Is My Spouse Covered by My Medicare Coverage?
What to know when you’re eligible for Medicare but your spouse is not.
It’s one of the most common questions that vexes soon-to-be Medicare enrollees: Is my spouse also covered by my Medicare coverage?
Like many others, you may have received health insurance coverage through your employer with a plan that covered your spouse and family, as well.
And because people are familiar with having a family plan that covers their spouse prior to Medicare eligibility, many assume that Medicare must work in a similar fashion.
So, let’s tackle that question right away.
Because Medicare is an individual-based program, your Medicare eligibility and coverage does not extend to your spouse.
While there are some exceptions based on disability and specific medical conditions, in general, your spouse is not covered by your coverage.
With this in mind, let’s explore the different coverage options that will be available to you and your spouse, as well as cover other important matters of eligibility.
The Basics: Overview of Medicare Eligibility and Coverage
Whether you’re already a Medicare enrollee inquiring about your spouse or just beginning research on the enrollment process, let’s start with a quick overview of the basics.
Medicare is a federal health insurance program primarily designed for individuals who are 65 and older.
It certain cases, however, Medicare also provides coverage for younger individuals with disabilities and those with end-stage renal disease.
To be eligible for Medicare, you or your spouse must have paid Medicare taxes for at least 10 years.
For many, these taxes are automatically taken from your paycheck in the form of FICA tax (Federal Insurance Contributions Act).
Medicare coverage consists of four different parts that cover different services, and for this reason the coverage you receive from Medicare can differ slightly from one individual to the next.
For starters, Part A, also known as hospital insurance, is provided premium-free with eligibility and covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
Next up, Part B, also known as medical insurance, comes with a monthly premium and covers doctor visits, outpatient services, preventive care, and durable medical equipment.
Together, Part A and Part B are known as Original Medicare.
From here there are two different routes you can take to supplement your coverage.
One route consists of adding Part D prescription drug coverage and/or Medicare supplement coverage.
While the other route is Part C coverage, more commonly known as Medicare Advantage.
Medicare Advantage plans are an alternative to traditional Medicare coverage offered by private companies, combining the coverage of Part A, Part B, and Part D.
Many Medicare Advantage plans also offer additional benefits like hearing, dental, and vision.
How Does Medicare Eligibility Work for Spouses?
As we mentioned in the introduction, Medicare coverage is an individual insurance program (not a family plan), so each spouse must meet the eligibility criteria in order to receive coverage.
It’s important to note, however, that certain eligibility criteria can be shared among spouses.
In particular, the work history of one spouse (i.e. FICA tax payments) can work toward the Medicare eligibility of the other spouse.
So, when you reach the age of Medicare eligibility at 65, even if you did not personally pay 10 years of FICA tax but your spouse did than you may still be eligible for Medicare if you meet one of the following criteria:
1. You’re currently married to a spouse that’s eligible for Social Security benefits and have been married for at least one year prior to applying for Medicare.
2. You’re currently divorced (now single) and your former spouse is eligible for Social Security benefits, and you were married for at least 10 years.
3. You’re widowed and currently single and you were married for at least nine months prior to the passing of your spouse.
If your spouse is already receiving Social Security benefits when they turn 65, they will be automatically enrolled in Medicare Parts A and B.
However, if they aren’t receiving Social Security benefits, they’ll need to actively enroll in Medicare during their Initial Enrollment Period (IEP).
The IEP is a seven-month period that includes the three months before their 65th birthday, the month of their birthday, and the three months after.
Remember: If your spouse is eligible for Medicare, they must enroll on their own to receive coverage. One spouse’s Medicare coverage does not extend to the other.
Coverage Options for Spouse Not Yet Medicare Eligible
Okay, now here’s where it can get a bit trickier.
What if one spouse is eligible for Medicare but the other spouse hasn’t yet reached the age of eligibility at 65?
1. Inquire About Retiree Health Coverage
Your first course of action should be to check with your employer about a retiree health plan.
While it’s true that private-sector employers are not required to provide health benefits to retiring employees, some do offer retiree health coverage.
Retiree health coverage is a group health plan much like those offered to active employees.
And for those who retire before they’re eligible for Medicare, retiree health coverage can help to bridge the gap between your employer health coverage and Medicare.
Additionally, retiree health coverage can work in coordination with Medicare, helping to cover some of the costs and services that Medicare doesn’t cover.
So, if one spouse is eligible for Medicare but the other has not yet reached the age of eligibility, you may still have the option of keeping the retiree health coverage for the ineligible spouse while the eligible spouse signs up for Medicare.
2. Shop for Short-Term Health Plan
If your employer doesn’t offer a retiree health plan, your next course of action should be to find a short-term health plan to bridge the gap until Medicare eligibility.
Short-term medical insurance, also known as temporary insurance, is offered as a means for filling gaps in insurance coverage and works in the same familiar manner as other insurance plans.
There isn’t an enrollment period for short-term plans, meaning that you can enroll at any time and start coverage as soon as the next day.
Coverage for these plans can apply to timeframes as short as 30 days or last up to as long as 364 days, with enrollments lasting up to 3 years.
These plans are generally more affordable and typically cover doctor appointments, inpatient and outpatient services, unexpected illness and injury, emergency room visits, and certain prescription medications.
Keep in mind, however, these plans are more affordable because they do not cover all the benefits that an Affordable Care Act plan would cover, such as pre-existing conditions and maternity care.
Also, your own plan costs will vary based on your age and the coverage offered by the plan you choose.
As you shop the short-term health plans available in your area, consider all your healthcare needs while weighing costs.
Many short-term plan providers offer convenient and customizable plans without provider networks to worry about and additional benefits like dental and vision insurance.
Ensuring Comprehensive Healthcare for You and Your Spouse
Understanding the various coverage options available to you and your spouse leading up to Medicare eligibility will go a long way in ensuring your healthcare needs are covered under any circumstance.
Affordable and convenient, short-term health plans are the best option for covering any gaps that may occur in your healthcare coverage between retirement and Medicare eligibility.
Remember to carefully review the spousal coverage rules and requirements of any health plan before enrolling and consider consulting with a Medicare specialist or financial advisor for personalized guidance.
If you’re nearing eligibility for Medicare and want to learn more about the enrollment process, check out our Complete Guide to Medicare Enrollment.
Or if you’re ready to begin looking for a short-term health plan to bridge the gap in your coverage, you can start browsing plans available in your area right now.