The Adequacy of the Provider Networks on the Public Exchange

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After the “if you like your plan, you can keep it” controversy died down, another is coming to light-the “if you like your doctor, you can keep him.” Some enrollees in the public exchange have been discouraged when finding their doctor or hospital is no longer “in network.” This means they will have to pay significantly more out of pocket to keep the doctor they like. But, how true is that claim? And does it even really matter?

Health plans offered on a state’s public exchange must have a network including a “sufficient choice” of providers and the “essential community providers” that often serve the poor. However, in order to keep prices competitive to attract consumers, a number of exchange plans offer narrow networks that offer less choice in providers to push premiums lower. Lower premiums are typical in narrow network plans because providers agree to lower reimbursement from an insurer in exchange for access to more patients.

Narrow networks are not bad. Access to care is not limited, but it’s possible your current doctor will not be “in network.” Normally, if this is important to the consumer, access to that doctor can be obtained at a lesser benefit. Also, some question the motivation for excluding certain providers. Is it just about price? What about the quality of the provider? Unless the narrow network is part of an accountable care organization, which pays physicians based on quality, price is the controlling factor determining whether a provider will be part of a narrow network.