Building on the features of existing price transparency tools, essential elements of price information for insured patients include the total estimated price of the service, the provider's network status, and the patient's estimated out-of-pocket responsibility, along with other available provider- and service-specific information. 

Total estimated price of the service. This is the amount for which the patient is responsible plus the amount that will be paid by the health plan or, for self-funded plans, the employer. The amount will necessarily be an estimate for several reasons. The patient, for example, may use additional services not included in the estimate or the physician may code and bill for a service different from the service for which the patient sought an estimate.

The price estimate for in-network services is a communication between the health plan and the insured patient and should follow the form of an explanation of benefits, representing the total estimated price (i.e., the plan’s negotiated rate for the service) as a dollar amount, not as a percent discount from charges, to avoid confusing the patient. For services received from out-of-network providers, because the provider's pricing information is not available to the health plan, the health plan can only provide information about the benefit structure for that type of out-of-network care (e.g., a 20 percent co-insurance obligation).

Network status. The tool should provide a clear indication of whether a particular provider is in network and information on where the patient can try to locate an in-network provider, such as a list of in-network providers that offer the service.

Out-of-pocket responsibility. Another essential element is a clear statement of the patient's estimated resulting out-of-pocket payment responsibility, tied to the specifics of the patient’s health plan benefit design, including coinsurance and the amount of deductible remaining to be met (as close to real time as possible).

Other relevant information. Information related to the provider or the specific service sought (e.g., clinical outcomes, patient safety or satisfaction scores) should be included where it is available and applicable. This information should clearly communicate what has been measured and to whom the measurement pertains (e.g., to the facility, the physician, etc.).

Publication Date: Tuesday, March 10, 2015