Strategy: Self Only Vs. Family Health Insurance

ByJames Hutchens

Selecting the right type of Federal Health Plan can be difficult – especially given all the options. In some cases, you may find some value not including your spouse or family in your coverage. This is often a function of age and type of coverage they may have elsewhere and if they also work in the Federal Government.

Your decision of coverage type is often much different for households where both adults are federal employees. For most of you, the coverage will not really change. Your decision is quite simply going to revolve around cost structure. So, as you consider options during Open Season, look closely at any potential cost savings that may occur under each scenario.

1. General Overview

The fundamental rule for dual-federal couples under Office of Personnel Management (OPM) guidelines is that no individual may be covered under more than one FEHB enrollment at the same time. You cannot be the primary policyholder on a “Self Only” plan while also being listed as a dependent on your spouse’s “Self Plus One” or “Self and Family” plan. 

When to Choose Separate “Self Only” Plans

For many dual-federal couples without children, carrying two separate policies is the standard path to minimize expenses.

  • To Reduce Premium Costs:
    • The Rule: Under OPM premium structures, the combined cost of two “Self Only” premiums is routinely less expensive than a single “Self Plus One” premium for the exact same plan.
  • To Segment Differing Medical Needs:
    • The Rule: Deductibles and out-of-pocket maximums are tracked per enrollment.
    • The Benefit: If one spouse is highly healthy and wants a low-cost, high-deductible plan (HDHP), but the other spouse has chronic medical conditions requiring a robust fee-for-service plan, keeping separate policies prevents the healthy spouse from overpaying for insurance they do not use. 

When to Combine onto One “Self Plus One” or “Family” Plan

Combining coverages is typically driven by dependents or tax advantages. 

  • When You Have Children:
    • The Rule: If you have children to cover, you cannot use “Self Only”.
    • The Benefit: One spouse usually steps up to carry a “Self and Family” policy to cover both themselves and the children, while the other spouse either joins that plan or remains separate on their own “Self Only” plan.
  • To Reach One Deductible Faster:
    • The Rule: Family plans aggregate deductibles.
    • The Benefit: If both spouses have high healthcare usage, combining onto one plan means all co-pays and medical expenses go toward satisfying a single family deductible and catastrophic out-of-pocket limit, rather than having to satisfy two separate ones. 

2. Key If/Then Scenarios

  • IF you are a dual-federal couple with no children and both have similar, standard health needs, THEN electing two separate “Self Only” plans is typically the most cost-effective path.
  • IF one spouse plans to leave federal service or retire soon, THEN you must ensure the continuing spouse’s policy is set to “Self Plus One” or “Self and Family” so the departing spouse can maintain continuous health coverage into retirement. 

3. Standard Operating Procedure (Next Steps Checklist)

  1. Run the Math: Add up the cost of two “Self Only” premiums versus one “Self Plus One” premium for your preferred carriers.
  2. Audit the Deductibles: Compare the total out-of-pocket limits to see if your combined medical usage makes hitting a single family deductible easier.
  3. Plan for Retirement: If one of you is nearing retirement, verify that you are covering your spouse or that the spouse has their own FEHB plan to satisfy the mandatory 5-year continuous coverage rule. 

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