Health Plan Networks And Specialty Hospitals

by Center for Policy and Research

July 1, 2015

Key Highlights

Specialty HospitalsConsumers have access to specialty hospitals through health plan contracts with these facilities, centers of excellence, and processes to access out-of-network care when necessary.

 

Differences between average chargesA recent AHIP analysis found striking differences between the average charges of specialty versus non-specialty hospitals for many routine procedures.

 

Flexibility is EssentialMaintaining flexibility for health plans to design their provider networks is essential to promoting access, affordability, and value for consumers.

 

Background

Provider networks have been a mainstay of private health insurance coverage for more than 35 years – providing consumers with access to a broad range of hospitals, physicians, and other health care providers along with financial incentives for members to obtain care within the plan’s provider network. Virtually all private health insurance coverage – including benefits administered by private plans in public programs such as Medicare, Medicaid and CHIP – utilize provider networks to deliver health care benefits and services. It is estimated that 90 percent of all hospitals and physicians participate in health plan networks.

Provider networks serve the dual purposes of promoting safe, quality care, as well as affordability. By including hospitals, physicians, and other key care providers who have met standards set by established accrediting organizations in their networks, health plans work to ensure that consumers have access to high-quality, effective care. Provider networks also enable health plans to make care more affordable for consumers by negotiating better prices with physicians and hospitals and protecting consumers from “balance billing” by network providers.