LGBT Older Adults with many resources including a tool that helps you find resources in your state.
Veterans Affairs LTC Benefits
While "Don't Ask, Don't Tell" is gone now, the impact of its demise on LGBT veterans is yet to be determined. In general, VA benefits are some of the best. Should you want to do some research before contacting the VA directly, here are a few resources you may find helpful:
- The United States Department of Veterans Affairs has a list of organizations that may be of assistance.
- The Servicemembers Legal Defense Network has a lot of information for LGBT service members on their website and offer free legal advice.
Long-term Care Insurance
Many issues need to be considered before buying Long-term Care Insurance. In addition to the information provided in the Costs & How to Pay Section of this site, you should note that:
- Different states have different policies and these may include different definitions of "family" that could affect eligibility requirements for same-sex partners.
- These definitions may also affect a public employee's ability to buy into benefits, depending on the state. Thorough research should be done before purchasing any policy.
- As you read this section, it may be a good time to reference Lambda Legal's map of relevant state laws.
For LGBT people living with others, where the home is not jointly owned, you may want to consult an LGBT- friendly lawyer, Lambda Legal, or the National Center for Lesbian Rights for assistance.
The use of Annuities to pay for long-term care may not involve special considerations for LGBT people, but seeking advice from a trusted professional is always advised:
- There may be issues under "Immediate Annuities" for transgender individuals because payment is gender-based under the assumption that women live longer than men and therefore receive smaller monthly payments
- Work with a trusted legal professional or consult the National Center for Transgender Equality to determine how being transgender affects the calculation for this insurance in your state
Charitable Remainder Trusts may be a good option for LGBT individuals with assets, though same-sex couples should be sure that state laws don't have a negative impact on them should one partner die. For more information, refer to Lambda Legal's "Take the Power: Tools for Life and Financial Planning."
Spousal Impoverishment Laws in your state may impact how same-sex couples are treated under Medicaid Disability Trusts, so be sure to do your homework before entering into this arrangement. To learn more, see the National Resource Center on LGBT Aging's "Medicaid and the LGBT Community: Paying for Long-Term Care."
- Resources - Public & Private
Listed below are a number of useful resources, as well as the reports where much of the information in this section was obtained. Many have been referenced earlier in Long-Term Care Considerations for LGBT Adults.
- The National Resource Center on LGBT Aging – www.lgbtagingcenter.org
- Lambda Legal – www.lambdalegal.org
- Center for American Progress, "How to Close the LGBT Health Disparities Gap" – http://www.americanprogress.org/issues/2009/12/lgbt_health_disparities.html
- LGBT Older Adults in LTC Facilities: Stories from the Field – http://www.lgbtlongtermcare.org/
- SAGE publication – Medicaid, Spousal Impoverishment and Same-Sex Couples – http://sageusa.org/resources/publications.cfm?ID=119
- The Center on Veterans Health and Human Services website on Veterans LGBT Health Policies: http://www.youarestrong.org/category/resources/sexual-minority-veterans-lgbqqti/
- Servicemembers Legal Defense Network – http://www.sldn.org
- National Center for Transgender Equality – http://transequality.org/
- National Center for Lesbian Rights – www.nclrights.org
- The Aging and Health Report – http://caringandaging.org/