What to know about new right to medical care estimates
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Patients have a new way to check up on their expected medical costs.
Many health insurers, effective Jan. 1, are required to give patients a written estimate of how much it will cost them out of pocket to seek a specific type of care from a given medical provider. Vision and dental insurers don't need to provide estimates.
New Yorkers have struggled to get clear price estimates to budget for health care, sometimes with costly consequences. In some cases, insurers' customer service staff told patients they’d only be responsible for a certain portion of the final bill, but a higher percentage was used on the actual statement, according to Diane Spicer, supervising attorney for Community Health Advocates, a program run by the nonprofit Community Service Society of New York, which helps consumers navigate health insurance and billing.
"I would have an advocate call back the health insurer with the consumer and say, 'Well, on this day you told them it would cost them this amount; this would be your cost-sharing.' And they would say, 'We have no record of that,' " Spicer said. "This will be very useful for those consumers, who in the past, had gotten just plain misinformation."
The estimates are required under the federal Transparency in Coverage rule, which has gradually required more price information sharing from medical and insurance institutions.
To help New Yorkers get up to speed, Spicer answered questions about how estimates work. Her responses are paraphrased.
Q: What are patients entitled to as part of the estimate?
People who call their insurer and say they want to get a specific service at a particular location — whether it's in or out of the insurance's provider network — may ask for an idea of how much it will cost, in writing.
The correspondence should show how much patients have paid toward their deductible and out-of-pocket maximum, and how much the care would cost them. The letter should include any pre-authorizations that must be obtained or steps patients must take before the treatment is covered.
Q: How long will it take to get the estimate?
Insurers must mail the information no more than two business days after receiving a request. Health plans also may be willing to provide estimates via email.
Q: Does this apply to all health insurance plans?
It doesn't apply to some plans created before the Affordable Care Act, which had its major provisions go into effect in 2014. It also doesn't cover dental and vision insurance. That's an issue. We get so many complaints about dental plans on our health line.
Q: What can people do if they can't get the information?
They can call their plan's customer service team. If people feel their plan isn't complying, they can file a grievance with the insurer and a complaint with regulators.
Understanding that you're entitled to this information is one hurdle. Getting a customer service representative who understands you can be another. People sometimes only grasp what patients are asking for when they cite specific regulations and terms in them.
New Yorkers may get help from Community Health Advocates, at 888-614-5400 or cha@cssny.org, and local consumer affairs organizations.
Q: How helpful will the estimates be?
It's an estimate, not a guarantee that insurance will pay a certain amount, but I think it will be very useful.
We get many, many, many cases where consumers are told one thing by the customer service rep and then wind up with a different cost-sharing or a different expense. And the consumer would have no proof. It will be helpful to get something in writing that you can use at a later date.
People will still need help understanding what the estimate means and how to use it to make better decisions and advocate for themselves. This is complicated stuff.
Patients have a new way to check up on their expected medical costs.
Many health insurers, effective Jan. 1, are required to give patients a written estimate of how much it will cost them out of pocket to seek a specific type of care from a given medical provider. Vision and dental insurers don't need to provide estimates.
New Yorkers have struggled to get clear price estimates to budget for health care, sometimes with costly consequences. In some cases, insurers' customer service staff told patients they’d only be responsible for a certain portion of the final bill, but a higher percentage was used on the actual statement, according to Diane Spicer, supervising attorney for Community Health Advocates, a program run by the nonprofit Community Service Society of New York, which helps consumers navigate health insurance and billing.
"I would have an advocate call back the health insurer with the consumer and say, 'Well, on this day you told them it would cost them this amount; this would be your cost-sharing.' And they would say, 'We have no record of that,' " Spicer said. "This will be very useful for those consumers, who in the past, had gotten just plain misinformation."
The estimates are required under the federal Transparency in Coverage rule, which has gradually required more price information sharing from medical and insurance institutions.
To help New Yorkers get up to speed, Spicer answered questions about how estimates work. Her responses are paraphrased.
Q: What are patients entitled to as part of the estimate?
People who call their insurer and say they want to get a specific service at a particular location — whether it's in or out of the insurance's provider network — may ask for an idea of how much it will cost, in writing.
The correspondence should show how much patients have paid toward their deductible and out-of-pocket maximum, and how much the care would cost them. The letter should include any pre-authorizations that must be obtained or steps patients must take before the treatment is covered.
Q: How long will it take to get the estimate?
Insurers must mail the information no more than two business days after receiving a request. Health plans also may be willing to provide estimates via email.
Q: Does this apply to all health insurance plans?
It doesn't apply to some plans created before the Affordable Care Act, which had its major provisions go into effect in 2014. It also doesn't cover dental and vision insurance. That's an issue. We get so many complaints about dental plans on our health line.
Q: What can people do if they can't get the information?
They can call their plan's customer service team. If people feel their plan isn't complying, they can file a grievance with the insurer and a complaint with regulators.
Understanding that you're entitled to this information is one hurdle. Getting a customer service representative who understands you can be another. People sometimes only grasp what patients are asking for when they cite specific regulations and terms in them.
New Yorkers may get help from Community Health Advocates, at 888-614-5400 or cha@cssny.org, and local consumer affairs organizations.
Q: How helpful will the estimates be?
It's an estimate, not a guarantee that insurance will pay a certain amount, but I think it will be very useful.
We get many, many, many cases where consumers are told one thing by the customer service rep and then wind up with a different cost-sharing or a different expense. And the consumer would have no proof. It will be helpful to get something in writing that you can use at a later date.
People will still need help understanding what the estimate means and how to use it to make better decisions and advocate for themselves. This is complicated stuff.
Sarina Trangle covers affordability and cost of living issues and other business topics. She previously worked as an editor and reporter at amNewYork.
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