How to Find Out How Much Your Health Insurance Will Pay in Advance
Last year, hospitals had to publish lists of the prices they charge for each procedure . Access to the data was not easy, and the major drawback was that these were simply fixed prices, not the prices that insurers or anyone else actually pays. Now from July 1, insurers must post lists of negotiated prices. It’s much more useful, but again, it’s really hard to use this for shopping.
One of the reasons this is all so confusing is because there are so many companies involved. If you’ve ever scrutinized the Explanation of Benefits (the one that comes in the mail after a procedure and says “It’s not a bill”), you know that the price you pay depends on how much the hospital charges. up to what the insurance company negotiates them, and then how much the insurer expects from you. The new price transparency rules are designed to provide you with all of this information before you receive a transaction or service.
The July 1 deadline marks the first of three phases of the new price transparency law.
- Right now, insurance companies must publish a “machine-readable” list of all the prices they have negotiated with hospitals and service providers.
- From January 1, 2023, they need to be provided with a convenient online tool that will provide price estimates for 500 “purchasable services” (that is, things that could be bought in advance, such as non-emergency surgeries).
- From January 1, 2024, this online tool will need to cover all covered services of an insurance company.
(Many insurance companies already have cost estimation tools, but they vary in their usefulness. Often, this tool requires you to be logged into a member account and may not include all covered services or provide as much information as you ultimately need. in law).
There are several other potential barriers to getting an accurate price for your upcoming treatment. First, insurers may simply decide that they do not want to publish the required information. (According to a report by the Patient Rights Advocate, only 14% of hospitals published their price transparency listings in their first year.) Fortunately, fines for non-compliant insurers are higher than for hospitals: “per day, which can very quickly become very cool.
The other big hurdle at the moment is that the required material is machine readable . Imagine something like a spreadsheet, only harder to read and too big to scroll through. They also take forever to load. As one insurance company (Anthem) describes it: “These files are in a CMS defined format (JSON) and are not intended to be an easy way to find rates, benefits, or cost sharing.”
The idea is that third party services or apps will help people shop for better coverage. We’ll have to wait to see how well this plan works.
Meanwhile, the files themselves are easy enough to google. Enter the name of your insurance company into a search engine along with the words “machine-readable files” and a page with something will open. (Some of them seem incomplete, but they are apparently being worked on.) To get you started with the top five insurers, here are the pages for Aetna , Anthem , Cigna , Kaiser , and United Healthcare .