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EVAWI > Resources > Forensic Compliance > FAQs > SAFE Payment
Forensic Compliance Frequently Asked Questions

Note: The information on this website is designed to: (a) communicate the requirements of the Violence Against Women Act (as reauthorized in 2005 and 2013), and (b) offer recommended practices for implementation. The goal is to highlight examples of communities striving to achieve a higher standard of the “spirit of the law,” rather than simply meeting the “letter of the law” for VAWA forensic compliance.  It is critically important that readers consult state laws and regulations, as well as local policies and protocols, because they may have additional requirements beyond those included in VAWA 2005 and VAWA 2013. For more information specific to your state or territory, contact the STOP Grant Administrator or coalition of advocacy organizations providing services for sexual assault victims.  A listing is available from the website for the Office on Violence Against Women, U.S. Department of Justice.

Q What does VAWA require for payment of medical forensic exams?
Q Is there a law that mandates who will pay for exams in my state?
Q Which costs are required to be covered?  Just forensic evidence collection, or medical testing and treatment?
Q What about treatment for STI’s and EC?
Q Can private insurance be billed for the cost of the exam? 
Q Can the victim be billed for the co-pay for any medical expenses beyond the exam?
Q What about costs for follow-up care?
Q Who pays for medical forensic exams across state lines?
A What does VAWA require for payment of medical forensic exams?

Under VAWA, grantees of the STOP Violence Against Women Formula Grant Program must meet certain requirements concerning payment for the forensic medical exam in order to receive funds. Specifically, states, territories, and tribes must certify that they or another governmental entity "incurs the full out-of-pocket cost of forensic medical exams" for victims of sexual assault. If one part of the jurisdiction (such as a county or city) is requiring victims to incur any of these costs, they will not be able to make this certification and will be ineligible for STOP grant funds.  

For more information, this article was originally published in the Sexual Assault Report in 2006, and it provides a summary on the provisions of VAWA 2005. It is also now available under the Articles tab on the Forensic Compliance Resource Page. However, keep in mind the 2006 publication date; the article does not include information updated since that time.
A Is there a law that mandates who will pay for exams in my state?

Many professionals have questions about the laws in their own state or territory, pertaining to forensic compliance and payment for sexual assault medical forensic exams. Answers can be found on EVAWI’s Safe Payment Map, which provides the laws in your own state or territory.  

Also, the document entitled, Summary of Laws and Guidelines with Charts:  Payment of Sexual Assault Medical Forensic Examinations was created by AEquitas: The Prosecutors’ Resource on Violence Against Women, in collaboration with EVAWI. You can download the whole 228-page document, which includes the laws and guidelines for each U.S. state and territory, as well as a number of charts summarizing the provisions. For an overview, you can also download the 13-page Summary of Laws and Guidelines.
A Which costs are required to be covered?  Just forensic evidence collection, or medical testing and treatment?

Within VAWA, a sexual assault forensic examination is defined as including, at a minimum: examination of physical trauma determination of penetration or force patient interview; and collection and evaluation of evidence [28 C.F.R. § 90.2(b) (1)] This means that states, territories, and tribes have discretion regarding payment for medical testing and treatment.

The regulations also state that “the inclusion of additional procedures (e.g., testing for sexually transmitted diseases) to obtain evidence may be determined by the state ... in accordance with its current laws, policies, and practices” [§90.2(b)(2)].  In other words, although VAWA requires states to pay for the forensic aspects of the exam (as defined above), they are given discretion regarding whether to pay for medical aspects of the exam.  

Practices thus vary both as a result of state laws and specific practices within the community. Victims of sexual assault may find that all, none, or some of the costs for medical testing and treatment procedures are covered. 

When medical services are provided as part of a forensic examination, the costs will often be paid through the existing Crime Victims Compensation fund.  However, victims may be required to pay for the costs of medical testing and treatment upfront, and then submit an application to be reimbursed through the Crime Victims Compensation Fund. 

Unfortunately, the eligibility criteria for most state Crime Victims Compensation funds require victims to report the sexual assault in a timely manner (often 72 hours to 5 days) and cooperate with the criminal justice system. Victims of sexual assault typically report to law enforcement after a delay of days or weeks (if they report at all), and many decide that they are unable to participate in the investigation and prosecution of their sexual assault. Therefore, even if medical services are reimbursed using state funds, the eligibility criteria for the Crime Victims Compensation funds will often limit the availability of these funds for many victims of sexual assault.
A What about treatment for STI’s and EC?

Some jurisdictions include treatment for Sexually Transmitted Infections (STIs) and Emergency Contraception (EC) as part of the forensic exam, and costs are covered with the payment mechanism that is used for medical forensic exams. Yet in other places, these services are not included in the definition of a forensic exam and the costs are not covered. 

In the National Protocol for Sexual Assault Medical Forensic Examinations, it is recommended that health care providers facilitate evaluation and care for both pregnancy and STIs. Given these services are recommended by the National Protocol, protocols can be created to ensure victim access.
A Can private insurance be billed for the cost of the exam? 

Yes, as long as victims do not incur any out of pocket costs. Prior to VAWA 2013, jurisdictions were allowed to reimburse victims for out of pocket costs, but now they need to ensure that the exam is free of charge to the victim- reimbursement to the victim is no longer allowed. This means that insurance billing can still be used for medical forensic exams, but it will be administratively complicated because victims cannot be charged for any co-pays, deductibles or any out of pocket costs. 

Insurance billing can also present complications for victims, including a loss of confidentiality. This is why OVW specifically discourages it in rather strong language:
We urge States to keep in mind that, in some cases, insurance billing can present a hardship for victims. For example, a victim of spousal rape may not want her husband to find out that she got a forensic exam. If the victim is forced to submit the claim to her insurance company and she is on her husband’s insurance, he may receive a statement from the insurance indicating that she got the exam. For this reason, the Office on Violence Against Women strongly encourages States to not require victims to file a claim with their insurers (OVW, 2007, pp. 24-25).
Even in the absence of abuse, partners or parents who receive an insurance statement will likely have questions about the purpose of any medical treatment, and this may eliminate the victim’s choice regarding whether or not to disclose the sexual assault. 

Insurance billing is thus one example of a practice that may meet the letter of the law for VAWA forensic compliance, but clearly fails to achieve the spirit of the law – which is to provide victims with prompt and unobstructed access to a medical forensic exam.
A Can the victim be billed for the co-pay for any medical expenses beyond the exam?

As stated above, states, territories, and tribes have discretion regarding which medical services, beyond the forensic exam, will be included in their payment mechanism. It is therefore quite common for victims to be billed for the costs of medical testing and treatment following standard procedures. This may require a co-pay. Victims may be eligible to apply to Crime Victim Compensation to have these expenses reimbursed, if they follow proper application procedures and meet eligibility requirements.

Victims cannot be required to pay for any part of the forensic examination, as defined by VAWA (see above). This includes any co-pay for the exam.
A What about costs for follow-up care?

This general statement regarding medical testing and treatment also applies to costs for follow-up care, including follow-up surgeries or reconstructive surgeries. These services would not typically be included in the definition of forensic examination - and therefore would not be paid by the entity covering the costs of medical forensic exams - unless this is the protocol established by the state, territory, or tribe (or even by the community or facility providing exams). In most cases, these medical costs will be billed following standard practices and the victim could apply for reimbursement through Crime Victim Compensation if she/he follows the application procedure and meets the eligibility requirements.
A Who pays for medical forensic exams across state lines?

A great deal of confusion surrounds the payment for medical forensic exams across state lines. Who should pay for these exams? How should payment be handled? The Sexual Violence Justice Institute (SVJI) at the Minnesota Coalition Against Sexual Assault (MNCASA) developed an informative yet simple fact sheet to offer helpful information about the policies for exam payment in Minnesota and a number of neighboring states. This tool can serve as a model for other organizations that want to create a similar resource.
This project is supported by Grant No. 2013-TA-AX-K045 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed on this website are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women.
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