What Happens When One Spouse Goes on Medicare?

When one spouse becomes Medicare-eligible, it significantly shifts a couple’s healthcare planning. Medicare provides health insurance for individuals aged 65 or older, and certain younger people with disabilities. This transition requires careful consideration for both partners, particularly if one is not yet eligible. Understanding the enrollment process, coverage options, and financial implications ensures continuous healthcare coverage for the household.

Enrollment Steps for the Medicare-Eligible Spouse

Individuals become eligible for Medicare at age 65, though some with disabilities may qualify sooner. The program has different parts: Part A (hospital), Part B (medical), Part C (Medicare Advantage through private plans), and Part D (prescription drugs). Most receive Part A at no cost if they have worked and paid Medicare taxes for at least 10 years.

The Initial Enrollment Period (IEP) is a seven-month window: three months before, the month of, and three months after an individual’s 65th birthday. Enrolling during this period helps avoid late enrollment penalties for Part B and Part D. Missing the IEP means facing a General Enrollment Period (GEP) from January 1 to March 31 each year, with coverage starting July 1 and incurring penalties.

A Special Enrollment Period (SEP) is available for those delaying Medicare enrollment due to active employer-sponsored health coverage through their own or a spouse’s current job. This SEP allows enrollment without penalty, within an eight-month window after employment or group health coverage ends. However, COBRA or retiree health plans do not qualify for this SEP.

To apply for Medicare, documents include a Social Security card, proof of age (e.g., birth certificate), and proof of U.S. citizenship or legal residency. Work history (e.g., W-2 forms) and existing health insurance details may also be required. Applications can be completed online via the Social Security Administration website, by phone, or in person at a local Social Security office.

Ensuring Continued Health Coverage for the Non-Medicare Spouse

When one spouse transitions to Medicare, the non-Medicare eligible spouse’s health coverage requires immediate attention. If both spouses were covered under a family health plan, such as an employer-sponsored plan, the non-Medicare spouse may lose coverage once the Medicare-eligible spouse separates from it. This necessitates exploring alternative avenues for continued health insurance.

One option is the Consolidated Omnibus Budget Reconciliation Act (COBRA), allowing eligible individuals to continue group health benefits for a limited time after a qualifying event, such as a spouse becoming Medicare-eligible. COBRA coverage lasts 18 months for the employee, but dependents (including a spouse) can extend coverage up to 36 months under specific circumstances like the covered employee’s Medicare eligibility. COBRA premiums are paid entirely by the beneficiary, often including an administrative fee, making it an expensive short-term solution.

Another option is securing coverage through the Affordable Care Act (ACA) Marketplace. Losing employer-sponsored coverage due to a spouse’s Medicare enrollment qualifies as a special enrollment period, allowing the non-Medicare spouse to enroll outside the annual open enrollment period. Depending on household income, subsidies may be available to reduce premium costs for plans purchased through the Marketplace.

If the non-Medicare spouse is employed, enrolling in their own employer-sponsored health plan is a cost-effective solution. Many employers offer comprehensive health benefits providing continuous coverage. Directly purchasing a health insurance plan from a private insurer is also an option, though these plans may not offer the same subsidies as those available through the ACA Marketplace.

Financial Considerations for the Couple

The transition to Medicare for one spouse introduces new financial dynamics for the couple’s healthcare expenses. Medicare has distinct components, each with its own cost structure: premiums, deductibles, copayments, and coinsurance. Premiums are monthly payments for coverage; deductibles are amounts paid before insurance begins to pay; and copayments and coinsurance are shares of costs after the deductible is met.

For 2025, the standard monthly premium for Medicare Part B is $185. Part D prescription drug plans have an average monthly premium of around $46.50, though this varies by plan. Medicare Advantage (Part C) plans, which bundle Part A, Part B, and often Part D, have an average monthly premium around $17, with many plans offering a $0 premium. Medigap (Medicare Supplement Insurance) plans, which help cover out-of-pocket costs not covered by Original Medicare, can range from $100 to $300 per month, depending on age, location, and plan type.

For higher-income couples, the Income-Related Monthly Adjustment Amount (IRMAA) can increase Part B and Part D premiums. For 2025, if a couple’s modified adjusted gross income (MAGI) from two years prior exceeds $212,000, they pay a higher premium for both Part B and Part D. These surcharges are based on a sliding scale across income brackets, with the highest earners paying the most.

While Original Medicare (Parts A and B) does not have an annual out-of-pocket maximum, Medicare Advantage plans include a limit on out-of-pocket costs for covered services. For 2025, the federal cap for in-network services under Medicare Advantage is $9,350, with a combined in-network and out-of-network cap of $14,000. Medicare Part D also has an out-of-pocket spending cap, set at $2,000 for covered prescription drugs. Understanding these costs helps budget healthcare expenses in retirement.

How Medicare Coordinates with Other Health Plans

When an individual becomes Medicare-eligible, especially within a couple with other health coverage, understanding how Medicare coordinates with other plans is important. This coordination determines which insurance pays first (primary payer) and which pays second (secondary payer). Proper coordination ensures efficient claims processing and helps prevent unexpected costs.

For individuals covered by an employer group health plan, the employer’s size dictates Medicare’s role. If the employer has 20 or more employees, the employer’s group health plan pays primary, and Medicare pays secondary. If the employer has fewer than 20 employees, Medicare becomes the primary payer for the Medicare-eligible individual, with the employer plan paying secondary. These rules apply whether the Medicare-eligible spouse is still working or is covered under their spouse’s employer plan.

Medicare also coordinates with other government-sponsored health programs. For active military personnel, TRICARE pays before Medicare. For veterans receiving healthcare through the Department of Veterans Affairs (VA), VA benefits are used for service-connected conditions, while Medicare covers other healthcare needs. If an individual qualifies for both Medicare and Medicaid, they are “dually eligible.” In such cases, Medicare always acts as the primary payer, and Medicaid serves as the payer of last resort, covering costs Medicare does not, such as deductibles, copayments, and potentially long-term care.