Health insurance probably isn’t something you think about every day, but we all need it. Health insurance helps us pay for medical bills – from a routine check-up to a major surgery – and everything in between.
Of course, not all insurance plans are created equal. There are a lot of options out there for the consumer. Choices are good, but it’s important to make sure you have a health plan that works for you and your family.
“At Privia Medical Group North Texas (PMGNTX), we want all our patients to have the best health plan for their situation,” says Dr. Jason Ledbetter, an internal medicine physician in Fort Worth. “Our doctors and other healthcare professionals are committed to giving you the best care possible, which is why PMGNTX is proud to be included in most major insurance networks in North Texas.”
For many people, fall is the ideal time to take stock of your health insurance. Many private employer plans feature an open-enrollment period toward the end of the calendar year. Check when yours is – it may be coming up soon.
In addition, open-enrollment periods for major government plans, such as Medicare, are also approaching. Finally, there are some changes coming for 2025 that may affect you. Keep reading to learn what those are.
Health Insurance Basics
As with all forms of insurance, health insurance is intended to protect consumers from unacceptable levels of financial risk.
Younger, healthy people may not always see the value of insurance if they only need a yearly checkup. But they should ask themselves: does anyone ever plan to be in a car crash and end up in the hospital? Do people schedule a serious illness, like cancer? Of course not. That is why insurance is so necessary: it financially protects us from the unexpected and yes, the things we hope never happen.
Even for people fortunate to avoid a serious illness or injury, routine health care needs can be expensive. Lab tests to check for cholesterol and blood sugar can easily run several hundred dollars. Common diagnostic and screening tools, such as an MRI or a CT scan, can cost thousands.
Just as with homeowners or auto insurance, the premise behind health insurance is one of spreading risk. By having many customers, insurance companies collect premiums from a broad base and then use a portion of those funds to pay policyholders’ claims.
“Health insurance is far from perfect,” says Dr. Taylor Bradley, an OB/GYN in Fort Worth. “It is confusing for patients and even for those of us who deal with it every day. Some plans can leave patients and doctors footing the bill for essential health care expenses that should be covered.”
Nonetheless, there have been positive developments in health insurance. The COVID-19 pandemic underscored the value of telemedicine, allowing patients to see doctors virtually for many needs. Now, more of those visits are covered by insurance. Additionally, mental health care is better covered by insurance than it used to be.
Health Insurance Options
People obtain health insurance in a variety of ways. These are the most common:
Your Employer
This is the traditional way most non-seniors in America have health insurance. You select a plan offered by your employer and pay a premium that is deducted from your paycheck, before taxes. Generally, the employer pays a share of the employee’s coverage and in some cases, a share of the employee’s family members’ coverage.
The Health Insurance Marketplace
The Health Insurance Marketplace is an option for American citizens under 65 to purchase health insurance. People generally use this option if coverage is not available through their employer. In Texas, an increasing number of people have turned to the Marketplace for coverage: enrollment has more than doubled since 2020, with roughly 3.5 million Texans on a Marketplace plan.
Some plans have low premiums and high deductibles, which may make sense for younger, healthy people who don’t have a lot of medical needs. Other plans are more expensive but cover more, which makes sense the older you get. Most enrollees qualify for savings in the form of a federal income tax credit.
Regardless of which plan you select, all Marketplace plans provide the following:
- 10 Essential Health Benefits, including prescription drugs, emergency care, hospitalization, pregnancy care, mental health care, rehab and more.
- Free preventive health services, such as vaccines and screening tests
- Coverage for pre-existing conditions. This means you cannot be denied coverage or treatment for a condition like diabetes, hypertension or cancer.
Medicare
This is the federal health insurance program for American citizens who are 65 and older. People who are approaching age 65 should visit Medicare.gov for enrollment information. Some people are automatically enrolled at 65, while others need to enroll themselves. There are three main components of Medicare:
- Medicare Part A is known as hospital insurance, covering hospital stays and some long-term care needs.
- Medicare Part B is medical insurance, covering physician visits and medical screenings and labs.
- Medicare Part D is a prescription drug insurance program.
Some people choose to delay enrollment in Medicare Parts B and D if they have health insurance through an employer that they prefer to keep while they are still working. However, a late enrollment penalty may apply.
Medicare Advantage
Also known as Medicare Part C, these are private plans sometimes purchased by seniors to supplement the coverage provided by Medicare. Medicare Advantage plans are offered by private companies but must be approved by Medicare. Those with a Medicare Advantage plan still have Medicare coverage, but they receive their benefits through the plan directly, not traditional Medicare.
The additional benefits provided by Advantage plans may include dental, hearing and vision coverage. Out-of-pocket expenses vary between Medicare Advantage plans, as do the provider networks they offer. For these reasons, it is important to compare Medicare Advantage plans just as you would employer-based plans.
Veterans Administration
Veterans of the United States Armed Forces may be eligible for health benefits through the VA, depending on a variety of factors, including length of time served, discharge circumstances, income and service-connected disability. VA health care benefits have recently expanded: veterans who were exposed to Agent Orange, burn pits and other toxic substances are eligible for enhanced coverage. For more information, visit VA.gov.
Tricare
Tricare is health insurance for active-duty military personnel, as well as some military retirees. For more information, visit Tricare.mil.
Medicaid and CHIP
Medicaid and the Children’s Health Insurance Program (CHIP) primarily serve lower-income families. In Texas, Medicaid eligibility is usually limited to children and women who are pregnant, as well as moms who have given birth in the past year. CHIP is available for some families who earn too much to qualify for Medicaid. Visit www.healthcare.gov or the Your Texas Benefits website.
What’s New in Health Insurance for 2025?
There are several significant changes in various government health insurance programs for 2025 that should be of benefit to the consumer.
The biggest changes will help seniors enrolled in Medicare Part D. Beginning in 2025, out-of-pocket costs for prescription drugs in Medicare Part D are capped at $2,000 per year.
In addition, seniors can opt to participate in the Medicare Prescription Payment Plan, allowing them to spread their prescription costs out over the calendar year, instead of having to pay their full co-pay each time they get a prescription filled.
Medicare Part D coverage also now means there is no co-pay for recommended vaccines.
One of the biggest recent changes in Medicare helps patients who take insulin for diabetes. Insulin covered by Medicare is now capped at $35 for a 30-day supply, regardless of whether the Part D deductible has been met.
In addition, Medicare has negotiated lower drug costs for certain popular medications. Those lower costs will be in effect in 2026.
In the Health Insurance Marketplace, enrollees will continue to benefit from reduced premiums.
Not all the news is good. One of the biggest changes for many Texans over the last couple of years involves those with Medicaid coverage. More than 2 million Texans lost coverage in the last two years due to changes in government rules.
Some of those people are truly no longer eligible for Medicaid. However, others who have been dropped may still qualify. People who previously had coverage and may still be eligible should create an account and re-apply at the Your Texas Benefits website. If denied after re-applying, visit HealthCare.Gov to look into additional coverage options.
Key Dates for 2025 Coverage
If you have health insurance through your employer, you should check with your plan to find out when open enrollment is. For government insurance programs, here are some key dates to keep in mind:
Health Insurance Marketplace:
- Open enrollment begins November 1, 2024
- Enroll by December 15 for coverage to begin on January 1, 2025
- Open enrollment ends January 15, 2025
Medicare:
- Open enrollment runs October 15 – December 7, 2024
- During this period, enrollees can make the following changes:
- Join, drop or switch Medicare health plans (Medicare Parts A & B)
- Add or drop prescription drug coverage (Medicare Part D)
- Change from a traditional Medicare plan to a Medicare Advantage Plan (Medicare Part C)
- Change from a Medicare Advantage Plan to a traditional Medicare plan
Medicare Advantage:
- Open enrollment runs from January 1 – March 31, 2025
- During this time, people enrolled in Medicare Advantage may:
- Switch to a different Medicare Advantage plan
- Switch to traditional Medicare
- Note: you can only change plans once in this period
Selecting a Health Plan
Whether you have employer-based health insurance, are shopping for insurance in the Health Insurance Marketplace or are choosing a Medicare Advantage or Part D program, you will likely have a few options to choose from.
For example, a Health Maintenance Organization (HMO) may be less expensive than a Preferred Provider Organization (PPO) but may also provide fewer benefits or not allow you as many provider options. On the other hand, if you are relatively young and healthy, a less-expensive plan may be right for you. Your employer probably has Human Resources staff knowledgeable about available benefits – if so, take advantage and make an appointment to get your questions answered.
On the Health Insurance Marketplace, you will find a variety of plans at varying costs: bronze, silver, gold and platinum. You’ll pay the least for bronze and get the fewest benefits; at the other end of the scale, platinum is the most expensive but provides the most comprehensive overall coverage.
You can also compare additional plans on the Texas Department of Insurance (TDI) website.
Cost Factors
When comparing costs on any plan, be sure to consider four separate cost factors:
- Premium: the amount you pay each month to maintain coverage.
- Copay: the amount you will pay each time you visit a provider or get a prescription filled.
- Coinsurance: a percentage of the total bill you will pay, after you have met your deductible.
- Deductible: the amount you must pay out-of-pocket each year before your health plan begins to cover the cost of medical services.
You may find an inexpensive plan but later discover you must meet a high deductible before you benefit from any coverage from the plan. You may also find that your co-pay for each visit, procedure or prescription is higher than you expected. For some people, these low premium/high-deductible and co-pay plans work just fine; just make sure you have all the facts before deciding.
An additional tool some employers offer for people who opt to enroll in a high-deductible plan is a health savings account (HSA). This is essentially a medical savings account that people can contribute pre-tax income to and then spend later to cover deductibles and other out-of-pocket costs.
Health Insurance Networks
Insurance plans have a group of health care providers they refer to as a “network.” These are providers, such as physicians, hospitals and labs, with which the insurer has a contract that stipulates what the provider will be paid by the insurance company.
Understanding an insurer’s network is critical to evaluating a health insurance plan. No matter what type of plan you select, you will pay higher out-of-pocket costs to see a provider who is not in your plan’s network.
Whenever possible, you want to stay within your network to keep costs down and you definitely want to make sure your primary care provider – your medical home– and any specialists you see are in your plan’s network. Health insurance plans usually have a directory of providers on their website. PMGNTX providers are in-network for most major insurance plans in North Texas.
Take Your Time & Ask Questions
“As doctors, our main job is to keep you healthy, and health insurance is an essential component of your health care,” says Dr. Ashita Gehlot, a Fort Worth gynecologist. “Needless to say, health insurance can be complex and confusing, especially when you don’t deal with it every day. That’s why it is important to ask questions and do your research.”
Familiarize yourself with the open enrollment dates and various deadlines associated with the health insurance products relevant to you. The more time you spend understanding your benefits and knowing what your options are, the more comfortable you will be navigating the world of health insurance to get the best health plan for you and your family.
This article has been reviewed and approved by a panel of Privia Medical Group North Texas physicians.
This article contains information sourced from:
Centers for Medicare & Medicaid Services
