Patients see narrow networks in ACA marketplace plans, KFF finds
Twenty-three percent of marketplace enrollees were in a plan with a network that included a quarter or fewer of the doctors in their area.
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On average, Affordable Care Act marketplace enrollees had access to 40% of the doctors near their home through their plan's network, with considerable variation around the average, according to a new KFF analysis.
Twenty-three percent of marketplace enrollees were in a plan with a network that included a quarter or fewer of the doctors in their area, while only 4% were in a plan that included more than three-quarters of the area doctors in their network.
Some of the narrowest network plans were found in large metro counties, where enrollees on average had access to 34% of doctors through their plan networks. Marketplace enrollees in Cook County, Illinois (Chicago), and Lee County, Florida (Fort Myers), were enrolled in some of the narrowest networks (with average physician participation rates of 14% and 23%, respectively).
Plans in rural counties tended to include a larger share of the doctors in the area, though rural counties had fewer doctors overall relative to the population, compared to large metro counties.
On average, more than one-quarter (27%) of actively practicing physicians were not included in any Marketplace plan network. Also, Silver plans with higher shares of participating doctors had higher total premiums. Compared to plans where 25% or fewer of doctors participated in-network, those with participation rates between 25% and 50% cost 3% more, while those with participation rates of more than 50% cost 8% more.
Meanwhile, more than four million enrollees (37% of all enrollees) lived in a county in which the two lowest-cost Silver plans included fewer than half of the doctors in the area, and where a broader plan was available. In order for these enrollees to enroll in the cheapest Silver plan that included at least half the doctors, they would have needed to spend an additional $88 per month.
Silver plans are mid-level plans in terms of patient cost-sharing and are particularly significant because they are the benchmark for federal premium subsidies, said KFF.
WHAT'S THE IMPACT?
According to KFF, limiting the size of the physician networks serving their plans is one way insurers seek to control costs. Providers agree to lower fees and other terms with insurers in order to be included in one or more of the networks they offer. Insurers then either limit coverage to services provided by network providers or encourage enrollees to use network providers through lower cost-sharing.
Reducing the number of providers in-network can effectively reduce plan costs, but it also limits enrollees' choices, increases wait times and can complicate the continuity of care for those switching plans, KFF said. Enrollees receiving care from out-of-network providers often face coverage denials or substantially higher out-of-pocket expenses.
The breadth of provider networks in the ACA marketplaces has been the subject of significant policy interest. Insurers often compete aggressively to be among the lowest-cost plans, potentially leaving enrollees with poor access. According to the 2023 KFF Survey of Consumer Experiences with Health Insurance, one in five (20%) consumers with marketplace plans reported that in the past year, a provider they needed was not covered by their insurance, and nearly one in four (23%) said a provider they needed to see that was covered by their insurance did not have appointments available.
Enrollees with marketplace coverage were more likely than those with employer coverage to face these challenges.
THE LARGER TREND
While the Centers for Medicare and Medicaid Services establishes minimum standards for the adequacy of provider networks for Marketplace plans, insurers retain considerable flexibility in how they design networks and how many providers they include, KFF said. As a result, the breadth of plan networks varies considerably within counties, potentially presenting challenges for consumers who need to select a plan with little information on the network breadth of their options.
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.
