Who can be on your health plan?

Ensuring that your loved ones have health insurance is a top priority. But who can you put on your health plan?

The Affordable Care Act (ACA) extended the age for children to get coverage on a parent’s plan. Also, the Supreme Court expanded coverage to same-sex married couples when it legalized same-sex marriage. 

Beyond federal and state law, employers and insurance companies have their own rules. So, it can get confusing. 

Here’s what you need to know about adding people to your health plan. 

Who you can add to your health insurance plan

Generally, if you can claim someone as a dependent on your tax return, you can add them to your health plan. 

Your child can be covered under your health plan until he or she turns 26. That even includes if your child: 

• Doesn’t live with you
• Is married
• Attends school
• Is financially independent 
• Is eligible to enroll in an employer’s plan

The ACA allows parents to cover their children, whether biological, adopted, stepchild or foster. However, it doesn’t require those parents to keep their children on the insurance. It’s up to the parent to decide whether they to cover the child. 

Keep in mind that your employer may require you to complete dependent or biological verification to add a family member to your plan. The company may ask for your marriage certificate, your child’s birth certificate or adoption paperwork.

Another important thing to know is that state and federal law govern health insurance. Congress eliminated the individual mandate tax penalty that required nearly all Americans have health insurance. However, businesses with at least 50 full-time employees must provide coverage. 

These employers are legally required to cover an employee’s dependents. However, they aren’t forced to cover spouses. That’s especially true if the spouse qualifies for a health plan through an employer. 

However, many companies, especially large ones, still offer coverage for spouses. 

What if my spouse or child lives out of state?

Adding a family member or dependent to your health plan is pretty straightforward if you have a traditional living or family situation. But what happens when you don’t?

Though you can add your spouse or child to your plan, things can get complicated if you live in different states.

There are several reasons families may live apart — a job change, marital separation, a child away at college or a temporary relocation to care for an aging or ill family member.

In these situations, you should understand the health plan’s network of providers and hospitals. Insurers contract with providers. Those contract set rates paid to doctors and facilities. They could also include provisions that the providers must follow, such as meeting quality metrics. 

Insurers don’t have contracts with all providers and hospitals. So, make sure you know which providers and hospitals are considered in-network. If you go to an out-of-network provider, you may have to pay the full bill. 

Make sure you understand also whether your plan covers for out-of-network providers and hospitals — and how much they’ll give. 

Here are the out-of-network differences by plan:

• Health maintenance organization (HMO) — HMOs have a restricted network of providers. HMOs usually don’t provide any help with out-of-network care. 
• Preferred provider organization (PPO) — PPOs will likely pay for part of your out-of-network care, but you’ll get a larger bill than if you received in-network care. 
• High-deductible health plan (HDHP) — HDHPs may or may not chip in any money for out-of-network care. As the name implies, an HDHP has a high deductible, which means more out-of-pocket costs than HMOs or PPOs. 

If your loved ones live in a nearby state, it might be best for them to seek care in your state from an in-network provider. In these cases, domestic medical travel insurance or supplemental insurance like a hospital indemnity plan may help to fill coverage gaps. If you’re self-insured, consider purchasing a multi-state health plan from a private insurer.

“If your spouse or children don’t qualify for coverage under an employer plan, you still should be able to shop for coverage on the [health insurance] marketplace,” says Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation.

So, before you add a loved one who’s out of state to your plan, check:

• Whether your insurer offers a national network (most don’t)
• What providers are considered in-network 
• The costs of out-of-network coverage for your plan

What if I’m divorced or separated?

If you’re legally separated, your spouse can remove you from his or her health plan. With a divorce, your spouse legally can’t keep you on his or her health plan. However, your dependents can stay on your spouse’s plan if they don’t have any other coverage.

Divorce and legal separation are considered qualifying events for special enrollment. Special enrollment is a time when you can change health plans outside of open enrollment.

During that period, you could get new coverage through your employer, the marketplace or qualify for COBRA coverage through your spouse’s employer-sponsored group health plan for up to three years. You could also check to see if you’re eligible for your state’s Medicaid program. 

What if you have a domestic partner or same-sex spouse?

The rules vary by employer and state. If your state allows coverage, establishing a domestic partnership should ensure your loved ones get coverage. To create a domestic partnership, you need to meet your state’s qualifications, which typically include being 18 or older, living with your partner for at least six months and being financially responsible for one another.

If you meet these qualifications, you’ll have to complete the required paperwork with your state or municipality and provide this proof to your employer — if they offer domestic partner benefits (some don’t). However, if your employer provides coverage to spouses, depending on state law, they must give the same coverage to domestic partners and their dependents (however, these benefits may be treated as taxable income). They must also offer coverage to same-sex spouses.

“Domestic partners do not have the same federal legal protections as married couples. However, the same general principle applies: if your employer provides coverage for opposite-sex domestic partners, they probably must extend that coverage to same-sex partners,” Donovan says.

Same-sex couples also can buy insurance with spousal coverage from the health insurance marketplace, Donovan says. However, for same-sex couples who want their spouse to be covered through an employer-sponsored plan, it can be tricky.

“Same-sex couples enjoy at least some degree of protection in 33 states and the District of Columbia, but that still leaves 17 states that do not prohibit employment discrimination on the basis of sexual orientation,” Donovan says. “There are also some states that only prohibit discrimination in the public sector, leaving people who work for private employers vulnerable. In these states, unfortunately, the simple act of filling out a benefits form could out an employee to their employer, leading to discrimination or the loss of a job.”

Unfortunately, same-sex couples will have to weigh these considerations when deciding whether to add a spouse to their employer’s health plan.

In most states, you’re not able to add a live-in girlfriend or boyfriend’s children — even if you’re in a long-term, committed relationship or common-law marriage. 

Other important things to know about who can be on your health plan

Review your plan summary and call the insurer for more details if something is unclear before you decide who to add to your policy. Also, make sure you understand what these policy additions will cost you. Look both at premiums and potential higher out-of-pocket costs, including for out-of-network care. 

Going from single coverage to spouse or family coverage could double, triple or even quadruple your premiums. Kaiser Family Foundation estimated that the average annual premiums for single coverage was $1,243 in 2020. That’s compared to more than $5,588 employees paid on average for family coverage. 

“If your employer has a benefits booklet or something similar, you may be able to find out what kind of benefits they extend to spouses or dependents. If you’re confident that you won’t experience discrimination, you can ask your HR representative as well,” Donovan says. “If you’re nervous about discrimination, you may be able to call your insurer to see if they can tell you who you can add to your plan without directly asking your employer.” 

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