Changes coming in health care

Legislative, industry factors expected to impact coverage, hike costs

By Michael Pramik, Ohio Public Employees Retirement System

Nov. 20, 2025 – Several legislative and industry factors could affect health care coverage and costs next year for OPERS retirees. For instance, while health insurance premiums change every year for a variety of reasons, a recent report indicates that most ACA marketplace insurers are expecting pre-Medicare premiums to increase by an average of 20%.

These same legislative and health-care industry shifts are expected to increase Medicare Advantage premiums by about 6% and Medigap premiums by about 9% for the Medicare population.

OPERS retirees should be aware of these factors during open enrollment, which is their opportunity to review and update health-care coverage. Open enrollment runs through Dec. 15 for pre-Medicare retirees and through Dec. 7 for Medicare retirees. OPERS vision and dental open enrollment runs through Dec. 15.

Pre-Medicare

Pre-Medicare retirees will have access to three or more insurance carriers in each Ohio county next year. The following factors could impact coverage and cost in 2026:

Premium rate increases

Key drivers of anticipated premium rate increases include:

• The potential expiration of enhanced premium tax credits, sometimes referred to as PTCs
• Increased cost and frequency of use of health care services
• Inflation and rising labor costs
• Rising drug prices, especially for weight-loss medications
• An unhealthier risk pool, as healthier individuals drop coverage because of rising premiums

Expiration of enhanced PTCs

One of the primary points of contention during recent discussions at the federal level focus on the extension of enhanced Premium Tax Credits (PTCs). Enhanced PTCs were introduced in the American Rescue Plan Act (2021) and then extended under the Inflation Reduction Act (2022). Since introduced, the enhanced PTCs have made pre-Medicare health plans more affordable for millions. The plans were not extended under the sweeping economic package passed earlier this year, referred to as the “Big, Beautiful Bill.”

Pre-Medicare retirees who have opted out of receiving the OPERS Health Reimbursement Arrangement should be evaluating how the expiration of enhanced PTCs may impact them. 

Dedicated outreach will be conducted to those who may be impacted. If you currently use a PTC and you are eligible for the OPERS HRA, you can opt in by contacting Via Benefits by Dec. 15.

What can you do?

• Watch for notifications from your insurance carrier. If your premiums are rising beyond your comfort level or your plan is ending, contact Via Benefits.
• For those who have opted out of the HRA, make sure that you take the time to do the math on how much your monthly premium will be in 2026. Calculate your premium with your current PTC, with the reduced PTC (if the Enhanced PTCs don’t get extended), and with the HRA allowance amount that you are eligible to receive.
• Compare plans on the Via Benefits website or call Via Benefits to speak with a licensed benefit advisor during open enrollment. They will help you find coverage suited to your health needs and budget. Change is constant, but with support from Via Benefits, you can remain confident in your coverage selection.

Medicare

Medicare benefit recipients should be aware of several key changes that could impact coverage and costs in 2026. Via Benefits is here to guide you every step of the way.

Premium rate increases

Because of inflation and shifts in legislation and the health-care industry, retirees enrolled in Medicare plans in Ohio will see the following estimated increases:

• Medicare Advantage premiums: About 6%
• Medigap premiums: About 9%

Each year, health insurance premiums are adjusted based on a variety of factors. This year’s key contributors include:

• Increased use and cost of health-care services, especially outpatient care
• General inflation and rising labor costs across the health care system
• Changes to Medicare Part D, which now requires individual plans to cover more costs with less government support
• Rising prescription drug prices, particularly for specialty medications used to treat complex conditions

Prior authorization reforms

Starting in January, Medicare will test a new system in six states—Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. In these states, doctors will need to get approval (called “prior authorization”) before providing certain outpatient services.

• Doctors can either request approval ahead of time or have their claims reviewed after the service is provided.
• The rules for what’s covered aren’t changing, and licensed medical professionals will make the final decisions.
• This change affects people using original Medicare, including Medigap enrollees, not those with Medicare Advantage.

Beginning in 2026, new federal rules will change how Medicare Advantage and Medicaid managed-care plans handle patient requests for treatment and coverage. These insurers will be required to decide authorization requests—such as for tests, procedures or specialist visits—more quickly and to publicly report how often they deny such requests.

The goal is to make the process faster and more transparent while ensuring patients receive necessary, effective care rather than unnecessary or low-benefit treatments. The new rules also call for clearer explanations when coverage is denied, so patients and doctors better understand the reasons behind those decisions.

Prescription drug plan changes

OPERS is anticipating a shifting landscape in prescription drug coverage for 2026. We encourage you to review these changes carefully and reach out to Via Benefits with any questions during open enrollment.

• Drug price negotiation program: The Centers for Medicare & Medicaid Services has negotiated lower prices for certain high-cost, single-source medications that do not have generic or biosimilar alternatives. These new prices will take effect on Jan. 1 and apply to drugs that account for approximately 20% of total Part D costs. For more details and a list of the affected medications, please refer to the CMS fact sheet.
• Out-of-pocket cap: Beginning in 2026, the annual out-of-pocket limit for retirees will be $2,100. As a result, some of the cost of providing this benefit may be reflected in Part D premium adjustments.
• Plan consolidation and transitions: Due to legislative and industry-wide changes, several national PDP carriers will be consolidating their plans. About 6,000 OPERS retirees will be automatically transitioned into new PDP plans, with about 50% moving to a $0 premium plan. Both the carriers and Via Benefits will communicate with affected individuals to ensure they are informed and can make changes during open enrollment, if desired.
• Changes to benefit structure: Many carriers are expected to shift from a copay model to a coinsurance model for brand-name drugs. This means enrollees may pay a percentage of the drug cost rather than a fixed copay.

What can you do?

While some years bring more change than others, you don’t have to navigate it alone. Via Benefits will help you stay informed and confident.

• Update your Via Benefits profile: The information in your Via Benefits Profile powers Coverage Checkup, which is a comprehensive coverage recommendation tool used by Via Benefits.
• Watch for notifications from your insurance carrier: If your premiums are rising beyond your comfort level or your plan is ending, contact Via Benefits.
• Compare plans on the Via Benefits website or schedule your enrollment appointment early. Via Benefits is ready to help you find a plan that matches your health needs and budget.