Health Insurers Reveal Cost Sharing

The Insurance Division doesn’t intend to approve or police insurance company web sites, said its acting administrator Teresa Miller. It will, however, closely track consumer comments about problems using the new information. Insurers must also file year-end reports on the number of requests for estimates received in a calendar year, divided into in-network procedures and out-of-network procedures.  

 

Several insurers have already shared their new web sites with regulators. “Some are providing even more information than the bill requires,” said Miller, adding that Oregon is in the forefront of insurance transparency. There were no off-the-shelf solutions to meeting the new rules.

 

PacificSource has developed a treatment cost navigator, according to its vice president and chief of operations, Sujata Sanghvi. The tool will provide real-time cost estimation tools for more than 40 procedures in orthopedics, obstetrics, radiology, laboratory, immunizations, endoscopy and office visits. Those tools will reconcile out-of-pocket costs with a member’s current accumulated deductible and/or out-of-pocket maximums.

 

Physician offices can also enter procedure and cost information, and then submit the details to PacificSource’s claims processing system. That way both the physician and the patient will know, in advance, the patient’s share of the charges.

 

At Providence Health Plan, its software will be accessible to physicians both inside and outside of their network, said Dan Nipe, senior project manager. “It’s been pretty challenging to program the many benefit plans in a way that determines where an individual stands regarding out-of-pocket costs,” he said. 

In general, all insurers must:

• specify what information is needed in order to provide an estimate;
• describe how the insured may obtain an estimate for procedures and services included in the insurer’s categories;
• provide a general explanation for obtaining an estimate for out-of-network procedures or services;
• mention that the law does not require an estimate for procedures or services not included in the insurer’s categories;
• make it clear that the accuracy of an estimate depends on the accuracy of information provided by the enrollee, and 
• provide the information by online access and by telephone.

 

Cost estimates must itemize the enrollee’s deductible, the amount of the deductible already met by processed claims, coinsurance, copayments or other cost sharing to be paid by the enrollee, along with any applicable benefit maximum.