How to know in advance how much your health insurance will pay

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Last year, hospitals they had to start publishing lists of the prices they charge for each procedure. The data was not easy to access, and a serious flaw is that these were just the sticker prices, not the prices that insurers, or anyone else, actually end up paying. Now, as of July 1, the insurers they have to publish lists of negotiated prices. That’s much more useful, but again, it’s hard to use it to compare prices.

Part of the reason this is all so confusing is that there are so many companies involved. If you’ve ever looked closely at your Explanation of Benefits (the thing that comes in the mail after a procedure and says “This is not a bill”), you know that the price your payment depends on how much the hospital charges, how much the insurance company negotiates them for, and then how much the insurer expects you to pay. The new price transparency rules are meant to give you all of this information. prior to receive the surgery or service.

The July 1 deadline marks the first of three phases in the new price transparency law.

  1. Right now, insurers are required to post a “machine-readable” list of all the prices they’ve negotiated with hospitals and providers.
  2. As of January 1, 2023, they must provide a human-usable online tool that provides price estimates for 500 “purchasable services” (that is, things one could possibly buy in advance, such as surgeries that are not of emergency).
  1. As of January 1, 2024, that online tool must cover everybody services covered by the insurer.

(Many insurers already have cost estimating tools, but they vary in their usefulness. Often, you must be logged into a member account to use the tool, and it may not include all covered services or provide as much information as you will eventually be). required by law).

There are still several potential obstacles to getting an accurate price for the next care. Insurers might simply decide that they don’t feel like publishing the required information in the first place. (Only 14% of hospitals published their price transparency lists in the first year, according to a report from the Patient’s Rights Advocate.) Fortunately, the fines for non-compliant insurers are higher than for hospitals: $100 per “affected member” per day, which could add up quickly.

The other big hurdle right now is that the material required is machine readable. Imagine something like a spreadsheet, only harder to read and too big to scroll. They also take forever to download. As described by one insurer (Anthem): “These files are in the format defined by CMS (JSON) and are not intended for easy member lookup of rates, benefits or cost sharing.”

The idea is that third-party services or apps will emerge to do the work of helping people shop for the best coverage. We’ll have to wait to see how well that plan works.

But in the meantime, the files themselves are pretty easy to Google. Type the name of your insurer into a search engine along with the words “machine readable files” and a page with something is bound to appear. (Some of these appear to be incomplete, but presumably, they’re working on it.) To get started with the five largest insurers, here are the pages to Aetna, Anthem, Cigna, EmperorY united health.

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