What Happens when a Spouse on a Family Plan Turns 65?

[beachbum2012]

So if a husband and wife have a family plan with a family deductible and max out-of pocket, what happens to the plan once one spouse leaves and gets on Medicare? Does the existing plan just transition to an individual plan, or does the non-Medicare spouse have to re-enroll in a new plan? How about the deductible and MOOP?

Let's say the deductible was $3000/$6000 and the MOOP was $5000/$10,000 for individual/family. Let's also say the non-Medicare spouse was going thru some serious health issues and had already spent $4000 towards the deductible. If the Medicare-eligible spouse leaves, will the remaining spouse have to meet the family $6k deductible and $10k MOOP, or will the amounts drop down? Just wondering how the mechanics of this works since I'm dealing with a couple potential Medicare clients in this exact situation.

 

[bluediamond]

The existing plan is already an individual plan. When spouse drops off the other is only responsible for individual deductible. If the spouse already spent $4000 then they are $1000 over deductible and should be paying co-insurance to $5000 or when the co-pays and co-insurance = $5000 the spouse will be at their moop.

 

[DS4]

what happens to the plan once one spouse leaves and gets on Medicare?

Who is the primary insured?

If the younger spouse is primary, very simple, just delete dependent turning age 65.
If the older spouse is the primary, you might have to re enroll the dependent spouse under a new id #.

 

[beachbum2012]

Who is the primary insured?

If the younger spouse is primary, very simple, just delete dependent turning age 65.
If the older spouse is the primary, you might have to re enroll the dependent spouse under a new id #.

By "primary" do you mean primary wage earner? In one of my cases, the retired husband worked and will be getting on Medicare, and the homemaker wife will still need ACA coverage. In the other case, the lower-earning wife will be getting Medicare leaving the retired higher-earning husband needing ACA coverage.

 

[RayNY]

By primary, he means "primary insured".

On the app, this is the "applicant", while the other person will be the "spouse", referring to your specific case.

If the "spouse" is going to medicare, we expect you should be able to drop the "spouse" from the "primary"s plan (convert couple to individual) and have the plan continue in the primary's name. Cash paid towards deductible/MOOP should be honored, as it's a change to an existing plan and not a new plan (think of hitting your deductible, and giving birth, or [god forbid] having someone on the policy die. Deductible and MOOP are never wiped).

If the "primary" is the one becoming eligible, and the "dependent/spouse" is the one staying on the plan, it's our understanding that, in this scenario, it's a wipe and re-apply. The Primary (policyholder) is terminating, due to medicare eligibility. The dependent/spouse would re-apply as an individual. Deductible/MOOP contributions would be wiped and started over. This should qualify as an SEP, now that individual insurance abides by an "open enrollment period" eligibility system.

I hope that's clear enough. Please note, this is my understanding of the law and is, of course, subject to carrier approval and guidelines. They make the rules, I just give my educated interpretation.

 

[AllenChicago]

If the policy was purchased on the Exchange/Marketplace, perhaps the Report Life Changes button will allow the removal of a spouse, or any other family member?

 

[beachbum2012]

So how do I know who the primary insured is? One couple is already enrolled; and I will be working with the other couple to enroll them next month. Can you choose either spouse to be primary, or is it maybe the first person listed on the tax return?

 

[AllenChicago]

I usually choose the youngest as the primary unless a couple is dead set against it.

 

[DS4]

So how do I know who the primary insured is? One couple is already enrolled; and I will be working with the other couple to enroll them next month. Can you choose either spouse to be primary, or is it maybe the first person listed on the tax return?

Whose name is on the Id card?

 

[Yagents]

Primary is the first person listed on HC.gov

Bigger issue is the subsidy amount will change dramatically when that person turns 65. Their costs will go up by whatever medicare costs that person.