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 receiving unexpected bills still exists, in part because the fine print on most policies “can become 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 the health insurance industry already under fire from Congress for its role in 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 next year, whether you’ve already received your new insurance card or are still looking for coverage.
Get Covered To Get Started
About 164.7 million Americans receive health care benefits through their employers, according to estimates by the Kaiser Family Foundation. 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 purchase your own insurance plan. So if you haven’t done it yet and you intend to do it, make it your first priority this January.
Make sure your providers are still part of the network
Most insured people 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 leave 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, if requested, of how much certain services will cost.
Patients have some safeguards in case of emergency. A federal “no surprises” law that went into effect in 2022 limits the costs of, for example, a surgery performed by an in-network doctor that requires drugs 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 those charges.”
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” (meaning your employer pays a fixed monthly premium to the insurer) in your plan documents.
In any case, insurers sometimes overbill patients, Long warned. “If you believe you are being denied coverage or required to pay more than you thought you should have paid, you have the right to appeal,” he noted.
Review 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 benefits face increased scrutiny.
In July, the Federal Trade Commission (FTC) 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, something the companies have denied.
Still, your insurer is required to disclose your plan formulary, so Long suggests checking it to see if your prescriptions are covered. If not, you may have to pay out of pocket, but you may still have options. Sometimes doctors prescribe a brand-name drug when a generic drug 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 in the Biden-Harris Administration’s Inflation Reduction Act. . That rule is expected to particularly benefit cancer patients, who face high costs for many of the drugs they are prescribed.
Find the fees you need to pay
Your deductible, the amount you have to pay each year before your plan begins to cover expenses, could have changed even if you signed up for the same benefits again this year, so it’s always worth checking.
According to KFF, the average deductible for employer-sponsored plans in 2024 was $1,787 for individual coverage and $4,991 for family coverage. The average deductible for Marketplace plans is higher, at $3,057, but varies depending on the “metal level” of the plan; Most people choose the “silver”, with a deductible of 5,241.
If you’re looking for a new plan, Young said to consider how often you incur health care expenses. High-deductible plans tend to have low premiums or monthly fees, but any chronic condition that requires frequent visits or prescriptions could make a higher-premium plan more cost-effective, as it likely comes 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 very complicated, and that’s one of the ways you can end up with a very large bill that you didn’t anticipate,” Young said. A common coinsurance is 80% paid by the insurer.
So, for example, he said, “if a doctor charges $2,000 for any service he or she provided, you are obligated to pay 20% of that amount” — or $400 — “and that’s nothing.”
