For better or worse, most of what you already know about health insurance isn’t changing next year.
For starters, get covered
Some 164.7 million Americans receive health care benefits through their employers, Kaiser Family Foundation estimates. For many of them, the open enrollment period has been over for weeks, and they’ve already selected new coverage options or been 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 kicked off in November and runs until Jan. 31, meaning there’s still time to purchase your own insurance plan. So if you haven’t done so yet and intend to, make that your first priority this January.
Make sure your providers are still in network
Most insured people are familiar with in- versus out-of-network costs, which arise from the discounted rates health plans negotiate with doctors and hospital systems. But some patients don’t realize there’s always the risk that practitioners they’ve seen for years could slide out of their insurance network. The start of the year is a great time to check.
“It’s important to look at your plan documents ahead of time,” said Michelle Long, a patient and consumer protections analyst at KFF.
You can either call your provider and ask, or search your plan documents, most of which are typically available online, Long said. Insurers are also required to list their in-network providers and pharmacies, which you can usually find via search tools on their websites. To anticipate charges, providers must also provide an estimate upon request for what certain services will cost.
Review your medications
Insurance companies’ “formularies” dictate which drugs they cover, but what lands on those lists is sometimes a mystery — a point of political contention as drug companies and the middlemen that oversee prescription benefits face heightened scrutiny.
In July, the Federal Trade Commission accused these pharmacy benefit managers of inflating drug costs by excluding cheaper generics from their formularies; the PBMs have denied that. The FTC also sued the three biggest PBMs in September, accusing them of artificially raising insulin prices, which the companies have denied.
Still, your insurer is required to disclose your plan’s formulary, so Long suggests checking it to see if your prescriptions are covered. If not, you could be stuck paying out of pocket — but might still have options. Sometimes doctors prescribe a brand-name drug when a generic exists, and if so, your pharmacist can determine whether such an alternative is covered. It could save you money.
Look up the fees you’re on the hook for
Your deductible — the amount you have to pay each year before your plan starts picking up the tab — 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 single coverage and $4,991 for family coverage, according to KFF. The average deductible for marketplace plans is higher, at $3,057, but they vary depending on the “metal level” of the plan; most people choose “silver,” with a deductible of $5,241.
If you’re hunting for a new plan, Young advised considering how often you incur health care charges. High-deductible plans tend to have low premiums, or monthly fees, but any chronic conditions that require frequent visits or prescriptions could make a higher-premium plan more cost-effective, since it’s likely to come with a lower deductible and more robust coverage.
Conclusion
While the basics of health insurance may not be changing, it’s still crucial to stay informed and proactive to avoid unexpected bills. By reviewing your plan documents, checking your providers, and understanding your medications and fees, you can take control of your health care costs and ensure you receive the best possible care.
Frequently Asked Questions
Q: What is the average deductible for employer-sponsored plans in 2024?
A: The average deductible for employer-sponsored plans in 2024 was $1,787 for single coverage and $4,991 for family coverage.
Q: What is the average deductible for marketplace plans in 2024?
A: The average deductible for marketplace plans in 2024 is $3,057, but it varies depending on the “metal level” of the plan.
Q: What is the “no surprises” law, and how does it affect me?
A: The “no surprises” law limits costs for emergency services performed by out-of-network providers. Patients are protected from balance billing in emergency situations.
Q: How can I check if my providers are still in network?
A: You can either call your provider and ask, or search your plan documents, most of which are typically available online. Insurers are also required to list their in-network providers and pharmacies, which you can usually find via search tools on their websites.
