The Basics of Medicare and Spouse Coverage

• Medicare provides individual health insurance coverage for Americans 65 and older as well as younger Americans with disabilities or end-stage renal disease (ESRD).

• Married couples may be wondering how Medicare works for them since many become eligible for Medicare based on their age and work history. There are rules in place for such scenarios, such as one spouse reaching age 65 before the other.

• In the event only one spouse works, the non-working spouse may still be eligible for Medicare coverage based on their partner’s work history.

• For spouses who do not qualify for the same health benefits from Medicare based on their spouse’s work record, they still have other health insurance coverage options such as COBRA or a health plan under the ACA. They must pay premiums for either option.

Medicare is a federal health insurance program for Americans 65 years or older, as well as those with a permanent disability or end-stage renal disease (ESRD). Because Medicare consists of healthcare plans for individuals, there may be confusion on how Medicare coverage works for married couples since married people often share health benefits.

This resource will answer Medicare questions about the benefits and married couples.

Medicare is a federal government health insurance program that provides health insurance for those age 65 and older, younger Americans with disabilities, or those with ESRD (end-stage renal disease or permanent kidney failure). 

Medicare works under various parts; each one created to cover specific healthcare services. These parts include:

• Medicare Part A (hospital insurance): This covers inpatient care such as hospital stays, nursing care, nursing home or hospice care, and other home health care related services.

• Medicare Part B (medical insurance): This covers outpatient care such as medically necessary doctor’s appointments, durable medical equipment (DME), preventive care services, mental health services, and more.

• Medicare Part D (prescription drugs): This part is separate from Original Medicare (Part A and B) and must be purchased separately. It covers prescription drugs such as vaccines, anti-depressants, anti-cancer drugs, immunosuppressants, and others. Each plan is different and has a different formulary drug list of what it specifically covers.

Medicare beneficiaries also have the option to enroll in a Medicare Advantage Plan, known as a Medicare Part C plan or an MA plan. Medicare Advantage plans often include prescription drug coverage, as well as other benefits such as hearing, dental, and vision. Those interested in what extra benefits are offered via MA plans should contact their insurance company directly to confirm

To understand Medicare and spouse coverage, it is first important to understand how an individual is eligible for Medicare in general.

Adults age 65 and older are eligible to enroll in Medicare, as well as younger people with certain disabilities or ESRD. From there, these enrollees can either be eligible for premium-free coverage or paid coverage for Medicare Part A. Americans who are 65 and older, have worked at least ten years, and paid Medicare taxes are entitled to Medicare Part A premium-free. American citizens 65 and older whose work history does not match the aforementioned qualifications can still enroll in Medicare Part A but must pay for coverage. 

Medicare beneficiaries are also able to enroll in Medicare Part B, but this requires one to pay a premium. This amount will be based on an individual’s income. 

Once an individual is eligible for Medicare, they must enroll during their initial enrollment period (IEP) in order to avoid potential late enrollment penalties. 

Note: Learn more about Medicare eligibility at this resource.

In order for someone to qualify for Medicare, they must have acquired enough Social Security credits, which are earned via employment and where they paid Social Security taxes. In 2023, an employee earns one credit for every $1,640 made, up to a maximum of four credits annually. This amount is the same for self-employed workers.

Not all jobs earn someone Social Security credits. For example:

• Federal employees hired before 1984

• Railroad workers with 10+ years of service

• Certain employees of exempt state and local governments 

• Children under age 21 who perform household chores for a parent 

Note: Learn more about earning Social Security credits at this resource.

Since Medicare coverage is only available as individual plans, your Medicare plan can’t ​“cover” your spouse. However, your spouse’s work history may play a role in the premiums you pay or your potential coverage, even if you haven’t worked enough to qualify on your own.

Some non-working spouses may qualify for Medicare upon turning age 65 based on their spouse’s work history. Once a spouse turns 65, they could be eligible for premium-free Medicare Part A based on their spouse’s work history if:

• They are still married to their spouse.

• They are divorced from their spouse after being married for at least 10 years. The non-working, former spouse must currently be single.

• Their spouse passed away after at least nine months of marriage. The surviving spouse must be single.

Non-working spouses may qualify for Medicare at an earlier age if they have a disability, however. 

When it comes to Medicare Part B and spouse coverage, a spouse with an employer-sponsored health plan can choose to delay Medicare Part B enrollment. This is usually done to avoid paying premiums for both Part B and the employer’s coverage. If this is the case, this spouse does not pay a late enrollment penalty so long as they enroll during a special enrollment period (SEP). Before choosing to delay Part B enrollment, the working spouse should ensure they have creditable coverage through the employer plan.

In most cases, one spouse will become eligible for Medicare before the other. Younger spouses will still require some form of health insurance until they meet Medicare requirements. In some cases, older spouses may not qualify for Medicare based on work history and depend on their partner’s employer coverage.

If a non-working spouse was dependent on their spouse’s employer-sponsored health plan that is coming to an end, they still have ways to make sure they are covered if they are not eligible for Medicare under their spouse or former spouse’s work record.

It’s best to contact your employer benefits administrator to help navigate your options and see what is available to you. That said, there are a few options that are most common.

COBRA coverage

The Consolidated Omnibus Budget Reconciliation Act (COBRA) is one option for non-working spouses not eligible for Medicare to receive coverage. COBRA allows workers and their family members to continue employer coverage for a limited amount of time following life-changing events. For example, if a person’s spouse dies, the older spouse with employer-provided health care is retiring, etc.

While the insurance plan won’t change, the monthly premium cost will. COBRA often has an incredibly high monthly premium. 

Note: Learn more about COBRA coverage at this resource from the Centers for Medicare and Medicaid Services.

Marketplace Coverage Under the Affordable Care Act (ACA)

The Affordable Care Act (ACA) is another option for spouses. The federal government offers subsidized coverage for ACA plans for Americans earning less than the Federal Poverty Level.

Those who wish to enroll in an ACA marketplace plan must do so during open enrollment or a SEP, such as losing employer coverage.

What happens when one spouse goes on Medicare and the other isn't eligible?

If one spouse qualifies for Medicare, but the other doesn't, there are a few possibilities. A Medicare-covered spouse's work history could allow their spouse to receive premium-free Medicare Part A. If the other spouse still isn't covered, they will have to purchase a health insurance plan outside of Medicare to receive coverage.

Are there spousal benefits for Medicare?

While Medicare coverage can't be shared between spouses, there is one spousal benefit—if one partner worked for ten years and paid Medicare taxes during that time, both spouses qualify for premium-free Part A Medicare coverage when they each turn 65.