How to Complete and Submit the New York Spousal Refusal Medicaid Form

To use New York’s spousal refusal process, you file three documents with the Medicaid application: a written statement from the community spouse refusing to make income and assets available, the applicant’s declaration identifying that refusing spouse (Form MAP-2161 in New York City), and an assignment of support signed by the applicant. Together, these tell the Medicaid agency to evaluate eligibility on the applicant’s own finances alone. The right to do this comes from New York Social Services Law § 366(3)(a), which says Medicaid “shall be furnished” when a responsible relative’s resources are not available because that relative refuses to provide them.¹

The Three Documents You File Together

Spousal refusal is not a single form. It is a package, and leaving any piece out is the most common reason an otherwise valid refusal gets denied.

The Community Spouse’s Refusal Statement

The community spouse writes and signs a statement declaring that they refuse to make their income and assets available for the applicant’s medical care. New York does not publish a mandatory form for this — a letter works — but the language has to be unambiguous. Identify both spouses by full legal name, state the marital relationship, and say plainly that the community spouse is declining to contribute financially toward the cost of care. Sign and date it. Notarization is not required, but it doesn’t hurt.

The Applicant’s Declaration (MAP-2161 in New York City)

In New York City, the Human Resources Administration uses Form MAP-2161, “Applicant/Recipient Declaration Concerning Legally Responsible Relative’s Income/Resources.” The name is misleading in one important way: the applicant fills it out, not the refusing spouse.²

The form asks for:

Applicant’s name and case number (if a Medicaid case is already open)
Relationship to the legally responsible relative — check Spouse, Parent, or Other
The refusing relative’s name and Social Security number
The refusing spouse’s health insurance plan name, coverage type, and policy number, if any
Applicant’s signature and date

MAP-2161 does not require notarization. The form’s own instructions give you 10 days to sign, date, and return it in the enclosed envelope.² Outside New York City, the local county Department of Social Services handles the application and may use its own version of the declaration or request the same information in a different format. Call the county office before drafting anything so you use their preferred format.

The Assignment of Support

This is the piece that catches people off guard. The applicant must sign an assignment of support, which transfers to the local social services district the right to pursue the community spouse for a financial contribution. If the applicant cannot sign because of a physical or mental impairment, Medicaid must still be authorized as long as the refusal itself is properly documented and the inability to sign is on the record.³ Without the assignment, or evidence the applicant cannot execute one, the agency has grounds to reject the application even when a valid refusal exists.

Information to Gather Before You Start

Collect the following for both spouses before you sit down with the paperwork:

Full legal names and Social Security numbers
Current residential address for each spouse (they may live apart if one is in a facility)
The community spouse’s health insurance details: plan name, coverage type, policy number
The community spouse’s assets: bank, investment, retirement, and real estate holdings with current balances or values
The community spouse’s monthly income from every source: Social Security, pensions, employment, dividends, other
The applicant’s own income and assets, because the Medicaid application still requires a full financial picture of the person seeking care

Precise dollar amounts matter. The agency compares the applicant’s individual resources against the eligibility limits, and gaps between what you report and what they verify will delay processing. The community spouse’s numbers matter too, because they become the record the state uses if it later brings a recovery proceeding.

Where to File and How to Prove You Filed

In New York City, submit the refusal statement, the MAP-2161, and the assignment of support to the Human Resources Administration along with the Medicaid application itself.² Outside the city, file with the county Department of Social Services. The refusal paperwork and the Medicaid application should arrive together so the agency processes them as one package.

If you mail, use certified mail with return receipt requested. If you deliver in person, ask for a date-stamped copy of everything you hand over. Processing deadlines run from the date the agency receives a complete application, so proof of that date is the record that protects you in a dispute.

New York generally issues Medicaid eligibility decisions within 45 days of a complete application. When a disability determination is part of the case, the timeline can stretch to 90 days.⁴

What Happens After You File

Once the refusal is on file and the assignment of support is executed, the Medicaid agency evaluates the applicant on the applicant’s own income and resources. It cannot deny benefits solely because the community spouse has money and won’t contribute.¹ If the applicant individually meets the income and resource limits, coverage for long-term care begins.

This is why the refusal exists at all. Without it, a couple’s combined assets get measured against the spousal impoverishment rules, and everything above the Community Spouse Resource Allowance has to be spent down before the applicant qualifies. Spousal refusal skips that calculation. For couples whose combined resources sit well above the allowance ceiling, the difference can be substantial.⁵

The Trade-Off: Recovery Against the Refusing Spouse

Filing a spousal refusal does not put the community spouse out of the state’s reach. Section 366(3)(a) creates an implied contract, and the cost of care “may be recovered from such relative” through legal proceedings.¹ Social Services Law § 101 makes a spouse with “sufficient ability” responsible for supporting a partner receiving public assistance, and the local welfare district can enforce that duty in court.⁶

Whether the state actually sues is discretionary and decided case by case. When a proceeding is brought, the court looks at the community spouse’s real circumstances — income, assets, other dependents, length of the marriage, extraordinary expenses, earning capacity — to arrive at a contribution the spouse can realistically afford. Many of these matters settle for a portion of what Medicaid paid rather than the full amount. Expect this as a realistic possibility if you use spousal refusal, and keep the financial documentation you gathered for the application.

Mistakes That Get Applications Denied

Most spousal refusal denials come from paperwork gaps rather than eligibility problems. A refusal statement without the applicant’s declaration, or both of those without an assignment of support, can produce a denial even when the underlying refusal is valid. If the applicant cannot sign the assignment because of cognitive or physical impairment, document that inability in writing and submit it with the package.³

Do not confuse refusing to contribute with refusing to disclose. If the community spouse withholds financial information entirely, the agency may deny the application because it cannot determine eligibility, and the applicant will have to show undue hardship to get the case processed.³ The strategy works when the community spouse provides the financial data but formally declines to use those resources for the applicant’s care.

Keep copies of everything you file. The 10-day return window on MAP-2161 is tight, and if the agency later says it never received a document, a certified mail receipt or a date-stamped copy is what preserves your filing date.

1
New York State Senate. New York Social Services Law 366 – Eligibility
2
New York City Human Resources Administration. MAP-2161(E) – Applicant/Recipient Declaration Concerning Legally Responsible Relative’s Income/Resources
3
New York State Department of Health. New York State Medicaid Update – February 2023 Volume 39 – Number 5
4
New York State Department of Health. How to Apply for NY Medicaid
5
New York State Department of Health. New York State Income and Resource Standards for Non-MAGI Populations – 2026
6
New York State Senate. New York Code Social Services Law – SOS 101 – Liability of Relatives to Support