August 11, 2010 

Office of Consumer Information and Insurance Oversight 

Department of Health and Human Services 

Attention: OCIIO-4150-IFC 

P.O. Box 8016 

Baltimore, Maryland 21244-1850 

In a notice published in the Federal Register on May 13, 2010, the Department published an 

interim final rule for group health plans and health insurance issuers relating to dependent coverage 

of children to age 26 and solicited public comment on those rules. On behalf of the Guttmacher 

Institute, I am pleased to submit the following comments on the implications of these important 

rules for individuals seeking reproductive health services. 

The extension of dependent coverage to young adults is a critical component of the health care 

reform legislation. Historically, young adults have been the age-group most likely to lack health 

insurance coverage.1

 When it comes to reproductive health, individuals aged 18–24 have the 

highest rate of unintended pregnancy; in this age-group, more than one unintended pregnancy 

occurs for every 10 women, a rate twice that for women overall.2

Allowing young adults to obtain coverage as dependents on their parents’ policies will provide a 

critical pathway to insurance for many. However, in order for this coverage to be usable for the 

care individuals in this age-group need—including the reproductive health services that are among 

the services accessed most frequently by individuals in this age-group—additional steps must be 

taken to ensure that they are able to obtain care on a confidential basis. To do so, it is of the utmost 

importance that attention be paid to widely used claims-processing procedures that unintentionally 

abrogate confidentiality, such as by sending an explanation-of-benefits form to the policyholder 

when a dependent receives care or services under the policy. Although this practice was established 

for the laudable goal of protecting policyholders and insurers from fraud and abuse, it often 

precludes the receipt of confidential care. 

The inability to access confidential services may have serious consequences. For example, 

someone who foregoes or even delays testing and treatment for STIs puts not only himself or 

herself at risk, but his or her partners as well. Similarly, the specter of parental notification has 

distressing implications for teens and young adults seeking contraceptive services. A nationwide 

study of adolescents attending family planning clinics found that 60% younger than 18 said their 

parents knew they used a clinic for sexual health services—typically because they had told parents 

themselves or their parents had suggested it. But among teens who said they had not already 

 

1

 Cohen RA, Martinez ME and Free HL, Health Insurance Coverage: Early Release of Estimates from the 

National Health Interview Survey, 2007, National Center for Health Statistics, 2008, 

<http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur200806.pdf>, accessed Aug. 9, 2010. 2

 Finer LB et al., Disparities in unintended pregnancy in the United States, 1994 and 2001, Perspectives on 

Sexual and Reproductive Health, 2006, 38(2):90–96. 

 
discussed their clinic visit with a parent, 70% said they would not seek family planning services 

and one-quarter said they would have unsafe sex if they were unable to obtain confidential care.3

National data show that many insured teens and young adults already appear unwilling to use 

insurance coverage to pay for their contraceptive care. According to an analysis by the Guttmacher 

Institute of data from the National Survey of Family Growth, only 68% of privately insured teens 

and 76% of privately insured young adults aged 20–24 who obtained contraceptive services used 

their coverage to pay for their care, compared with 90% of insured women older than 30.4

 

Feeling that they are unable to use their insurance coverage, teens and other dependents often turn 

to publicly funded services to obtain confidential care. This puts a severe strain on scarce public 

resources, such as those available for the federal Title X family planning program, to provide care 

that is already being paid for as part of a family’s insurance coverage. In short, failure to provide 

confidential access under health insurance drains public programs while leaving private insurers to 

reap a windfall from having factored the cost of care into the premiums they charge without 

actually being asked to pay for the services delivered. 

We therefore urge the Department to move quickly to address this critical issue. As a first step, we 

urge the Department to examine the authority available under the Health Insurance Portability and 

Accountability Act, as well as any avenues possible through state law and policy, to afford 

protection to dependents needing confidential access to care. To do so, it will be critical that the 

Department work in concert with insurers, state departments of insurance and health care provider 

groups—such as the American Academy of Pediatrics, the Society for Adolescent Health and 

Medicine, the American Congress of Obstetricians and Gynecologists and the American Medical 

Association—to develop methodologies that ensure access to confidential care for those who need 

it. 

We hope you find these comments useful as you move to ensure that young adults have insurance 

coverage they are able to use to access the health care services, including reproductive health care 

services, they need. If you require additional information about the issues raised in this letter, 

please feel free to contact Rachel Benson Gold in the Institute’s Washington office. She may be 

reached either by phone at (202) 296-4012 or by email at rgold@guttmacher.org. 

Thank you for your consideration. 

Sincerely yours, 

Cory L. Richards 

Executive Vice President 

Vice President for Public Policy 

 

3

 Jones RK et al., Adolescents’ reports of parental knowledge of adolescents’ use of sexual health services 

and their reactions to mandated parental notification for prescription contraception, Journal of the American 

Medical Association, 2005, 293:340–348. 4

 Gold RB, Unintended consequences: how insurance processes inadvertently abrogate patient 

confidentiality, Guttmacher Policy Review, 2009, 12(4):12–16. 

Guttmacher Institute 2 August 2010