Expanded price transparency with our Cost Estimator tool

The way people shop for health care continues to change. Consumers are looking for cost transparency and want to know what they are paying for, the same as if they were shopping for a new car or appliance.   

To meet this consumer demand and to meet new government regulations, we’ll begin providing price and cost-sharing information for all covered procedures and services on January 1, 2024, to group and individual commercial members and providers through our Cost Estimator tool in partnership with Healthcare Bluebook. Cost Estimator will still be known by the same name.

Why are we making this change?

On October 29, 2020, the Departments of Health and Human Services (HHS), Treasury and Labor issued the “transparency in coverage” final rule. The rule imposes new transparency requirements on most group health plans and health insurers in the individual and group markets. The purpose of the requirements is to enable consumers to make informed health care purchasing decisions.

The final rule requires health plans to disclose prices and cost-sharing information for all covered services, including all encounters, procedures, medical tests, supplies, durable medical equipment and fees (including facility fees). 

Pricing for medications or other pharmacy benefits will not be included in this change.

What exactly is changing?

We’ve been a leader in the cost transparency space since 2014, when we originally launched the Cost Estimator tool. So this won’t be as much a fundamental shift as just an expansion of what we’ve already been doing.

It should be noted that the methodology for calculating a cost estimate is changing. Now, an estimate will be produced using allowed amounts from aggregated claims data. This may result in prices being estimated differently than they previously were.

What is the impact to the Priority Health network?

The new version of the Cost Estimator tool helps members avoid billing surprises by seeing costs ahead of time. Fewer billing surprises means fewer unhappy patients.

As with all procedures and services having cost estimates, you may also receive questions from patients about costs or experience the effects of patients shopping for lower costs. We believe that competition is a net positive and a key driver of care affordability.  

Can providers still access Cost Estimator?

Yes, you’ll continue to be able to access Cost Estimator via prism, where you’ll be able to see what your patients see and what their out-of-pocket costs are for services. More details will be coming in early 2024 about how to use the updated provider version of the Cost Estimator tool.