June 2000
Increasingly, employers, private insurers, state Medicaid agencies and the federal Medicare program are contracting with hospitals and health care systems that do not provide the full scope of reproductive health services. Or, hospitals and health systems that restrict access to reproductive health services may be part of your health plan network. Patients who enroll in these programs may have limited access to the reproductive health care services that they need. Unfortunately, patients are not always told, in advance, about these limitations or restrictions.
Hospitals and health care systems do not provide a full scope of reproductive care for a variety of reasons. Some health entities with religious affiliations refuse to provide them because those services are against their religion or they consider these services immoral. Sometimes the health system just does not want to pay for certain services which can potentially be expensive.
The scope of services that may not be available includes:[1]
- Contraception
- Sterilization
- Fertility Treatments
- Abortion
- Emergency Contraception for Rape Victims
- Condoms to Combat the Spread of HIV/AIDS and other STDs
This checklist is designed to help advocates and consumers find out about any potential restrictions on access before consumers must choose health plans and providers. It is important to know what services health facilities and providers will or will not provide before the services are needed. Consumers should have access to quality health care services and should be able to make informed choices with full information on what services their prospective health plans and providers will or will not provide. Even if you do not think you will need reproductive health services, your concern can help to ensure that these services are available for others in your community and can help bring attention to potential restrictions. If possible, ask for the answers in writing. If that is not possible, carefully document the answers you get so that you can share them with others in your community. You can also send your answers to Lourdes Rivera, Staff Attorney, National Health Law Program, 2639 S. La Cienega Blvd., Los Angeles, CA 90034.
Choosing Your Doctor
Sometimes doctors will not provide certain services because of their personal beliefs or for other reasons. They have the right to these beliefs and to make these decisions. But you can decide that you would rather obtain services elsewhere so that your full needs are met. In other cases, doctors are being forced to deny their patients services because they work for hospitals, medical groups, or health plans that restrict services. A doctor also could be renting office space in a building that is owned by a landlord that does not want certain services to be provided in the building. Make sure that you ask your doctor the following questions:
___ Do you have any objections to or would you refuse to provide any reproductive health services? (Ask about services that you need or think you might need).
___ For those services that you do not provide, can I get them elsewhere? Do you have formal referral arrangements for the services that you do not provide? Will you readily provide a referral?
___ Is your medical practice located on property that is owned or operated by a religious entity? If so, does your lease agreement restrict the type of services that you can provide?
___ Do you have admitting privileges at a hospital that prohibits or restricts sterilizations or other contraceptive services, fertility services, emergency contraception, or abortions? Do you have admitting privileges at a hospital where I can get these services?
___ If I deliver at the hospital where you have admitting privileges, can I get a sterilization (e.g., tubal ligation) at the time of delivery if I so choose? If not, do you have admitting privileges at another hospital where I can deliver? (Make sure the other hospital is covered by your health insurance or health plan, private or public).
___ Are you employed with a religious-affiliated medical group, hospital, or managed care plan (e.g., HMO, PPO)? If so, are there limitations or restrictions on the services that you can provide or make referrals for? Are there limitations or restrictions on payment that you receive for reproductive services or referrals?
Choosing Your Medical Group
Typically, your doctor will not be a sole practitioner. He or she may be part of a medical group or practice. This means that it is important to know if the medical group has any restrictions. You should ask the medical group (or your doctor) the following questions:
___ Is the medical group affiliated, owned, or operated by a religious health entity?
___ Does the medical group rent office space from a religious entity? Are there any lease agreements restricting what my doctor or medical group can provide?
___ Does the medical group have any objections or restrictions on the provision of any reproductive health services? (Ask about the services that you need).
___ If there are restrictions on services, does the medical group prohibit or penalize my doctor for making a referral to a provider not affiliated with the medical group?
___ Does the medical group have any referral arrangements with other providers who are not restricted? Will the medical group and/or its doctors readily make these referrals or do I have to ask for a referral first?
___ Does the medical group provide transportation to the referral provider?
___ Does my doctor get paid for the time spent on counseling me about all of my options?
___ Does the medical group and/or its doctors have admitting privileges or contracts with hospitals that are religious or that otherwise do not provide sterilizations or other contraceptive services, fertility services, emergency contraception, or abortions? If so, does the medical group and/or its doctors have admitting privileges at an alternative hospital where these services would be available?
___ If I want a sterilization (e.g., tubal ligation) at the time of birth, will the medical group/and or its doctors deliver my child at a hospital where I can get the procedure? (Check to make sure that the other hospital is covered by your health plan or insurance).
___ Will the medical group provide transportation to the alternative hospital if it is far away?
Choosing Your Hospital
The hospital that will be providing your inpatient care and emergency services is also an important link in your health care network. You want to make sure that you will receive the hospital-based services that you need when you need them without surprises. Thus, you should call the hospital that you think you might use, because of its location or because it is in the provider network of the health insurance or health plan that you are considering, and ask the following questions:
___ Is the hospital owned, affiliated, or operated with any religious entity?
___ Was the hospital previously owned by a religious entity?
___ Is the hospital considering any merger, affiliation or any other transaction with a religious hospital, entity, or health system?
___ Is the hospital under any obligation to follow the Ethical and Religious Directives for Catholic Health Care Services or any other religious directives or guidelines?
___ Are there any restrictions on provision of any of the reproductive health services? For example, can I obtain a sterilization (e.g., tubal ligation) at the time of delivery?
___ Will I be able to receive emergency contraception in the emergency room if I should ever be raped?
___ How many inpatient abortions do you provide per year? How many that are medically necessary and how many that are elective? Are your doctors trained to provide elective and/or medically necessary abortions?
___ Are there any plans to limit any of these services?
___ If there are restrictions on services, for what services and under what circumstances?
___ Will the hospital make referrals for reproductive services it does not provide? Does the hospital have formal referral arrangements for these services and with whom? Will the hospital readily make these referrals or would I have to specifically ask for a referral?
___ Does the hospital own, operate, or manage other health entities or resources (e.g., clinics, laboratories, medical office buildings)? If so, are there any restrictions on the provision of reproductive health services at these other sites? If so, what are they?
Choosing Your Managed Care Plan
Increasingly, both private and public health insurance programs are requiring individuals to join health plans ranging from preferred provider organizations, physician-hospital networks, to health maintenance organizations. What they have in common is that enrolled individuals will be limited to the health plans network of providers and health facilities, or they can pay more out-of-pocket to obtain services out-of-plan. (Medicaid beneficiaries can obtain family planning services from any appropriate participating Medicaid provider at no extra cost).
Depending on the type of health plan, the list of providers and hospitals to which the patient is limited can be less or more restrictive. Women and their families may have a choice of which health plan to join. Where there is a choice, it is important that women shop around and make sure that the health plan will provide, pay for, and make accessible the health care services that they need. Below is a list of questions to ask health plans to make sure that reproductive health care services will be accessible. Make sure to let the member services person or other health plan personnel know that you are checking their arrangements on reproductive health before you sign up:
___ Is the health plan owned, operated, and/or affiliated with a religious entity?
___ Is the health plan otherwise obligated to follow the Ethical and Religious Directives for Catholic Health Care Services or any other religious directives or guidelines?
___ Are there any religious or other restrictions on provision or payment for any reproductive health services? (Ask about the services that you need).
___ Are there any of these services that you otherwise do not cover? Why not?
___ Does your prescription drug benefit cover all FDA approved family planning methods, devices, and supplies?
___ What co-pays or deductibles apply to these services?
___ What hospitals belong to your network of providers? Are any of these owned, operated, or otherwise affiliated with a religious entity? Are any of these otherwise bound by religious rules that may impact reproductive health services? Do any of these otherwise refuse to provide reproductive health services such as fertility services, abortions, contraception, sterilizations, or emergency contraception?
___ If restrictions do exist on the network hospital, will you cover the cost of going out-of-plan to another hospital that is close to me if I need the services not offered by the network hospital?
___ Will you provide transportation or reimburse transportation costs if I need to travel to an out-of-network hospital or another hospital that is far away to obtain the reproductive health services that I need?
___ Will you cover the costs of my labor and delivery at an out-of-network hospital if I want sterilization (e.g., tubal ligation) at the time of giving birth and the network hospital/hospital closest to me does not provide sterilization services?
___ If the alternative hospital requires that I obtain prenatal care from a physician affiliated with the hospital in order to receive a tubal ligation and deliver at that hospital, will you cover the costs of these services?
___ Will you cover the costs for emergency contraception provided by an out-of-network hospital or clinic if I were to be sexually assaulted?
___ What physicians and medical groups belong to your network of providers? Are any of these owned, operated, or otherwise affiliated with a religious entity? Are any of these otherwise bound by religious rules that may impact reproductive health services? Do any of these otherwise refuse to provide reproductive health services?
___ If I am a patient of a medical group that has religious objections to providing certain reproductive health services, will you cover the costs of going to a doctor that is not with the medical group to obtain my services? What if the doctor is out-of-plan? Can I go outside of the medical group directly or would I need a referral first?
___ If I am a patient of a primary care doctor who belongs to one of your participating medical groups, am I limited to receiving all of my services from that medical group? Can I go to an obstetrician/gynecologist (OB/GYN) that is outside of the medical group (but still on your provider list)?
___ Can I choose an OB/GYN as a primary care provider?
___ Can I go to an OB/GYN without a referral? Will I have to obtain prior authorization from my primary care provider for drugs and treatments (e.g., contraceptives, treatment of STDs) that are provided or prescribed by the OB/GYN?
___ Do you require your plan providers to disclose their restrictions on provision of reproductive health services to potential and current enrollees?
___ Do you require your plan doctors/medical groups to make referrals for the reproductive health services that they will not provide? To have formal referral arrangements? Are these referrals made readily, or do I have to specifically ask for them?
___ What family planning clinics and other alternative sources of these services do you have in your network?
___ How quickly can I change primary care doctors, OB/GYNs, and/or medical groups if I find that I cannot get the reproductive health services that I need?
Questions to Ask Your Employer or Your Union Representative
If you have private health insurance, your employer or union may be negotiating coverage and services with potential health plans, providers, and medical groups on your behalf. It is important that you and your colleagues let your representatives know that the reproductive health services are important to you and that you oppose restrictions on access to reproductive health services. Share the questions listed above with your employer or union representative to use in their negotiations. Also, ask your employer or union about their own policies:
___ Will the employer or union refuse to cover or restrict coverage for any reproductive health services? (You may want to ask about the specific services you need).
___ Will the employer or union negotiate to include these services in my health insurance coverage? Are there any of these services that will not be covered in the contract with the health insurance provider? Why not?
___ Does the benefits manager (who will be negotiating benefits packages on your behalf) of the company or institution have any objections to the provision of any of the services listed above? If so, will the employer or union ensure that someone else will be responsible for negotiating for these services?
___ Will the health insurance plan cover all FDA approved contraception methods and supplies as part of its prescription drug package?
___ Will the employer or union require that the health plans and their medical groups and providers disclose in writing any restrictions or limitations on reproductive health services before enrollment, at the time of enrollment, and annually thereafter?
___ Will the employer or union ensure that the health insurance benefit allows employees to go out-of-plan when the network providers do not furnish needed reproductive health services? For example, will employees wanting sterilization right after giving birth be able to deliver and obtain a sterilization at an out-of-network hospital with full coverage?
___ Will the employer or union ensure that the health insurance plan offers accessible, affordable alternatives when network providers refuse to provide any of the needed reproductive health services?
Questions to Ask the Medicaid Agency
Medicaid provides coverage for the full scope of family planning services and abortion services in the cases of rape, incest, and to save the life of the mother. In some states, like New Mexico and California, the Medicaid program covers all medically necessary abortions, using state-only dollars for abortions other than when necessary to save the life of the mother or in cases of rape of incest. Medicaid beneficiaries that are enrolled in managed care plans also have the right to obtain family planning services from an out-of-network provider. However, there continues to be access problems. Advocates should use the following checklist to advocate with the state agency to make sure that Medicaid beneficiaries have access to the services to which they are entitled:
___ Is the state contracting with any hospital, managed care plan, or other health entity that restricts access to any of the reproductive health services listed above?
___ If so, does the Medicaid agency provide written disclosure on which of these entities or facilities have restrictions?
___ In the case of managed care, does the state require disclosure on which health plans, hospitals, and other health entities within the health plans network restrict access to any of these services before beneficiaries have to choose a health plan? After they enroll?
___ Does the state provide written, easy to understand notice on beneficiarys right to out-of-plan family planning? Does the state facilitate access to these out-of-plan providers by distributing provider lists? Making referrals? Scheduling appointments? Providing transportation?
___ Does the state require health plans that contract with hospitals, ambulatory care centers, medical groups and other health entities that restrict access to also contract with an accessible, alternative provider? To facilitate access to alternative providers by providing transportation? Making referrals? Scheduling appointments? Other?
___ In the case of women who want a sterilization at the time of labor and delivery, does the state require health plans to ensure that these services can be obtained at the same time? Even if it means paying for physician services, labor and delivery, and sterilization out-of-plan?
___ Does the state require contracting health plans to cover all FDA-approved contraceptive devices and supplies?
___ In the case of mandatory managed care, will the state default or automatically enroll individuals into health plans that restrict access to services? That contract only with providers that restrict access?
___ Will the state implement expedited disenrollment for beneficiaries who need to change primary care providers or health plans because they cannot get the reproductive services that they need?
___ Does the state require health plans to provide minor consent services (as state law allows)? How do health plans maintain confidentiality for adolescents accessing these services?
___ Can adolescents select their own primary care providers? Does the state require health plans to include adolescent health providers in their network?
___ Does the state require health plans to contract with family planning providers in the service area?
___ Does the state ensure that out-of-plan family planning providers are reimbursed promptly?
NHeLP would like to thank the California Womens Law Center for their input in the preparation of this checklist.
1 Not all of these services will be paid for by the public or private health insurance plan covering the consumer. Even if the service is said not to be covered, this information continues to be important because: (1) the services, in fact, may be covered (sometimes there is misinformation about what services will be paid for and under what circumstances); (2) it is important to know that providers are willing to make referrals for services that can be obtained from other no- or low-cost resources in the community; and (3) some consumers may be able to pay for needed services out of pocket.