SOURCE: KFF NEWS
Starting in 2028, some Affordable Care Act consumers may be able to pick plans that don’t have dedicated networks of doctors and hospitals, which patients use to qualify for negotiated in-network payment rates.
Under this new model, enrollees would seek out providers willing to accept the amount their insurer will pay toward whatever nonemergency care they need, such as a sore throat, a doctor visit, or childbirth.
The rule requires insurers to have “a sufficient choice of providers that accept the non-network plan’s benefit amount as payment in full.”
Regulators say the policy aims to reduce costs by getting consumers to “shop for lower prices and negotiate directly with providers.”
But how the plans will work — and how they will be monitored for having enough practitioners — isn’t yet clear, and that has raised concerns with some experts who say non-network plans might chip away at ACA safeguards intended to ensure enough medical providers are available in a given area. Patients could also find themselves on the hook financially when they find their doctor or hospital charges more than the insurer will reimburse.
Economist Matthew Fiedler, a senior fellow at the Brookings Institution, pointed out another potential pitfall with this approach.
“It may not always be obvious whether enough providers are willing to accept the plan’s rates,” he wrote in a comment letter to regulators. “If this is the case, non-network plans likely would offer lower premiums, mainly by paying lower prices for care and making accessing care harder.”
There will likely be variation by state in how such plans must prove they have an adequate number of care providers willing to accept amounts as payment in full, said Louise Norris, a health policy analyst for healthinsurance.org, a consumer information and referral website affiliated with Trove Group.
“I would put a big buyer-beware notice on non-network plans,” she told KFF Health News. “Consumers will need an understanding of how this will work, and also it puts the onus on the consumer to find out what the provider is charging.”
But other viewpoints, including from the Paragon Health Institute, a conservative think tank, consider the non-network plans a step forward for transparency and competition because shop,” noted Paragon’s comment letter.
It will take time and more federal guidance, though, before it becomes clear what additional requirements these plans will face and how many insurers will decide to offer them. Some clues can be found in non-network plans sold by Ohio-based Sidecar Health, which offers such coverage in Ohio, Florida, Georgia, and Texas with enrollees in 48 states — but only for employer plans because they empower consumers.
“When consumers can see what the plan will pay and how provider prices vary, they have incentives to shop,” noted Paragon’s comment letter.
It will take time and more federal guidance, though, before it becomes clear what additional requirements these plans will face and how many insurers will decide to offer them. Some clues can be found in non-network plans sold by Ohio-based Sidecar Health, which offers such coverage in Ohio, Florida, Georgia, and Texas with enrollees in 48 states — but only for employer plans.
