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Medicare and Health Insurance Tips for the New Year

As the new year begins, understanding how to maximize your health insurance benefits is essential. Policies and plans can change, and being prepared ensures smooth access to care and medications. Here are five critical things to keep in mind to make the most of your health insurance in 2025.

1. Stay In-Network

The most important rule is to stay within your plan’s network of providers to avoid unnecessary costs.

What Does It Mean to Stay In-Network?

Using in-network providers means visiting medical professionals who have contracts with your health insurance plan. This ensures lower costs and seamless billing.

How to Check if a Provider Is In-Network:

  • Use the provider portal on your membership card.
    • Log in with your member ID or search as a guest.
    • Look for tools like “Find a Doctor” or “Provider Directory.”
  • Search by location and specialty:
    • Enter your ZIP code and set a search radius (e.g., 5–15 miles).
    • Search by provider name or specialty (e.g., gastroenterologist).

Why It Matters:

  • HMO Plans: Out-of-network services are generally not covered, except in emergencies.
  • PPO Plans: Out-of-network services may be covered partially, but your share of the cost will be significantly higher.

Learn more about health insurance networks in our comprehensive guide to choosing the right plan.

2. Understand Cost Sharing

Even with insurance, you’ll share costs for most services through deductibles, copays, and coinsurance.

What to Expect:

  • Copays: Set fees or co-insurance (%) based on your Summary of Benefits.
  • Deductibles: The amount you pay before coverage begins for certain services.
  • Preventive Care: Often fully covered, such as vaccines and annual screenings.
  • Medicaid and Medicare Supplement Plans:
    • Medicaid often covers 100% of services.
    • Medicare Supplement Plan G, for instance, covers all Medicare-approved services after a small deductible ($257 in 2025).

Review your Summary of Benefits to understand your specific cost-sharing responsibilities. For more details, reach out to your broker or customer service of the insurance company

3. Keep an Eye on Prescription Costs

Prescription drug coverage varies, especially for brand-name medications.

Factors That Affect Prescription Costs:

  • Deductibles: Some plans require you to meet a drug deductible before coverage kicks in.
  • Tiers: Medications are classified into tiers; higher-tier drugs cost more.
  • Assistance Programs: Medicare beneficiaries who qualify for Extra Help may pay between roughtly $0 and $12 for medications.

New for Medicare in 2025:

  • Beneficiaries can enroll in a payment plan for drug costs.
    • Example: If out-of-pocket costs hit the $2,000 cap, payments can be spread out over $166/month instead of paying upfront.

Contact your drug plan customer service for details or learn more on Medicare.gov.

4. Monitor Plan Changes: Premiums, Formularies, and Deductibles

Health and drug plans often change terms and coverage annually.

What to Watch For:

  • Formulary Changes:
    • A drug covered in 2024 may not be covered in 2025.
    • Medicare Advantage and standalone drug plans can reclassify or exclude medications.
  • Premiums and Deductibles:
    • Example: A $28/month drug plan with a $250 deductible in 2024 could increase to $55/month with a $590 deductible in 2025 (this is just an example).

What to Do If Your Drug Isn’t Covered:

  • Request a formulary exception:
    • Your doctor must explain to the insurer why the drug is medically necessary.
    • Alternatively, check if a similar drug under a different brand name is covered.

 

5. Replace Missing Insurance Cards Quickly

If your plan hasn’t sent a new card, don’t panic:

What to Do:

  1. Use your old card if your plan remains the same; member IDs rarely change.
  2. Call your insurance company if your plan has changed but the card hasn’t arrived.
    • Provide your name, date of birth, and address.
    • Request your member ID and plan name, which you can use until the card arrives.

Need Help?

At Chief Insurance Services, we specialize in helping individuals and families navigate their health insurance. Whether you’re dealing with out-of-network providers, uncovered medications, or plan changes, we’re here to guide you.

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At Chief Insurance Services, we work with over 30 top insurance companies across all 50 states to help you find the best coverage for your needs.

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