In most of the scenarios, it is observed that spouses are covered under the same health insurance plan though this option doesn’t make sense always. Couples need to carefully decide whether having spousal coverage will be beneficial for them or they should have a separate health insurance plan. Find below some of the factors that will help the couple decide in making an informed decision regarding their health plan.
While deciding on a health plan couples need to consider the total out-of-pocket costs of the health plans they are considering to purchase. The Affordable Care Act has implied an upper cap on total out-of-pocket costs for the in-network treatment of essential health benefits. This amount is fixed each year by the Department of Health and Human Services and in the 2020 year, the upper limit for out-of-pocket costs is $8,150 for a single individual and $16,300 for a family and it will increase to $8,550 for individual and $17,100 for a family in 2021. The family out-of-pocket limit applies to a single plan covering members of the family and if the family is having separate plans such as employer-sponsored plans, individual plans, or Medicare plan, then the family out-of-pocket limits will apply separately for each plan. Therefore, if a couple decides to have one spouse on one plan and the other spouse on another plan, then they should know that each plan will have its own out-of-pocket limit, and the total costs could be higher than it would be if both were on one plan.
Couples should take the health care needs of both the partners into consideration before the decision upon health plans. There might be a situation where one partner is healthy and the other has significant medical conditions, then the couple should make the decision to have two separate health plans. The healthy partner should choose a low-cost health plan having restrictive healthcare providers and higher out-of-pocket costs, whereas the partner with medical conditions should opt for a high-cost plan having more extensive healthcare providers and lower out-of-pocket costs. However, this is not the ideal case, especially if one spouse has access to a high-quality employer-sponsored plan covering them both with a reasonable premium. Depending upon their circumstances, some partners find it beneficial to pick separate plans based on specific healthcare needs.
Employer-Sponsored Health Plans
It is a fact that about half of all Americans obtain health insurance through an employer-sponsored plan. Thus, if both spouses having employer-sponsored coverage, then both can have coverage from their plan. If only one spouse has employer-sponsored coverage, then the other need to decide whether he/she should have their plans or get himself/herself included in the spouse’s employer-sponsored plan. However, while deciding upon the best decision, couples need to keep few things in mind, it is not essential for employers to offer coverage to spouses and there is no requirement that employers have to offer coverage to employees’ spouses. Though the majority of employers offer coverage to spouses but only in the case if the spouse does not have access to their employer-sponsored coverage. Sometimes the cost of including the spouse is expensive and also makes the partner ineligible for subsidies in the exchange. Large employers pay a major share of the cost to add spouse, but the amount employers paid varies considerably depending on the organization size. Smaller organizations are less likely to pay a significant part of the premium to add a spouse.
Individual Health Insurance
If the spouses are having health plans through health insurance exchange or outside the exchange, then they have options to be covered under one plan or they can select two different plans. Spouses can select separate plans if they are enrolling in the exchange with premium subsidies. Married enrollees need to file a joint tax return to qualify for subsidies, but they both don’t have to be on the same health plan. The exchange calculates the total subsidy amount based on their household income and applies to the policies they select. One spouse can get an on-exchange plan, and other spouses can have an off-exchange plan, this might be considered by a couple if one spouse is receiving treatment from an in-network healthcare provider with off-exchange carriers. However, they should keep in mind that there are no subsidies available outside the exchange, so the spouse having an off-exchange plan will pay full price for the coverage.
Government-sponsored Health Plan
In some instances, one spouse becomes eligible for a government-sponsored plan while others are not eligible. In such a scenario, one spouse can opt for a government-sponsored health plan while the other can continue to have private health insurance. There may be a situation in which one spouse turns 65 and become eligible for Medicare while others who are younger than 65 will have to continue with the private health plan. Even if both the spouses are eligible for Medicare, then also they will have separate coverage under Medicare because all Medicare coverage is individual. Similarly, a pregnant woman can qualify for Medicaid or CHIP while her spouse will not qualify for these programs and need to have a private health plan.