A New Consumer State of Mind
After a long winter, the arrival of spring inspires us to think of new beginnings. But this year, it was not the warmer temperatures that we most welcomed. It was the start of New York State’s new health consumer protection law. Under the law, insured consumers who receive surprise bills for planned, non-emergency care from an out-of-network doctor or facility when they have tried to stay in-network, only have to pay the amount they would have owed for in-network care. Insured and uninsured patients also are held harmless for high bills for emergency care for serious and life-threatening conditions requiring immediate attention.
As part of the law, insurers must show how they calculate reimbursement for out-of-network services—so that consumers can compare their potential out-of-network costs—and must use FAIR Health’s 80th percentile benchmark charge as a comparison. The 80th percentile means that the charges of 80% of providers in a certain area equal that amount or less. If an insurer does not offer plans that reimburse for out-of-network care at the 80th percentile, consumers can request a plan that does. Other states may soon follow New York’s lead and extend similar rights to their residents.
These new protections are just one way that healthcare consumers can avoid surprise costs. Another is this issue of Consumer Access! It is devoted to helping you better plan your healthcare expenses—insured or not. If you have insurance, keep reading for more on getting the most out of your benefits. And, whether you are insured or uninsured, this Consumer Access will help you learn how FAIR Health’s cost lookup tools and educational resources can help you estimate your costs before you get to the doctor’s office.
We hope that after reading this issue, you will be inspired to plan your healthcare and related expenses for the year. After all, the first step to making the best choices for yourself and your family is to take on a new consumer state of mind.
You're Insured, Now What? Using Your Health Insurance ID Card
Your health insurance ID card is your proof of insurance when you visit the doctor, hospital or other facility. Not all health ID cards look the same or have the exact same information. But, you can expect to see standard facts on every card, such as: your name, member ID number, employer or group number, your plan’s phone number, type of plan and your cost-sharing requirements (such as co-pay).
Refer to your health ID card to easily and quickly see how much you have to pay for care. This information can help you plan your healthcare costs and get the care you need. Here are some tips:
- Check for Errors: Review your health ID card. Compare the cost-sharing features listed on your card to your “summary of benefits” and make sure it matches your coverage. If you spot any errors, call your health plan for clarification, and request a new card with correct information.
- Know Your Costs: Show your health ID at your doctor’s office. Make sure you are charged the co-pay listed on your card. Keep in mind that annual exams and other preventive services are now free to patients, and do not require a co-pay.
- Know Your Benefits: Make sure you know what your plan covers. Do you need a “pre-authorization” or a referral for certain visits or services?
- Know Your Network: Before you receive care, make sure you know your plan’s rules on what is covered. Which providers—doctors, hospitals and other facilities—are in your network? Do you have an out-of-network benefit, and if so, how much will you need to pay?
Learn more about health ID cards here. See a sample card here. Download Questions to Ask Your Plan and Questions to Ask Your Provider.
Whether Insured or Uninsured:Tips for Planning Your Healthcare Costs
Filing your tax return may have started you thinking about how much you will spend on your family’s healthcare this year. Will your family need medical and/or dental care? How much do you have left in your flexible spending plan? What if you’re not insured?
You can’t always predict the future, but planning ahead for care that you know you’ll need is half the battle. Of course, we are here to help!
The first step is visiting www.fairhealthconsumer.org (consumidor.fairhealth.org in Spanish) or downloading our mobile app from iTunes or Google play. Our website and app provide typical costs of services in your area, and can help you make decisions about whether to go out of your network for care, negotiate costs with your providers or support appeals to your insurers.
Our medical and dental cost lookup tools are organized by the same medical procedure code (CPT®) and dental procedure codes (CDT®) that providers use to bill insurance companies. This allows you to understand the cost of procedures and services the way you see them on your bills and Explanation of Benefit (EOB) forms. If you are not sure of the exact medical or dental procedure code for a treatment or service, you can also search our menu of medical or dental procedures provided as part of each of the cost lookup tools.
Using the website and app is easy!
Before you get care:
After you get care:
- First, enter the zip code (or city and state) where your procedure will take place. We have typical charges in almost 500 geographic areas from all 50 states, Puerto Rico and US territories.
- Next, enter the CPT or CDT code—if you don’t know it, ask your provider or search the user-friendly menu of procedures. Knowing these codes will help you get the most reliable cost estimate.
- Get your estimate! Use this estimate to decide whether you want to go out-of-network, stay in-network for care or negotiate with your healthcare provider.
- As above, enter the zip code (or city and state) where your procedure took place.
- Next, enter the CPT or CDT code—if you don’t know it, ask your provider, or look at your Explanation of Benefits (EOB) or search the menu of procedures. Knowing these codes will help you get the most reliable cost estimate.
- Get your estimate! Use this estimate to decide whether you want to appeal a reimbursement decision by an insurer or negotiate with your healthcare provider.
Keep in Mind:
Your actual out-of-pocket costs may vary based on factors specific to your provider and/or your plan. Some plans base their reimbursement rates on a percentage of “usual, customary and reasonable” (UCR) charges. Others use a formula based on the Medicare fee schedule that is published by the US Department of Health and Human Services. The FAIR Health cost lookup tool provides information for both types of plans. To learn how your health plan determines out-of-network reimbursement rates and covered services, call the member services number listed on the back of your insurance ID card. Learn more about different reimbursement methods here.
Finally, be sure to check the glossaries and FH Health Insurance 101 section on our website. (You may remember that it used to be called FH Reimbursement 101—we changed the name to reflect the broad range of topics that the section covers. We regularly add new content to the section, so check back often!)
Word to the Wise Consumer
Stay up to date on healthcare news, from details about New York State’s “surprise” bill law to trends in out-of-pocket costs.
Do You Know…?
- The difference between emergency care and urgent care? Check out our guide on understanding the differences between the two—and how this may affect your out-of-pocket costs.
- How out-of-network care may impact your out-of-pocket costs? Learn more from our guide.