Healthcare in Transition: 2025 U.S. Healthcare Outlook

Since the Trump administration took office, some healthcare related executive orders have been issued including one that reaffirms the administration’s commitment to improving health care price transparency for patients and consumers. Additionally, the new administration has begun to examine federal programs, including Medicare, to identify high rates of improper payments, and the Affordable Care Act to crack down on fraud while also strengthening regulations and requirements for consumers to receive coverage.

While these are some current events, major changes to healthcare programs were already being put in place before the new administration. In this article, FRG will dive deeper into the specific changes that are being made to healthcare programs in 2025 and how these changes can affect value-based agreements.

Program Changes Already Taking Affect in 2025

New federal and state healthcare laws all focus on one thing, strengthening consumer protections, according to a recent article by GoodRX.

Changes in Medicare Part D

• Getting rid of the “donut hole”: Customers will now have a deductible phase, which lasts until they spend $590 on covered prescriptions in 2025. Then they will enter the initial coverage phase, which means they are responsible for copays and coinsurance for all covered prescriptions until they spend $2,000 out of pocket. Once you spend $2,000, that’s when a customer reaches the catastrophic phase. At this point, they will have no cost sharing for covered medications and the plan pays 100%.
• Decreasing out-of-pocket limit for medications: In 2024, there was an $8,000 out-of-pocket cap. But now customers will need to spend only $2,000 on covered medications before cost sharing ends and the plan pays 100%.
• Implementing a new Medicare Prescription Payment Plan: This new payment plan allows customers to spread covered prescription costs over the calendar year. Even though this plan won’t save customers money, access to monthly payments can help enrollees better manage costs in 2025. Additionally, this new plan allows customers to avoid paying their $590 deductible up front and fill prescriptions on time.
• Offering medication substitutions: Biologics are medications derived from natural or living sources instead of chemicals. Their generic versions are known as biosimilars. These types of medication are nearly identical to their reference biologics but typically cost less.

In 2025, Medicare Part D will be able to switch customers from biologic to a biosimilar quickly if a formulary changes midyear. This can be done immediately if the biologic has an interchangeable biosimilar.

Changes in Medicare

• Expanding services for dementia caregivers: Relatives and unpaid caregivers for Medicare enrollees with dementia may be able to get more support using the Guiding an Improved Dementia Experience model.

This 8-year pilot program began in 2024 and is expanding in 2025. Benefits include access to temporary breaks because the program provides substitute caregiving and caregiver training.

• Telehealth policy updates: Medicare telehealth services have been widely available since the COVID public health emergency. However, there are new changes coming April 1, 2025, that vary based on the type of services you are receiving and where the care is delivered. For more information regarding these changes, visit https://telehealth.hhs.gov/.

Changes in Medicare Advantage

• Better access to mental health resources: Medicare Advantage plans have behavioral health facilities in their networks. These include substance use treatment center.

New rules will ensure that the services provided by behavioral health professionals who work in those facilities are also in network for those Medicare Advantage plans. These healthcare professionals include marriage and family therapists, mental health counselors, and addiction medicine physicians.

• New midyear notifications: Medicare Advantage plans offer more benefits than Medicare. These perks often provide hearing, vision, dental, and fitness services, but use by enrollees is low. Starting in 2025, Medicare Advantage plans must notify enrollees of unused supplemental benefits during the middle of the year between June 30th and July 31st.

How Do Program Changes Affect Value-Based Agreements?

Of these changes already taking place, the two that most impact value-based care will be the policy updates to telehealth and the newly implemented notifications related to supplemental benefits.

Telehealth improves the likely hood that underserved members are at least evaluated by their managing physician and eliminates transportation related issues when the services include two-way, real-time technology to communicate. Additionally, upcoming changes to telehealth affect the expansion of access to care for remote behavioral health services.

In a previous article FRG discussed the benefits of telehealth practice, wearable health monitoring technology, and at home diagnostic testing and the impact it has on reducing healthcare waste and supporting value-based care. These necessary tools improve the state of healthcare by “…giving patients more control over prioritizing which services they’d like via telehealth or in person care, both the new healthcare technology and diagnostic testing options make patients active participants in their own well-being. Additionally, they provide opportunities for both patients and providers to save time and resources.”

Newly implemented notifications related to supplemental benefits will impact value-based agreements in a positive way. This new requirement is important in helping remind enrollees of their benefits. So many customers waste and forget to fully utilize their coverage, leaving customers, health plans, and providers left without beneficial incentives and more gaps in healthcare.

Stay Informed & Drive Financial Performance with FRG

Since 1999, Financial Recovery Group (FRG) has helped health plans and physician groups create transparency in risk contracting, improve financial performance of service funds, and recover millions of dollars in overpayments through online analytical reporting and expert claims audit services.

For additional information about FRG’s services and our dedication to supporting value-based healthcare, email info@frgsystems.com or call 888-466-1025 today!