Despite recent advances in civil rights protection, the lesbian, gay, bisexual, and transgender (LGBT) community face significant health disparities.

The LGBT community continues to be among the most underserved populations. Homophobia and stigma negatively impact many in the LGBT community and their ability to receive suitable health care. Over 27 percent of transgender people in the U.S. report being denied access to health care. Mental health is another major concern for LGBT individuals often dealing with physical or emotional abuse, body dysmorphia, and depression.

In particular, LGBT older adults are most prone to socially isolate. They are twice as likely to live alone; half as likely to have close relatives to call for help; and four times less likely to have children to help them. Nearly one-in-four LGBT older adults has no one to call in case of emergency. At the same time, studies document LGBT older adults’ poor access to essential services such as visiting nurses, senior centers and meal programs compared to the general aging population.

Medicare rules for same-sex couples changed dramatically after two major Supreme Court decisions.

The first decision, United States v. Windsor (2013), found Section 3 of the Defense of Marriage Act (DOMA) unconstitutional. DOMA defined a spouse as “a man or woman who is legally married to a person of the opposite sex.” The wording excluded many people who were legally married to someone of the same sex from public benefits. Windsor was a good first step; however, not all LGBT same-sex married couples were eligible. It still depended on whether a state recognized same-sex marriage.

The second Supreme Court decision, Obergefell v. Hodges (2015), made same-sex marriage legal in all states. The court’s 2015 ruling, however, puts all married couples on the same legal footing in claiming benefits, anywhere in the United States and its territories. So, to be clear, if you are in a same-sex marriage, here’s a quick primer of your rights under Medicare.

•Becoming eligible for Medicare Part A on your spouse’s work record. The majority of people age 65 and older receive Medicare Part A (hospital) benefits without paying monthly premiums because they have earned 40 work credits (equivalent to about 10 years of work). If you haven’t earned 40 credits, you can qualify for premium-free Part A on the work record of your spouse, if he or she has achieved the required credits and is age 62 or older.

If neither of you have 40 credits, you can still receive Part A benefits by paying monthly premiums that are quite expensive. Note that work credits are not necessary to qualify for Part B (which covers doctors’ services, outpatient care and medical equipment) or for Part D (prescription drug coverage). You just pay the required premiums, same as anybody else, provided that you are either a U.S. citizen or a permanent legal resident (green card holder) who has lived in the United States for at least five years. (The five-year residency is waived if you are a green card holder who has been married for at least one year to a U.S. citizen or another legal resident who is at least age 62 and has 40 work credits)

For more general information about Part A enrollment, see Centers for Medicare and Medicaid Services: Enrolling in Medicare Part A & B, on

•Delaying Part B enrollment if you’re covered by your spouse’ health plan at work. Under Medicare rules, you can delay signing up for Medicare Part B beyond age 65 (and avoid paying its premiums) for as long as you are covered under a group health plan provided by an employer for whom you or your spouse is still actively working and provided that the employer has 20 or more employees. When that employment comes to an end, you are entitled to a special enrollment period of up to eight months to sign up for Part B without incurring late penalties.

If you were previously denied this right on the basis that your spouse was the same sex as you, and as a result incurred late penalties that were permanently added to your Part B premiums, be aware that you can apply to Social Security (1-800-772-1213) to have the late penalties reduced.

•Paying higher-income Part B and Part D premiums. Please be aware that Part B and Part D premiums will be assessed on the joint income of you and your spouse and not just you alone. To be liable for surcharges, the modified adjusted gross income (MAGI) declared on your latest tax return must be at least $85,000 if you’re single or married but filing separately; or $170,000 if you’re a married couple filing jointly. These dollar thresholds are the same for both Part B and Part D, but the surcharges you actually pay are different for each program and vary according to your income. Most people with Medicare don’t pay these higher premiums, but a relatively high salary from your work and/or your spouse’s or a sudden income boost (for example, from the sale of a house), could easily put you into a higher-income category.

•Applying for programs that lower Medicare costs. There are several programs that can reduce the costs for Medicare beneficiaries whose incomes and savings are under a certain level. Extra Help is a federal program that provides lower-cost Part D prescription drug coverage. Medicare Savings Programs are state-run programs under which the state pays Part B premiums and possibly other expenses (deductibles, copays and Part A premiums) according to income. Medicaid is the state-run safety net for health care that pays virtually all the medical costs of people who qualify. Please remember that your eligibility for these programs is based on the joint income and savings of you and your spouse just as it is for any married couple.

•Medicare and Transgender-related care. An important milestone for transgender older adults occurred on May 30, 2014 when the Department of Health and Human Services, Department Appeals Board ruled that Medicare must cover medically necessary care for individuals with gender dysphoria, just as any other medically necessary health condition. After a lifetime of being denied medically necessary care, transgender older adults are finally on a level playing field with other Medicare beneficiaries. Medicare now covers routine preventive care regardless of gender markers along with medically necessary hormone therapy and transition-related surgery.

LGBT older adults have fought the fight and opened the door to many recent Medicare benefits. But the fight isn’t over particularly if there are future cuts to Medicare and Medicaid or if the Affordable Care Act is repealed.

Joel Mekler is a certified senior adviser. Send him your Medicare questions at



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