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Health Law Plans Covered Fewer Providers Than Commercial Insurers, Study Finds

By Rebecca Adams, CQ Roll Call

July 15, 2015 -- Anecdotal reports of narrow networks in health law exchange plans are borne out by a new analysis showing that marketplace insurance covered fewer hospitals, cancer and cardiology specialists, mental health providers, and primary care physicians than commercial plans offered in the same geographic area.

The analysis of offerings for the 2015 plan year by the Avalere consulting firm found that networks in exchange plans had 42 percent fewer oncology and cardiology specialists and 32 percent fewer mental health and primary care providers than the average commercial plan in the area. The exchange plans covered 24 percent fewer hospitals than commercial plans on average. The commercial plan average was based on networks in both group plans and other individual plans outside of the marketplace.

The marketplaces created by the health care law are supposed to have adequate networks, but consumers have complained that the networks are sparse compared to other insurance plans.

Consumers who get care from out-of-network providers face higher costs—and the spending does not count toward out-of-pocket limits in the health law.

Avalere CEO Dan Mendelson noted in a statement that insurers sometimes seek to keep premiums low by being selective about which providers they will cover.

About 36 percent of the people who are eligible for exchange coverage had enrolled as of March 31, according to a separate analysis by the nonpartisan Kaiser Family Foundation that used data that the Centers for Medicare and Medicaid Services released in June.

Avalere examined the largest region in the five states with the greatest health exchange enrollment—Florida, California, Texas, Georgia, and North Carolina.

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