How to (try to) find out what your medical care will cost

The number of people with health plans that require them to pay a share of their medical costs has been growing, making it more important for them to know what care will cost. But it’s not always easy to find that out. Here are some tips from Connecticut and national experts on how to do so.

We originally published this story in 2014, but a Connecticut law passed in 2015 aims to make it easier for patients to learn the cost of care. Most of those provisions don’t take effect until 2016, but we’ve updated this piece to explain what you can expect, and when the changes will occur.

1. Ask your insurance company. But be sure you have the right information first.

Find out the exact procedure being done — and the billing code, if possible.

Your doctor might want you to get an MRI. But how much it costs will depend on the type of MRI. Will it be done with contrast or not? What part of the body will the test cover? Those differences affect the price — so it’s important to know exactly what type of procedure will be billed.

Similarly, an office visit with a doctor could have different prices depending on whether it’s a routine exam or a visit for an illness, and whether you’ve been there before or are a new patient.

Kathy Walsh, principal examiner for the Connecticut Insurance Department’s Consumer Affairs Division, said people could explain to their doctor’s office that they’re covered by a high-deductible plan and want to research the cost of the procedure the doctor is recommending, and ask for the code (official term: CPT code) for the service.

The location can make a big difference in what you pay.

That same MRI could cost one thing if it’s done in a free-standing outpatient facility and a totally different amount if it’s performed in a hospital.

What provider is delivering the care?

Because insurance companies negotiate payment rates with health care providers, your cost will vary depending on who delivers your care.

Check if your insurer has transparency tools you can use.

Aetna

A sample page from Aetna’s Member Payment Estimator, an online tool for finding out what care will cost.

Some insurers have online calculators that you can use to compare prices for services from different health care providers. Be sure to note if they’re specific to your plan so you can see how much you’d be responsible for paying.

2. Ask your health care provider.

Your doctor’s office might be able to find the price for you. Since they probably get different payment rates from each insurer, they might not know, and some office staff might not have time to call to find out. Still, you can always ask.

In some cases, health care providers or insurers won’t tell you the cost they’ve negotiated because they included a confidentiality clause in their contract. But starting Jan. 1, 2016, that won’t be allowed in new contracts between health care providers and insurers in Connecticut. (It’s part of the major health care law that passed in 2015. For more on what else is changing in the next year or two, see section 6.)

3. For an estimate, look at online tools like FAIR Health and Health Care Blue Book.

FAIR Health, a national nonprofit that works on transparency in health care costs, has an online tool that helps consumers find estimates of what their health care will cost. The Healthcare Bluebook, another web tool, provides a list of what it considers fair prices for individual health care services in a given area.

These tools can help you get a sense of what a particular treatment or procedure will cost. But they won’t tell you the exact cost someone with your insurance plan would pay.

4. Another approach: Know the worst-case scenario.

Timothy Jost, a law professor at Washington and Lee University, suggested that patients familiarize themselves with their health plan’s out-of-pocket maximum. That’s the limit on what you’ll have to spend in a year on medical costs if you get them from providers in your insurer’s network. You can find the limit on your insurance plan documents. Premiums don’t count toward that limit.

Knowing the limit won’t help you figure out how much an MRI will set you back. But it’s a good piece of information to know about your total exposure should you incur significant medical expenses.

5. Know the limits of price information.

It’s one thing to find the price of a single procedure performed by a provider in your insurer’s network — that can be difficult. It’s even harder to try to price out something more complicated, like surgery. In some cases, the price might depend on how long you’re in the operating room, how much anesthesia is used, how many surgeons are there, and other factors.

Similarly, if you choose to see a health care provider outside your insurer’s network, the provider won’t have a set rate with your insurer. Many insurance plans also leave members with higher out-of-pocket costs for seeing out-of-network providers.

6. Coming soon: More information available.

A wide-ranging health care law passed by the Connecticut legislature in 2015 aims to make it easier for patients to learn the cost of care and avoid surprise bills. Here are some of those key provisions, and when they’ll take effect:

Information on how much specific health care providers are paid for care by each insurer in Connecticut will be available on a website maintained by Access Health CT, the state’s health insurance exchange. The website isn’t required to include all care; by law, it only needs to cover the 50 most frequently occurring inpatient primary diagnoses and procedures, the 50 most frequently provided outpatient procedures, the 25 most frequent surgical procedures and the 25 most frequent imaging procedures (the exchange can request information on additional procedures).

It’s supposed to be designed to help consumers make informed decisions about their care and present information in a way the average consumer can understand. Insurers will be required to report information on what providers bill and how much they pay by Jan. 1, 2017.

Starting Jan. 1, 2017, hospitals will be required to notify patients who are scheduling nonemergency care – for any of the common procedures or diagnoses covered by the exchange’s website – that they have a right to request cost and quality information. If patients request it, the hospital must, within three days of scheduling the patient’s visit, provide written notice that specifies certain things:

• If the patient is uninsured, he or she must be told the expected charge for the care; if that can’t be predicted, the patient must get an estimated maximum charge.
• Patients with insurance must be notified of how much the care would cost as part of their insurer’s negotiated rate. The hospital must also give the patient information on how to contact his or her insurer to learn more about the charges and out-of-pocket costs.
• If a patient is insured and the hospital is outside the insurer’s network, the written notice the patient gets must also include a statement that the care will likely be deemed out-of-network and could leave the patient with higher costs.
• Hospitals will also have to provide information on what Medicare reimburses for the services.

If a patient is scheduled to receive a nonemergency admission, procedure or service, the health care provider must determine if the patient has insurance. Patients who don’t have insurance or whose insurer doesn’t include the provider in its network must be notified in writing of what will be charged for the services. (Health care providers can still charge patients for unforeseen services that aren’t covered in this notice.) This will be required starting Jan. 1, 2016.

Every health insurer must maintain a website and toll-free phone number that members can call to find out the cost for inpatient admissions, health care procedures and services, as well as what his or her estimated out-of-pocket cost would be. Members would also be able to get information about quality measures for the health care provider, a list of in-network health care providers, whether a provider is taking new patients, languages the provider speaks, and information on out-of-network costs for admissions, procedures and services. This takes effect July 1, 2016.

Have a health care topic you’d like some help understanding? Email Mirror health care reporter Arielle Levin Becker at alevinbecker@ctmirror.org.