SOURCE: HealthPocket


November 18, 2015 09:00 ET

2016 Brings Big Decline in Out-of-Network Coverage Among Obamacare Plans

Eroding Out-of-Network Coverage Increases Concerns Over Narrow Networks

MOUNTAIN VIEW, CA--(Marketwired - Nov 18, 2015) - HealthPocket analyzed recently released data for Affordable Care Act (ACA) plans offered on the marketplace and found 59 percent of 2016 ACA plans do not have standardized out-of-network coverage except in the case of sudden medical emergencies or when the health plan is formally petitioned for out-of-network care and the plan chooses to approve the request. This change represents a 24 percent increase in the percentage of plans lacking standardized out-of-network coverage as compared to 2015.

While most states had 2016 increases in the percentage of plans without standard out-of-network coverage, in eight states this percentage decreased in 2016 as compared to 2015: Arkansas, Delaware, Illinois, Iowa, Nevada, Oklahoma, Oregon and Wyoming.

Among the concerns regarding out-of-network care is not only the lack of insurance coverage but also the fact that out-of-network care does not benefit from the negotiated rates of in-network care nor caps on annual out-of-pocket costs, making out-of-network care all the more expensive for consumers. Moreover, the decline in out-of-network coverage has occurred during a period of increased use of narrow networks. These narrow networks of doctors and hospitals can increase a consumer's risk that the best care for a serious medical condition will be found out-of-network.

"More narrow networks and less out-of-network coverage have been unintended consequences of the Affordable Care Act's implementation," said Kev Coleman, head of research and data at HealthPocket. "As expenses increased to broaden benefits and accept all applicants regardless of health status, insurers have moved to aggressively control costs within the confines of existing regulations."

A lack of out-of-network coverage can leave consumers with a choice among accepting the limitations of their health care provider network, hoping prior authorization requests will be approved, or paying for out-of-network care without the assistance of insurance, perhaps at exorbitant rates and without the protection of a cap on annual out-of-pocket costs.

A 2015 study by the America's Health Insurance Plans (AHIP) found that the average out-of-network charges for the majority of medical procedures examined were 300 percent or higher compared to Medicare fees paid for the same services. Occasionally out-of-network expenses are discovered by consumers after the fact when they receive their billing for medical care. Consumer Reports National Research Center released a survey in 2015 that found nearly one-third of privately insured Americans in the past two years received a "surprise" medical bill where their health plan paid less than expected, with some of the surprises due to doctors thought to be in-network but were not.

The full findings, including state-specific data, as well as the report methodology can be reviewed at "2016 Brings Big Decline in Out-of-Network Coverage Among Affordable Care Act Health Plans." is a free website that compares and ranks all health insurance plans, helping individuals, families, and small businesses to make their best health plan decisions. HealthPocket publishes health insurance market analyses and other consumer advocacy research. HealthPocket's research is nonpartisan and uses only objective data from government, non-profit, and private sources that carry no conditions that might restrict the site from serving as an unbiased resource. HealthPocket, Inc. is independently managed and based in Mountain View, California. Learn more at

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