Narrow networks are more prevalent in public exchanges than the commercial market, and while this trend helps keep costs more manageable, it also significantly restricts any movement for consumers and could undermine network adequacy standards.

These conclusions are based on a new Avalere analysis of 2015 exchange plan enrollment in the nation’s the largest rating region. An average of 34% fewer providers in exchange plans relative to off-exchange options were found, along with 42% fewer oncologists and cardiologists; 32% fewer mental health and primary care providers; and 24% fewer hospitals.

A dearth of doctors in each of these categories, as well as in hospital systems, is expected to be considered by the Centers for Medicare and Medicaid Services when evaluating plans for compliance with network adequacy standards. The move is part of CMS’s annual guidance to plans seeking to participate in the exchanges.

“Plans continue to test new benefit designs in the exchange market,” said Dan Mendelson, Avalere CEO. “Given the new requirements put in place by the ACA, network design is one way plans can drive value-based care and keep premiums low.”

Also see: How to make the most of your narrow network

But there’s also concern about out-of-network visits not counting toward out-of-pocket limits under the Affordable Care Act. Avalere VP Elizabeth Carpenter, added the following caveat: “Patients should evaluate a plan’s provider network when picking insurance on the exchange. Out-of-network care does not accrue toward out-of-pocket maximums, leaving consumers vulnerable to high costs if they seek care from a provider not included in their plan’s network.”

Avalere compared the average number of primary care physicians, specialists and hospitals in exchange networks relative to group and individual markets outside the exchanges in Florida, California, Texas, Georgia and North Carolina. It also used provider network affiliation data for the 2015 plan year from Strenuus.


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