Few Physicians Participate in Both Medicaid and Marketplace Plans

Less than three in ten primary care physicians participating in Medicaid also participated in an average marketplace network, raising concerns about continuity of care for beneficiaries disenrolled from Medicaid.

States resumed Medicaid eligibility determinations in April 2023 before the COVID-19 public health emergency ended. As of March 2024, 17.7 million beneficiaries have been disenrolled from Medicaid or the Children’s Health Insurance Program (CHIP), according to KFF data.

Beneficiaries who lose Medicaid coverage may be eligible for premium subsidies on the Affordable Care Act (ACA) marketplace. However, care continuity may not be so simple for these individuals if there is not a lot of overlap between physicians accepting Medicaid and marketplace plans.

The study published in JAMA Internal Medicine used 2020 physician directory data and rating area information from CMS to assess Medicaid-marketplace overlap among primary care physicians. Researchers identified primary care physicians participating in Medicaid and marketplace plans offered in 15 states with statewide Medicaid networks.

The study assessed overlap among Medicaid-participating physicians for the average marketplace network. For each pair of Medicaid and marketplace networks offered in a county, the denominator was the number of physicians in the marketplace rating area participating in Medicaid, while the numerator was the number of physicians who also participated in the marketplace network.

Researchers also looked at an overlap measure consisting of the number of physicians participating in any available marketplace networks over the number of Medicaid-participating physicians.

The mean primary care physician Medicaid-marketplace overlap in the average marketplace network was 28.8 percent. Overlap varied from 8.5 percent in South Carolina to 59.6 percent in Iowa. At the county level, the overlap ranged from 3.4 percent to 78.0 percent.

The overlap was higher when measuring how many physicians in Medicaid also participated in any marketplace network, at 56.7 percent. Overlap ranged from 15.2 percent in South Carolina to 81.0 percent in Iowa. County-level overlap ranged from 6.1 percent to 96.1 percent.

With minimal overlap of physicians in both Medicaid and local marketplace plans, beneficiaries disenrolled from Medicaid may face barriers when trying to find a marketplace network that includes their primary care physician.

However, network overlap only matters if disenrolled Medicaid beneficiaries are enrolling in marketplace plans. Only 3 percent of people disenrolled from Medicaid enroll in a marketplace plan within six months, researchers noted.

Addressing this low turnover and improving physician network overlap should go hand in hand to help individuals maintain coverage and care access. State and federal governments should require payers to offer plans in Medicaid and on the marketplace with the same physician networks to help address these issues, researchers suggested.