For most of the history of American healthcare, you found out what something cost when the bill arrived. That has changed. Three federal rules now give patients a legal right to see prices before care, and together they cover hospitals, insurance plans and the doctors who treat you.
Knowing what each one gives you turns a confusing system into one you can plan around.
Hospitals must post their prices
Since January 1, 2021, the hospital price transparency rule has required every hospital in the US to publish its standard charges. That includes:
- the cash price it charges people paying for themselves
- the rate it has negotiated with each insurance plan
- its full list price, which almost nobody actually pays
Hospitals must also make common "shoppable" services, like an MRI, a colonoscopy or a joint replacement, easy to look up, either in a plain-language list or through an online price estimator.
Your insurance plan must show you its rates
The Transparency in Coverage rule applies to most private health plans, including employer plans. It does two things for you.
First, since July 1, 2022, plans have had to publish every negotiated rate they pay doctors, hospitals and other providers, in large machine-readable files. These files are where independent sites like US Health.io get their prices.
Second, plans must give members an online tool that estimates your own out-of-pocket cost for a service with a specific provider, based on your deductible and coverage. It covers every covered service for plan years starting in 2024 or later. If you'd rather not use a website, you can ask your plan for the same information.
The No Surprises Act protects you from surprise bills
The No Surprises Act took effect on January 1, 2022, and it does two things for patients.
It limits surprise out-of-network bills. For emergency care, and for care from out-of-network doctors at an in-network hospital or surgery center, you generally pay only what you would have paid in network. The doctor can't bill you for the rest unless you agreed to it in advance.
It gives uninsured and self-pay patients a good faith estimate. If you don't have insurance, or choose not to use it, a provider must give you a written estimate of the expected charges when you schedule care, or whenever you ask. If the final bill is at least $400 more than the estimate, you can dispute it through a federal process. You generally need to start within 120 days of receiving the bill.
What these rights don't do (yet)
These rules make prices visible, but they don't make them simple:
- The published files are huge and technical. One insurer's files can run to terabytes. Most people need a tool that has done the processing for them.
- A price isn't the whole bill. A procedure can bring a separate fee from the doctor and from the facility. Compare like with like (see why prices vary across town).
- Estimates are estimates. If your care changes on the day, the bill can too. Keep a copy of any estimate you're given.
How to use your rights
- Ask for the exact code. Your doctor's office can tell you the billing code for what they've ordered. Codes make comparisons precise.
- Check your plan's estimator for two or three in-network options.
- Ask about the cash price if you have a high deductible. It's sometimes lower than what you'd pay through insurance.
- Get a good faith estimate in writing if you're paying for yourself.
- Keep everything. Estimates and plan printouts are what you need if a bill doesn't match.
Price transparency is now the law. Using it takes a few minutes, and it's often the simplest way to cut a medical bill before you get it.