The Church’s HMO


When Nicole got pregnant three years ago, she asked her doctor about an abortion. The 27-year-old mother felt her family was already complete: Her son and daughter had just reached school age, freeing her to take a part-time job. But Nicole says her doctor refused to supply any information. “He just gave me some vitamin and iron pills and said, ‘We don’t do that here,’ ” she remembers.

“Here,” in Nicole’s case, referred to Fidelis Care health plan, the managed-care company she had enrolled in the previous year. Like many other managed-care companies at the time, Fidelis was making an aggressive sales pitch for medicaid patients. Marketers for the company had approached Nicole in the waiting room of her doctor’s office, offering her a free water bottle, which Nicole wanted to give to her children, and promising that the health plan would pay her carfare if she ever had to go to the emergency room.

What the Fidelis salespeople didn’t mention was that their health plan— which is also known as the New York State Catholic Health Plan and is sponsored by the Roman Catholic diocese of the state of New York— refuses on principle to provide family planning, contraception, or condoms to prevent sexually transmitted diseases. So, when Nicole asked about getting an abortion, she didn’t even get a referral to someone who could provide one.

Fidelis CEO and president Mark Lane says he has requested an investigation of Nicole’s case. “If the allegations prove true, we will take corrective action,” says Lane. Reproductive advocates, however, say that Nicole is just one of many women denied reproductive health care by Fidelis, and they fear the situation could soon worsen.

The reason: NYC is moving ahead with a plan to make managed care mandatory for most everyone on medicaid. So starting in February, medicaid recipients who don’t select one of 20 managed-care companies by mail will be automatically enrolled in one. According to some estimates, as many as 400,000 people could be automatically enrolled, and some 20,000 women could wind up in Fidelis. Those who are assigned to Fidelis may be unaware of the plan’s limitations or their right to reproductive care from other providers.

Medicaid recipients are usually poor: women without children must take in less than $353 per month to qualify. And women who will end up being automatically assigned are likely to be the poorest and most vulnerable. They may not have telephones, may not be able to read, or their lives may just be too chaotic for them to respond to a mailing. For these women, decent reproductive care can be essential to keep life manageable. As Nicole says of her third child— now 22 months old, “I love my son, but I could have gone back to school and gotten a good job if things had been different.”

Earlier this year, City Council member Ronnie Eldridge introduced legislation that would prohibit the city from automatically assigning medicaid recipients to any managed-care plans that don’t provide either reproductive health care or contract with another provider who does. “We do not want those poor women assigned to plans that would not offer them the full range of health services,” says Eldridge.

In fact, Fidelis is the only plan that would be kept out of the automatic assignment process under the proposed regulations. (Community Premier Plus, the only other medicaid managed care plan that doesn’t include reproductive health services in its flat per-patient fee, has already arranged to provide that care.) Noting his special situation, Fidelis’s Mark Lane says he feels the company has been unfairly singled out. “There’s a constant attack on our religious beliefs,” says Lane. As he tells it, Fidelis is complying with current law— and does inform women that they can get family planning elsewhere.

“We never wanted to be punitive toward Fidelis,” says Kelli Conlin of the New York affiliate of the National Abortion and Reproductive Rights Action League, which helped write the legislation. Conlin says the bill won’t prevent people from choosing Fidelis on their own.

Moderate though it may be, the proposal has its adversaries. The Greater New York Hospital Association, which indirectly represents some managed-care plans, including Fidelis, has come out against it, pointing out that state law already requires plans to let people know if they don’t cover certain services and to let them know they can get those services outside their plans by using their medicaid cards.

“We feel the legislation is unnecessary,” says Doris Varlese, GNYHA’s assistant general council. “If folks feel that the goals of this legislation are not being accomplished, there are better ways of achieving them.” She suggests improved education of medicaid managed-care patients and enforcement of laws already in place.

The Giuliani administration has also opposed the bill, worrying that the city could be held liable for damages in suits by medicaid patients and arguing that it doesn’t have the authority to expand on existing regulations. (“That’s the first time I’ve ever seen him cede authority to a state agency,” notes Conlin.)

But the bill’s supporters, including 41 council members and several advocacy groups, clearly feel the city has the authority— even an obligation— to make stronger laws. “Apparently there isn’t enough leverage to get Fidelis to abide by the current regulations,” says Shirley Gordon, who interviewed several women in the plan who were denied birth control and other reproductive services. “Fidelis has to follow the ethical directives set by the church hierarchy,” says Gordon, “and they’re simply not going to follow the guidelines unless it’s written in law.”

For her part, Nicole, who testified before the City Council during recent hearings on Eldridge’s bill, has voted with her medicaid card. She dropped out of Fidelis not long after giving birth to her son and went back to the old-style payment, in which she just goes to a doctor who accepts medicaid and presents him or her with her card. Sooner or later, though, she’ll have to choose a managed-care plan. At this point she isn’t sure which one it will be, but she knows it won’t be Fidelis. “I don’t think they’re very good,” says Nicole. “They’re not up-front about the stuff”.