Updated Oct. 25 with Marketplace plan preview link

The election and severe weather dominate the headlines and social media right now. Which means you might have missed big news about health insurance. 

Yawn, right? Health insurance is boring.

Not this year.

No matter what kind of health insurance you have, or if you don’t have it, this fall is the time to pay attention – regardless of what else is going on in the world or your life. 

Decisions you make now during Open Enrollment for Medicare, for your job-based coverage or on Healthcare.gov, could affect you and your wallet for all of next year. 

You could end up spending, or saving, hundreds or even thousands of dollars more by the end of 2025 depending on which plan you choose.

So it’s important to choose carefully. In many cases, you can get help from unbiased professionals to figure out your best option. 

Not boring at all!

Don’t make this health insurance mistake

Mark Fendrick, M.D., a health costs researcher and primary care doctor at Michigan Medicine, says a lot of people make a key mistake every fall: not taking time to really look at their options. 

Plus, he says, this year there are new rules and programs that could really change costs for many people. 

“It’s so easy just to click ‘renew’ on the plan you have now,” he said. “A substantial minority of Americans, when given options, still do not pick the health plan that meets their clinical and financial needs. There’s a lot of information out there, and you need to use it.” 

Fendrick says a lot of people focus a lot on the monthly cost of having an insurance plan, called a premium. But they don’t factor in all the other types of health costs that their insurance will require them to pay during the year, depending on what plan they pick, what medicines they take, and what happens with their health. 

“As Yogi Berra said, ‘It’s hard to make predictions, especially about the future,’ but what care and prescriptions you used last year can be a decent predictor of what you’re going to use next year,” he explains.

Depending on your situation, your out-of-pocket costs under a plan with a low premium might add up to more than what you might ‘save’ if you went with a plan that has a higher premium but less cost-sharing throughout the year.

Alena Hill agrees. She leads a team of financial counselors at Michigan Medicine that helped more than 2,300 people last year get the information they needed to decide what plan was best for them and their family, and discover programs that could help them cut their total costs. 

“Open Enrollment is a crucial time, and trained guides like my team are here to help people understand their best options,” she said. “The biggest thing we say is, if you have doctors and other providers you especially want to see next year, a hospital you prefer, or specific medicines that are working for you, it’s crucial to check whether they’re in the provider networks and on the prescription plan formularies of every option open to you, before you make a final choice.”

You can also find lists of which plans are accepted by a particular health system’s doctors or hospitals by looking at their website. 

For example, here’s a page that lists the 2024 health plans for which U-M Health providers and hospitals are in-network; it will soon be updated for 2025. UM Health-Sparrow’s list of 2024 in-network plans is here. 

But be careful, Hill says: you need to look for the precise name of the plan you’re considering, since insurance companies often have multiple plans with similar names.

If you do change your insurance plan for 2025, be sure to tell all your usual health care providers right away as soon as the New Year arrives, so that they will bill the right plan if you need care. You may be able to do this directly in your patient portal.

Below, find key dates, tips and updates for people with different kinds of insurance. 

Click the type of insurance to go to that section: 

• Know the lingo 
• Medicare 
• Job-related insurance 
• Insurance you buy yourself
• Medicaid
• Veterans’ (VA) health benefits
• No insurance

Know the lingo:

• Network: The list of providers that an insurance plan will allow you to see, unless you get a special exception. Just because a doctor has referred you to another doctor, or for a test, scan or procedure at a specific center, that doesn’t mean they’re in-network for your plan, Hill says. Plans add and remove providers and facilities in their networks every year, so you should always check. 
• Formulary: The list of prescription drugs for which a plan will cover some or all of the cost. Even if a doctor writes a prescription for as specific drug, an insurance plan can require you to try lower-cost drugs first, and only cover the cost of a more-expensive drug if the first or second drug doesn’t work for you. (That is, unless you want to pay for the exact drug out of your own pocket without using insurance.) A plan can also require your doctor to seek permission before being allowed to prescribe you a certain drug (called prior authorization), or require you to meet certain health or lifestyle criteria to get coverage for a drug.
• Premium: What you pay, usually monthly, in order to have health insurance coverage and/or prescription drug coverage, and access to health care services as outlined in the insurance plan. If you are employed, your employer probably pays part of your premium too.
• Co-pay: The amount you pay out of your own pocket each time you get a service or fill/refill a prescription. The amount is set by your insurance policy. There is no co-pay for certain prevention-focused services, like cancer screenings and vaccines, under the Affordable Care Act, but you have to get them from an in-network provider and you may have to pay for follow-up tests after an abnormal screening test result.
• Co-insurance: The amount you must pay toward your care in some plans, which is a percentage of the total cost for a service or drug. It’s generally higher in plans with low monthly premiums.
• Deductible: An amount you must pay for all the services or medicines you receive, starting with the first day of your coverage each year, before your insurance “kicks in” and starts paying costs for the rest of the year. Some plans have no deductibles. But an increasing number of plans have high deductibles, of thousands of dollars. If you choose one of these, the government also allows you to save money tax-free in special health savings accounts. 
• Percent of poverty level: A specific dollar figure for total income for a person or family, which is used to determine eligibility for programs and cost assistance.  See the 2024 levels here.
• Health Maintenance Organization (HMO): A type of health plan that offers a local, limited network of doctors and hospitals for you to choose from. Because of this, an HMO plan usually has lower monthly premiums than a PPO or an EPO health plan. HMO plans often require you to select a primary care physician (PCP) and require referrals to see specialists. They generally won't cover out-of-network care except in an emergency.
• Preferred Provider Organization (PPO): A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. This kind of plan typically offers a larger network than an HMO.
• Exclusive Provider Organization (EPO): A type of health plan that offers a local network of doctors and hospitals for you to choose from but networks are generally larger than HMO networks. An EPO is usually more pocket-friendly than a PPO plan. However, if you choose to get care outside of your plan’s network, it may not be covered (except in an emergency). 

Medicare:

Who: People over 65 and people with Social Security disability coverage

What: 

• Choose to stay in, or switch between, Traditional Medicare and Medicare Advantage
• Choose to stay in or switch your Medicare Advantage plan if you already have one
• Choose to stay in, or switch, your Part D prescription drug plan if you have Traditional Medicare or a Medicare Advantage plan that doesn’t cover prescriptions, or choose a Part D plan if you’re switching from a Medicare Advantage plan that covers prescriptions to another option that doesn’t. 

When: Oct. 15 to Dec. 7 (or later if you’re turning 65 in 2025) 

Key updates for 2025: 

Changes in plans available to you:

Some health insurance companies have announced they’re ending some plans, or opening new ones. All plans run by insurance companies recently announced their updated networks, formularies, benefits, premiums and other costs. 

Use the Plan Compare tool to see which Medicare Advantage and Part D plans are available in your area for 2025. Be sure to look up specific providers, hospitals and drugs by name to see if they are in-network or on-formulary for each plan you’re considering. You can also see new star ratings that indicate the level of quality of the plan; these just got updated for 2025. It’s available in English or Spanish . 

If you have a lower income, you may also be eligible for one of Medicare’s income-based financial assistance programs. Visit www.medicare.gov/basics/costs/help to learn more.

A $2,000 cap on prescription drugs, and other savings

This new cap, which was part of the Inflation Reduction Act passed by Congress in 2021, mandates that no person with Medicare will have to pay more than $2,000 total for their prescription drugs included on their Part D plan’s formulary for all of 2025. 

If you use insulin, your monthly out of pocket cost will be capped at $35 month. And if you get a vaccine at a location that is in-network for your plan and recommended for you based on age or health status, the cost will be fully covered by your plan. 

Learn more about all of these drug-cost provisions, and how to get extra help with prescription costs if you have a very low income.

You may have also heard that Medicare is negotiating prices with drugmakers for the first time. However, these changes will not be implemented until 2026, and therefore will not affect the price of drugs for 2025. 

In addition to what Medicare offers, some states offer discount cards or drug cost assistance programs. Look up your state’s program here. 

A new way to “smooth out” your prescription drug costs throughout the year: 

This new option, called the Medicare Prescription Payment Plan (MPPP), could help you avoid high one-time drug bills in 2025. 

The MPPP is an ‘opt in’ program and therefore you must choose to enroll in MPPP during Open Enrollment. It’s available whether you choose Part D coverage or you get prescription drug coverage through a Medicare Advantage plan. 

Once you enroll, you’ll get a bill from your prescription plan for each month’s ‘smoothed out’ costs, rather than paying the pharmacy where you get your medicines. Check out the MPPP website to learn more.

Fendrick notes that many people haven’t heard about this option, and prescription plan administrators may not go out of their way to tell people it’s available. But it could really help people who have a fixed income, especially if they are likely to have high out of pockets costs for their prescriptions.

How to get help choosing: 

Figuring out which Medicare options are right for you can be confusing. Fortunately, there are trained, unbiased volunteers and staff who can help, thanks to the State Health Insurance Assistance Programs located in each state. 

You may be able to meet with one at your local library, senior center or community center, or meet with one online. Visit www.shiphelp.org to find your state’s program and how to connect with an assister. Michigan’s program is called the Michigan Medicare Assistance Program; visit mmapinc.org or call 1-800-803-7174.

Job-related insurance:

Who: Anyone whose employer offers health insurance, 

What: A chance to switch plans (if the employer offers more than one)

When: Varies by employer, but typically in October and November

Key updates for 2025: 

Changing plans, networks & formularies: 

As health care costs rise, employers are looking to save money on their share of the cost of insurance, so plans may change, or they may raise the costs to the employee. This might mean higher premiums, a higher deductible, narrower networks of providers, and restrictions on which drugs are on the formulary or how hard it is to get access to an expensive drug.

Make sure to look at all the options available to you, and look at whether your preferred doctors, providers, hospitals and medicines are included in the networks and formularies of the plans you can choose from. Make sure you’re looking at the network and formulary information for 2025!

New high-deductible plan amounts:

If you choose a plan with a high deductible, make sure you know what the deductible is and are prepared to pay it. 

For 2025, that can be as low as $1,650 if you only cover yourself, or $3,300 for family coverage, all the way up to  $8,300 for yourself or $16,600 for family coverage. This is the amount you will be responsible to pay for almost all the care you receive, before your insurance takes over – except for certain free preventive services.

To help you be ready to pay for your costs up to your deductible, you should also open a Health Savings Account, if you don’t already have one. This allows you to put money in tax-free and withdraw it to pay for medical expenses and drug costs. You should set up your HSA through an authorized financial institution, and tell your employer to set up automatic withdrawals from your paycheck to go into the HSA starting in January. This way you’ll have money saved up when you need care and you haven’t yet met your deductible.

Note: An HSA is different from a Flexible Spending Account, which some employers offer to employees no matter what insurance plan they choose. You have to spend all the money in an FSA each year, while money can build up and carry over from year to year in an HSA.

How to get help choosing: 

Your employer’s human resources person or office may be able to help you. 

Buying insurance yourself:

Who: People who don’t qualify for other kinds of insurance, or aren’t sure if they qualify for Medicaid or another program

What: A chance to buy a plan for 2025 using the national Healthcare.gov marketplace website or a state-run marketplace

When: Nov. 1 to Dec. 15 for coverage that starts Jan. 1, 2025. Enrollment continues through Jan. 15 for coverage that will start Feb. 1. 

Key updates for 2025: 

Different plans and costs: 

The number of plans offered on the national and state Marketplaces often changes from year to year. All such plans must abide by the rules of the Affordable Care Act, also called the ACA or “Obamacare.” Even if a plan stays the same, it can raise the cost of premiums and other costs, and change its network of providers and hospitals, and its formulary of prescription drugs, each year.

That’s why you should check all of your options, even if you’ve bought your own insurance this way before. From Oct. 25 to 31, you can preview the plans that will be available to you at https://www.healthcare.gov/see-plans/ . Make sure to look at their networks and formularies, as well as costs like premiums, copays, coinsurance and deductibles. Use this calculator to estimate your income for 2025.

Continued help to lower costs: 

Most people can get discounts on the cost of the plans they buy on the national and state marketplaces yet again for 2025, even with a relatively high income, because of an extension of part of the American Rescue Plan Act of 2021. These discounts can include reduced premiums and tax credits. 

No one will pay more than 9% of their income for a plan they buy directly. The federal government estimates that four in five HealthCare.gov customers will be able to find health care coverage for $10 or less per month for 2025 after subsidies.

You can get a sense of whether you might qualify for these cost reductions using this calculator. 

But to find out your actual costs for any particular plan, you’ll need to put information into an application form starting Nov. 1; gather the information you’ll need using this checklist. 

Eligibility expansion:

People who had been covered by Medicaid during the past few years, but lost their coverage because their income no longer qualified them, can enroll in a Marketplace plan and may be able to get coverage before 2025 begins.

People brought to the U.S. as children who have qualified for DACA status are eligible to buy health insurance on the national and state Marketplaces for the first time. They are eligible for cost reductions. 

People who live in Georgia and have low incomes can use their new state marketplace to find coverage.

If your income is not higher than 150% of the federal poverty level, you can enroll in a plan on the federal or state marketplace at other times of the year.

How to get help choosing: 

There are trained, unbiased “assisters” nationwide who can help you navigate your choices on healthcare.gov or your state marketplace. 

Visit localhelp.healthcare.gov to find one – be sure to click the Assisters tab after getting the results for your ZIP code. (The main results also show brokers, who can assist you too, but have a financial stake in the outcome because they are paid by the plans they represent.)

Michigan Medicine’s assister team can help anyone in Michigan, even if they are not a Michigan Medicine patient. They are available by phone at 877-326-9155 between 8 a.m. and 4 p.m. Monday-Friday, or by email at [email protected]. 

The Washtenaw Health project also offers Medicaid enrollment help to people in Michigan. Visit https://washtenawhealthproject.org/ to learn more.

Medicaid:

Who: People with lower incomes, of any age or disability status, including people who also qualify for Medicare

What: Year-round enrollment and annual renewal

When: New enrollment: any time. Annual renewal: By the date given to you by your state

Key updates for 2025: 

Annual renewal requirements are back:

During the height of the pandemic, people who had qualified for Medicaid because of their income did not need to requalify every year. That has ended, and now everyone must show each year that their income is still low enough to qualify for Medicaid, or leave the program.

Important note for Michiganders:

The state has been sending notifications to people who have applied for Medicaid for the first time or as a renewal, letting them know they have been granted coverage under the new Plan First! family planning program. Plan First! covers birth control and other family planning services, as well as testing for sexually transmitted infections and screening for certain cancers. It’s open to anyone in Michigan with an income up to 200% of the poverty level who is not eligible for Medicaid or the Healthy Michigan Plan, which have lower income limits. But it does not cover all kinds of medical care. Do not confuse it with full coverage. 

If you do not qualify for Medicaid and you have been enrolled in Plan First!, you should also go to Healthcare.gov to look at what kinds of health plans and discounts you can get. 

How to get help choosing: 

Your state’s Medicaid agency has a call center that you can contact. Find information here. 

Michigan Medicine’s assister team can help anyone in Michigan, even if they are not a Michigan Medicine patient. They are available by phone at 877-326-9155 between 8 a.m. and 4 p.m. Monday-Friday, or by email at [email protected]. 

The Washtenaw Health project also offers Medicaid enrollment help to people in Michigan. Visit https://washtenawhealthproject.org/ to learn more.

Veterans’ (VA) health benefits:

Who: Veterans who currently have, or may be newly eligible for, health coverage from the Veterans Health Administration

What: More veterans are now eligible to enroll because of expanded criteria 

When: Anytime – those newly eligible do not need to wait for a disability determination

Key updates for 2025:

Millions more veterans eligible: 

Under a federal law called the PACT Act, veterans health benefits are now available to many more people who served the nation and received an honorable discharge, including people who did not deploy overseas but have a presumptive exposure to toxic substances. 

Find out more at www.va.gov/health-care/eligibility/ and www.va.gov/resources/the-pact-act-and-your-va-benefits/ . Enroll at www.va.gov/health-care/apply-for-health-care-form-10-10ez/introduction.

Getting care at non-VA healthcare facilities using veterans benefits: 

The Community Care program for veterans with VA benefits offers the opportunity for care at in-network locations for certain types of care under certain conditions. But veterans need to get prior authorization for each appointment or service – even if they got a referral from a non-VA provider at the same location after seeing them. If a veteran has another kind of health insurance as well as having veterans’ benefits, this is especially important, because there are time limits on how long after the care occurs the VA will pay for it. 

How to get help: 

Call the VA’s toll-free hotline at 877-222-8387 to get help with an application, or find an accredited person or service organization to help. 

No insurance:

Who: Anyone who does not have health insurance

What: Take action to get coverage for 2025, and seek help to understand your options and costs

When: Almost any time, especially if you have lost a job that had insurance, had a major life change that affected your income, or have health issues you’ve been neglecting.

Key updates for 2025:

If your income is under 150% of the poverty level, or you’ve just lost a job or your Medicaid coverage, or had a life change like getting married or divorced, you can visit Healthcare.gov any time of the year to pick a plan that will start on the first of the next month. If your income is low enough to meet your state’s Medicaid requirements, you can also find out via healthcare.gov how to apply for your state’s program. 

If you have medical debt from past care, your city or county may be participating in debt-relief efforts – but you cannot apply for this kind of assistance; you will be notified if your debt is being forgiven. However, you can visit this site to find other resources that might be able to help with medical debt: www.unduemedicaldebt.org/medical-debt-resources/ 

How to get help choosing: 

There are trained, unbiased “assisters” nationwide who can help you navigate your choices on healthcare.gov or your state marketplace, or tell you if you might be eligible for your state’s Medicaid plan. Visit localhelp.healthcare.gov to find one.

Michigan Medicine’s assister team can help anyone in Michigan, even if they are not a Michigan Medicine patient. They are available by phone at 877-326-9155 between 8 a.m. and 4 p.m. Monday-Friday, or by email at [email protected]. 

The Washtenaw Health project also offers Medicaid enrollment help to people in Michigan. Visit washtenawhealthproject.org/ to learn more.

Disclosure: Michigan Medicine co-owns the University of Michigan Health Plan, which offers two Medicare Advantage plans as well as plans offered by employers and to individuals.