Once you are married, you can get health insurance through your spouse if they already have health coverage. Marriage is a qualifying life event for enrolling in a health insurance plan outside the Open Enrollment period. Acquiring your spouse’s health plan will take a bit of communication and comparing costs, medical needs, and expectations.
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How to Get Health Insurance Through Your Spouse in 3 Steps
If you have recently gotten married, you have sixty days from your wedding date to be added to your spouse's plan or add your spouse to your own. During these sixty days, your marriage is considered a “qualifying life event,” allowing you to bypass the Open Enrollment Period. If you have waited until after the 60 days, you will have to wait until the Open Enrollment Period, which begins November 1 and goes until December 15 of each year.
Joining your spouse’s plan or having them join your plan may spark some new conversations for you and your newly-wed. If you both already have employer-sponsored plans, you may have to pay a fee when joining your spouse plan, as you already have a means for health coverage. If you are covered by an individual Marketplace plan, it will likely be more affordable to expand to a family plan through the employer-sponsored plan. You will want to consider your budget, health needs, and age for family health coverage.
Step 1: Talk to Your Spouse
You should first talk with your spouse about the budget for your family plan. When adding another family member to your plan, the costs may nearly double. According to the Kaiser Family Foundation, in 2020, the annual premiums for employer-sponsored health insurance reached $21,342, with employees paying on average $5,588 for the cost of their coverage. In 2020, the upper limit for out-of-pocket costs for a family was $17,100.
Depending on the health needs of you and your spouse, these premiums may fluctuate depending on the frequency and intensity of each of your care. It may be more affordable for you and your family if you remain on individual plans unless you plan on further expanding your family. At which point, a joint family plan may be the most affordable. The plan category of your spouse may not be the most comprehensive for your needs.
If your spouse has an employer-sponsored plan, the portion of your family’s premium likely comes right out of their paycheck. You may want to define who will cover the costs or whether you will have a plan in place to share the costs of your premiums. If you are considering your eligibility for health insurance subsidies, you and your spouse will have to file taxes jointly.
Step 2: Speak With a Representative
After speaking with your spouse about budgets and health care needs, you will be well-equipped to speak with a representative. Be sure to have a copy of your marriage certificate handy to show eligibility for enrollment outside of the Open Enrollment Period.
If you are insured privately, you should call a representative from the insurance company to understand what paperwork is required and the costs associated with adding members to your plan. You may also be able to find this information by logging into your insurance portal. Typically, you will need to fill out a few forms and show your marriage license to verify your qualifying life event for changes to your insurance plan. You may wish for more assistance and transparency regarding specific items or services covered under each plan or the costs of various plan types - such as Bronze, Silver, Gold, or Platinum plans.
If you or your spouse have employer-sponsored health insurance, you can also get assistance from the human resources department of your organization to discuss your current plan and benefits and whether your plan offers additional dependents. You can also determine if there are fees associated with spousal coverage if this is something your employer provides. You may also determine what other plan types exist and whether they provide more comprehensive coverage for your family.
Step 3: Understand Your Options
After speaking with your human resources department or a representative for additional clarity about your insurer provider’s plan offerings, you will want to determine which plan is most suitable for your family’s needs. Below is a breakdown of the different plan types and coverage options. You may find it makes sense to keep the plan you have now, or you may want to consider other options that meet the needs of your whole family.
When comparing health plans, you will often find plans categorized by either metal tier, price, or type of health plan such as HMO, PPO, POS, EPO, etc. The type of health plan indicates the flexibility you have in choosing your healthcare providers and requiring a referral to seek a specialist. Metal tiers can have plans of any network provider type, for example, a silver PPO plan.
Health Plan Types
Below is the defined list of health insurance plan types: HMO, PPO, POS, and EPO plans.
- Health Maintenance Organizations (HMOs): typically have lower insurance premiums and out-of-pocket costs because they require a primary care physician (PCP) referral before seeking specialty care. When employees sign up for an HMO plan, they should choose a trusting PCP since they will be the gatekeeper of their other health needs.
- Point of Service Plans (POSs): Like an HMO, a POS plan requires a referral from a primary care physician before seeing a specialist. These plans usually have higher premiums than HMOs because they cover out-of-network doctors and higher expenses for in-network care.
- Preferred Provider Organization (PPOs): PPOs typically have higher premiums than HMOs or POS plans, but enrollees can freely seek specialists and out-of-network physicians, with no referral needed. These plans are a great option for those requiring frequent and various care and can afford higher premiums.
- Exclusive Provider Organization (EPO): EPO’s are lesser-known and only cover in-network services, but the network is generally larger than HMOs, so they may not require a referral from a primary care physician. The premiums for EPOs are higher than HMOs but lower than PPOs.
Metal Tier Plans
The type of plan that will be most affordable to you will depend on your medical needs, your income, as well as your state. Bronze plans tend to offer the most coverage for the least amount for individuals requiring moderate and preventative care. Gold and Platinum plans work best for people often needing care and are willing to pay more each month for greater coverage. Below is a breakdown of the shared costs associated with metal tier plans.
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When weighing your options, understanding the contribution of your cost-sharing and the various offerings of different plan types can help determine which plan is right for you and your spouse. When you determine what is best for you, you should be well-equipped after discussing each of your needs with your spouse and speaking with a professional about navigating your options and their process for adding spousal coverage.
How to Get Health Insurance Through Your Spouse Frequently Asked Questions (FAQs)
Navigating health insurance can be daunting. We have answered some frequently answered questions regarding health insurance basics and spousal coverage below.
What are deductibles, premiums, and copayments, or coinsurance?
- Deductible: The amount you pay before your insurance covers your care. Your insurance provider may cover certain preventative care and screenings regardless of meeting your deductible, but each plan is different.
- Premium: The cost you pay per month to keep your insurance. These rates vary across insurer and plan types. Determining your monthly premium will likely be based on the demands of your medical needs, income, and your state.
- Copayment/Co-insurance: A copay is a flat rate you pay when visiting a physician’s office. Typically, specialist visits have a higher copay. For example, you may have to pay $20 out of pocket when you see your primary care physician but $25 when you see a specialist. Similarly, coinsurance is the percentage you are required to pay when you receive care; for example, your insurer may require you to pay 20 percent of the cost when you visit our primary care physician.
Can an employer deny spousal coverage?
Under the Affordable Care Act (ACA), employers are not required to offer health insurance to their employees’ spouses, but they must offer health insurance to their employees’ dependents. Spouses are not considered dependents, but biological or adoptive children under 26 years old are. Neither stepchildren nor foster children are considered dependents.
When would it be more affordable to stay on individual plans?
It may be more affordable to remain on individual plans if your medical needs drastically differ. Perhaps your or your spouse’s plan requires a high deductible before the insurance kicks in, but you do not regularly seek care. You may or your spouse may prefer the doctors and medical relationships you have formed through the network within your individual insurance plan, and switching may change the doctors and services offered. Review your plan offerings and explain benefits when deciding what makes the most sense for you and your partner.
Joining your spouse’s plan is not as complicated as it may feel. Speak with your spouse about their medical needs and your budget and compare the costs associated with spousal coverage. Speaking with a representative and being well-equipped with your family’s needs can help you find the most comprehensive and affordable plan. Stay on top of your timeline, as you have 60 days from your wedding date or 30 days from your loss of coverage to get on your spouse’s plan.
With Mira, there is no Open Enrollment Period or Special Enrollment period for those with qualifying life events. We provide care when you need it for as little as $45 per month. Mira even offers family plans and up to 80 percent discounted rates on over 1,000 prescriptions. Try Mira today!