Health insurance might not be grabbing headlines amid election news and severe weather, but it’s critical this fall. Whether you have employer-based coverage, Medicare, or need to use Healthcare.gov, Open Enrollment decisions can impact your finances throughout 2025. Choosing the right health insurance plan could save you thousands of dollars. Expert advice is available to help determine the best option.
Avoid Common Health Insurance Mistakes
Mark Fendrick, M.D., a health costs expert, warns against hastily renewing current plans without reviewing new options. He emphasizes the importance of understanding how new rules could affect costs. While many focus on premiums, other health expenses should also be considered. “As Yogi Berra said, ‘It’s hard to make predictions, especially about the future,’” Fendrick explains, noting that last year’s medical needs can help forecast next year’s expenses.
Alena Hill, who leads Michigan Medicine’s financial counselors, advises considering provider networks and prescription formularies. “Open Enrollment is crucial, and trained guides are here to help,” she states. It’s essential to verify that preferred doctors and medications are covered under the plans you’re considering.
Know the Lingo
- Network: The providers your plan covers. Always check your plan’s network, as it changes annually.
- Formulary: Drugs your plan covers. Plans may require trying cheaper drugs first or prior authorization.
- Premium: Monthly cost for health coverage. Employers often cover a portion if you’re employed.
- Co-pay: Out-of-pocket cost for services or prescriptions, set by your plan.
- Co-insurance: Your share of costs, usually a percentage, often higher in low-premium plans.
- Deductible: The amount you pay before insurance covers costs. High-deductible plans offer tax-free Health Savings Accounts.
- Health Maintenance Organization (HMO): A plan with a local network, often requiring referrals for specialists.
- Preferred Provider Organization (PPO): A plan with a wider network; costs less if in-network.
- Exclusive Provider Organization (EPO): Typically larger than HMO networks, but out-of-network care isn’t covered except emergencies.
Medicare
Who: Individuals over 65 or with Social Security disability coverage.
What: Decide between Traditional Medicare and Medicare Advantage or change your Part D plan.
When: Oct. 15 to Dec. 7 for 2025 coverage.
Key Updates for 2025
Plan Changes:
Insurance companies may introduce new plans or discontinue existing ones. Use the Plan Compare tool to review 2025 Medicare Advantage and Part D options in your area. Check specific providers and medications to ensure they are covered.
Prescription Drug Cap:
A $2,000 limit on prescription drug costs is set for 2025. Insulin will cost no more than $35 monthly, and certain vaccines are fully covered. More information is available here.
Prescription Payment Plan:
The new Medicare Prescription Payment Plan (MPPP) allows spreading drug costs over the year. Enroll during Open Enrollment to benefit from this option.
Buying Insurance Yourself
Who: Those not qualifying for employer insurance or unsure about Medicaid eligibility.
What: Purchase 2025 plans on Healthcare.gov or state marketplaces.
When: Nov. 1 to Dec. 15 for Jan. 1 coverage; continue until Jan. 15 for Feb. 1 start.
Key Updates for 2025
Plan Variability:
Marketplace plans may vary yearly in terms of costs, networks, and formularies. Visit healthcare.gov to explore options.
Cost Assistance:
Discounts on Marketplace plans continue for 2025. Check eligibility using this calculator. For detailed costs, start an application on Nov. 1.
Eligibility Expansion:
DACA recipients and low-income individuals in Georgia can now purchase Marketplace plans. Medicaid coverage changes may also affect eligibility.
How to Get Help:
Assisters are available nationwide. Visit localhelp.healthcare.gov for assistance.
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