Government-run insurance marketplaces often fail to help women choose appropriate plans

Women seeking information about which plans cover which breast-health services in Affordable Care Act (ACA) marketplaces have been getting a lot of underinformed advice from customer-service reps. As a result, more than a few women have likely been buying plans that won’t meet their needs.

The study behind this finding and conclusion was published online Feb. 3 in the Journal of the American College of Radiology.

Ruth Carlos, MD, and colleagues at the University of Michigan identified 158 unique customer-service numbers for insurers offering plans through the federal marketplace. They supplemented this sample with four call-in numbers for Access Health CT, the state-run exchange in Connecticut.

The team used a standardized patient biography to have a single investigator pose as a shopper, calling each number and asking for info on breast health coverage.

They compared the information provided by the reps with the ACA mandates on BRCA testing in high-risk women and with state-specific legislation on screening ultrasound in women with dense breasts.

On the BRCA test coverage, insurer reps gave information that was inconsistent with the ACA mandate in 60.8 percent of cases.

Another 22.8 percent were unable to provide any coverage information at all.

When the mystery shopper asked about ultrasound screening for dense breasts, almost half the reps (48.1 percent) gave coverage information that didn’t match with state-specific legislation.  Some 18.5 percent of them couldn’t offer any information.

“Insurers themselves are responsible for barriers and challenges to making a meaningful insurance choice,” the authors write in their discussion. “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.”

They underscore that health insurance shoppers need help in selecting plans that fit with their personal health histories as well as their economic status.

Health insurance customer service reps “can be a good resource in guiding consumers to make individualized plan choices,” the authors add, “as long as the representatives themselves are informed of plan details and able to communicate them effectively to customers.”

The study was completed before there was a strong chance the ACA—and potentially its marketplaces—will go away. Time will tell if “repeal and replace” comes to pass and, if it does, whether the customer’s eye concerns raised by Carlos et al. will receive the attention the authors suggest they deserve.