Ask These 10 Questions to Find Out How Much Your Healthcare Will Cost

If you think you are spending more on healthcare costs than ever, you are probably right. The national health expenditure projections from the Centers for Medicare & Medicaid Services (CMS) predicts that U.S. healthcare spending will grow an average 5.4% each year from 2019 to 2028 — reaching an estimated $6.2 trillion at that time. 

Healthcare costs vary based on a number of factors. Median out-of-pocket spending on health care ranged from $360 per year in Hawaii to $1,500 per year in Nebraska, according to a 2019 report from The Commonwealth Fund. While some costs are set, such as the premium price for your health plan, others can be planned or negotiated if you know the right questions to ask.

What factors affect how much you pay for healthcare?

The total amount you spend on healthcare depends on several factors. If you have insurance, one factor is your level of coverage. For example, a policy that only covers catastrophic or severe illnesses, such as cancer or a heart attack, is likely to have a lower premium or monthly cost than a more comprehensive policy that covers an array of conditions. However, with catastrophic coverage, you might pay a high deductible before cost-sharing with the insurance company begins or pay more out of pocket to see a doctor for something like a sinus infection. 

Some plans require you to pay a deductible, or a certain dollar amount, before health insurance coverage kicks in. Others require copayments and coinsurance — out-of-pocket payments each time you see a doctor or receive a service. A plan also may charge you more if you see a doctor outside of its provider network.

Prescription drug costs also are included in how much you spend on healthcare. If you have prescription drug coverage through a private insurance plan or through Medicare Part D, you may pay less out of pocket for prescriptions — though you will have to budget the costs of the plan. GoodRx helps you compare pharmacy prices and find discounts, which can reduce how much you pay for your healthcare.

For healthcare covered by insurance, a 2019 report from the Health Care Cost Institute found that the same procedure, test, or visit can vary widely in negotiated price — what the insurer pays plus the out-of-pocket consumer cost — depending upon where you live. For example, the median price in 2016 for a C-section in San Francisco was $20,721, compared to just $4,556 in Knoxville, Tennessee; a common blood test was $443 in Beaumont, Texas, but only $18 in Toledo, Ohio. Even established-patient office visits ranged from $165 in Anchorage, Alaska, to $60 in the Miami-Fort Lauderdale-West Palm Beach, Florida, metro area.

How much power do you have to negotiate healthcare costs?

Since there is no universal fee for healthcare services, you may be able to arrange to pay your healthcare provider less than a quoted price or less than what you are charged. For example, the National Consumer Law Center points out that nonprofit hospitals are required by law to have a written financial assistance policy, which could include free or discounted care. 

Insurance providers typically negotiate prices, as does the federal government when determining how much Medicare or Medicaid will pay for services. In fact, a 2020 Kaiser Family Foundation review of recent studies found that private insurers pay, on average, nearly double what Medicare pays for all hospital services.

Just as insurers can negotiate prices for healthcare services — so can you.

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How can you adjust your health insurance today to protect against unexpected medical expenses?

Simply having health insurance can protect you from racking up thousands of dollars in medical bills. For example, you may have to pay up to $7,500 to repair a broken leg if you are uninsured, according to the federal government’s HealthCare.gov. With insurance, you likely would pay far less out of pocket.

Depending on the type of insurance plan you have, you can avoid unexpected charges by understanding what is covered and what’s not. You also can purchase a secondary policy that will pay some of the costs your primary insurance doesn’t cover. For example, Medicare Supplement Insurance, known as Medigap, pays for some of the charges that original Medicare doesn’t cover, such as copayments and deductibles.

What questions can you ask to anticipate healthcare costs?

You don’t have to be in the dark about your medical bills or simply wait for surprises. Here are 10 questions that can help you determine what your healthcare costs might be in advance. In some cases, these inquiries may help you reduce what you pay.

1) Is there a charge for missed or late appointments?

Some medical providers charge a fee, such as $25 or $50, if you miss an appointment without canceling by a certain deadline or if you show up late. According to the American Medical Association, such charges are ethical if there is a published policy notifying patients in advance, because the medical practice loses money by holding appointments for no-shows. However, some insurers, including Medicare, will not pay for these fees.

2) Is there a generic version of this medication that can be an option on my prescription?

Generic versions of medications can cost as much as 85% less than their brand-name counterparts, yet they contain the same active ingredients. That means you don’t sacrifice functionality for a lower price.

3) Is there a less expensive medication that treats the same condition?

Even if there is no generic version of a medication, there may be a less expensive brand-name drug that is just as effective. One way to know is to ask, so start the conversation with your provider.

4) How transparent are hospital costs for this procedure?

The federal government has made it easier for patients to learn the price of some hospital services or procedures through hospital cost transparency. Since January 21, 2021, hospitals have been required to post pricing information online for at least 300 services that can be scheduled in advance. According to the CMS, such information must be in a machine-readable file that includes all services and a consumer-friendly format that lists available services.

GoodRx research has found that these price lists aren’t fully transparent. If you can’t find the information you seek on a hospital’s web site, call and ask if the procedure you are considering is listed and where you can find the price published in writing.

5) How many different provider bills will I receive for this treatment?

When you have a service or procedure, you may receive multiple bills depending upon how many providers are involved. For example, you may get a bill from your doctor and a separate bill from the hospital or outpatient facility where you had the procedure. To avoid confusion, ask upfront who will be charging you and how many bills you will receive.

6) Can you check to see if this referral is in my insurance network so that I don’t pay more?

If your health insurance plan gives you the option to choose between providers in your insurance network and those outside of the network, you can expect medical services performed by in-network providers to be less expensive than those by out-of-network providers. That’s because in-network providers have agreed to charge lower rates.

7) Do I need prior authorization to make sure this procedure is covered?

When a doctor gives you a referral to another medical provider, that does not mean your insurance plan will cover the service or that the provider is in network. To find out if the service is covered, call your insurance company and ask if you need them to authorize the service beforehand. Since prior authorization, or pre-authorization, does not mean that your insurer will pay the entire cost of the procedure, also ask about specific coverage and about your anticipated out-of-pocket expenses.

8) Can this procedure happen at an outpatient facility rather than a hospital?

Procedures or services offered in a hospital may cost more than those provided in an outpatient facility or clinic — even if they are the same.

9) Is there a facility fee?

Some medical providers charge what’s known as a facility fee, which is meant to cover the maintenance of a healthcare location in addition to the cost of healthcare services. For instance, if you go to an emergency room for a nonemergency condition, your costs may include a facility fee. Before agreeing to a procedure, ask if such a fee is charged. If so, contact your health insurance plan to see if this fee will be covered.

10) Have I met my deductible?

Your deductible is the amount of money you must pay out of pocket before your health insurance plan picks up the costs for services. By tracking your deductible, you will have a better idea about your expected out-of-pocket expenses. For example, if you have only spent $225 toward a $500 deductible, expect to pay another $275 out-of-pocket for services before your insurance kicks in.

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Written by:

Tamara E. Holmes

Tamara E. Holmes is a Washington, DC-based freelance journalist and content strategist who has been writing about personal finance, health, and health insurance for more than a decade. Her work has appeared in various print and online publications, such as USA Today, AARP, Working Mother, and Diversity Woman.

Edited by:

Cindy George, MPH

Cindy George, MPH, is the senior personal finance editor at GoodRx. She is an endlessly curious health journalist and digital storyteller.

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