Understanding the ins and outs of health insurance can feel like a daunting task. But knowledge is power, which is why we've asked Dr. Angel Marie Johnson, Director of Women's Health at GBU, to discuss the following:
- What happens during open enrollment?
- What are high-deductible health plans?
- What's the difference between original Medicare vs. Medicare Advantage?
What happens during open enrollment?
Open enrollment is when people have a designated window to enroll, renew, or change their healthcare insurance. People can shop and compare plans through the federal health insurance marketplace and their state's insurance marketplace. (Here's the link to the Massachusetts Health Connector.)
Key dates for Marketplace open enrollment
- November 1: Open enrollment begins. This is when people can enroll, renew, or change their plans.
- December 15: This is the last day people can enroll, renew, or change their plans for coverage to start on January 1.
- January 15: Open enrollment ends.
It's possible to get health insurance outside of open enrollment for specific "qualifying events," such as marriage, pregnancy, divorce, or job loss. Learn more about qualifying events.
Medicare open enrollment runs from October 15 to December 7, but you can learn specific details on Medicare.gov.
What are high-deductible health plans (HDHPs)?
Different health insurance plans come with different parameters and price tags. One popular option is a high-deductible health plan (HDHP).
With a high-deductible health plan, your monthly premium tends to be lower, but your deductible is typically higher. Insurance won't cover health care costs until you've met your deductible (except preventive care, like mammograms). Keep in mind that your deductible resets every 12 months. (It's similar to how auto insurance coverage works.)
For 2025, the IRS has defined a high-deductible health plan as one with a minimum deductible of $1650 for an individual plan and $3300 for a family plan. Again, that's the minimum deductible.
HDHPs have caps on out-of-pocket expenses. According to the IRS, in 2025, the numbers are $8,300 for self-only coverage or $16,600 for family coverage.
One reason HDHPs are attractive to people is that they cover catastrophic events, like car accidents, heart attacks, and the like.
Dr. Johnson explains, "Anything that requires you to be hospitalized would cost you more than your deductible, and that's when your insurance would cover the remaining costs.
Another benefit of having a high-deductible health plan is that you can usually contribute to a health savings account (HSA).
Dr. Johnson explains, "You can set aside money from every paycheck to go into that account, and you can use the money to reimburse yourself for healthcare expenses. So, if a blood test costs $100, you can pay for it from your HSA. You can also use the HSA as an investment tool. And that's what many people do—they begin putting money in that HSA when they're 30, and they'll pull that money out when they're 65 and have higher healthcare costs. So you can use it as a pre-tax savings account as well."
As this article from USA Today explains, "Because unused funds roll over from year to year, you can build up your HSA to cover future health care costs, invest the balance and enjoy tax-free investment gains. Plus, withdrawals to pay for qualified medical expenses are tax-free."
Example of a high-deductible health plan in action
Let's say your deductible is $3600, and you visit your doctor on January 2 for a health issue like a UTI. Since it's the beginning of the calendar year, you haven't met your $3600 deductible yet. You'll be responsible for all billable charges until you meet your deductible. These charges include office visits, blood tests, and everything the physician is legally allowed to bill for during your visit."
Dr. Johnson says, "Patients often pick health insurance based on cost and assume they are covered for all health-related expenses. However, patients often fail to understand the high deductible, meaning that if you see a doctor in January, you will pay for everything from that visit."
Dr. Johnson says charges can add up quickly since everything that happens during the office visit has a charge associated with it. If you haven't met your deductible yet, then you are 100% responsible for those charges.
Bottom line: If you're considering a high-deductible health plan, ask yourself whether you have the financial means to meet your deductible or start saving now.
Understanding Original Medicare vs. Medicare Advantage
The federal government administers original Medicare (also known as Parts A and B), and private health insurance companies sell Medicare Advantage (known as Part C). Here's a helpful glossary of terms and a chart from Medicare.gov. Note: Original Medicare is sometimes referred to as "traditional" Medicare.
With original Medicare, people can see any provider who accepts Medicare. They don't need prior authorizations (PAs), either. With Medicare Advantage, people need to stay in-network, and they need PAs.
According to AARP, both original Medicare and Medicare Advantage must cover the same medical services, such as blood work, diagnostic tests, and hospitalizations. Original Medicare doesn't include dental, vision, or hearing, while most Medicare Advantage plans provide at least some coverage for those things.
Dr. Johnson says some people assume that Medicare Advantage is better than original Medicare, but that's not necessarily true.
"Original Medicare, in general, will cover 80% of your healthcare costs," she explains. "The majority of physicians accept original Medicare. And the beauty of original Medicare is that it doesn't require prior authorization, meaning that if your doctor and you decide on a procedure, you can have it done. It doesn't involve waiting on a third party for approval."
Dr. Johnson says patients with original Medicare can get their procedures done sooner since they're not waiting on authorizations. This is a critical advantage right now, especially in Massachusetts, given wait times for so many procedures have increased.
People who opt for original Medicare can also get Medicare Supplemental Insurance, known as Medigap, to cover costs that Medicare doesn't cover.
Dr. Johnson explains, "So again, original Medicare covers 80% of essentially everything, but then you're responsible for 20%. And 20% of a big number can still be a big number. Getting a secondary insurance to help cover the 20% can be helpful. Meaning a patient has original Medicare as their primary, and their secondary can be a private product, like Harvard Pilgrim, Blue Cross, Aetna, and so forth, to help decrease that 20%."
Always compare apples to apples.
Keep in mind that private insurance companies like Blue Cross Blue Shield have multiple products under their name, each with different costs and benefits. (For example, BCBS has 12 in total in Massachusetts at the time of publication.) When shopping for plans, it's important to look at the comparison charts.
Dr. Johnson recommends comparing the following:
- Regular office visits
- Specialist visits
- Prescription drugs
- ER copay
Dr. Johnson warns that bills, especially for emergency care, can add up quickly. "It's about $1,500 a night to stay in the hospital," she says. "And it's about $2,500 a night to stay in the ICU. So it gets very expensive very quickly."
When comparing plans, consider your current health conditions but also your future needs. For example, are you going to have that knee replacement next year? Maybe your knee has been hurting for a few years, but now it's intolerable. This might be the year you want better inpatient or physical therapy coverage since you'll need those services.
Don't forget about your prescription drugs.
If you're on original Medicare, you can choose to buy a separate Part D plan since original Medicare doesn't include prescription drugs.
If you're considering a Medicare Advantage plan, look at the costs of ALL drugs you're on.
Dr. Johnson says, "Compile a list of your current medications. Look at the cost of each med. Many plans like to publicize their generic costs, but remember, there is a difference between generics and name brands. Generic medications are only 80% the same. Sometimes that 20% difference can be meaningful."
She says the best example of this is Synthroid versus levothyroxine. "That's a very common medicine used for hypothyroid," she explains. "Some people respond better to one versus the other because that 20% can be meaningful. Keep in mind that medications less than 10 years old often do not have a generic option. Some of the newest medications work better and are safer than the older alternatives."
Dr. Johnson cautions about opting for a Medicare Advantage plan that's negotiated a great price for one drug without reviewing the pricing for all the medications you're currently taking.
She explains, "Let's say you have diabetes, and you realize the cost of insulin is significantly less on one of the Medicare Advantage plans. That might motivate you to accept that plan. But what about your meds for other conditions? Sure, the plan might have negotiated down their insulin prices, but maybe their blood pressure medicines are higher than they should be."
In the U.S., people tend to have multiple healthcare conditions that require multiple medications, so it's critical to consider the complete picture.
Dr. Johnson advises, "Ask yourself, 'Have I saved on this drug? What's the overall cost of my prescription drugs, and am I ending up ahead at the end?' Because you don't want to make a decision during open enrollment that you're now going to be stuck with for a year that could potentially negatively impact your physical or financial health."
- Please see this article on how pharmacy location/type can impact medication costs.
- And please read Dr. Johnson's pharmacy fact sheet. (Opens PDF.)
More helpful reading:
- Compare Original Medicare & Medicare Advantage – Medicare.gov
- The Big Choice: Original Medicare vs. Medicare Advantage - AARP
- Medicare Advantage vs. Medicare: Which Should I Choose - NerdWallet
Bottom line: If you have questions about your coverage, call your insurance provider and ask.
Health insurance is complex and has many nuances. If you have questions, write them down and call the number on the back of your insurance card.
More helpful reading for patients