Study Finds Misinformation Risk When Seeking Mandated ACA Coverage

February 2017 ~

New research published in the Journal of the American College of Radiology shows patients face misinformation from insurers when seeking Affordable Care Act (ACA)-mandated coverage.

The report, which was conducted by a group hailing from the University of Michigan Medical School, found widespread misinformation about ACA-mandated breast health coverage, using a mystery shopper claiming to be a 40-year-old woman who previously underwent screening mammography and was notified she had dense breasts. The shopper spoke with insurance representatives over the phone and asked about coverage for genetic screening and ultrasound for women with dense breasts, which are both required to be covered under the ACA.

The results show that of the nearly 160 representatives they spoke to, only 17% were able to provide breast health information consistent with U.S. Preventative Service Task Force guidelines, and 23% were unable to provide any coverage information at all.

Insurer representatives gave BRCA test coverage information that was not consistent with the ACA mandate in 60.8% of cases. Nearly half (48.1%) of insurer representatives gave coverage information about ultrasound screening for dense breasts that was not consistent with state-specific legislation, and 18.5% could not provide any information.

The authors concluded that Insurance customer service representatives in the federal and state marketplaces frequently provide inaccurate coverage information about breast health services that should be covered under the ACA and state-specific legislation. Misinformation can inadvertently lead to the purchase of a plan that does not meet the needs of the insured.

“Insurers themselves are responsible for barriers and challenges to making a meaningful insurance choice,” the report notes. “Although the ACA mandates that coverage information provided by plans should have information about categories of coverage, cost sharing, deductibles, and copayments in a standardized summary of benefits and coverage format to increase patient comprehension, it remains difficult for the average insurance shopper to compare different plans.”

“Customers need help in choosing plans that are right for their personal health histories and economic status,” the authors continue. “Health insurance customer service representatives can be a good resource in guiding consumers to make individualized plan choices, as long as the representatives themselves are informed of plan details and able to communicate them effectively to customers.”

Source(s): Radiology Business, February 2017; Journal of the American College of Radiology, February 2017;