From Coverage to Care: Networks, Cost-Sharing, and Access

Session Submission Type: Panel

Abstract

Insurance coverage does not guarantee timely access to appropriate care. Across Medicare and the Affordable Care Act (ACA) Marketplace, beneficiaries’ ability to obtain needed services depends on the practical availability of in-network providers, the affordability of cost-sharing at the point of care, and insurers’ responses to benefit design requirements. This panel brings together four studies that examine how provider networks and cost-sharing policies shape realized access and financial protection, with particular attention to mental health care, prescription drugs, and end-of-life care. 

The first paper (Tetlow, et al) evaluates Medicare’s outpatient mental health cost-sharing parity phase-in (2008–2019) among beneficiaries with depression and comorbid diabetes or heart disease. They find increased outpatient mental health service use after parity without significant increases in out-of-pocket spending, with the largest utilization gains among beneficiaries with multiple chronic conditions.

The next paper (Smith, et al.) characterizes “ghost networks” for specialty mental health care in Medicare Advantage by comparing advertised in-network directory listings to realized provider activity in billing data. The study finds substantial discrepancies between advertised and realized provider networks, raising concerns that nominal network breadth may overstate actual access for older adults with mental healthcare needs.

Extending the network adequacy lens beyond Medicare, the next paper (Anderson, et al.) examines hospice contracting in the 2025 South Carolina ACA individual marketplace, linking hospice participation in insurer networks to CMS quality measures (Star Ratings and CAHPS). Findings indicate that higher-quality hospices may be more likely to contract with Marketplace plans, informing debates about network adequacy and access to high-quality end-of-life care as an Essential Health Benefit.

In the final paper, Myerson et al. evaluate insurer responses to a major affordability policy: the Inflation Reduction Act’s $35 monthly insulin out-of-pocket cap in Medicare Part D. Using data on stand-alone Part D plans from 2021–2024, they find evidence consistent with cost shifting and market adjustment. Plans with greater exposure to the policy were more likely to exit the market and remaining plans had higher premium safter the policy. This paper highlights how out-of-pocket caps that reduce costs for some beneficiaries may induce unintended consequences for others.

Together, these papers show that moving “from coverage to care” requires aligning and anticipating network transparency and adequacy, cost-sharing design, and insurer incentives and responses. The panel demonstrates where access barriers persist despite coverage, how insurers may respond to affordability mandates, and which policy and regulatory tools may be needed to ensure that coverage translates into accessible, high-quality care.

Policy Area

• Health Policy

Chair

• Mika Hamer, University of Maryland, College Park

Discussants

• Sih-Ting Cai, University of Southern California

• Adam Ira Biener, Lafayette College

Organizer

• Mika Hamer, University of Maryland, College Park

Individual Presentations

• Mental Health Service Use Among Medicare Beneficiaries with Depression, Diabetes and Heart Disease After Cost-sharing Parity - Presenting Author: Sonia M Tetlow, Georgia Budget & Policy Institute

• Ghost Networks in Medicare Advantage: Implications for Mental Healthcare Access for Older Adults - Presenting Author: Rachel Smith, University of Maryland

• Characteristics of Hospices in the 2025 South Carolina ACA Marketplace - Presenting Author: David Anderson, University of South Carolina

• Unintended Consequences of the Inflation Reduction Act’s Out-of-Pocket Cap for Insulin - Presenting Author: Rebecca Myerson, Emory University