Access to In-Network Emergency Physicians and Emergency Departments Within Federally Qualified Health Plans in 2015

The Western Journal of Emergency Medicine
Stephen C DornerAli S Raja

Abstract

Under regulations established by the Affordable Care Act, insurance plans must meet minimum standards in order to be sold through the federal Marketplace. These standards to become a qualified health plan (QHP) include maintaining a provider network sufficient to assure access to services. However, the complexity of emergency physician (EP) employment practices - in which the EPs frequently serve as independent contractors of emergency departments, independently establish insurance contracts, etc… - and regulations governing insurance repayment may hinder the application of network adequacy standards to emergency medicine. As such, we hypothesized the existence of QHPs without in-network access to EPs. The objective is to identify whether there are QHPs without in-network access to EPs using information available through the federal Marketplace and publicly available provider directories. In a national sample of Marketplace plans, we found that one in five provider networks lacks identifiable in-network EPs. QHPs lacking EPs spanned nearly half (44%) of the 34 states using the federal Marketplace. Our data suggest that the present regulatory framework governing network adequacy is not generalizable to emergency care, representi...Continue Reading

Citations

Mar 28, 2017·The American Journal of Emergency Medicine·Lawrence H BrownJohn E Gough
Jul 10, 2018·Health Affairs·Alexander J CowellBrendan Wedehase

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