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On average, ACA-exchange enrollees’ plans covered only 40 percent of the doctors near them. About 25 percent of exchange enrollees were in a plan that included fewer than one-quarter of doctors in their area, and 70 percent of enrollees were in a plan that included no more than half of the doctors near them. Primary-care physicians participate at particularly low rates. In some areas of the country, like Chicago, more than 80 percent of doctors do not participate in ACA-plan networks.
The KFF analysis found that people of color were more likely to have plans with an extremely limited choice of providers. The people most negatively affected are those who have the greatest medical needs. More than one in three exchange enrollees in fair or poor health reported that a particular doctor or hospital they needed was not covered by their plan, a rate that is more than twice as high as it is for those with an employer plan.
Some hospital based physician networks have policies to capture referrals internally. They can dictate, “if you want out specialists, you have to take our primary care physicians.” I was in a health plan affiliated with a local hospital system. I searched for a primary care physician and notice almost all were on the hospital campus. The hospital affiliated health plan could capture almost $9000 worth of my deductible before they began to experience claims against the plan. I suspect (but never confirmed) that created a perverse incentive to refer me to expensive services.
This is bad, for sure….but I thought that many health plans now offer 3 primary care visits for a low cost or free.
I am on Medicare and not at all current with the under-65 market.
On my Medicare Advantage plan, I get all the primary care visits I want for $15 to $35 each in deductibles.