Key takeaways:
New federal and state healthcare laws in 2025 strengthen consumer protections.
Medicare Part D enrollees now have a $2,000 annual out-of-pocket cap. They can also spread their cost sharing throughout the year by making monthly payments with the new Medicare Prescription Payment Plan. Part D’s plan redesign also eliminated the “donut hole,” or coverage gap phase.
New state laws increase access to postpartum care planning, paid prenatal care leave, and medication-assisted treatment.
In 2025, new healthcare laws and regulations will provide more affordability and access to care. Some of the most profound updates will involve Medicare. Read on to learn more about what’s changing.
Medicare Part D changes
More than 67 million people in the U.S. are covered by original Medicare (Part A and/or Part B) or a private Medicare Advantage plan. In 2024, 53 million Medicare enrollees — nearly 80% — had prescription coverage as a stand-alone Part D plan or rolled into a Medicare Advantage plan.
Several changes to Part D in 2025 can help enrollees save money or manage out-of-pocket costs:
No more “donut hole”: The Part D plan design had four phases in 2024 but has only three in 2025. This is because the coverage gap known as the donut hole has been eliminated. Now, you have the deductible phase, which lasts until you spend $590 on covered prescriptions in 2025. Then you enter the initial coverage phase, when you are responsible for copays and coinsurance for all covered prescriptions until you spend $2,000 out of pocket. That’s when you reach the catastrophic phase. At this point, you have no cost sharing for covered medications; your plan pays at 100%.
$2,000 out-of-pocket limit: In 2024, there was an $8,000 out-of-pocket cap. But now you’ll need to spend only $2,000 on covered medications before your cost sharing ends and your plan pays at 100%.
Medicare Prescription Payment Plan: This new payment option lets you spread your costs for covered prescriptions over the year. The plan won’t save you money, but monthly payments can help you manage costs during 2025. You can also avoid paying the $590 deductible up front and fill your prescriptions on time.
Biosimilar substitutions: Biologics are medications derived from natural or living sources instead of chemicals. Their generic versions are known as biosimilars. These are nearly identical to their reference biologics but typically cost less. In 2025, your Part D plan can switch you from a biologic to a biosimilar more quickly if your formulary changes midyear. This can be done immediately if the biologic has an interchangeable biosimilar.
Medicare changes
Original Medicare enrollees can expect these updates to their benefits in 2025:
Services for caregivers of enrollees with dementia: Relatives and unpaid caregivers for original 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 expands in 2025. Benefits include access to temporary breaks because the program provides substitute caregiving and caregiver training.
Telehealth: Medicare telehealth services have been widely available since the COVID public health emergency. Some changes are permanent, while others will remain in place through at least September 30, 2025. Medicare Advantage plans may offer more telehealth benefits, including services from your home.
Medicare Advantage changes
Medicare Advantage enrollees will see these changes to their benefits in 2025:
Improved access to mental health: Medicare Advantage plans have behavioral health facilities in their networks. These include substance use treatment centers. 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.
Midyear notifications: Medicare Advantage plans offer more benefits than original Medicare. These perks often provide hearing, vision, dental, and fitness services. But use by enrollees is sometimes low. Starting in 2025, Medicare Advantage plans must notify enrollees of unused supplemental benefits during the middle of the year between June 30 and July 31.
New state laws effective in 2025
Here are some of the new state laws designed to expand healthcare coverage and access in 2025.
California: No prior authorization for medication-assisted treatment
Often, medication-assisted treatment requires prior authorization, such as step therapy. This usually delays treatment. Starting in 2025, health plans in California must cover at least one FDA-approved medication without utilization review for each of these categories:
Opioid overdose reversal, such as naloxone (Narcan)
Substance use disorder treatments, such as daily oral buprenorphine
Long-acting buprenorphine
Long-acting injectable naltrexone
Medicare Part D has a lower out-of-pocket cap. When you spend at least $2,000 out of pocket on covered prescriptions in 2025, your plan pays 100% for covered medications for the rest of the year.
Medicare enrollees can spread prescription costs over time. In 2025, anyone with Medicare Part D coverage will have the option to make payments for out-of-pocket prescription medication costs through the new Medicare Prescription Payment Plan.
Part D donut hole gone in 2025. The Medicare Part D coverage gap known as the “donut hole” expired in 2024. You now reach the catastrophic phase when you spend $2,000 out of pocket on covered medications.
New Jersey: Postpartum care plans to decrease maternal mortality
Beginning in May 2025, postpartum care plans will be a required part of treatment for pregnant women and new mothers in New Jersey. A maternal mortality report found that most pregnancy-related deaths in the state happen during the postpartum period.
A new law requires New Jersey healthcare professionals to provide guidance on the signs and symptoms of postpartum depression and other mental health needs. The postpartum care plans also must be offered to individuals who experience stillbirth and pregnancy loss.
New York: Paid leave for prenatal care, first in the nation
Starting in 2025, New Yorkers will have access to paid time off from work to get prenatal care. Employers are required to provide up to 20 hours of paid leave for physical exams, medical procedures, monitoring, testing, and discussions with healthcare professionals related to the pregnancy. This paid prenatal leave is a stand-alone benefit separate from other leave laws and policies. It’s the first of its kind in the U.S.
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The bottom line
New healthcare laws in 2025 provide easier access to covered medication-assisted treatment in California, institute paid leave for prenatal care in New York, and require postpartum care plans in New Jersey to reduce maternal mortality.
Some of the most significant healthcare changes in 2025 involve Medicare, particularly updates to Part D prescription coverage. Out-of-pocket costs are now capped at $2,000 per year for covered medications. A new Medicare Prescription Payment Plan lets enrollees spread their cost-sharing responsibilities over the entire year.
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References
California Academy of Family Physicians. (2025). New laws impacting family physicians in 2025.
Centers for Medicare & Medicaid Services. (n.d.). Guiding an Improved Dementia Experience (GUIDE) model.
Centers for Medicare & Medicaid Services. (n.d.). Guiding an Improved Dementia Experience (GUIDE) model: Information for patients & caregivers.
Centers for Medicare & Medicaid Services. (2024). Contract year 2025 Medicare Advantage and Part D final rule (CMS-4205-F).
Cubanski, J. (2024). A current snapshot of the Medicare Part D prescription drug benefit. KFF.
Data.CMS.gov. (2024). Medicare enrollment dashboard. Centers for Medicare & Medicaid Services.
Medicare.gov. (n.d.). Telehealth. Centers for Medicare & Medicaid Services.
New Jersey Maternal Mortality Review Committee. (n.d.). New Jersey maternal mortality report 2016-2018.
New York State. (n.d.). New York State paid prenatal leave.
New York State. (n.d.). New York State paid prenatal leave: Frequently asked questions.
New York State. (2024). Money in your pockets: Ahead of January 1, 2025 start date for first-in-the-nation paid prenatal leave, Governor Hochul announces new campaign to mobilize eligible New Yorkers.
State of New Jersey. (2024). Governor Murphy signs legislation ensuring pregnant patients receive personalized postpartum care plan.
Telehealth.HHS.gov. (2025). Telehealth policy updates. Health Resources & Services Administration.
