How to Find Out What Your Health Insurance Will Pay Beforehand

Last year, hospitals had to start posting lists of the prices they charge for each procedure. The data wasn’t easy to access, and a serious flaw is that these were just the sticker prices—not the prices that insurers, or anybody else, actually end up paying. Now, as of July 1, the insurers have to post lists of negotiated prices. That’s much more useful, but—once again—it’s hard to actually use this to shop around.

Part of the reason this is all so confusing is that there are so many companies involved. If you’ve ever pored over your Explanation of Benefits (the thing that comes in the mail after a procedure and says “This is not a bill”), you’ll know that the price you pay depends on how much the hospital charges, what the insurance company bargains them down to, and and then how much the insurer expects you to kick in. The new price transparency rules are meant to give you all of this information before you get the surgery or service.

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

1. Right now, insurers need to publish a “machine-readable” list of all the prices they have negotiated with hospitals and providers.
2. Starting Jan. 1, 2023, they need to provide a human-usable online tool that will give price estimates for 500 “shoppable services” (that is, things that one could conceivably shop for in advance, like non-emergency surgeries.)

1. Starting Jan. 1, 2024, that online tool will need to cover all the insurer’s covered services.

(Many insurers already have cost estimation tools, but they vary in their usefulness. You often have to be logged in to a member account to use the tool, and it may not include all covered services or provide as much information as what will eventually be required under the law.)

There are still several potential obstacles to getting an accurate price for upcoming care. First, the insurers might just decide they don’t feel like posting the required information. (Only 14% of hospitals posted their price transparency lists in the first year, according to a report from Patient Rights Advocate.) Fortunately, the fines for insurers who don’t comply are higher than they were for hospitals: $100 per “affected member” per day, which could get real steep real fast.

The other big obstacle right now is that the required stuff is machine readable. Imagine something like a spreadsheet, only harder to read and too massive to scroll through. They take forever to download, too. As one insurer (Anthem) describes it: “These files are in the CMS defined format (JSON) and are not meant for a member-friendly search of rates, benefits, or cost sharing.”

The idea is that third party services or apps will spring up to do the job 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 easy enough to google. Throw your insurer’s name into a search engine along with the words “machine readable files” and a page with something is bound to pop up. (Some of these appear to be incomplete, but presumably, they are working on it.) To get you started with the five biggest insurers, here are the pages for Aetna, Anthem, Cigna, Kaiser, and United Healthcare.