Health Insurance Options If You’re Retiring Before Age 65

If you want to retire before age 65 or find yourself forced to retire due to health issues, downsizing, or family circumstances, what will you do for health insurance until you’re eligible for Medicare?

This article will explain your options and what you need to know about maintaining health coverage until you can transition to Medicare.

For some people, health insurance is the thing that keeps them tethered to a job, even after they’d prefer to retire and have enough money to do so. Before the Affordable Care Act (ACA), this was much more of a concern, as people with serious pre-existing conditions were sometimes entirely ineligible for self-purchased coverage. Today, self-purchased coverage is an option in every state, regardless of medical history. And the ACA also created income-based subsidies that make coverage much more affordable than it would otherwise be.

The ACA has made health insurance coverage a much less challenging situation for people who retire before age 65. This is especially true for people with medical conditions or limited finances—both of which could be obstacles for early retirees seeking coverage in the pre-ACA era.

And the American Rescue Plan (ARP) and Inflation Reduction Act have improved the ACA’s affordability provisions through the end of 2025. It would take another act of Congress to extend that into future years.

Roughly half of Americans—and most Americans under the age of 65—get their health insurance from an employer. At age 65, nearly all Americans become eligible for Medicare.

It’s common for people to make the transition from employer-sponsored health coverage directly to Medicare. Depending on the circumstances, they may continue to receive supplemental coverage from their employer, either as an active employer or a retiree.

But if you retire before you are eligible for Medicare, there may be several possible options for health coverage for the time between your retirement and eligibility for Medicare. This article explores the state health insurance Marketplace (exchange), continuation of benefits through COBRA or state continuation, using your spouse’s health plan, and Medicaid.

State Health Insurance Marketplace

As a result of the Affordable Care Act, every state has a health insurance Marketplace/exchange where private individual/family health plans can be purchased. These plans are all guaranteed-issue. This means you can enroll regardless of medical history, and any pre-existing conditions you have will be covered as soon as your plan takes effect.

Enrollment is limited to an annual open enrollment period or a special enrollment period triggered by a qualifying event. The loss of your employer-sponsored health plan is a qualifying event, so you’ll be able to switch to a plan in the marketplace when you leave your job and your health plan ends.

Premium Subsidies

The Affordable Care Act provides income-based premium tax credits (premium subsidies) that are available through the Marketplace/exchange in your state. These subsidies offset a large chunk of the premiums for most people who enroll in health plans through the marketplace.

From 2021 through 2025, the American Rescue Plan and Inflation Reduction Act have made those subsidies larger and more widely available. The subsidies cover a larger percentage of total premiums, and the income cap for subsidy eligibility—normally 400% of the poverty level—has been eliminated.

Congress could choose to extend these provisions past 2025. But if they don't, there will once again be an income limit of 400% of the poverty level to qualify for premium tax credits.

If you shop for health insurance in the Marketplace, you’ll see a variety of available plans. In some areas of the country, just a single insurer offers plans—although that’s much less common than it used to be. But even in areas where just a single insurer participates in the Marketplace, several different plans are available.

You’ll generally see plans at the Bronze, Silver, and Gold levels, and in some areas, Platinum plans will also be available. If your income doesn’t exceed 250% of the poverty level, the available Silver plans will include built-in cost-sharing reductions.

For 2024 coverage, 250% of the poverty level for a single person in the continental United States amounts to $36,450; for a couple, it’s $49,300 (note that these amounts are based on the poverty levels for 2023, as the prior year’s numbers are always used).

Although cost-sharing reductions are available to people with income up to those levels, they’re strongest for applicants whose income doesn’t exceed 200% of the poverty level. If your income is between 200% and 250% of the poverty level, you might find that a gold plan provides a better overall value than a silver plan.

If you’re retiring, your income is likely to fluctuate quite a bit in the year you retire. Since the financial assistance available in the marketplace depends on your income, it’s useful to understand how income is calculated for subsidy eligibility. It’s a form of modified adjusted gross income (MAGI) specific to the ACA and differs from MAGI used for other purposes.

Eligibility for subsidies is based on your income for the whole year—not just your income for the months you’re enrolling in a Marketplace plan.

If your income from your job is fairly high and you’re retiring mid-year, you’ll need to account for the income you earned earlier in the year—in addition to any income you’re expecting for the remainder of the year—when you apply for subsidies in the marketplace.

The elimination of the “subsidy cliff” through at least the end of 2025 is particularly important for early retirees. They may have otherwise found that their income from the months before their retirement pushed them above the eligibility limits for premium subsidies. In some cases, that's still true, if their income was high enough in the early part of the year to make them ineligible for subsidies despite the elimination of the subsidy cliff.

And since health insurance premiums are generally much higher for older enrollees, that may have meant that self-purchased coverage was simply unaffordable. But that’s no longer the case through at least the end of 2025. For the time being, you won't have to pay more than 8.5% of your household MAGI to purchase the second-lowest-cost silver plan in the Marketplace, regardless of how high your MAGI is.

Where to Look

If you’re considering early retirement and want to see the options available to you, go to HealthCare.gov. If your state runs its own exchange, you’ll be redirected there. You can browse the available plans based on your age, zip code, tobacco status, and income to see your options.

If you’re currently receiving any medical treatment, be sure you pay close attention to the applicable provider networks and drug formularies. Don’t assume they’ll be the same as the plan you have at work, even if the same health insurance company offers them.

COBRA or State Continuation

If Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage or state continuation coverage is available to you, it might be a good alternative. This will depend on several factors, including:

• How long it will be until you’re eligible for Medicare
• How much you’ve already spent on out-of-pocket costs for the year
• Whether you’re eligible for subsidies in the marketplace/exchange
• Whether you’d be able to keep your existing medical providers if you switch plans

Unless your employer offers to subsidize your COBRA coverage as part of a severance package, you’ll have to pay full price for your coverage while you have COBRA. This can be quite expensive, especially if you’re accustomed to your employer paying a significant portion of the cost.

But if you’ve already met your out-of-pocket cap for the year or are in the midst of complicated medical treatment and don’t want to worry about switching health plans, COBRA or state continuation can be very useful in the months after leaving your job.

If you only have a short time until you’ll be 65, you may find that you’re able to continue your employer-sponsored plan until that point using COBRA or state continuation. Or you might find that it works well during the year you retire, with a transition the following year to a marketplace plan based on your new retired-life income.

Your Spouse’s Health Plan

If your spouse is still working and has access to a health insurance plan that offers spousal coverage, you’ll be able to enroll in that plan when your own coverage terminates. Your loss of coverage will trigger a special enrollment period for your spouse’s plan, just as it does for a Marketplace plan.

Even if both you and your spouse were covered under your plan, you’ll both be able to transition to your spouse’s employer’s plan—assuming coverage is available—when your existing plan terminates.

Note that if you’re eligible to enroll in your spouse’s plan, you may or may not be eligible for a premium subsidy for a Marketplace plan. The IRS fixed the “family glitch” as of 2023.

But when one family member enrolls in a group plan and the other enrolls in Marketplace plan, subsidy eligibility is still based on the cost of only the Marketplace plan versus the entire household income.

Medicaid

If your income drops to a fairly low level after you retire, you may find that you’re eligible for Medicaid. In most states, Medicaid is available to adults under age 65 if their income doesn’t exceed 138% of the poverty level.

For a single person in the continental U.S. in 2024, that amounts to $20,782 in annual income; for a couple, it’s $28,207. The current year’s poverty level numbers are used for Medicaid eligibility determinations once states begin to use them, which is typically in March or April; FPL numbers are higher in Alaska and Hawaii.

But Medicaid eligibility can be determined based on monthly income (as opposed to Marketplace premium subsidies, which can only be based on annual income). So if your monthly income doesn’t exceed 1/12th of the annual income cap for Medicaid eligibility, you may be eligible for that coverage regardless of how much you earned earlier in the year.

Ten states have not expanded Medicaid under the ACA as of 2024. In these states, premium subsidy eligibility in the marketplace begins at 100% of the poverty level, but there’s a coverage gap (in nine of the ten states) for people who earn less than the poverty level. If you’re in one of those states, you may find that you’re not eligible for Medicaid, even with a very low income.

If you’re eligible for Medicaid and planning to use it until you turn 65, be sure you understand your state’s rules regarding Medicaid estate recovery. Some states only recover the cost of long-term custodial care services funded by Medicaid. But other states will recover any Medicaid costs for enrollees over the age of 55. This can include the money the state pays to a Medicaid managed care plan, which could exceed the actual cost of the person's care if they didn't need much medical treatment.

Also, be aware that Medicaid eligibility is much different for people who are 65 or older. At that point, eligibility is based on income and assets rather than just income. Some people find that the transition from Medicaid to Medicare results in significantly higher premiums and medical bills, so this is something to understand well in advance.

Summary

If you retire before age 65, you have several options for health insurance until you reach eligibility for Medicare. Which options you are eligible for and are best for you depends on your specific circumstances. You may enroll in coverage through the health insurance Marketplace in your state, continue your employment-related benefits through COBRA or state continuation, enroll in your spouse’s health plan, or apply for Medicaid.

Depending on your circumstances, you might find that it makes the most sense to continue working (and using your employer-sponsored health coverage) until you’re eligible for Medicare. But if you want to retire earlier than that, you’ll have options for affordable health insurance.