Is My Husband a Dependent on Health Insurance?

For health insurance, a spouse is considered a dependent based on a legal marital relationship. It differs from the financial dependency often associated with children or tax dependents. A marriage certificate is typically required as proof of legal union.

Health plans do not require a spouse to be financially dependent on the policyholder for coverage. While the Affordable Care Act (ACA) mandates that employers with 50 or more full-time employees offer coverage to employees and their children up to age 26, it does not require them to offer coverage to spouses to avoid penalties. Most employers voluntarily extend health benefits to spouses. Some plans may also extend coverage to domestic partners or those in civil unions, though eligibility rules can vary significantly by insurer and state, often requiring documentation to prove a committed relationship.

Employer-sponsored plans have specific guidelines, and some may implement “working spouse rules” that require a spouse to enroll in their own employer’s plan if available, or even impose a surcharge if they have access to other coverage but choose to join their spouse’s plan. ACA Marketplace plans include the tax filer, their spouse if married, and tax dependents for eligibility and premium tax credit purposes. Medicare does not provide dependent coverage; each individual must have their own Medicare policy.

Enrolling Your Spouse

Enrollment is permitted during the annual open enrollment period, a designated time each year when individuals can sign up for new coverage or make changes to existing plans. For employer-sponsored plans, the employer’s human resources department sets these dates.

Outside of open enrollment, a spouse can be added during a special enrollment period (SEP). Marriage is a qualifying life event that triggers an SEP, allowing a window of 30 to 60 days from the date of marriage to enroll the spouse. Other qualifying life events include loss of other health coverage, birth or adoption of a child, or a change in employment status.

The enrollment process requires contacting the plan administrator, such as an employer’s human resources department for employer-sponsored plans, or the insurance company directly for individual plans. For Marketplace plans, changes can be made by updating the application online. Required information includes the spouse’s full name, date of birth, and Social Security Number. Documentation, such as a copy of the marriage certificate, is necessary to verify eligibility for a marriage-related special enrollment.

Coordinating Spousal Coverage

When both spouses have health insurance, Coordination of Benefits (COB) rules apply. COB rules determine which plan pays first (the primary insurer) and which plan pays second (the secondary insurer) to prevent duplicate payments for the same medical services. This process ensures that total payments do not exceed 100% of the medical costs.

The health plan covering an individual as an employee or policyholder is primary for that individual. The plan that covers the individual as a dependent, such as through a spouse’s employer, would then be secondary. Claims are first submitted to the primary insurer, which pays according to its benefits and coverage limits, including deductibles and copayments. Any remaining eligible costs can then be submitted to the secondary insurer for consideration, which may cover some or all of the remaining balance.

Couples weigh various factors when deciding whether to combine coverage or maintain separate plans. Considerations can include the total cost of premiums, deductibles, out-of-pocket maximums, and preferences regarding provider networks or specific benefits. Having dual coverage can potentially reduce out-of-pocket expenses, as the secondary plan may cover costs not fully paid by the primary plan. However, it is essential to compare the financial implications of each option, as combining plans might not always be the most cost-effective solution.