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Marital Status and Medicare Eligibility

How Medicare works when you're in a same-sex marriage

Medicare Benefits for Same-Sex Couples

Where do same-sex couples stand in relation to Medicare? — Corbis

En español

Q: I’m in a same-sex marriage and will soon be 65. How does my marital status affect my eligibility for Medicare?

A: Until quite recently, same-sex couples who had been legally married under the laws of their state or country were excluded from many federal benefits granted to married couples of the opposite sex. That was because the 1996 Defense of Marriage Act (DOMA) specifically defined a "spouse" as a man or woman legally married to a person of the opposite sex.

But in June 2013, the U.S. Supreme Court struck down parts of DOMA as unconstitutional, and since then federal officials have been working to clarify the ruling's practical effect on thousands of federal benefits, including Medicare.

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Not all issues have yet been resolved. But so far, here's what is known about where married same-sex spouses stand in relation to Medicare.

Becoming eligible for Medicare

Anybody who has earned enough credits from paying payroll taxes at work — 40 credits, equivalent to about 10 years' work — is entitled to full Medicare benefits in their own right at age 65. This means not having to pay monthly premiums for Part A (hospital insurance). The rule applies to anyone who is 65 or older and a U.S. citizen or a legal resident (green card holder), regardless of marital status.

If you haven't earned the required credits, you can qualify for premium-free Part A on your spouse's work record, if she or he is at least age 62 and has at least 40 credits. In the case of same-sex couples, however, this right has not yet been fully clarified and currently depends on where you live.

As of this writing, it's clear that you can qualify for premium-free Part A benefits on your spouse's work record if you live:

  • In the same state as the one where you married.

  • In another state (or the District of Columbia) that permits same-sex marriage or recognizes the marriage laws of another state or foreign country. (Same-sex couples married abroad automatically come under the rules of the District of Columbia.)

  • Anywhere in the United States if you or your spouse works for the federal government or for the Department of Defense in a military or civilian job. (The federal government announced equality of benefits for all employees immediately after the Supreme Court decision.)

But if you live in a state that does not recognize same-sex marriage or the marriage laws of the state where you wed, the situation is far less clear. The Supreme Court ruling allows states to refuse to recognize same-sex marriages legally performed in other states. Also, the Social Security Administration (the federal agency that administers Medicare eligibility and enrollment) has always looked to the laws of the state where people live when they apply for benefits — not for where they were when they married. Officials from SSA and the Department of Justice are still working on these issues. Meanwhile, if you’re in this situation and in your initial enrollment period for Medicare, go ahead and apply to Social Security for premium-free Part A benefits based on your spouse’s work record—so that if the rules change, your application is already in the system and can be processed faster.  For up-to-date information, call Social Security at 800-772-1213 (TTY:  1-800-325-0778) or go to its website and type "DOMA" into its search engine.

Note: If you cannot qualify for premium-free Part A benefits on your own or your spouse's work record, you can choose to buy these benefits by paying monthly premiums for them (in 2014, $426 a month for people with fewer than 30 credits; $234 a month for those with 30 to 39 credits). You qualify for Part B benefits (doctor visits, outpatient care, medical equipment) and Part D (prescription drug coverage) by paying the same premiums as anybody else. These benefits don't depend on work credits.

Next page: Delaying Part B enrollment. »

Delaying Part B enrollment if you're covered by your spouse's health plan at work

Under Medicare rules, people can delay signing up for Part B beyond age 65 (and avoid paying its premiums) for as long as they're covered under a group health plan provided by an employer for whom they or their spouse are still actively working. When that employment comes to an end, they're entitled to a special enrollment period of up to eight months to sign up for Part B without incurring any late penalties.

Before the Supreme Court ruling on DOMA, people in same-sex marriages with health coverage under their spouse's employer plans did not have the right to this special enrollment period. Therefore, if they didn't enroll in Medicare Part B at age 65, they were landed with late enrollment penalties — added permanently to their premiums — after they finally signed up.

That discrimination has now ended.  On April 3, 2014, the Centers for Medicare & Medicaid Services (CMS) announced that all same-sex spouses—wherever they live in the United States—would have the same right to this special enrollment period (SEP) as other married couples.  (CMS works under different rules from Social Security.)  

Therefore, if you are in this situation, you can delay Part B enrollment after age 65 based on coverage from your spouse’s current work, without risk of being penalized when this employment comes to an end.

If you’ve already applied for a SEP but Social Security has placed your request on hold, it can now be processed and your coverage will be backdated to when Social Security received your request.

If you previously asked for a SEP but were denied solely because of being in a same-sex marriage, you can now apply again.  To qualify for this second opportunity, you must meet the following conditions:

  • Your eight-month SEP (following the date when your spouse ceased employment) had to start after October 2012
  • Your eight-month SEP has to end before May 2014
  • You must file your second SEP request no later than May 31, 2014
  • You must meet all the other eligibility conditions for an SEP—namely, you’ve been covered under the group health plan provided by an employer for whom your spouse has been working, and you are legally married to that person.

If you were denied an eight-month SEP in the past on the basis of being in a same-sex marriage—and, as a result, were late enrolling in Part B and therefore have had to pay late penalties added to your premiums—you can now apply to Social Security for a reduction in the amount of the penalty. You can apply for this reduction regardless of when you and your same-sex spouse were married or where you currently live.

For more information, see CMS’s guidance on the new rules

Note:  Your spouse’s employer may require you to sign up for Part B when you turn 65 if the employer has fewer than 20 employees—or, if you have Medicare through disability, fewer than 100 employees.  In these situations, always consult the employer about how its health insurance plan fits in with Medicare.

Next page: Applying for programs that lower Medicare costs. »

Paying higher-income Part B and Part D premiums

If you live somewhere that recognizes your same-sex marriage, be aware that your Part B and Part D premiums will be assessed on the joint income of you and your spouse and not just you alone.

To be liable for surcharges, the modified adjusted gross income (MAGI) declared on your latest tax return must be at least $85,000 if you're single or married but filing separately; or $170,000 if you're a married couple filing jointly. These dollar thresholds are the same for both Part B and Part D, but the surcharges you actually pay are different for each program and vary according to your income.

Most people with Medicare don't pay these higher premiums — which actually represent a means test designed to reduce the amount of government subsidies for wealthier people. But a relatively high salary from your own and/or your spouse's work, or a sudden income boost (for example, from the sale of a house) could easily put you into a higher-income category.

For more information, see the Social Security Administration document "Medicare Premiums: Rules for Higher-Income Beneficiaries (pdf)."

Applying for programs that lower Medicare costs

Several programs can reduce the costs of Medicare beneficiaries whose incomes and savings are under a certain level. These include:

  • Extra Help — a federal program that provides lower-cost Part D prescription drug coverage

  • Medicare Savings Programs — state-run programs under which the state pays Part B premiums and maybe other expenses (deductibles, copays and Part A premiums) according to income

  • Medicaid — the state-run safety net for health care that pays virtually all the medical costs of people who qualify

If you live in a state that recognizes the validity of same-sex marriages, your eligibility for these programs is based on the joint income and savings of you and your spouse — even if you're the only one applying for assistance — just as it is for any married couple. Usually the income limits for a married couple are significantly lower than those for two single people.

Patricia Barry writes the AARP Ask Ms. Medicare column and is the author of Medicare for Dummies (Wiley/AARP, October 2013).

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