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Privacy for Dependents

posted on Wed, Feb 8 2012 3:06 pm by Robyn Rontal


More than 70 million non-elderly people in the United States are dependents on their parent’s or spouse’s employer-sponsored health insurance.* The Affordable Care Act (ACA) expanded benefits so that young adults ages 19-25 can now remain on their employed parent’s health care policies. This increased the percentage with private insurance for this age group from 51 percent during 2010 to 55.8 percent during the first half of 2011.

However, by using insurance to pay for health care, dependents may forfeit privacy about services they receive. When claims are made for any person covered under a policy, private insurers send the subscriber an explanation of benefits (EOB) that identifies the provider and describes the services. This means that the parent or spouse, as the subscriber, receives details for sensitive services, such as services related to mental health, substance abuse, reproductive health care, sexually transmitted diseases (STDs), HIV/AIDs or domestic violence.

EOBs are required by insurance laws in most states. They serve important functions by giving subscribers details regarding how their insurance company processed medical insurance claims. Subscribers are then able to protect themselves from provider or insurer’s errors and avoid overpaying or paying for services that were not provided. In this way, EOBs also help protect insurance companies from paying for fraudulent or erroneous claims.

At the same time, EOBs can negatively impact dependents’ health and public health. In most states, minors can provide consent to obtain sensitive services without the permission or knowledge of their parents. Privacy concerns can chill care seeking behavior, especially by minors and young adults. Low screening rates for Chlamydia among sexually active females aged 16 to 26 illustrates this scenario. Chlamydia is the most common STD and can cause infertility, pelvic inflammatory disease and ectopic pregnancy. Even though minors can consent to STD testing and treatment without parent’s involvement, health plans report that Chlamydia screening since 2000 has remained below 50 percent nationally. Low screening rates in the insured population have been attributed to patient concerns about breaches in confidentiality due to billing disclosures.

Alternatively, minors and young adults may seek care from publicly funded programs, such as Title X family planning providers, that provide reproductive care including STD testing and treatment. This means that the public pays for care covered by insurance. National data shows that many insured teens and young adults aged 20–24 already appear unwilling to use their insurance coverage to pay for their contraceptive care. According to a Guttmacher Institute analysis of data from the National Survey of Family Growth, only 68 percent of privately insured teens and 76 percent of privately insured young adults who obtained contraceptive services used their coverage to pay for their care, compared with 90 percent of insured women over 30.

Potential solutions that have been successfully implemented by some states and health plans include:

  • Send EOBs to the patient, not the subscriber. Note that mail may still be opened by the parent of a minor if at same address.
  • Require EOBs only when there is liability for payment beyond the normal co-payment. No EOBs would be sent for preventive services where the ACA prohibits cost-sharing such as      co-payments or deductibles (e.g., Wisconsin Insurance Commission; CIGNA).  
  • Prohibit the disclosure of sensitive diagnoses and treatments on EOBs (e.g., Washington Administrative Code §284-04-510).
  • Eliminate state EOB requirements when dependents receive sensitive services.
  • Enable minors or health care providers to request that no EOB be issued to the subscriber for a sensitive service (e.g., Hawaii Rev Stat §577D-2 (2010).
  • Implement a process (CPT code modifier) to support health care provider requests to suppress the mailing of an EOB when billing for sensitive services. Note, this may require system changes for health plans.
  • Educate providers and consumers about existing rights and duties. For example, under the HIPAA privacy rule, health plans must accommodate reasonable requests by patients for communications by alternate means if disclosure would “endanger” the requestor. In addition, the HITECH Act requires a health plan to comply with the requested restriction if the protected health information was for a service that was paid out of pocket in full.

On a positive note, the ACA has already triggered heightened awareness of confidentiality concerns. Recently, officials at the Department of Health and Human Services (HHS) responded to privacy concerns about the ACA’s Claims and Appeals process by amending its rules to relax the requirement that diagnosis and treatment codes and descriptions be disclosed on all notices of adverse benefit determination, such as EOBs. Rather than automatically disclose diagnosis and treatment codes on all EOBs, health plans must now inform members that this information will be provided on request.

Without changes in billing practices, access to sensitive services and the related public health benefits may not be fully realized. Balancing the EOB benefits of financial accountability and fraud reduction with the confidentiality rights of dependents seeking sensitive services will require a partnership among stakeholders and the implementation of a variety of concurrent solutions.

*Calculation based on an estimated 150 million non-elderly employer-sponsored insured with 48 percent covered as an employee’s dependent.

To read more on this topic, please see the following resources:

This blog was written by Robyn Rontal, J.D., M.H.S.A, a collaborator on health information data sharing for the Network for Public Health Law – Mid-States Region.

The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.

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