Healthfirst has contracted with FAIR Health, an independent not-for-profit organization, to provide information, education and a cost lookup tool to help participants in Healthfirst plans and those considering participation, better understand their health insurance options.

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Healthfirst is pleased to provide this website to help educate participants and potential enrollees about the health insurance reimbursement system. The site includes numerous articles and videos that explain how health insurance plans work and how to plan in advance for your share of health care costs. In addition, the site enables you to estimate the costs, by location, for thousands of specific medical procedures. The cost lookup feature illustrates how much you can expect to pay if you are uninsured or if you are considering seeking care outside of your plan’s provider network. Use this website in conjunction with Healthfirst plan information to help you select the plan that is right for you. And once you have enrolled, come back often. The information and cost estimates can help make you a smarter consumer of health care services.

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Who is FAIR Health?

FAIR Health is an independent, national not-for-profit corporation whose mission is to bring transparency to healthcare costs and health insurance information through comprehensive data products, consumer resources, and support of scientific and economic research on medical care. FAIR Health uses its national database of billions of billed medical services to power a free website that enables consumers to estimate and plan their medical expenditures. The website also offers clear, unbiased educational articles and videos about the healthcare insurance reimbursement system. In addition to its consumer offerings, FAIR Health licenses data products to businesses, governmental agencies, healthcare professionals and researchers. With its professional staff of experts in healthcare, statistics, technology and communications, FAIR Health strives to offer accurate, consistent and timely information to all stakeholders in the healthcare system.

Why was FAIR Health created?

FAIR Health was created in 2009, after then-New York State Attorney General uncovered potential conflicts of interest in the methods that health insurers were using to determine reimbursements to patients who received care from providers outside their health plans’ networks. The Attorney General’s office entered into settlement agreements with health insurance companies that do business in New York State. These agreements focused on bringing fairness and transparency to the out-of-network reimbursement system.

FAIR Health, created as part of this settlement, owns and maintains a database of charge data for billions of billed medical procedures and offers a free website (www.fairhealthconsumer.org) to help consumers estimate charges for medical services and procedures in their geographic area. The website also provides information about the healthcare reimbursement system. Insurers nationwide also use our data to help determine reimbursement rates for out-of-network claims.

Can I learn more about FAIR Health’s other initiatives and stakeholders?

To learn more about FAIR Health, visit the corporate website at www.fairhealth.org.

Does FAIR Health set "usual and customary rates" (UCR) for insurers?

No. FAIR Health offers benchmark charge data that some insurers may use to inform their determination of usual and customary rates (UCR) for out-of-network reimbursement. FAIR Health does not set UCR rates or out-of-network reimbursement amounts for insurers — these decisions are made by insurers themselves. Many insurers license FAIR Health data to assist them in determining their out-of-network reimbursement schedules.

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Does FAIR Health have cost information for every state?

Yes. The website at www.fairhealthconsumer.org includes medical cost data for all 50 states, Washington DC, Puerto Rico, and the US Virgin Islands.

Where does FAIR Health get its data?

FAIR Health collects charge data from private insurers and health plan administrators across the country. These charges represent the full, undiscounted fees that healthcare professionals report to insurers as part of the claims process. They are not the negotiated rates that apply when visiting a network provider. New charge data are continually added to the FAIR Health database, which currently contains billions of billed services and procedures.

How does FAIR Health get its data?

FAIR Health operates a robust data contribution program. Data are contributed by payors (insurance plans and administrators) across the country based on the claims they receive from physicians, dentists, hospitals, and other healthcare providers. The database currently contains data for billions of billed procedures. The consumer website is based on this database and reflects 12 months of recent claims. The website is updated twice a year.

How does FAIR Health ensure that its data are reliable?

FAIR Health employs a robust auditing and validation program to ensure the integrity of its data. Data are carefully validated before being accepted into the FAIR Health database. Part of this process involves testing the data with statistical algorithms. Before data are made available through the website, they are examined by in-house experts in statistics and technology and are audited and validated through a comprehensive review process. Learn more by visiting the corporate site here.

What are "usual and customary ("UCR") rates?

"Usual, customary and reasonable rates," or UCR, is a term often used to describe how insurers determine reimbursement amounts for out-of-network care. If your plan covers out-of-network care, your insurer may base the payment on a price that it determines to be "usual, customary and reasonable" in your area. Each insurance company makes its own decisions when setting UCR rates.

It’s a good idea to ask your insurance plan before undergoing a service or procedure what their UCR rate is and how it is set. You can then ask your healthcare professional how much s/he will charge for the service. With this information, you can know what to expect to pay for a service if you receive it out-of- network.

Who helps FAIR Health analyze and organize its claims data?

A team of healthcare researchers from leading academic institutions known as the Upstate Health Research Network (UHRN) advises FAIR Health on the best methods for analyzing its national claims data. This team includes experts in healthcare policy, medicine, economics, and statistics from New York State and across the country.

FAIR Health is also advised by an independent Scientific Advisory Board of prominent researchers that reviews our statistical methods and data. Many other stakeholder groups offer input on our work. They include consumer and patient advocacy groups, healthcare providers, health plans, policymakers, actuaries, and state and federal officials.

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What information can I find on the website?

The FH Consumer Cost Lookup features the FH Medical Cost Lookup tool, which allows you to obtain cost estimates for medical services. You can also find articles and educational videos about health insurance reimbursement (FH Health Insurance 101), links to healthcare resources, and a glossary of commonly used insurance terms.

If you are insured, you can use these tools to estimate what the healthcare provider will bill, how much your health plan will reimburse if you receive a medical service out-of-network, and how much you may owe out-of-pocket for that service.

If you are uninsured, you can use the cost lookup tool to estimate the full costs of medical procedures (select the uninsured option in Step 2 of the search page on the cost lookup tool).

How do I use the cost lookup tool on the site to plan and manage my healthcare expenses?

If you are covered by private insurance or are uninsured, you can use the website to plan and manage your healthcare expenses.

If you are insured, you can use the cost lookup tool:

• Before you decide whether to go out of your insurer’s network for a medical procedure or service — you can estimate the bill you might receive for the service out-of-network. You can also estimate how much of that bill you will be responsible for paying.

• After receiving an out-of-network medical service — you can compare the cost estimate on the site with the information on your Explanation of Benefits (EOB) form or bills. If there’s anything you don’t understand, you can discuss this with your healthcare professional or plan.

If you decide to stay in-network for the service, the cost will be based on the amount the healthcare provider has negotiated with the insurance company in advance. Because each insurance plan negotiates with healthcare providers separately, the website does not display negotiated network rates. If you have questions about how much you will pay when obtaining services from a network provider, please call your insurance plan at the number on the back of your insurance ID card.

If you are uninsured, use the cost lookup tool to estimate the full cost of a procedure or service. This can help you plan for healthcare expenses and assist you when speaking with your doctors, dentists, and other healthcare professionals about the costs of care.

Do the medical cost estimates on the FAIR Health consumer site apply to individuals who are covered by government programs such as Medicare and Medicaid?

No. The medical cost estimates on the FAIR Health consumer site are relevant to those who are covered by private insurance or who are uninsured. These cost estimates are not relevant to those who are covered by government programs such as Medicare, Medicaid, or Tricare.

Note: The FH Medicare Compare feature on the website is useful for individuals covered by private (i.e., non-government) insurance plans that use Medicare fees to determine out-of-network reimbursement.

Can I use the site to estimate the cost of related procedures that are part of a medical treatment?

Yes, FH Estimate Assist® allows you to estimate the cost of a medical treatment that involves two or more procedures. When you select certain common medical procedures, FH Estimate Assist will suggest additional related procedures which you may choose to include in your cost estimate, giving you a fuller picture of the cost of care. This feature is available for procedures with this symbol:

What does it mean when I see N/A when I search for a medical procedure cost estimate?

If you search for a medical cost estimate and receive a result of N/A (Not Available), this means that our database does not have enough data to provide a cost estimate for the procedure code in the geographic area you searched.

Does your site offer a list of healthcare professionals whose charges are similar to the ones on the site?

No. The site offers cost estimates based on billed amounts in our database for procedures by geographic area. FAIR Health does not have information on specific healthcare professionals. Healthcare professionals set their own fees and for a variety of reasons charges may be higher or lower than the estimates on our site.

Contact a specific healthcare professional or facility to learn how much a service or procedure will cost.

Can you let me know when new features are added to the site?

Yes. Learn about updates to the website by signing up for one or both of FAIR Health’s newsletters, and by joining FAIR Health on Facebook and Twitter. Recent additions to the website also are highlighted on the site’s homepage.

How do I get help using the site?

For help using the website, contact FAIR Health Monday to Friday, from 9:00 am to 6:00 pm Eastern Standard Time.

Is the site available in Spanish?

Yes. Visit the Spanish version of the website at http://hfcostlookup.org/es or click on the "Español" link at the top of the page at HFCostLookup.

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What do I need to know to use the FH Medical Cost Lookup tool?

To use thee cost lookup tool, you’ll need to know the zip code where the procedure took place. You also need to know the procedure you’d like to search. Because each procedure on the cost lookup tool is noted by a specific numeric medical (CPT) code, it’s generally more helpful to enter the specific code for a procedure, as this will better identify the procedure you are searching. If you don’t already know these codes, you can get them from your healthcare professional, or in some cases, from the Explanation of Benefits (EOB) form that you receive after having a procedure.

If you don’t know the CPT code, you can use the menu of procedures on the website. However, to better ensure that you are estimating the cost for the correct procedure, it is best to use the code.

What is a Current Procedural Terminology (CPT®) code and how do I find it?

Current Procedural Terminology (CPT) codes are numbers assigned to medical services and procedures. The codes are part of a uniform system maintained by the American Medical Association (AMA) and are used by medical professionals, facilities, and insurers.

Each code is unique and refers to a number and description for over 10,000 medical services and procedures. CPT codes are often used on medical bills to identify the specific services and procedures that are billed by the healthcare professional to you and/or your insurer. Most CPT codes are very specific. For example, the CPT code for a 15-minute office visit is different from the CPT code for a 30-minute office visit.

You may see a CPT code on your Explanation of Benefits (EOB) form. You can also ask your healthcare professional for the CPT code for a procedure or service you will undergo, or have already received.

When using the website, it is a good idea to use the CPT code to better ensure that you are researching the exact procedure you will undergo (or have already received.)

I don’t know the CPT code for my procedure. Can I use the cost lookup tool?

Yes. If you don’t know the CPT code for your procedure, you can use the menu of procedures on the website. You will find these menus under Step 3 when using the FH Medical Cost Lookup.

What is a geozip?

FAIR Health organizes its data by geozip. A geozip is a geographical area generally defined by the first three digits of U.S. zip codes. Geozips may include areas defined by one three-digit zip code or a group of three-digit zip codes. The geographic areas, local billing patterns and the quantity of available data are taken into consideration when forming geozips. Geozips generally do not include zip codes in different states.

When you look up a cost estimate on the website, the results will be based on billed charges for procedures or services in the FAIR Health database that were performed in your geozip.

What is a percentile?

A percentile is a statistical measure that represents the value below which a specific percentage of observations fall. For example, 80% of the charges in the FAIR Health database for a procedure code in a geographic area are less than or equal to the value for the 80th percentile. Similarly, 50% of the charges in the database are less than or equal to the value for the 50th percentile. Percentiles are important because they are used by many insurers to determine the highest level of a billed charge that they will consider for reimbursement.

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What is the "Emergency Medical Services and Surprise Bills" law?

This new law gives consumers in New York State the information they need to avoid unexpected healthcare costs and protect them from "surprise" bills for planned care and bills for emergency services from out-of-network doctors, hospitals and other facilities. Insurers will need to explain what out-of-network services they cover and how they decide what they will pay for out-of-network care, using the same standard so that you can easily compare different plans. Consumers also will have access to more information about exactly which doctors, hospitals and facilities are in their plan’s network.

The law protects consumers if they have checked to make sure that all of their providers—including doctors, hospitals and any other facilities (like labs or imaging centers) were in their plan’s network and later receive a "surprise bill" for services.

How can I find out if a doctor or hospital belongs to my plan’s network?

Every year, your plan should provide you with a list of all of the doctors and facilities in your network. In addition, your plan will list all of its network doctors and facilities on its website. If providers or hospitals join or leave the network, the plan must update the website within 15 days. Before you get care, you should double-check this information by contacting all of your healthcare providers and asking if they participate in your plan’s network.

What can I do if a doctor or hospital tells me that it is "in-network" when it actually is not?

You should let your plan and your provider know that you asked about the provider’s network status before you got care and that the information you received was wrong. Since you tried to stay in your network, you should have to pay only the in-network cost, including your co-pay, co-insurance and deductible. The provider and insurer will need to settle the rest of the bill with each other, or through New York’s new dispute resolution program.

If I don’t have insurance, will the new law help me with large bills?

If you are uninsured, the new law provides some protection from bills for emergency services and for certain surprise bills from hospitals or ambulatory surgery centers that have not made legally required disclosures on a timely basis. If an emergency or surprise bill seems too high, you may submit it for referral to the state’s dispute resolution program and an independent dispute resolution entity will decide on a reasonable price for you to pay.

Of course, the Affordable Care Act requires all individuals to have healthcare insurance. If you don’t have insurance through your employer or a public program like Medicaid, you can take advantage of the New York State Health Insurance Exchange and choose a plan that suits your needs. Depending on your income level, you may be able to get a federal tax subsidy to help pay your monthly premium.

What standard costs will plans use in their examples?

To help you compare costs across plans, insurers’ examples can use FAIR Health’s 80th percentile charge as the "allowable amount", or the most money they will pay for a service. The "80th percentile" generally means that 80% of providers in a certain area charge that amount or less for a service. Many insurers use the 80th percentile to determine their allowable amount.

Will health insurance plans also need to use the 80th percentile benchmark as their allowable amount?

No. It’s important to understand that even though plans are required to give consumers cost examples using the 80th percentile charge that may not be the amount they will actually pay for out-of-network care. Plans can base their allowable amounts on other percentiles, other data sources besides FAIR Health’s, or even on their own or another plan’s fee schedules, like Medicare. The 80th percentile benchmark is just meant to help you understand and compare how different plans work.

My plan doesn’t use the 80th percentile charge as its allowable amount. If I want a plan that does, how will l find one?

If your insurer does not usually offer a plan that uses the 80th percentile benchmark as the allowable amount, you can ask for one. All insurers have to make these plans available, unless they get an exemption from the state Superintendent of Insurance. But remember, your total costs in an 80th percentile plan may not be lower than your costs in a plan that uses a different standard. It’s important to weigh all of the plan’s costs, including the premium, co-pays or coinsurance and deductible. Of course, if you use in-network providers, they have already agreed to accept your plan’s payment and you won’t have to worry about allowable amounts.

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Why does the website limit the number of searches I can conduct?

FAIR Health’s license agreements with external parties place limits on the number of medical searches that can be done on the site.

When looking up medical costs, you can conduct 20 searches, consisting of one medical code each, per week. Inputting a procedure code counts as one search. Search limits are reset at the end of the weekly search period to enable consumers to estimate costs for additional codes.

FAIR Health uses a computer’s IP address to track searches. If you are using a computer for which the IP address is shared throughout an office, library or other organization, you may reach the limit before you have personally conducted 20 searches.

The site is designed for consumer use. It is expected that in most cases, consumers will be able to meet their needs before reaching the search limit. For information on licensing FAIR Health data for healthcare professionals and commercial businesses, contact info@fairhealth.org.

Do the search limits reset?

Yes. The medical search limit resets after a week.

I’m working on an appeal and need additional searches, but have reached my limit. What can I do?

If you are working on an appeal, with a filing deadline before the search limit resets, e-mail info@fairhealth.org with an explanation of your situation.

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How does FAIR Health develop its cost estimates?

We collect data on healthcare charges from private payors (insurance companies and plan administrators) as submitted by healthcare providers as part of the claims process. The charges represent the full (undiscounted) amount of the healthcare provider’s bill (not the contracted, discounted rates that are paid to providers in a plan’s network).

FAIR Health analyzes the data, and uses statistical methods to develop cost estimates for procedures by geozip, a geographic area, which generally includes zip codes that share the first 3 digits).

Is the cost estimate that I receive from the website the exact amount that I will owe?

Not necessarily. The cost estimates on the site represent what healthcare professionals typically charge for a procedure in the geographic area searched. While these estimates are based on the extensive data we have related to the fees that are charged by providers in your area, other factors may influence the amount that you will have to pay for out-of-network healthcare services. Actual billed charges may be higher or lower than the estimate you receive on the site.

Please note that FAIR Health does not determine, develop or establish appropriate fees or reimbursement levels for any medical procedure or service. Healthcare professionals determine their own fee schedules. All of our estimates are provided for informational purposes only.

How can I know if my health plan uses FAIR Health data to set its reimbursement rates?

Many insurance plans use FAIR Health data to assist in the determination of their out-of-network reimbursement rates (sometimes called usual, customary and reasonable or "UCR" rates). You can review your plan documents, or contact your health plan for this information. Most insurance companies have member areas of their websites, online question forms, and in some cases, opportunities to conduct live chats with customer service representatives. You may also call the phone number listed on the back of your insurance card.

Note that plans may use FAIR Health data in different ways and have access to additional data sources that are not available on the FAIR Health consumer website.

How do I estimate my out-of-pocket medical costs if my plan uses the Medicare fee schedule to set out-of-network reimbursement rates?

If your plan reimburses out-of-network services based on Medicare fees, you can re-calculate your reimbursement estimate and out-of-pocket costs by selecting the "Medicare-Based" button on the right side of the results page on the FH Medical Cost Lookup.

Note: This feature only applies to the FH Medical Cost Lookup.

Medical Cost Estimate

How often are the medical cost estimates on the site updated?

The medical cost estimates on the consumer site are updated every six months and are based on 12 months of data.

Why is the cost estimate on the website different from what I was charged for an out-of-network service?

Many factors may influence how much you will be asked to pay for a medical procedure received out-of-network. Your actual costs may vary depending on factors specific to your healthcare professional or health plan in the following ways:

• Healthcare Professional: Healthcare professionals set their own fees and may charge different amounts for the same service. For example, a doctor’s fees may be based on the number of years he or she has been in practice, or whether he or she is a general practitioner or a specialist, is board-certified or has received other special training or designations. In addition, expenses such as rent, salaries for office staff, insurance and other overhead can influence how much a doctor charges. The healthcare professional or facility you choose may bill more or less than the cost estimate on our site and this can impact both the amount your health plan will reimburse and the amount you will owe out-of-pocket.

• Health Plan: The design of your health plan also may influence your share of costs for out-of-network care. For example, you may need to meet an annual deductible before your insurer will begin to reimburse for the care you receive. Your insurer may use a formula different than those available on the FAIR Health website to calculate out-of-network reimbursement. Our website allows you to estimate costs based on a traditional "UCR-based" reimbursement method or you may recalculate your estimate if your plan uses a Medicare-based formula for out-of-network reimbursement. However, to obtain the most accurate cost estimate, you will need to know the details of your health insurance plan. You can learn more about your plan by reviewing your plan documents and contacting your employer or insurer with questions.

I have a high deductible health plan. How can I better manage my healthcare dollars?

If you have a high deductible health plan, learn more about better managing your healthcare dollars by reading Understanding High Deductible Health Plans.

How do I learn more about how my insurer determines out-of-network reimbursement rates?

You can refer to your plan documents or contact a member services representative at your plan to find out how reimbursement is determined. You can also ask the benefits administrator at your employer.

Where can I find more information on how my insurer determines out-of-network reimbursement?

You can refer to your plan documents or contact a member services representative at your plan to find out how reimbursement is determined. You can also ask the benefits administrator at your employer.

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How can I learn more about my medical plan benefits?

Understanding your share of costs for out-of-network services and the percentile your plan uses to determine reimbursement will help you customize the estimates available on the site to most closely match your plan provisions.

Learn more about your plan’s specific benefits by:

• Consulting your plan documents

• Asking Your Employer: Ask your employer's human resources department or speak with your company’s benefits administrator about the specifics of your coverage.

• Contacting member services at your insurance company: Most insurance companies have member areas of their websites, online question forms, and in some cases, opportunities to conduct live chats with customer service representatives. You may also call the phone number listed on the back of your insurance card.

I went to an in-network hospital, but the healthcare professional who provided my care was not in my plan’s network. Now I am presented with a bill. What can I do?

Unfortunately, this experience is not uncommon. You may first choose to contact your insurer and discuss this with a member services representative, who may be able to provide some suggestions.

For additional information, you may also choose to consult the FAIR Health guide on Appealing a Reimbursement Decision.

Where can I find sources of assistance for appealing a reimbursement decision?

Visit the Healthcare Resources section under Insurance Appeals and Assistance, where you can find information on consumer assistance programs. In the "Healthcare Resources by State" section, you will find contact information for the agencies that regulate insurance in your state. You can also refer to the article on Appealing a Reimbursement Decision.

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