A 47-year-old woman comes to a multidisciplinary community health center. She is uninsured, and the center's social worker counsels the patient regarding options for insurance enrollment. The patient reports high levels of stress due to financial constraints and the recent deaths of her sister and mother from breast cancer. She wishes to establish care with a primary care physician to be screened for breast cancer and discuss cancer prevention. The patient is eligible to enroll in a private health insurance plan through the Health Insurance Marketplace exchange. She states, "Every dollar counts right now. I'm scared the doctor will charge me a big fee to get a mammogram." Which of the following best describes this patient's expected out-of-pocket spending to obtain a mammogram?

Question

A 47-year-old woman comes to a multidisciplinary community health center.  She is uninsured, and the center's social worker counsels the patient regarding options for insurance enrollment.  The patient reports high levels of stress due to financial constraints and the recent deaths of her sister and mother from breast cancer.  She wishes to establish care with a primary care physician to be screened for breast cancer and discuss cancer prevention.  The patient is eligible to enroll in a private health insurance plan through the Health Insurance Marketplace exchange.  She states, "Every dollar counts right now.  I'm scared the doctor will charge me a big fee to get a mammogram."  Which of the following best describes this patient's expected out-of-pocket spending to obtain a mammogram?

Quizplus · Accepted Answer

Explanation: Uninsured individuals who do not qualify for federal health insurance programs (eg, Medicaid) and lack affordable access to private insurance plans (eg, due to unemployment) can purchase insurance through the Health Insurance Marketplace ("exchange"), which was established by the Affordable Care Act and operated by the federal government (with varying state involvement). According to the Affordable Care Act, insurance plans must adhere to the following regulations: Plans cannot deny coverage or increase premiums (ie, monthly insurance payment) due to a patient's preexisting health conditions (eg, history of diabetes or cancer) Plans must cover essential health benefits, a list of 10 services (eg, prescription drugs, mental health). Depending on the plan, patients may still incur out-of-pocket spending such as copays (ie, fixed cost of service) or coinsurance (ie, fixed percentage of service cost) on certain essential health benefits. However, for preventive services (eg, screening mammogram), insurance must cover all costs so that patients have zero out-of-pocket spending (eg, no copay or coinsurance). These rules apply to all Marketplace plans, regardless of insurance type (eg, Health Maintenance Organizations, Preferred Provider Organizations) and annual deductible (ie, amount patient spends out of pocket before insurance coverage begins). Therefore, this patient's expected out-of-pocket spending for a mammogram is zero on any health insurance plan (Choice A). (Choice C) The patient's income may allow her to receive subsidies to offset the monthly premium but does not influence the expected copays (ie, zero) for mammograms. (Choice D) Because insurance would cover the full cost of the mammogram, this patient will spend more if she chooses to self-pay. Educational objective: Federal law mandates that insurance plans cover 100% of costs associated with preventive health care services (eg, screening mammogram), so that patients incur zero out-of-pocket spending (eg, no copay).

A 47-Year-Old Woman Comes to a Multidisciplinary Community Health Center