Three Things You Should Know About Abortion Insurance Coverage: Shots

Abortion rights supporters gather at Minnesota State Capitol Building in downtown St. Paul after US Supreme Court ruling to quash Roe v. Wade.

Michael Siluk/Universal Images Group via Getty Images

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Michael Siluk/Universal Images Group via Getty Images


Abortion rights supporters gather at Minnesota State Capitol Building in downtown St. Paul after US Supreme Court ruling to quash Roe v. Wade.

Michael Siluk/Universal Images Group via Getty Images

Will your health insurance pay for an abortion now that the US Supreme Court has been overturned? Roe v. Wade?

Even before the June 24 ruling, abortion insurance coverage varied widely. Now the issue is even more complicated as states set different rules – about half are expected to restrict or prohibit abortion in almost all circumstances.

To be clear, whether an insurance plan covers abortion is not the same as whether abortion is allowed in a state. Coverage issues are more complicated and determined by many factors, including the level of abortion access a state allows.

How dense is a thicket? Abortion can be covered in a health plan, but if health care providers are not available, patients will not be able to access it. However, people with insurance that doesn’t cover abortion can still get one — but only if it’s available in their country or if they can afford to travel and pay out of pocket. There are also plenty of unanswered questions about whether states that restrict abortion have the legal authority to target coverage in employer plans.

The issues are likely to come to court for years to come.

“States will pass laws, there will be a conflict, and then it will go to the courts,” said Erin Fuse Brown, director of the Center for Law, Health & Society at Georgia State University College of Law. “It may take a while.”

In the meantime, here are answers to three frequently asked questions.

Are health plans — or employers — required to provide coverage for elective abortions?

The simple answer is “no”.

“There is no law requiring a health plan, employer-based or otherwise, to cover an elective abortion,” said Fuse Brown.

Whether they do is more complicated.

Some work-based health plans cover elective abortions. Patients can search their plan documents or call their insurer directly to verify.

Coverage is more likely in plans offered by confident employers because those plans are generally exempt from state laws. Self-funded employers, which are usually the larger ones, pay their employees’ medical bills out of pocket, although they generally hire third parties, sometimes health insurance companies, to handle claims and administrative work.

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Yet millions of Americans work for smaller employers, who tend to buy plans directly from health insurers, who then pay the medical bills. Those plans, known as “fully insured,” are subject to state laws, which have long varied regarding abortion coverage.

Eleven states prohibit those private plans to cover abortion in most cases, according to the Kaiser Family Foundation, although some states allow people to purchase insurance that would cover the cost.

If you are not sure what type of health plan you have, ask the administrators.

“There’s no way to tell from the front of your insurance card if you’re fully insured or self-funded,” said Fuse Brown.

For the more than 14 million Americans who purchase their coverage through Affordable Care Act marketplaces, their state of residence is critical.

Twenty-six states restrict abortion coverage in ACA plans, while seven states require it, according to KFF. Those states are California, Illinois, Maine, Maryland, New York, Oregon, and Washington.

The rules for Medicaid, the federal state’s health program for low-income people, also vary. Thirty-four states and the District of Columbia are following the Hyde Amendment, which prohibits federal funds from paying for abortions except in cases of rape or incest or to save the mother’s life, although some states allow coverage for others medically necessary abortions.

For all those reasons, it’s not surprising that research published in April in the journal Health Affairs found that patients paid for most abortions out of pocket (69% in one study). The researchers found that the median cost of a drug abortion was $560 and those abortion procedures ranged from a median of $575 in the first trimester to $895 in the second.

What about coverage for pregnancy-related complications that require treatment similar to abortion?

Insurance policies must cover care for essential health services, including medically necessary maternity care and abortion when carrying to term would endanger a patient’s life.

Under the Pregnancy Discrimination Act of 1978 and other rules, Fuse Brown said, “Pregnancy and prenatal care, including high-risk pregnancies, and obstetric care in general should be covered.”

In an ectopic pregnancy — when a fertilized egg implants outside the uterus — the embryo is not viable and the condition is generally life-threatening to the mother without medical treatment. Many other scenarios can come into play, such as if a woman miscarries but not all of the tissue is expelled, potentially leading to a dangerous infection.

While all state laws currently restricting abortion include an exception to save the mother’s life, it’s not always clear what a life-threatening scenario is. That means doctors in states that prohibit abortion may have to weigh the medical risk to the mother against possible legal ramifications.

“This is less a matter of coverage and more of a question of whether providers in the states that prohibit abortion will provide the care,” said Katie Keith, a research faculty member of the Center on Health Insurance Reforms at Georgetown University. “All of these laws are designed to cool behavior, to make it so unappealing or scary for providers to prevent them from doing it.”

Can residents of states where abortion is illegal get coverage in other states or get help with travel expenses?

In recent weeks, many major employers — including Microsoft, Bank of America, Disney and Netflix — have said they will set up programs to pay for travel expenses so that employees or other beneficiaries can legally access abortion services in states where it remains legal.

But it’s not as easy as it sounds. Employers will need to find out whether employees are reimbursed through the health plan or otherwise. Privacy protection can also be a problem. Some consultants also said employers should consider other conflicts as well. For example, if an employer reimburses travel expenses for abortion procedures but not an eating disorder clinic, does that violate the Equality of Mental Health and Addiction Care Act? If a plan doesn’t have providers willing or able to do abortions, does it violate state or federal rules that require reasonable network access to doctors and health services?

Lawmakers need to think about these conflicts, says Jessica Waltman, vice president for compliance at MZQ Consulting, a benefits company. “They could put all employer group plans in their state in a very precarious position if that state law prohibited them from complying with federal law,” she said, especially if they restrict access to benefits called for in the Pregnancy Discrimination Act.

There are other potential conflicts if an employer is in a state that allows abortion but an employee is in a state that restricts it. “If I’m an Oregon-based company, my insurance plan should provide abortion coverage, but what should I do with an Oklahoma employee? I don’t know the answer,” said René Thorne, director of the Jackson Lewis law firm, where she oversees litigation. involving confident companies.

It is also uncertain whether state laws will target insurers, employers, or others that cover abortion services, including travel or television visits.

Laws that restrict abortion, Thorne wrote in a paper on her company’s website, generally apply to the medical provider and sometimes to those who “help or encourage” the abortion. Some states, including Texas, allow private citizens to sue for $10,000 anyone who performs an illegal abortion or helps someone access an abortion.

Whether those laws are applied to employers or insurers will undoubtedly come to court.

“We are in uncharted territory here, as we have never been in a situation before where plans, as well as their employer sponsors and those managing the plans, could be held criminally liable in connection with a plan benefit,” said Seth Perretta, a director. at the Groom Law Group, which advises employers.

Answers won’t come anytime soon, but “there will be so many lawsuits about this,” Thorne said.

KHN (Kaiser Health News) is a national editorial that produces in-depth journalism on health issues. It is an editorially independent work program of KFF (Kaiser Family Foundation).