For better or worse, most of what you already know about health insurance won’t change next year.
The good news is that you won’t need to relearn the basics if your plan changes in 2025. The bad news is that the risk of unexpected bills remains, in part because the fine print on most policies “can get very complicated.” . said Gary Young, director of the Center for Health Policy and Healthcare Research at Northeastern University.
This year, frustrations are especially high. The murder of UnitedHealthcare CEO Brian Thompson has sparked an outcry against a health insurance industry already under fire from Congress for its role in setting prescription drug prices. Meanwhile, millions of people struggle with medical debt as the costs of care continue to outpace inflation.
Here’s what you need to know to help keep your healthcare costs down over the next year, whether you’ve already received your new insurance card or are still looking for coverage.
To start, cover yourself
About 164.7 million Americans receive health benefits through their employers, KFF estimates. For many of them, the open enrollment period ended weeks ago and they have already selected new coverage options or automatically re-enrolled in their existing plan.
Another 21 million people selected coverage through the federal Healthcare.gov portal last year. Open enrollment on that marketplace began in November and runs through Jan. 31, meaning there’s still time to shop for your own insurance plan. So if you haven’t already and intend to, make it your first priority this January.
Make sure your providers are still in network
Most policyholders are familiar with in-network and out-of-network costs, which arise from discounted rates that health plans negotiate with doctors and hospital systems. But some patients don’t realize that there is always a risk that professionals they have seen for years could be left out of their insurance network. The beginning of the year is a good time to check it out.
“It’s important to review your plan documents ahead of time,” said Michelle Long, patient and consumer protection analyst at KFF.
You can call your provider and ask, or look up your plan documents, most of which are usually available online, Long said. Insurers must also list their in-network providers and pharmacies, which you can usually find through search tools on their websites. To anticipate charges, providers must also provide an estimate, upon request, of how much certain services will cost.
Patients have some safeguards in emergencies. A “no surprises” federal law that took effect in 2022 limits the costs of, for example, a surgery performed by an in-network doctor that requires medication from an out-of-network anesthesiologist.
“You didn’t choose to go to an out-of-network hospital or provider, but that’s where you ended up because you were in an emergency,” Long said. “In those cases, you should be protected from that balance billing.”
Some states have their own laws that apply to all marketplace plans and some employer-sponsored plans. However, Long cautioned that you may not be protected by certain state laws if you are among the 63% of people with employer-sponsored insurance who have “self-funded” plans. You can check whether your plan is self-funded or “fully funded”—that is, your employer pays a set monthly premium to the insurer—in your plan documents.
In any case, insurers sometimes overcharge patients, Long said. “If you believe you are being denied coverage or required to pay more than you thought you should pay, you have the right to appeal,” he said.
Check your medications
Insurance company “formularies” dictate what drugs they cover, but what appears on those lists is sometimes a mystery, a point of political contention as drug companies and the middlemen who oversee prescription profits face increased scrutiny. .
In July, the Federal Trade Commission accused these pharmacy benefit managers of inflating drug costs by excluding cheaper generics from their formularies; PBMs have denied this. The FTC also sued the three largest PBMs in September, accusing them of artificially raising insulin prices, which the companies have denied.
Still, your insurer must disclose your plan formulary, so Long suggests checking it to see if your prescriptions are covered. Otherwise, you could be forced to pay out of pocket, but you may still have options. Sometimes doctors prescribe a brand-name drug when a generic is available, and if so, your pharmacist can determine if that alternative is covered. It could save you money.
There’s good news for seniors with Medicare: A new $2,000 annual limit on out-of-pocket costs for prescription drugs will take effect in 2025, due to a provision of the Inflation Reduction Act signed by the Biden-Harris administration. . That rule is expected to particularly benefit cancer patients, who face high costs for many of the drugs they are prescribed.
Find the rates you’re on the hook for
Your deductible (the amount you must pay each year before your plan starts paying the bill) could have changed even if you re-enrolled in the same benefits this year, so it’s always worth checking.
The average deductible for employer-sponsored plans in 2024 was $1,787 for individual coverage and $4,991 for family coverage, according to KFF. The average deductible for Marketplace plans is higher, at $3,057, but varies depending on the “metal tier” of the plan; most people choose “silver,” with a deductible of $5,241.
If you’re looking for a new plan, Young recommended considering how often you incur health care charges. High-deductible plans tend to have low premiums or monthly rates, but any chronic condition that requires frequent visits or prescriptions could make a plan with higher premiums more cost-effective, as it is likely to come with a lower deductible and a more solid coverage.
After you meet your deductible, some plans will still require you to cover a certain amount (a copay) or percentage (coinsurance) of each bill. Copays and coinsurance are more common in plans with low deductibles, especially for prescription drugs, emergency room visits, hospital stays, diagnostic imaging, and other services.
“Coinsurance can be really complicated, and that’s one way you can end up with a really big bill that you didn’t anticipate,” Young said. A common coinsurance is paid by the insurer 80%.
So, for example, he said, “if a doctor charges $2,000 for any service they provided, you will have to pay 20% of that” (or $400) “and that’s nothing.”
