Health Plan Weekly

ACA Marketplace Insurers Pay Lower Rates Than Off-Marketplace, Small-Group Plans

  • Dec 06
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    Dec 06, 2024

    Affordable Care Act (ACA) marketplace nongroup insurers paid providers significantly less than employer small-group insurers paid for professional services, outpatient hospital services and inpatient hospital services in 2021, according to a recent Health Affairs study.

    Using 2021 claims data from CMS, the researchers estimated prices for three market segments: nongroup plans sold on the ACA marketplaces, nongroup plans sold off the marketplaces and small-group employer plans. They found that overall, ACA marketplace prices were 152% of Medicare prices, whereas the prices paid by small-group insurers were 179% of Medicare prices. Weighted average price ratios — also known as price indices — relative to Medicare payment rates were highest for outpatient services, followed by inpatient and professional services.

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    • Jinghong Chen

    Jinghong has been producing infographics and data stories on employer-sponsored insurance, public health insurance programs and prescription drug coverage for AIS Health’s Health Plan Weekly and Radar on Drug Benefits since 2018. She also manages AIS Health’s annual executive compensation database for top insurers and Blue Cross and Blue Shield affiliates. Before joining AIS Health, she interned at WBEZ, Al Jazeera English and The New York Times Chinese. She graduated from Missouri School of Journalism with a focus on data journalism and international reporting.

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