Study: Some Federal Exchange Plans Lack Access to Specialty Care
About 15% of silver-level health plans sold through the Affordable Care Act's federal exchange in 2015 lacked an in-network physician in at least one specialty, according to a study published Tuesday in the Journal of the American Medical Association, the Los Angeles Times reports.
According to the Times, the ACA requires plans sold on the exchanges to have physician and hospital networks that are "sufficient in number and types of providers ... to assure that all services will be accessible without unreasonable delay."
For the study, researchers reviewed 135 silver-level health plans sold in 34 states that used the federal exchange for enrollment in 2015 (Levy, Los Angeles Times, 10/27). The researchers used the plans' physician directories to determine the number of in-network specialists covered by each plan, including specialists in:
- Obstetrics and gynecology;
- Pulmonology; and
- Rheumatology (Seaman, Reuters, 10/27).
According to the researchers, the provider directories could "overestimate" the number of in-network providers (Dorner et al., JAMA, 10/27).
Out of 135 reviewed plans as of April 2015:
- 18 plans in nine states did not have in-network providers within a 100-mile search area for at least one of the specialties; and
- 19 did not have in-network specialists within a 50-mile search area.
The most commonly excluded specialists were:
- Psychiatrists; and
According to Reuters, six of the 19 plans had added more providers when the researchers examined them again in May (Reuters, 10/27).
The researchers did not name which states had more-limited plans (Kodjak, "Shots," NPR, 10/27). According to the researchers, the insufficient plans were found across the country, in both rural and urban areas (Los Angeles Times, 10/27). However, they noted that access to in-network specialists could be less likely in rural areas (Reuters, 10/27).
Patients' Out-of-Pocket Costs
In addition, five of the 19 plans found to be deficient also did not cover any of patients' costs for out-of-network physicians. Further, 11 of the 19 plans required patients to pay 50% or more of the costs associated with seeing an out-of-network physician ("Shots," NPR, 10/27).
Stephen Dorner, the study's lead author, said, "This translates into huge cost burdens for patients." He added, "Down the road, we likely will have to make sure (regulations) are sufficient and that we are guaranteeing patients access to affordable in access care" (Los Angeles Times, 10/27).
Meanwhile, Clare Krusing, a spokesperson for America's Health Insurance Plans, said the study did not account for state-based time and distance standards. She also noted that the study did not consider the number of specialists located in the states. Further, she said the study did not acknowledge that plans have procedures to ensure individuals' access to care (Reuters, 10/27).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.