UPDATE, January 8, 2019: Following its sale to Centene, Fidelis said on its website that as of January 1 it will directly cover reproductive health services including birth control, emergency contraception, sterilization, pregnancy testing, HIV and STD testing, and “abortion that you and your doctor agree is needed.”

Emily Popek was sure her new health insurance plan would cover her birth control. In late 2015, the then-37-year-old newspaper editor in Oneonta, a city in upstate New York, enrolled in a government-subsidized plan from the nonprofit insurance company Fidelis Care, for which she paid $20 each month. Popek was thrilled by the insurance option for people who don’t qualify for Medicaid but earn too little to afford most plans on New York’s Affordable Care Act marketplace. Her daughter, Ramona, was 3, and Popek was the sole breadwinner for her family. She and her husband were not planning on having another child.

“I think I just had this idea in the back of my mind: Birth control is just covered. It just is,” Popek told Rewire.

But it turned out that getting birth control coverage through her new insurance company was so infuriating and confusing, she ultimately gave up.

That’s because unbeknownst to Popek, although it reaps billions in taxpayer funding through Medicaid each year and is one of the most dominant insurers on New York’s state-run exchange, Fidelis is officially called the New York State Catholic Health Plan, Inc. and is sponsored by the state’s Catholic dioceses.

As such, like many Catholic-sponsored companies, Fidelis refuses to cover a range of reproductive health services that conflict with directives from the United States Conference of Catholic Bishops, including abortion, sterilization, and most forms of birth control. Instead, New York state has allowed an outside company to cover some reproductive health-care services for Fidelis members who buy certain plans on the exchange.

Fidelis’ expansion in New York exemplifies a broader trend: the quiet creep of religious beliefs into many aspects of U.S. health-care delivery.

“The incursion of religious doctrine into health insurance is something that would be a surprise to many people and is clearly not well known by women signing up for health insurance plans,” said Lois Uttley, director of MergerWatch, which tracks religious restrictions on health care, in an interview with Rewire.

A Rewire investigation has found the New York state accommodation has created a bureaucratic obstacle course for patients like Popek, who sometimes discover only after they’ve enrolled that Fidelis is Catholic-sponsored, and won’t cover their reproductive care. When they try to access birth control, these patients encounter multiple hurdles, from Fidelis employees who supply only sparse, scripted, or even inaccurate information, to a selection of providers that excludes most Planned Parenthood and family planning clinics. Finally, if they succeed in getting a birth control prescription, they sometimes must cajole confused pharmacists into billing a third-party insurer.

Advocates say the state has not done enough to ensure access to contraception for these patients.

“If the state wants to accommodate a religiously sponsored health plan like Fidelis that objects to contraception, there is a responsibility to make sure that the accommodation doesn’t create an obstacle course for women who are enrolled in the plan,” Uttley said.

The Affordable Care Act (ACA) requires health insurance companies to cover birth control without a co-pay, and advocates say Fidelis must follow that rule, despite its religious identity.

“Fidelis as a plan offering coverage on the marketplace to individuals should be providing the birth control benefit,” Gretchen Borchelt, vice president for reproductive rights and health at the National Women’s Law Center (NWLC), told Rewire. “It does not have any kind of exemption or accommodation.”

While the future of the ACA remains uncertain, reproductive health-care advocates say they fear the incursion of religion into public life, including health care, is likely to expand dramatically under the Trump administration.

Already, the U.S. Supreme Court’s 2014 Burwell v. Hobby Lobby decision in favor of corporate religious rights, along with an onslaught of so-called religious freedom laws at the state level, have emboldened companies and individuals that seek to impose their religious views on their consumers and employees by denying them access to certain services or benefits.

From transgender patients denied hysterectomies to women denied care for miscarriages or even dislodged IUDs, religious directives in health care are putting people’s lives at risk.

“I think we are likely to see increasing demands by religious employers, hospitals, and insurers for the right to refuse to provide or pay for reproductive health care,” Uttley said. “In the new administration, these religious objectors are likely to find a receptive ear.”

A “Carve-out” Plan for Catholic Insurers

A little more than half of enrollees on New York’s Affordable Care Act exchange are female and, according to the Guttmacher Institute, about 1.23 million women in the state were in need of publicly supported contraceptive services and supplies in 2014. Although research has shown contraception access is key to women’s economic success and health, one of the exchange’s biggest insurers largely refuses to provide it.

With 1.54 million total members—amounting to about one in 13 New Yorkers—Fidelis is New York’s largest Medicaid managed care plan, with 1.17 million Medicaid members. It’s also the largest provider of both the Essential Plan (for low-income people like Popek who don’t qualify for Medicaid), and Qualified Health Plans (QHPs) sold on New York’s individual exchange; Fidelis’ market share among those QHP enrollees is more than double that of any other company, according to the latest state report. (Advocates say this is in part because Fidelis’ premiums are relatively low.)

Fidelis’ Medicaid members can obtain reproductive health services, including abortion, from any Medicaid provider; some Essential Plan members get similar coverage. Adolescents on Fidelis’ Child Health Plus plan have a different arrangement involving third-party insurers.

But multiple complaints submitted to the New York State Department of Health reveal difficulties relating to Fidelis members’ reproductive health coverage.

“I received a call from Ms. [redacted] from the billing office at University OBGYN Assoc. and she stated that Fidelis as well as Medicaid refuses to pay for services,” reads the 2015 record of one such complaint. Rewire obtained the records from an attorney who sued Fidelis over the unrelated issue of errors in its provider directory.

Those who buy Fidelis plans on the exchange and can’t get their family planning through the avenues described above must go through a separate company, Unified IPA, which, like Fidelis, does not cover “voluntary termination of pregnancy.” 

Despite the ACA’s requirement that birth control be covered without a co-pay, these patients face a series of hurdles. (New York is one of several states seeking to enshrine this requirement in state law, even if the ACA is repealed.)

Unified IPA doesn’t cover contraceptives prescribed for “medical purposes,” instead saying such claims should be sent to Fidelis. But Fidelis refused to explain to Rewire by deadline what constitutes such a “medical purpose.”

If members want to obtain contraception as part of their routine well-woman exam, Fidelis will refuse to pay if the provider bills for it specifically.

“Fidelis reimburses a provider who bills a comprehensive Well Woman exam,” Fidelis spokesperson John O’Hara wrote to Rewire. “If the provider directly bills a family planning service, it would be denied.”

Rewire reviewed several complaints to the New York attorney general’s office in the past few years that reveal frustration among patients trying to navigate this system.

“Fidelis rejected a bill from my gynecologist who had advised me on birth control in a simple office visit,” one consumer complained in 2015, the records show. “When I called Fidelis, they told me I had to tell my health care provider to go through the third party vendor, Unified IPA. This is nowhere near seamless. And any consumer who doesn’t follow up themselves is being wrongly charged for services. Fidelis is not meeting the needs of non-Catholics enrolled in its health plan.”

Another Fidelis member told the attorney general’s office in 2015 that Fidelis had denied a claim for his wife’s NuvaRing “simply by saying ‘we do not cover it, and you cannot appeal this [decision].'”

Unified IPA was created in 2013 specifically to cover reproductive health care for Fidelis patients on New York’s exchange, according to Michael Elliott, one of its principals. (In addition to family planning and sterilization, it also covers certain infertility services.)

Nationwide, Elliott said Unified IPA’s parent company, Unified Life Insurance Company, serves about nine other religious health insurers, and has at times provided a similar service to about 15 or 20 religious health plans since the 1980s.

“We provide a service that is able to help members, individuals, people who need health care get health care and still allow Catholic health plans to abide by their Ethical and Religious Directives,” he said. “So everybody wins.”

Elliott refused to identify the other religious plans, citing their beliefs as a reason for concealment.

“Every one of the companies we work for is Catholic, and they have this document that’s called the Ethical and Religious Directives of the Catholic Church,” Elliott told Rewire. “If you were a Catholic, and if you had really read it and understood it, then you would understand that they have a real sensitivity to not being involved in this, OK?”

Emily Popek didn’t know about any of this when she enrolled in Fidelis. Unaware that her insurance company was Catholic-sponsored, she called Fidelis to find out more about her birth control coverage, and was surprised when a representative told her she would have to call Unified IPA, a separate company that she had never heard of.

When Popek went on Unified IPA’s website, the closest provider listed in its database was about 60 miles away, meaning she would have to take half a day off work just to get her prescription.

“It felt like a bait and switch … because none of this stuff was transparent to me when I chose this plan,” she told Rewire. “It doesn’t seem right to me that there should be this whole secondary system for getting this one kind of care, that’s completely outside of the plan that I purchased.”

IPA stands for “independent practice association,” and indeed, Fidelis represents Unified IPA as a separate provider network, repeatedly noting in statements to Rewire that family planning services are provided “independent of Fidelis Care.”

But Elliott of Unified IPA claimed Fidelis members aren’t required to find a Unified IPA provider in order to get a prescription for birth control. In fact, they can go to any provider in the far-broader Fidelis network, he said, as long as that provider knows to bill Unified IPA for family planning services.

This process is not outlined in any of the Fidelis policy documents reviewed by Rewire, or in the benefits schedule issued by Unified IPA, which directs patients to “the Unified IPA network of participating providers.”

“I kind of wish Fidelis would have just told me that,” Popek said, when Rewire informed her. “It seems like that would have been really simple … that was not the impression I had at all.”

A De Facto Denial of Care

Fidelis’ employees are not always accurate when explaining the company’s restrictions on family planning, Rewire found. Rewire posed as a potential enrollee and asked a Fidelis representative whether the company’s plans cover all services. Initially, the employee was evasive, saying simply that all plans exclude some services, such as acupuncture. Only when pressed on whether there were any other services excluded did she acknowledge Fidelis is Catholic and doesn’t cover family planning.

She then incorrectly suggested a patient would have to pay for birth control out of pocket, and recommended Planned Parenthood Mohawk Hudson in Schenectady, which was listed in Fidelis’ online provider directory.

“We do participate with them for your regular OB-GYN, so you could go to them and get a Pap smear if they required [it] in order for you to get your birth control through them,” she said.

But Kim Atkins, CEO of Planned Parenthood Mohawk Hudson, said his center is not actually a Fidelis participating provider. Fidelis confirmed it does not contract with any Planned Parenthood affiliates, telling Rewire the center is listed in its provider directory because it is “contracted directly with CVS/Caremark as a pharmacy.” But Atkins said his affiliate doesn’t actually dispense medication.

“It’s misleading to people who think that they can get things from us through Fidelis,” Atkins said. (Since Rewire inquired about the listing, it appears to have been removed from Fidelis’ directory.)

Health-care advocates told Rewire that the confusion about Fidelis and its relationship with Unified IPA is widespread, and it can result in a de facto denial of care.

Fidelis members “don’t know there is a third party; they don’t know how to reach that third party; they aren’t given information about how to get the birth control coverage,” Gretchen Borchelt of NWLC, which operates a contraception access hotline, told Rewire. “We know women who have paid out of pocket because they just didn’t think they had that coverage … that, to us, is Fidelis not meeting its obligations under this birth control coverage requirement.”

Even when Fidelis members manage to navigate the first steps of the obstacle course and secure a prescription for contraception, they may face even more difficulties once they get to the pharmacy.

Such was the experience of Joya Banerjee, a public health professional who enrolled in Fidelis coverage a few years ago, having taken special care to ensure that her birth control pills were covered.

According to a complaint letter sent to Fidelis on Banerjee’s behalf by the New York attorney general’s office in September 2014, when she went to the pharmacy to pick up her birth control, the pharmacist said it wasn’t covered by Fidelis. Banerjee then called Fidelis, who told her she could seamlessly get her birth control through Unified IPA. Banerjee said she spent “hours” at the pharmacy on multiple occasions trying to navigate this system to get her prescriptions, according to the complaint.

In its response to the New York attorney general’s office, Fidelis blamed Banerjee for the mix-up, claiming she had attempted to “obtain drugs that were not covered on the Exchange formulary.” Banerjee denies this, saying she intentionally chose a birth control pill she knew would be covered. Indeed, Banerjee told Rewire that she was particularly incensed by Fidelis because obtaining birth control was her top priority when she picked a health insurance plan.

Unified IPA’s Michael Elliott said it’s not patients, but pharmacists, who are to blame for these problems.

“If they enter the information off of the ID card, the very first sentence that appears on their screen is as follows: ‘Fidelis Care does not cover contraceptives, bill alternative carrier.’ Then three lines down they’d find out who the alternative carrier is,” Elliott told Rewire. “I can tell you 90 percent of the time the pharmacist stops at that point. They don’t read any further. They’ve got a busy day in front of them, they’ve seen Fidelis doesn’t cover it. They simply tell the member, ‘You’re not covered.'”

Most members then call Fidelis, Elliott said.

“Ninety-nine percent of them will then pick up the phone and call Fidelis and Fidelis will read them a script that tells them to call us and within ten seconds they get the answer from us,” he said.

But advocates say that ultimately, this kind of confusion can block access to care. Lois Uttley of MergerWatch, who has studied Fidelis for at least a decade, said the state should do more to facilitate access for Fidelis members.

“I think the problem with the Fidelis Care arrangement in New York is that it is not well constructed and it’s very poorly overseen by state officials,” said Uttley, whose team sent state officials a report last year documenting rampant weaknesses in Unified IPA’s database, from outdated listings to disconnected numbers and duplicate entries.

“Essentially, state officials have let Fidelis get away with not covering contraception, and have allowed [it] to use a third-party mechanism to get coverage for its enrollees, but that mechanism has had very little scrutiny and so we don’t really know the day-to-day experience of women who have enrolled in Fidelis without realizing the consequences for contraceptive coverage,” Uttley told Rewire.

In a written statement to Rewire, Fidelis said, “No action has been taken by any regulatory agency against Fidelis because these agencies have not found that Fidelis violated any regulation or contractual requirement related to family planning services.”

“They Shouldn’t Be Subsidized That Way”

Despite problems encountered by its members, Fidelis has grown rapidly in recent years, opening new offices, peppering the state with billboards, and reaping a projected $8.3 billion in revenue last year, $5.4 billion of that from Medicaid. In some counties, Fidelis is one of only a few options for certain health plans: In Popek’s county of Otsego, it is one of only two providers of the Essential Plan. Much of this growth has been made possible by accommodations from New York state, which is generally seen as one of the most progressive when it comes to issues of reproductive rights.

The New York State Department of Health and the New York State Department of Financial Services both failed to respond by deadline to multiple requests for comment.

The New York attorney general’s office declined to comment about the complaints it has received about Fidelis, saying only that it has “been able to directly resolve numerous complaints related to Fidelis,” without providing further detail.

But reproductive health advocates have been far from silent about the state’s decision to do business with a company that refuses to cover basic health care.

“I would love to see Fidelis be required to offer a full range of services,” Chelly Hegan, president and CEO of Upper Hudson Planned Parenthood, told Rewire. “And if not, then they have to get out of the marketplace. They shouldn’t be subsidized that way.”

Advocates also worry that these accommodations are set to become more common due to the barrage of state-level religious imposition laws, a Republican-led Congress that seems intent on repealing the ACA, and a nominee for U.S. Department of Health and Human Services secretary who has called the birth control benefit “a trampling of religious freedom.”

“That’s what we’re worried about seeing under the new administration—an expansion of the kinds of health-care entities that can refuse to provide services,” said NWLC’s Borchelt. “What we’re expecting from a new Congress with the approval of a new administration is even more entities to be able to refuse certain health-care services. Right now under federal law, a health insurance plan basically can refuse to cover abortion and we know that there is an interest in expanding that to more entities and to more services.”

Ultimately, Emily Popek was able to obtain her birth control, but not through the health plan she had purchased on the New York state exchange, for which she was still paying. Instead, she found a family planning clinic in her hometown, where she got contraception at no cost under a sliding scale supported, in part, by taxpayer funds.

Ironically, the clinic, Family Planning of South Central New York, had wanted to contract with Fidelis, but was rejected because its name contains the phrase “family planning,” said CEO Debra Marcus. Fidelis says it has no record of receiving a contracting inquiry from Marcus’ clinic, but confirmed it does not contract with any family planning clinics.

“Many of us in the reproductive health community felt that the Department of Health should never have awarded these [Medicaid managed care] contracts to an insurance plan that leaves out a critical, critical, critical part of health care and that’s not upfront to people,” Marcus told Rewire.