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State Motion to Defend and Promote Abortion Entry in State-Regulated Well being Plans

By Rachel Swindle and Karen Davenport

Within the 2022 determination Dobbs v. Jackson Ladies’s Well being Group, the U.S. Supreme Courtroom reversed the long-standing precedent of Roe v. Wade, taking away a beforehand acknowledged constitutional proper to abortion. Dobbs didn’t outlaw abortion companies, however the determination permits states to impose restrictions and bans beforehand deemed unconstitutional. Over the past yr, a number of states have restricted abortion entry or prohibited abortion companies fully. Different states have taken steps to protect abortion entry, resembling enshrining abortion rights in state constitutions. Along with defending the supply of abortion care, states can pursue focused insurance policies to develop entry to abortion companies in state-regulated medical health insurance plans.

Abortion Utilization, Price, and Protection As we speak


Abortion is a typical medical process; based on the latest evaluation by the Guttmacher Institute, almost one in 4 girls will terminate a being pregnant previous to age 45. For comparability, one in 4 girls will obtain a coronary coronary heart illness prognosis whereas one in eight girls shall be recognized with breast most cancers of their lifetime.

Price and Protection

Abortion prices fluctuate considerably based mostly on the kind of abortion (medicine or procedural), setting (free-standing clinic or hospital), trimester of being pregnant, and whether or not the affected person pays for the process themselves or by their medical health insurance. In 2020, median prices for self-pay sufferers had been $560 for first trimester medicine abortions, $575 for first trimester procedural abortions, and $895 for abortions within the second trimester. However prices might be a lot larger—generally 1000’s of {dollars}—for individuals who want hospital-based care to terminate a being pregnant.

Even insured sufferers could face these prices. A survey of abortion sufferers in non-hospital settings from 2021­–2022 discovered 11.4 % of respondents used personal insurance coverage to pay for abortion care although a 3rd of respondents had personal protection. In an earlier examine, the commonest motive privately insured sufferers cited for not utilizing their well being plan to pay for abortion care was that the process was not coated. In an extra indication that privately insured sufferers could not have protection for abortion care, KFF’s 2019 Employer Well being Profit Survey decided that 10 % of staff with employer-sponsored medical health insurance work for corporations that requested their well being plan or third-party administrator to exclude protection for abortion care in some or all circumstances. Customers coated by the Reasonably priced Care Act (ACA) Market additionally face insurance-related boundaries to abortion care. In 2020, shoppers in 33 states couldn’t entry a Certified Well being Plan (QHP) on the ACA Market that coated abortion.

States Can Defend and Promote Abortion Entry Inside State-Regulated Plans

States stay the first regulators of personal medical health insurance. Congress precluded the ACA from pre-empting state legal guidelines associated to abortion protection, apart from an present exemption for “self-funded” employer well being plans. Accordingly, states can promote abortion entry for residents enrolled in well being plans bought on the ACA Market in addition to “absolutely insured” employer plans by pursuing a variety of coverage modifications.

Requiring State-regulated Plans to Cowl Abortion

States can require QHPs and different state-regulated well being plans to cowl abortions. In accordance with the Guttmacher Institute, eight states at the moment require personal well being plans to cowl abortion companies. Eleven states limit abortion protection in all state-regulated plans, sometimes by limiting protection to circumstances resembling “life endangerment,” whereas one other 14 states particularly limit or prohibit abortion protection in QHPs alone. The remaining states—resembling Connecticut and Minnesota—neither require nor prohibit state-regulated plans from protecting abortion. Among the many states that require state-regulated personal medical health insurance merchandise to cowl abortion companies, some, resembling Oregon, have required protection for years, whereas others, resembling Massachusetts, have solely lately codified this requirement. Most lately, New Jersey’s Division of Banking Insurance coverage introduced the adoption of laws extending the abortion protection requirement for state-regulated particular person and small group market plans, which had been in place for the reason that starting of this yr, to the absolutely insured giant group market within the state.

Defending Privately Insured Customers from Out-of-Pocket Prices

States may take steps to scale back or take away out-of-pocket prices related to abortion care. In accordance with the Guttmacher Institute, all states mandating abortion protection in state-regulated plans additionally limit insurers from charging value sharing for abortion care, however the scope of safety varies by state. For instance, whereas Oregon prohibits state-regulated plans from imposing any value sharing on abortion care, New York solely bans value sharing for “in-network abortions” (permitting insurers to cost out-of-network value sharing) and permits high-deductible well being plans to use the deductible to abortion companies. Analysis has discovered important regional variation in whether or not abortion suppliers settle for insurance coverage, making restrictions on out-of-network value sharing necessities a important client safety in some states.

Limiting or Eradicating Boundaries to Look after Enrollees

To additional enhance abortion entry, states can restrict or prohibit profit designs and plan practices that pose obstacles for enrollees searching for abortion care. Earlier analyses have discovered that QHPs impose a variety of limits on abortion protection, resembling annual and lifelong limits on the variety of abortions a member could obtain, restrictions on the kind of abortion companies they cowl (i.e., procedural versus medicine abortion), or limitations based mostly on the period of being pregnant. In most states, personal well being plans may apply utilization administration strategies to abortion care, resembling prior authorization or referral necessities. Some states have restricted or banned sure utilization administration practices. For instance, as of 2023, California prohibits state-regulated plans from making use of lifetime or annual limits, prior authorization, or referral necessities to abortion care. State insurance coverage regulators, resembling these in Massachusetts and California, have bolstered these statutory restrictions by implementation and enforcement actions.

Facilitating Simpler Market Enrollment

When Market plans cowl abortion—whether or not in response to a state profit mandate or in states the place they’re allowed however not required to cowl abortion companies—federal regulation prohibits the usage of federal funds to pay for abortion protection past the circumstances of rape, incest, or life endangerment. Which means that federally funded premium subsidies out there to Market enrollees can’t cowl the portion of the premium used to insure for prices associated to most abortion care. As well as, insurers providing QHPs should segregate premium funds for abortion protection from funds for protection of all different companies, they usually could individually itemize or individually invoice premiums associated to abortion protection. Though the portion of Market premiums attributable to abortion companies in plans that cowl abortion is small—solely round $1—nominal premiums can cut back enrollment and retention in well being plans.

States can enact insurance policies to offset this value and cut back the executive burden of enrolling in Market plans. California, for instance, affords a $1 per member monthly premium subsidy to cowl the portion of the premium attributable to abortion companies. Maryland supplies an identical premium subsidy for a narrower inhabitants—Market enrollees between the ages of 18 and 35 who’re eligible for a 0 % premium contribution below the state’s Younger Grownup Subsidy Program.


When the Supreme Courtroom issued the Dobbs determination, they allowed states to find out abortion coverage. Whereas many states have wielded this energy to ban or limit abortion, others have taken the chance to guard and enhance entry to this primary and essential well being care service, together with by their function as main regulators of personal insurance coverage. These protections embody profit mandates, prohibiting or limiting value sharing for abortion companies, stopping restrictive profit design and utilization administration strategies, and protecting the portion of Market premiums associated to abortion protection. With public help for abortion rights at an all-time excessive, state policymakers have a chance to guard and enhance abortion protection for residents enrolled in state-regulated well being plans.



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