Different Insurance Coverage for Different Family Members

In our continuing coverage of the health insurance reforms resulting from the Affordable Care Act (ACA, or “Obamacare”), this week, courtesy of KaiserHealthNews.org (KHN), we look at different insurance plans for different members of a family.

If you want coverage from a plan offered on healthcare.gov, the federal insurance marketplace, or on one of the individual state exchanges, is it necessary for all members of a family to buy the same level of coverage? For example, can a husband opt for a gold plan, and his wife a silver? (Amount of coverage, from most to least, is denoted by platinum, gold, silver and bronze plans.)

And must couples sign up for the same plan in order to qualify for tax credits?

In a word, says KHN’s expert, no. But this is health care – of course it’s not that simple!

Individuals within a couple may sign up for different level plans and still qualify for tax credits to subsidize premium costs if their incomes are less than $62,000 for a couple (about $46,000 for individuals). If couples buy different plans, the tax credit will be split between them instead of reducing the premium for one family plan.

But consider this: If you buy two individual plans instead of one family plan, you must satisfy two separate deductibles each year. So as a family, you’ll probably pay more out of pocket over the course of the year, especially if you are a big consumer of health care.

And the cost-sharing subsidies that reduce copayments, deductibles and other out-of-pocket expenses for couples with incomes as high as $38,775 are available only to those who buy silver-level plans. So if you choose two different levels, have limited income and one plan is lower than silver, it could cost you.

For people with chronic conditions that typically carry high costs (diabetes, heart problems, rheumatoid arthritis, etc.), health policy advocates suggest that you consider paying a higher premium for a more comprehensive platinum-level plan, even if other family members choose less expensive coverage. Because the higher-level plans plans generally must cover 90% of medical costs, your out-of-pocket limits could be significantly lower. So in the long run, it’s a better deal.

If you’re an exchange shopper, review the health profiles of each person in your family who’s seeking coverage. Pencil out the different deductibles, copays and other out-of-pocket expenses relative to each person’s anticipated or foreseeable health-care needs according to the plans you’re considering.

In some cases, a single plan for the family makes sense, but depending on your expected consumption of services, maybe different plans are best.

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