Public Health Safety Net for Commercially Insured Adolescents Seeking Confidential Reproductive Health Services Dawn Middleton, BS Region II Infertility Prevention Project Director Cicatelli Associates Inc National STD Prevention Conference March 13, 2008 – Chicago, Illinois

Overview NYS Insurance Regulation Public and Commercial Insurance - Defining Principles Public Health “Insurance” Options  Title X Family Planning Program  NYS Family Planning Benefit Program Concluding Remarks

Commercially-Insured Adolescents NYS Insurance Regulation Mandates an Explanation of Benefits (EOB) forwarded to the primary insurance subscriber (usually parent or caregiver) following a filed claim  EOB must contain information about date, cost, and scope of services  No exceptions Laboratory testing and results can be available to primary subscriber NYS Insurance Regulation, Section 3234

Commercial vs. Public Insurance Defining Principles Commercial Insurance Defining Principle: Insurer has a fiduciary responsibility to the primary subscriber That responsibility results in due diligence to inform subscriber of claims and denials (EOB) Public “Insurance” Defining Principle: “Insurer” has no fiduciary responsibility to the primary subscriber No responsibility no need for due diligence to inform subscriber of claims and denials

Title X Family Planning Program Enacted in 1970 as Title X of the Public Health Service Act (Public Law ) Federal grant program dedicated solely to providing individuals with comprehensive family planning and related preventive health services Administered by the Office of Population Affairs (OPA) Priority low income Confidential – regardless of age

Title X Family Planning Service Network Diverse network of 88 grantees and 4,400+ clinics receive Title X funding ≥1 clinic in 75% of U.S. Counties 4,992,498 total users in 2006  26% age <24 yrs  94.5% female

Title X Services Scope Core Ensure access to broad range of family planning and related preventive health services for females and males  Comprehensive reproductive health history, physical exam, laboratory tests, as indicated for method  Family planning education and counseling  Contraceptive methods available on-site  Referral and follow-up

Title X Services Scope Enhanced Related Preventive Health Services  Breast and cervical cancer screening  STI screening and treatment  HIV counseling, testing and referral

Title X and Adolescents Assured confidential services and follow- up Do NOT require parental or guardian consent for provision of services Service provider CANNOT notify parents or guardians before or after a minor requests or receives services Promote family/caregiver involvement

Title X and Commercially-Insured Adolescents Seeking Confidential Care Clients cannot be denied services based on inability to pay Sliding Fee Scale  Income ≤101% FPL cannot be charged  Family income 101%-250% of FPL (schedule of discounts)  Fees must be waived for individuals with family incomes above this amount who are unable to pay for family planning services (“good cause” determined by service provider)  Eligibility for discounts for minors who receive confidential services must be based on the minor’s income Title X Program Guidelines 2001 – Section 6.3 “Financial Management”

Title X and Commercially-Insured Adolescents Seeking Confidential Care Projects must seek payment from third parties who are authorized or legally obligated to pay for services unless, in doing so, patient confidentiality would be compromised. OPA Program Instruction Series – OPA 97-1: Fee Charges to Title X Low Income Clients and Teenagers (Revised) – April 24, 1997

NYS Family Planning Benefit Program (FPBP) Medicaid Waiver Program  90% federally funded and 10% state funded Extends medical coverage based on income (up to 200% FPL) for females and males seeking family planning services Health care providers must be enrolled in Medicaid Program In order to bill, services must be provided within the context of a “family planning visit”

NYS FPBP Eligibility Criteria U.S. citizen, NYS Resident, satisfactory immigration status Women, men and adolescents (age 10-64) with incomes ≤200% of poverty level  Minors (under 21 yrs) who are commercially insured and express confidentiality concerns can be covered (dual coverage)

NYS FPBP Enrollment Medicaid Office Health care provider facilitated enrollment (MOU from HRA) Required Documentation  Verification of Identity, Age, Citizenship  Social Security number  Proof of income or self-attestation form  Proof of residency/address Adolescent issued an insurance card Annual recertification

NYS FPBP Benefits All Family Planning and reproductive health services for a period of 1 year:  Comprehensive reproductive health exam  All FDA-approved birth control methods, devices and supplies (includes Pharmacy Rx)  Emergency contraception and follow-up  Pregnancy testing and counseling  STI screening and treatment (does not include STI treatment medications)  HIV counseling and testing  Abortion and colposcopy not covered

FPBP and Commercially-Insured Adolescents Seeking Confidentiality Minors (under 21 yrs) who are commercially insured and express confidentiality concerns can be covered  Allowing for dual coverage No fiduciary responsibility – No EOB Services must be provided within the context of a “family planning visit” in order to access benefit

Concluding Remarks NYS Insurance Regulation effectively deny an adolescent the ability to access confidential reproductive health services via their commercial health plan. OPTIONS AVAILABLE: High level of self-efficacy (adolescent) Significant enrollment barriers to accessing NYS FPBP (documentation, annual re-certification, no provisions for undocumented residents) FPBP requires high level of motivation (provider) Small % of males served