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Helping Texans Compare & Understand Their Health Care Options

Estimating Prices with Coverage

You often can compare the prices of different providers and choose one that provides the care you need and fits within your budget.

Questions to ask when planning an upcoming medical procedure. Use this form to help you estimate a procedure's cost. Take this form to your doctor and ask them the questions on it.

Planning Ahead

Talk to your doctor and hospital.  Sometimes you will need care from several providers, rather than just one.  For instance, a surgery might include multiple surgeons, an anesthesiologist, and a radiologist.  Each one can bill you separately.

  • Make sure your insurance plan covers the services you need and check that the hospital you want to use is in your network.
  • Get the names of all the providers who will be involved in your care and a list of the services each will provide.  Find out whether each provider is in your network.  If not, make sure you know what they will charge.  Remember that you might have to pay the full cost of any out-of-network services you get.
  • Ask whether you will need additional services, such as lab tests or radiology scans.
  • Call other hospitals and get the same information so you can compare prices.

Talk to your insurer or HMO.  Next, ask your insurer about the health care services you need.

  • Make sure to give the insurer the list of providers that will provide your care to confirm which providers are in your network.
  • If any providers aren’t in your network, ask your insurer to help you find an in-network provider.  Health plans are required to have enough providers to supply all services covered under the plan.
  • Ask your insurer for an estimate of what it will pay the hospital and in-network providers for the services you need, and ask what you will owe.  Also, ask for the plan’s estimated payment for any services an out-of-network provider will provide, so you can anticipate how much you might owe in balance billing.  Out-of-network providers can balance bill you for any costs that your insurer won’t pay, but in-network providers can’t.
  • Ask your insurer if it covers the tests, scans, or other services you need.
  • Note: You can call your insurer for a price estimate for the services you need, but talking directly to providers will give you a more accurate estimate.

Read Avoiding Surprise Bills for more details on how to choose providers and avoid expensive medical bills.

Tips if You Have Coverage

  • Your insurer must give you an estimate of what it will pay if you ask for one.
  • Out-of-network providers must give you an estimate of the costs for the services you plan to get if you ask for an estimate.
  • Many insurers have online tools that allow you to compare costs for different in-network providers.  These tools reflect the discounted prices for your insurer so they will give you the most accurate estimates.
  • If your treatment becomes more complicated, it might cost more than expected.
  • Websites such as txpricepoint.org or fairhealthconsumer.org help you estimate the prices of procedures.

Next Section: Estimating Prices When You Don't Have Coverage



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Last updated: 10/06/2015