Breast Health Services: Accuracy of Benefit Coverage Information in the Individual Insurance Marketplace.
OBJECTIVE
The aim of this study was to determine if breast health coverage information provided by customer service representatives employed by insurers offering plans in the 2015 federal and state health insurance marketplaces is consistent with Patient Protection and Affordable Care Act (ACA) and state-specific legislation.


METHODS
One hundred fifty-eight unique customer service numbers were identified for insurers offering plans through the federal marketplace, augmented with four additional numbers representing the Connecticut state-run exchange. Using a standardized patient biography and the mystery-shopper technique, a single investigator posed as a purchaser and contacted each number, requesting information on breast health services coverage. Consistency of information provided by the representative with the ACA mandates (BRCA testing in high-risk women) or state-specific legislation (screening ultrasound in women with dense breasts) was determined.


RESULTS
Insurer representatives gave BRCA test coverage information that was not consistent with the ACA mandate in 60.8% of cases, and 22.8% could not provide any information regarding coverage. 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.


CONCLUSIONS
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.
University of Michigan Medical School, Ann Arbor, Michigan.
Mariam S
MS
Hamid
Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.
Giselle E
GE
Kolenic
University of Michigan, Ann Arbor, Michigan.
Jessica
J
Dozier
Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan; Program for Women's Health Effectiveness Research, University of Michigan, Ann Arbor, Michigan.
Vanessa K
VK
Dalton
Program for Women's Health Effectiveness Research, University of Michigan, Ann Arbor, Michigan; Department of Radiology, University of Michigan, Ann Arbor, Michigan; Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan. Electronic address: rcarlos@med.umich.edu.
Ruth C
RC
Carlos
D001941:Breast Diseases / Q000000981:diagnostic imaging* / Q000235:genetics*; D003237:Connecticut; D005260:Female; D062265:Health Insurance Exchanges; D006801:Humans; D033181:Information Dissemination; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D007348:Insurance, Health / Q000706:statistics & numerical data*; D058991:Patient Protection and Affordable Care Act; D013219:State Government; D014481:United States
Affordable Care Act; Mystery shopper; access to care; benefit design; health insurance marketplace; insurance coverage; secret shopper