Patients are increasingly exposed to the risk of high, unexpected medical bills as the share of ACA health plans with out-of-network benefits declines, according to an analysis from the Robert Wood Johnson Foundation.
The analysis, which was based on plan data from Vericred, found the share of individual market plans that offer out-of-network coverage declined from 58 percent in 2015 to 29 percent in 2018. The share of small group market plans that offer out-of-network coverage fell from 71 percent to 64 percent during the same period.
Kathy Hempstead, with the foundation, said the less-steep decline in the small group market likely reflects changes in carrier participation in the individual market.
"National commercial carriers, which are more likely to offer broader network plans, exited the individual market in droves in 2016 and 2017, leaving a market that is dominated by [Blue Cross Blue Shield] and Medicaid managed care organizations," she wrote. "MMCO plans almost always offer closed-network plans, and even many Blues plans have shifted to narrow network offerings in the individual market."
The analysis found out-of-network benefits are not comprehensive. According to researchers, the median out-of-network deductible in the individual market in 2018 is about $12,000, with some deductibles greater than $20,000. Additionally, many plans do not cap the amount a beneficiary would be required to cover for out-of-network services during a certain period.
Ms. Hempstead said these characteristics, along with the narrowness of networks, increase exposure to out-of-network bills, especially in the individual market. But she noted that patients with more robust out-of-network coverage are also exposed to high out-of-network medical bills when care costs exceed insurer reimbursement rates.
Read the full analysis here.
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