Mandated Services & Unresolved Issues
Presented at the
2014 Women’s Policy Summit
The federal Affordable Care Act (ACA) presents unprecedented opportunities to increase medical and mental health care for survivors of domestic violence as well as opportunities to increase preventative screening, counseling and care as a core women’s preventative health benefit.
This policy brief:
- Documents the connection between domestic violence and the need for health services;
- Describes domestic violence services available through the federal Affordable Care Act;
- Identifies unresolved issues related to the provision of services to domestic violence survivors, including mandated reporting, privacy and confidentiality, and billing for services; and
- Identifies ways that local domestic violence programs are forming partnerships to help with enrollment in health plans and educate health care providers about the domestic violence provisions of ACA.
DOMESTIC VIOLENCE IMPACTS HEALTH AND ECONOMIC OUTCOMES
Physical injuries caused by abuse are the most recognized health impacts of domestic violence. Frequently unrecognized are a victim’s ongoing health impacts of violence and abuse.
Research has found that apart from physical injuries, domestic violence contributes to many ongoing health problems, including traumatic brain injury, migraines and headaches, chronic pain syndromes, anxiety, depression, post-traumatic stress disorder (PTSD), and pregnancy difficulties including low birth weight and perinatal deaths. Of women experiencing abuse, 40 percent report their pregnancy was unintended; in women not experiencing abuse that number was only 8 percent.
The chronic physical and mental health impacts of abuse can also take a serious toll on victims’ economic security. Medical expenses can be significant, and many victims are forced to miss time at work. The nationwide annual cost of domestic violence, sexual assault and stalking in 2003 was estimated at $8.3 billion dollars for medical and mental health services and lost productivity from paid work and household chores. In California, a survey done by the Legal Aid Society – Employment Law Center found that 59% of survivors reported having missed work due to domestic violence, 38% of survivors reported either having been fired or fearing termination because of their domestic violence situation, and 34% reported having to quit a job because of domestic violence.
Access to health coverage through ACA not only allows domestic violence victims access to emergency and ongoing health care, it also increases their economic security.
DOMESTIC VIOLENCE PROVISIONS IN THE AFFORDABLE CARE ACT
In addition to providing access to health coverage for domestic violence survivors, ACA includes provisions specific to domestic violence screening and care as part of its women’s preventive health requirements.
As of January 2014, insurers are:
- Prohibited from denying coverage to victims of domestic violence as a pre-existing condition, which was implemented in some states prior to ACA.
- Required to cover screening and brief counseling for lifetime exposure to domestic violence and interpersonal violence as a core women’s preventive health benefit, at no cost to the individual.
These new screening and brief counseling components have the potential to increase early intervention and referrals to domestic violence programs, changes which could have real, positive benefits for victims.
However, lack of specific federal guidelines and regulations has left a number of important implementation issues unresolved.
The California Partnership to End Domestic Violence is in dialogue with state agencies, private providers, federal regulators and nonprofit partners to address the following issues:
In California, health care providers are required to report if they provide medical services to a patient whom they suspect is suffering from a physical injury as a result of assault or abuse, or inflicted by a firearm.
Regulations are not yet finalized to guide practitioners about whether or not information about domestic violence disclosed in the screening and brief counseling required under ACA will need to be reported under California’s mandated reporting law – particularly in cases where no physical injuries are apparent.
Until this issue is resolved, providers should seek guidance from their health facility council – and always disclose to patients the limits on confidentiality and what cases require a mandated report. More information about California’s domestic violence mandatory reporting law is available here.
Electronic Health Records and DV Survivors
ACA requires health care records to shift to electronic health records (EHRs), which will be stored in databases with the ability to be shared and accessed by multiple providers. While this change can have positive benefits in streamlining health care, it is important for programs and survivors to understand the potential privacy implications.
For victims fleeing an abusive relationship, their ability to keep personal identifying information confidential, including address and contact information, is an important means of maintaining their safety. Victims are at greatest risk of homicide at the point of separation or after leaving their violent partner.
Privacy Protections for DV Survivors in California
In preparation for the January 1, 2014 effective date for the Medi-Cal expansion and health exchanges, California passed a number of new laws during the 2013 legislative session. Of particular note for domestic violence survivors and their advocates is SB 138 (Hernandez), which allows individuals to request alternate, confidential communications about their health services if the communication is related to “sensitive services” or if the disclosure of the medical information could endanger the individual.
Confidential communications can include an alternate email address, phone number, or mailing address used to send information about health services.
While this law offers potential protection for survivors and their children who may still be receiving their health insurance through the abuser, it does not go into effect until January 2015,
Survivors should also speak with their insurance provider about setting up alternate, confidential communications in advance of the January 2015 date as some insurance companies may implement this sooner.
What Agencies Can Provide and Be Reimbursed for Brief Counseling
It is not yet clear whether or not local domestic violence shelters will be eligible to bill for providing brief counseling. Reimbursement could occur directly through Covered California or through private health plans.
While there are currently no local domestic violence programs that bill for brief counseling to survivors insured under ACA plans, the Partnership will continue to work with state agencies, private providers, federal regulators and nonprofit partners to facilitate this process.
BUILDING RELATIONSHIPS BETWEEN DOMESTIC VIOLENCE PROGRAMS AND HEALTH CARE PROVIDERS
Domestic violence advocates already recognize the importance of health care providers in addressing domestic violence, and the Affordable Care Act offers opportunities for programs to strengthen existing partnerships and to form new collaborations.
Programs may want to consider partnerships with setting-specific health care providers, including reproductive health care and family planning programs and home visitation programs.
Below are examples from domestic violence programs in California that offer different approaches and strategies for ACA-related partnerships:
• Technical Assistance through a Community Clinic
A community clinic nurse in Los Angeles County who works directly with families in emergency shelter helps identify which medical benefits the family may qualify for and ensures that the family connects with navigators in the area to enroll in the programs they qualify.
• Partnership with Kaiser Permanente
Another domestic violence program is in collaboration with their local Kaiser violence prevention program, working with the doctors and nurses who make referrals to the local domestic violence program. (UNCLEAR, let’s discuss briefly – why family planning?) While they do have a relationship with family planning professionals, they refer on a case-by-case basis only if the survivor wants the referral to the local domestic violence program. They also have a health care provider conducting weekly health care workshop within the shelter program. Many local domestic violence programs have formal and informal working relationships with healthcare providers and social service organizations that offer natural settings to coordinate access to ACA enrollment for survivors and their children. For counties with a dedicated Domestic Violence Coordinating Council, there is an existing infrastructure whereby these efforts can be further discussed and institutionalized in a meaningful manner.
To further such partnerships, Futures Without Violence has two publications deserving special note, available at www.futureswithoutviolence.org.
- Ten Steps to Create a Domestic Violence Health Care Response
- How to Create a Healthcare-based Domestic Violence/Sexual Assault Program