Episodes of Care
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.