What Happens When One Spouse Is on Medicare and the Other Isn’t?

When one spouse qualifies for Medicare and the other doesn’t, couples face healthcare and financial planning challenges. This often happens due to age or health differences. Understanding the implications and options ensures continuous coverage for both.

Understanding Medicare Eligibility

Medicare eligibility generally begins when an individual reaches 65 years of age. To qualify for premium-free Medicare Part A, which covers hospital insurance, most individuals need to have worked and paid Medicare taxes for at least 40 quarters, equivalent to 10 years. Those who have not met this work requirement may still qualify for premium-free Part A based on a spouse’s work history.

Medicare eligibility can also be granted to individuals under 65 who have specific medical conditions or disabilities. Those who have received Social Security Disability Insurance (SSDI) benefits for 24 months become eligible for Medicare. Exceptions to this waiting period include individuals diagnosed with Amyotrophic Lateral Sclerosis (ALS), who qualify immediately upon SSDI approval, and those with End-Stage Renal Disease (ESRD), for whom eligibility begins after three months of dialysis or immediately following a kidney transplant.

Medicare is an individual health insurance program; coverage cannot be extended to a spouse or dependents. Each person must qualify and enroll based on their own eligibility criteria. This individual nature explains why one spouse may be on Medicare while the other is not, requiring separate healthcare arrangements.

Healthcare Options for the Non-Medicare Spouse

When one spouse transitions to Medicare and the other remains ineligible, securing alternative health coverage for the non-Medicare spouse becomes a primary concern. Several options exist, each with its own structure and cost implications.

If either spouse is still actively employed and their employer offers health benefits, continuing or enrolling in an employer-sponsored health plan is a cost-effective solution. These plans can provide comprehensive coverage for the entire family. Employers with 50 or more full-time equivalent employees are required to offer affordable, minimum-value insurance. An employer plan is considered affordable if the employee’s premium contribution for self-only coverage does not exceed 9.02% of their household income in 2025. If the employee’s coverage is affordable but family coverage is not, the non-Medicare spouse may be able to access subsidized coverage through the Health Insurance Marketplace.

Purchasing health insurance through the Health Insurance Marketplace, established by the Affordable Care Act (ACA), is another option. These plans offer various coverage levels, categorized by metal tiers (Bronze, Silver, Gold, Platinum), with varying premiums and out-of-pocket costs. Individuals and families may qualify for financial assistance, such as premium tax credits, which reduce monthly premiums, and cost-sharing reductions, which lower deductibles, copayments, and coinsurance. For 2025, there is no income cap for eligibility for premium tax credits, meaning individuals will not pay more than 8.5% of their household income for a benchmark Silver plan. Eligibility for cost-sharing reductions applies to those with household incomes between 100% and 250% of the federal poverty level, provided they enroll in a Silver-tier plan.

For individuals who recently lost job-based health coverage due to a qualifying event, such as job loss or reduction in hours, the Consolidated Omnibus Budget Reconciliation Act (COBRA) allows for temporary continuation of the previous employer-sponsored plan. COBRA coverage lasts 18 months for employees, though it can extend up to 36 months for dependents under certain circumstances, or 29 months with a qualifying disability. While COBRA maintains the same benefits, it can be expensive, as the individual is responsible for the full premium plus an administrative fee, 2% of the cost. Average monthly COBRA premiums can range from $400 to $700 per person.

Medicaid offers health coverage to individuals and families with limited income and resources. Eligibility criteria vary by state, but income limits are tied to a percentage of the federal poverty level. For instance, in 2025, individual income limits for certain Medicaid programs can range from approximately $1,300 to $2,900 per month, with asset limits around $2,000 for an individual. Some states also have “Medically Needy” pathways, allowing individuals with higher incomes to qualify if their medical expenses reduce their disposable income below a certain threshold.

Directly purchased private health insurance plans are available outside the Marketplace, but they do not offer the same subsidy opportunities. These plans are more expensive than other options, with average monthly premiums ranging from about $380 for Bronze plans to over $540 for Platinum plans in 2025, depending on factors like age, location, and plan type.

Financial Considerations for Couples

The transition to Medicare for one spouse while the other remains on a different health plan introduces financial considerations for the couple. Healthcare costs will encompass premiums, deductibles, copayments, and coinsurance from two separate insurance arrangements. For the non-Medicare spouse, the cost of their chosen healthcare option, whether it’s an employer plan, a Marketplace plan, or private insurance, will be a significant factor.

Marketplace plans involve monthly premiums that vary based on the chosen plan’s metal tier, the individual’s age, and where they live. The couple’s combined household income plays a direct role in determining eligibility and the amount of premium tax credits and cost-sharing reductions available for the non-Medicare spouse’s Marketplace plan. While there is no income cap for premium tax credits through 2025, the amount of subsidy reduces as household income increases.

Out-of-pocket expenses, including deductibles, copayments, and coinsurance, will apply to both spouses under their respective plans. The deductible is the amount paid for covered services before the insurance begins to pay, while copayments are fixed fees for services like doctor visits, and coinsurance is a percentage of the cost paid after the deductible is met. These costs can vary significantly between plans and tiers, necessitating careful review of each plan’s summary of benefits.

For the Medicare-eligible spouse, their income can affect Medicare Part B and Part D premiums through the Income-Related Monthly Adjustment Amount (IRMAA). This surcharge applies to individuals with higher modified adjusted gross incomes (MAGI) from two years prior. For 2025, married couples filing jointly with a 2023 MAGI exceeding $212,000 will pay higher Part B and Part D premiums. The standard Part B premium for 2025 is $185 per month, with IRMAA surcharges ranging from $74 to $443.90, depending on income brackets. This means the couple’s joint income can directly impact the Medicare spouse’s monthly healthcare expenditures.

Paths to Medicare Eligibility for the Other Spouse

The non-Medicare eligible spouse will also qualify for Medicare, simplifying the couple’s healthcare landscape. The primary path to Medicare eligibility is reaching age 65. When this occurs, the spouse can enroll in Medicare Part A, Part B, and potentially other parts like Part D or Medicare Advantage plans.

Another path to eligibility before age 65 is through a qualifying disability. If the non-Medicare spouse receives Social Security Disability Insurance (SSDI) benefits, they become eligible for Medicare after a 24-month waiting period from the start of their disability benefit entitlement. Exceptions to this waiting period exist for individuals diagnosed with ALS, who qualify immediately, and those with ESRD, whose Medicare coverage begins after three months of dialysis.

A spouse may also qualify for premium-free Medicare Part A based on their current or former spouse’s work history. This applies if the spouse has worked and paid Medicare taxes for at least 40 quarters. For a current spouse, they must be married for at least one year. Divorced spouses may qualify if the marriage lasted at least 10 years and they remain unmarried. This spousal benefit ensures that individuals who may not have accumulated enough work credits on their own can still access premium-free Part A.