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Weekly Checkup

Exchange Plans Cover Limited Specialists In-Network

The Robert Wood Johnson Foundation recently released a report finding that 41 percent of “silver” Exchange plans had physician networks that were “small” or “extra small”. A second study examined 135 silver plans across 34 states using the federal exchange in 2015 for coverage of in-network specialists. Of the 9 specialities included, not one had 100 percent of plans offering in-network coverage to a specialist in that field, as shown below. Nearly 1 out of 5 plans were deemed “specialist-deficient” for covering fewer than six specialists in a particular field within 100 miles. People needing a rheumatologist (for arthritis, joint, or muscle pain); a psychiatrist (for mental health services); or an endocrinologist (for hormonal problems) were most likely to be without an in-network provider. These patients are then left with no choice but to use “out-of-network” providers if they are in need of those specialty services. Out-of-network care is typically significantly more expensive than in-network care. For example, one recent study found the average out-of-network billed charge for an electrocardiogram was 1,382 percent of Medicare’s fee. Additionally, payment for out-of-network care doesn’t typically count towards one’s deductible meaning health care costs for these individuals could get very expensive.

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