Insurers negotiate lower hospital prices for HIX than for commercial groups

• Published in: The American journal of managed care 2022-09, Vol.28 (9), p.e347-e350
• Main Authors: Randall, Samantha, Duffy, Erin L, Green, Sarah, Trish, Erin
• Format: Article
• Language: English
• Subjects: Aged; Alliances; Contract negotiations; Cost control; Costs and Cost Analysis; Cross-Sectional Studies; Health insurance; Health insurance exchanges; Hospital costs; Hospitals; Humans; Insurance Carriers; Medicare; Medicare Part C; Outpatient care facilities; Patient Protection & Affordable Care Act 2010-US; Prices; United States
• ISSN: 1088-0224; 1936-2692
• DOI: 10.37765/ajmc.2022.89228

This study investigates a sample of the pricing data released by hospitals under the price transparency law effective January 2021 to better understand the prices paid by health insurance exchange (HIX) plans relative to commercial group and Medicare Advantage plans. Cross-sectional analysis of hospital pricing data. We compared allowed amounts for 25 common inpatient services and 56 common outpatient services across 22 hospital-insurer dyads, selected by the availability of plan-specific pricing data from the top 100 hospitals by bed counts and the top 100 hospitals by gross revenue based on 2017 CMS data. Insurers in our sample generally negotiated allowed amounts for their HIX plans that were lower than their commercial group rates and well above their Medicare Advantage contracts within the same hospital. Allowed amounts for HIX plans were generally lower than commercial group rates and higher than Medicare Advantage rates. Better information on HIX pricing is needed as the federal government and states consider additional ways to expand health care coverage, such as public options or expanded Medicaid or Medicare eligibility.