Copays, Deductibles, and the Real Cost of Procedures: How to Be a Smart Healthcare Consumer

June 8, 2015

The landscape of healthcare is evolving daily. In the past few years, the impact of far-reaching legislative healthcare reform has fostered a national conversation on healthcare. Many states are now providing healthcare exchanges that allow individuals and families to obtain coverage in a competitive marketplace. Subsidies are available for low-income families who need insurance coverage and pre-existing conditions are a memory of the past. In these changing times, it is increasingly important to remain educated and aware as a patient and consumer of health care.

The healthcare arena can be difficult to navigate at times. You are often at your most vulnerable when dealing with healthcare issues, either because you or a loved one is in some distress. Generally, you want to be somewhat familiar with the details of your healthcare coverage and the applicable networks, facilities, and coverages before an emergency arises.

How do copays and deductibles factor in?

For non-emergency medical services, it also is important to completely understand your coverage and the options that may be available to you. If you are in an insurance plan that has some level of patient cost-share, as most do, research and planning can really make a financial difference.

Copays, deductibles, and coinsurance are often part of your insurance coverage. In many instances, you may need to meet a particular deductible amount before the insurance covers your medical bills. Additionally, you may be subject to coinsurance charges on certain types of medical services.

For example, if you are having an in-patient procedure at a hospital, you may be subject to an in-patient admission copay, and then you may need to meet your deductible amount before your insurance begins payment. Further, once you have met your deductible, you may be subject to a coinsurance percentage of the overall charges (for example, 20%).

For more information about how your health insurance coverage may work and for relevant terminology, click here.

How much should procedures cost?

Resources may be available to you to research the best price options for a particular procedure that you may need. Your insurance carrier may offer a price-comparison tool that allows you to compare prices charges by various providers and facilities in your network for the same service or procedure.

For example, if you know that you will need joint replacement surgery, you may be able to price-compare various hospitals in your area to see the average price that hospital charges in your network for a knee or hip replacement. Price differences for the same procedure between various facilities and providers can be surprising.

The price-comparison tools often also have quality metrics for the facilities and providers, as well as reviews. You may find that facilities and providers with the same high quality metrics charge very different prices for the same medical procedures and services – a key consideration when you are responsible for a portion of the cost-share.

You may want to also check with your employer or health insurer for any specific programs or narrow networks that provide savings on particular procedures or medical services.

For general pricing information, the Center for Improving Value in Health Care (CIVHC), maintains the All Payer Claims Database (APCD) for Colorado.  Public and private health care payers in the state submit claims pricing information to the APCD and the information is then provided to the public in a searchable format in a web tool called Colorado Medical Price Compare.

Additional providers and types of services are continuously added to the database.  For example, you can search for a hip joint replacement surgery in a particular geographic area or zip code (or by facility name), and see the estimated price of that surgery by facility.

Being an educated and informed health care consumer is increasingly important in today’s health care environment.  Ensure that you understand your health care coverage and the options that are available to you, because your health and your dollars are on the line.

This post was written by Julie Borisov, a staff attorney at Colorado PERA. Would you like to write a guest post for The Dime? Email us at dimecontact@copera.org.