Episodes of Care

Summary

If you have an ongoing illness or need a complicated procedure, it's a good idea to get an episode of care cost estimate.

Ongoing, or chronic, illnesses, like diabetes, usually require many different medical services. Complicated procedures, like a knee replacement, also require many different services. The bundle of services you receive is often called an episode of care. An episode of care runs from the time your symptoms start until all your treatments end. For chronic conditions, episodes of care include the typical services for the condition over the course of one year.

The costs for the various services you need can add up. You can use the FAIR Health Medical Cost Lookup Tool to find out how much your entire episode of care might run.

The results page for the procedure or condition you choose will show you two main results: out-of-network/uninsured and in-network episode of care prices. The out-of-network/uninsured price is an estimate of how much you'll have to pay if you don't have health insurance. It's also what you may have to pay—or a portion of what you may have to pay—if you have insurance but your healthcare providers don't take your insurance. The in-network price is an estimate of how much the episode will cost if you have health insurance. That includes both your insurer's share of the cost and your share.

If you have health insurance, you can use your episode of care estimate to help you budget and plan for your healthcare costs. This is especially important if you have a high-deductible health plan. If you're considering using out-of-network services, the estimate will help you understand the difference between your in-network and out-of-network share of costs. It can also help you to negotiate a price with out-of-network providers.

If you're uninsured, having an estimate will help you to negotiate a price with any healthcare providers for their services. It will also allow you to understand the potential benefits of coverage.

Episode of Care


If you have an ongoing, or chronic, illness, such as diabetes, or a complicated procedure, such as knee replacement, your treatment will usually require many different medical services. For instance, if you have your knee replaced, you'll need anesthesia, lab tests, imaging and other services.

The bundle of services you receive for long-term conditions or complicated procedures is often called an episode of care. An episode of care runs from the time your symptoms start until all your treatments end. For chronic conditions, episodes of care include the typical services for the condition over the course of one year.

The costs for the various services you need can add up, so it's a good idea to get a cost estimate for the whole episode of care. This estimate is a single amount that includes the costs for all the services you'll need.



Estimating Costs for Episodes of Care


You can use the FAIR Health Medical Cost Lookup Tool to find out how much you might pay for your entire episode of care in your zip code. If you have a chronic condition, you'll find out how much a year's worth of common services for that condition might run.

First, enter your insurance status and location in the tool, then click “Episode of Care.” You can then enter a procedure code or keyword, or you can select one of the following procedures and conditions:

  • Allergic Rhinitis/Chronic Sinusitis
  • Asthma
  • Breast Cancer
  • C-Section
  • CABG, Valve Repair, Complex Heart Surgery
  • Cataract Surgery
  • Colonoscopy
  • COPD
  • Diabetes
  • Gall Bladder Surgery
  • GERD
  • Glaucoma
  • Hip Replacement and Hip Revision
  • Hypertension
  • Hysterectomy
  • Knee Arthroscopy
  • Knee Replacement and Knee Revision
  • Low Back Pain
  • Osteoarthritis
  • Pneumonia
  • Pregnancy
  • Prostate Cancer
  • Upper GI Endoscopy
  • Upper Respiratory Infection
  • Vaginal Delivery



 

Out-of-Network/Uninsured and In-Network Episode Costs


The results page for the procedure or condition you choose will show you two main results: out-of-network/uninsured and in-network episode of care prices.

The out-of-network/uninsured price is an estimate of how much you'll have to pay if you don't have health insurance. It's also what you may have to pay—or a portion of what you may have to pay—if you have insurance but the doctors, hospitals or other providers caring for you don't take your insurance. Some plans will pay something for such care, which is called “out-of-network,” but others don't. Check your plan documents or call your member services representative for the out-of-network benefits, if any, associated with your plan.

Out-of-network providers don't have a contracted rate with your health plan. So, you'll probably pay more if you go to them. There might be times, though, when you prefer to go to an out-of-network provider. If you or a loved one is facing a serious illness, you may want more choices than you can get in your network. See When Out-of-Network Care Can Be Covered in Network. You could even go out of network by accident. That can happen if you get care from an out-of-network provider at an in-network facility. See Out-of-Network Docs at In-Network Facilities.

The in-network price is an estimate of how much the episode will cost if you have health insurance. That includes both your insurer's share of the cost and your share. In-network providers are doctors, hospitals and other providers who have agreed to accept your insurance plan's contracted rate for their services.

Your share of the cost is determined by your health plan's terms and conditions. It may be in the form of a copay, coinsurance or deductible. Copays are a set amount for a service, like $20 for a doctor's visit. Coinsurance is a percentage of the cost, such as 15 percent of the in-network price. A deductible is a set amount you have to pay each year before your plan starts paying for your care.



 

What Services Are Included in an Episode of Care?


The results page for each condition or procedure will also show you the services that make up your episode of care. These services are separated into categories, such as anesthesia, doctor's visits, lab tests and surgery. You can customize some estimates based on your specific situation to get the best result. For example, in the case of a heart surgery, you can choose among three different types. Each episode has a different cost.



 

How Can I Use My Episode of Care Cost Estimate?


If you have health insurance, getting an estimate for your episode of care will help you to budget and plan for the costs of an episode of care. It's especially important to get an estimate if you have a high-deductible health plan. That's a plan that won't pay for your care until you've already paid a certain amount. Even if you're using in-network doctors, you'll want to know the in-network costs, because you'll have to pay the costs in full until you pay off the deductible.

If you are considering using out-of-network services, an estimate will help you understand the difference between your in-network and out-of-network share of costs. If you decide to go out of network, the estimate will help you to negotiate a price with the out-of-network providers. If you're uninsured, having an estimate will help you to negotiate a price with any healthcare providers for their services and also allow you to understand the potential benefits of coverage.



 

Why the Estimate Might Be Different from the Amount Billed


Keep in mind that the actual amount you may be asked to pay might be different from the estimate you obtained with the Cost Lookup Tool. This can happen for a number of reasons. We base our estimates on care for patients who don't have any complications or additional risk factors. If you have any underlying conditions or other risk factors, or if complications appear during your course of treatment, you may have to pay more than the estimate.

There can be other reasons for differences, too. For instance, different providers may choose to treat your condition in different ways. Individual charges for the services and procedures that they perform can vary as well.



Your Action Plan: Estimating Costs for an Episode of Care


  • Chronic conditions, such as diabetes, and complicated procedures, like knee replacement, require multiple services. Together, these services can end up costing you a lot of money.
  • Use the FAIR Health Medical Cost Lookup Tool to get an estimate of these costs.
  • If you have health insurance, you can use the estimate to budget for expenses. It's especially important to get an estimate if you have a high-deductible health plan, because you'll have to pay the full costs of care until you meet the deductible.
  • If you're uninsured or plan to use out-of-network providers, you can use the estimate to help you negotiate fees with your providers.

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