The Healthscore CT Cost Estimator is an important consumer tool that analyzes data about insurance coverage of common inpatient and outpatient services and procedures to provide consumers with useful information about the typical costs of specific medical services and procedures throughout the state.

The Healthscore CT Cost Estimator uses insurance claim data from the state’s All Payer Claims Database (APCD), which uses information about payments made by the insurance companies for these procedures, and includes estimates of what an individuals’ out-of-pocket costs may be at health facilities throughout Connecticut. However, given the significant variation in how insurance plans cover medical services, i.e. how much you may have left on your deductible, whether you have a co-pay, etc., these numbers may be different from each individual’s responsibility. Accordingly, you should always check with your insurance provider to confirm coverage prior to receiving non-emergency healthcare services, and your medical provider about costs.

The Connecticut All-Payer Claims Database (APCD) was created in 2012 as a program to receive, store, and analyze health insurance claims data from many of the insurance payers insuring CT residents. The purpose of the APCD is to make available information related to safety, quality, cost-effectiveness, transparency, access and efficiency for all levels of health care to improve the health of Connecticut’s residents at all levels of health care delivery.

Instructions and Overview

Instructions

Why Use the Cost Estimator?

This CT Cost Estimator shows the typical costs, or typical paid amounts for common healthcare procedures and services at various facilities across the state. These costs are also referred to as median costs and are based on amounts that have been paid, by the health insurance company, to the facilities and providers for their services. The amount that gets paid by the health insurance company varies, and is based on the insured person’s health insurance plan or policy.

It is important to note that these costs do not represent the entire amount a person will or could pay, as that actual cost will be dependent on various factors – for example, health insurance plans have different patient out-of-pocket costs that can include co-pays, deductibles, and co-insurance for covered services. It is important to check with your insurer about the out-of-pocket costs for your specific situation.

The Cost Estimator does not provide details on full charges for these health care services, but only the discounted insurance amount, or the allowed amount. If you are uninsured, you may be responsible for these full charges, and while this information could be used as a reference to help you negotiate with your healthcare providers, the provider is not required to reduce their charges.

How to Use the Cost Estimator Tool

When you use the Healthscore CT Cost Estimator Tool you will be prompted with a few drop down selections.

  1. Select the Outpatient or Inpatient (Hospital) tab
  2. Select a Service
  3. If desired, select a City/Town – to narrow your search to your location
  4. If desired, select Distance – to narrow the search to facilities within a certain distance from your preferred city/town.
  5. Sort By – allows you to view the information based on your specific interest, such as typical cost from high to low, typical cost low to high, and closest distance (to your selected city/town).

Once you have entered your selections, you will see a figure with your results. For each result, you will see a Facility, Typical Cost and Cost Breakdown.  

Facility is where the service physically takes place

Typical Cost is the estimated (median) amount paid for the service that includes both facility and professional (or provider) costs.

Cost Breakdown is a bar graphic of the typical cost broken down by facility and professional costs with an icon indicating whether the Typical Cost it is above or below the Connecticut Median Cost for this service.

If you place your mouse over a bar graphic, you can see detailed cost information, including the Charged Amount, which is considered the costs you may have to pay if you are uninsured.

Cost Estimator Methodology Overview

The data used for the Cost Estimator is derived from the state’s All Payer Claims Database (APCD). Connecticut-regulated insurers and pharmacy benefit managers are required to submit their health insurance claims to the state’s APCD. For these calculations, the Cost Estimator excludes data from Medicaid, Medicare, and Medicare Advantage. The cost estimator uses the current readily available data and will be updated periodically with additional procedures and new data as it comes available.

The analysis includes some of the top procedures performed in Outpatient and Inpatient facilities. Outpatient services or procedures take place during the day and typically would not require an overnight stay. Inpatient services are acute care services that may not always be specifically associated with chronic diseases but would require a person to have an overnight stay in a hospital recovering from surgery.

In order to protect patient privacy, and consistent with the Centers for Medicare and Medicaid Services data privacy guidelines, data about any procedures or services performed less than 11 times at a particular facility are not included in the Cost Estimator’s analysis. Facilities that had 11 or greater procedures or services performed there were included in the Cost Estimator.[1]

Instead of a mean, the median cost for these procedures were used. The mean includes all data points in the calculation, which suggests the results can easily be skewed or misleading based on the number of extremely low or extremely highly paid amounts (called outliers) that are present. The median adjusts for these outliers, as the median is the number that falls exactly in the middle, such that half the numbers are higher and half are lower, as shown below.

Cost Calculations

These are based on the commercial insurance claims data in the APCD. The costs are estimates based on typical costs for common medical treatments and services. They exclude peripheral or associated costs not billed as part of the service. It also excludes payments or financial settlements like bonus incentives between providers and insurance companies since these are not reflected in the claims data.

  1. Charged Amount- the amount charged by the facility for the service (the costs you may have to pay if you are uninsured)
  2. Typical Cost- the estimated amount paid by the insurer and the amount paid by the patient (co-pay, co-insurance, and deductibles) combined for the service. This amount is a median for the facility where the service took place.
  3. Connecticut Median Cost– the amount for services at individual facilities compared to the median typical cost across CT.

Inpatient vs. Outpatient Costs

  1. Outpatient – These services were identified using Current Procedural Terminology (CPT) medical codes used to report outpatient medical and diagnostic procedures for medical purposes and billing. They are split into two categories:
    1. Surgical Services – include all claims for services rendered on the day of surgery (service) associated with that CPT code. For example, an “Arthroscopic Knee Surgery” would include the CPT code for the surgery as well as other codes, such as anesthesia, surgical supplies, and medications.
    2. Diagnostic Services – include all claims on the day of service associated with the CPT code. For example, an “X-ray” would include the actual x-ray procedure and any associated professional costs l, such as interpretation of the x-ray.
  2. Inpatient – these services were identified using International Statistical Classification of Diseases and Related Health Problems (ICD-10) medical codes used to report inpatient medical and diagnostic procedures for medical purposes and billing. This includes all services, medical, surgical, and diagnostic procedures rendered during a hospital stay.

Professional vs. Facility Cost breakdowns

  1. Professional Cost – any cost that is associated with medical care providers (or doctors, nurses, etc.), including anesthesiologist, physical therapy, and any other consultations and services linked to a physical person.
  2. Facility Cost – any cost that can be associated to the facility, such as room and board, medications administered, and lab work performed.

Data Exclusions

  1. If there were less than 11 procedures performed at a specific facility, they have been removed due to the CMS rule.2
  2. Zero charged amounts, zero allowed amounts, negative allowed amounts, and negative charge amounts were removed because they would skew the data down and show a less accurate amount.
  3. All Emergency Department Services and Claims that involved transportation by ambulance, because these claims are non-elective services and will skew costs in the estimator where patients are looking up costs for elective medical services.
  4. Medicare and Medicaid information because the Cost Estimator is only to include commercial data.

 

[1] AN ACT IMPLEMENTING THE GOVERNOR’S BUDGET RECOMMENDATIONS CONCERNING AN ALL-PAYER CLAIMS DATABASE PROGRAM (2012). Substitute House Bill No. 5038 Public Act No. 12-16. Retrieved Decemeber 16, 2019 from Connecticut General Assembly: https://www.cga.ct.gov/2012/ACT/Pa/pdf/2012PA-00166-R00HB-05038-PA.pdf

2 https://www.resdac.org/articles/cms-cell-size-suppression-policy