If you're used to group health insurance, it may surprise you to learn that Medicare coverage is for one person - you.
If you or your spouse are enrolling in Medicare health insurance, you may be wondering how much of the coverage will transfer between you. Understanding Medicare spousal benefits can be somewhat complicated, and there is a lot of variability depending on many factors. We’ll run through how this works in general, and discuss a few specific situations that you may run into.
If I enroll, will my spouse get Medicare coverage?
Not unless they also qualify for Medicare. Although most private insurance plans allow your insurance to also take care of members of your family, the Medicare program doesn't work the same way. To receive Medicare, your spouse has to be eligible for Medicare.
If you are eligible for Medicare Part A and Part B and then enroll, but your spouse isn’t eligible, then they won’t be able to enroll quite yet. This is common for people who turn 65, but who have spouses that are younger. If you enroll at age 65, but your spouse is only 62, they will have to wait three more years until they are eligible to enroll in Medicare. This can vary in cases of disability, but what we’ve described is the usual situation.
Basics of eligibility
Medicare eligibility can be a bit daunting, and we'll just go over the basics here. If you have reached age 65, if you receive Social Security benefits or Railroad Retirement Board benefits, and/or if you have certain disabilities or End-Stage Renal Disease (ESRD), then you'll be eligible for Medicare. Receiving disability benefits can also result in qualifying for Medicare.
What about Medicare Advantage?
Medicare Advantage is offered by private health insurance companies and not the United States government, and this means that it can sometimes offer more benefits. However, your spouse will still need to be eligible for Medicare in order to join a Medicare Advantage plan.
When do Medicare benefits combine?
If you turn 65 and get Medicare at the same time as your spouse, then you will both have your own Medicare plans. There will be no need to think of one of you as “on the other’s plan” as is common with private insurance; each person is independently a Medicare beneficiary.
However, there are certain aspects of Medicare that can be combined between spouses when one fills some criteria that the other doesn’t.
Premium-free Medicare Part A
Medicare Part A, often known as hospital insurance, is one of the key components of Original Medicare. With Part A, you’ll be covered for most inpatient healthcare services. This health plan is usually the most common part of Medicare that people enroll in, for good reason.
For many people, Part A has no monthly premium. Although it isn’t actually free because you still have deductibles and coinsurance costs, the premium-free nature of Part A makes it wise to enroll in for most people, even if they have a private health plan at the same time. In this case, Medicare will enter secondary payer status.
Unlike Part A, under Medicare Part B you will always have to pay the Part B premium.
How to get premium-free Part A
In order to be eligible for premium-free Part A, you or your spouse will have to pay the Medicare Tax for 40+ quarters, or ten years. This benefit does transfer from you to your spouse. If you’ve paid the Medicare Tax for only three years, but your spouse has paid it for ten years, then you will still be eligible for premium-free Part A as soon as you become eligible for Medicare.
The years here do not add up, however. If you’ve paid the Medicare Tax for five years, and your spouse has also paid it for five years, then neither will be eligible for premium-free Part A.
For those that have paid the Medicare Tax for 30-39 quarters, there is a reduced Medicare Part A premium of $278. This will also transfer from you to your spouse. If you have paid the Medicare Tax for just one year, but your spouse has paid it for 8 years, then you’ll pay the $278 per month premium.
If both you and your spouse have paid the Medicare Tax for under 30 quarters, then you’ll pay a higher premium of $506 per month. Once you or your spouse enters the number of quarters for paying the tax, your monthly premium cost will change.
What should I do if my spouse gets Medicare insurance, but I can’t?
It is relatively common for one spouse to become eligible for Medicare enrollment while the other has to wait. In this situation, there are a few things that you can do.
If you're still actively employed at a company with at least 20 employees, you can delay Medicare enrollment until you leave employment without incurring a late enrollment penalty. Your spouse can then remain on that group plan. You may also sign up for Medicare if you wish, and Medicare will be your secondary coverage. We typically recommend signing up for at least Part A, since it's premium-free for most people. The only exception is if you contribute to a health savings account (HSA), because you cannot have any part of Medicare while contributing to an HSA.
Your next option is for your spouse to find an insurance plan on the Healthcare Marketplace. They should be able to enroll outside of annual enrollment, since losing health insurance counts as a change of life event. Apply at Healthcare.gov.
For recent retirees, COBRA may be an option (see below).
A note on COBRA plans
If your spouse enrolls in Medicare and you are under their group health plan, then you may be able to get coverage for a while through a COBRA plan. In this case, you will receive some amount of coverage through your spouse’s former group health plan, although the timing will usually be limited.
If this is available to you, compare coverage and costs carefully to what you'd get through the Marketplace. COBRA plans tend to be pretty costly. But, they also tend to have pretty good coverage - maybe even better than the group insurance you had.
Medicare coverage after divorce
If you are divorced, then you may be able to receive some Medicare benefits through your ex-spouse. This specifically applies to the requirements for premium-free Part A, which vary depending on you and your spouse's work record.
If you were married for over ten years, are currently unmarried, have reached 62 years of age, and your own work history results in a smaller benefit than that of your spouse, then you'll be able to receive a Part A premium based on your spouse's work history.
How to find more details
There are many more situations available that it is outside of the scope of this article to discuss, but which may apply to you. There are many combinations of eligibility status related to work history, disability, time spent in marriage, and other factors. Depending on your unique situation, there may be more options available for you or your spouse to take advantage of.
In this case, your best bet is to talk to the Social Security Administration, or SSA, either online or through a local Social Security Office. They, along with the Centers for Medicare & Medicaid Services, will be in charge of your benefits and eligibility information.
Additionally, you can contact the Benefits Coordination & Recovery Center, or BCRC, which is in charge of benefits coordination. They will be able to understand the exact situation you’re in if you or your spouse have both Medicare and another form of insurance. You can call them at 1-855-798-2627 (TTY 1-855-797-2627).
Lastly, this document from Medicare.gov provides a comprehensive survey of information related to enrollment. Although seeking out individualized help is always good, you may find your answer easily there.
Spousal benefits: Things to keep in mind
The key thing to remember about spousal benefits under Medicare is that they aren’t as simple as they are for private insurance. When you have a private insurance plan, it will usually cover your spouse and dependents, but Medicare doesn’t work that way. Your spouse will need to be eligible for Medicare, either through age or disability, in order to receive coverage.
Understanding benefits coordination and the timing for Special Enrollment Periods is essential since it can offer you the chance to keep your employer-based health plan for a longer period of time and ensure that neither you nor your spouse experience a gap in coverage.