What will your health plan do now that the Supreme Court has ruled against you? Roe v. Wade?
Even before the June 24, ruling, insurance coverage for abortion was varied. Now the issue is even more complex as states set varying rules — about half are expected to limit or ban abortion in almost all circumstances.
To be clear, the question of whether insurance plans cover abortion is not the same thing as whether abortion is legal in a particular state. Coverage issues are more complex and governed by a variety of factors, including the state’s ability to allow abortion access.
How dense is it? Abortion may be covered by a health plan, but if no providers are available, patients don’t have access. However, people with insurance that does not cover abortion can still get one — but only if it’s available in their states or they can afford to travel and pay out-of-pocket. There are still many questions about whether employers will have the legal authority in states that restrict abortion.
These issues will likely remain before the courts for many years.
“States will pass laws, there will be some conflict, and then it goes to the courts,” said Erin Fuse Brown, director of the Center for Law, Health & Society at the Georgia State University College of Law. “It could be a while.”
Here are three answers to common questions.
1. Are health plans — or employers — required to offer coverage for elective abortions?
The simple answer is “no.”
“There’s no law that requires any health plan, employer-based or anything else, to cover an elective abortion,” Fuse Brown said.
It is not clear if they do.
Some employer-based health plans include elective abortions. Patients can check their plan documents online or call their insurers to verify.
Because a federal pensions law generally preempts any state regulation of these health plans, coverage is more likely for plans offered by self-insured employer plans. The larger self-funded employers tend to pay the most medical bills. However they hire third parties, often health insurers, to handle administrative work and claims.
Millions of Americans still work for smaller companies, which tends to purchase plans directly from their health insurers, who then pay the medical bills. Those plans, known as “fully insured,” are subject to state laws, whose approaches to abortion coverage have long varied.
Eleven states bar those private plansKFF states that abortion is not covered in all circumstances. However, some states allow consumers to buy an insurance rider to cover abortion costs.
If you’re not sure what type of health plan you have, ask the administrators.
“There is no way to tell from the face of your insurance card if you are fully insured or self-funded,” Fuse Brown said.
The state of residents is crucial for the over 14 million Americans who have purchased their coverage through the Affordable Healthcare Act marketplaces.
KFF reports that 26 states have restrictions on abortion coverage in ACA plans. However, seven states require it as a benefit to their plans. These states include Washington, California, Illinois, Maine and Maryland, New York, Oregon, Washington, and New York.
The Medicaid rules, a federal-state health program that helps people with low incomes, are available here also vary. Thirty-four states, as well as the District of Columbia, follow the Hyde Amendment. This prohibits federal funds from paying abortions, except in the case of rape, incest, or to save the mother’s life. However, some states allow coverage for medically necessary abortions.
For all those reasons, it’s not surprising that research published in the journal Health AffairsIn April, 69% of abortions were performed out-of-pocket. The median cost of a medication-abortion was $560, and the median cost of an abortion procedure ranged between $575 in a first trimester and $895 in the second.
2. What about coverage to cover pregnancy-related complications that are similar to abortion?
Insurance policies must cover essential health services. medically necessary pregnancy care and abortion when carrying a pregnancy to term would endanger a patient’s life.
The following are the guidelines Pregnancy Discrimination Act of 1978 and other rules, Fuse Brown said, “pregnancy and prenatal care, including high-risk pregnancies, and obstetric care in general is required to 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. Other scenarios are possible, including those in which a woman experiences a miscarriage, but not all of the tissue is removed, potentially leading to a dangerous infection.
While all state laws currently restricting abortion have an exception to protect the mother’s life, it is not always clear what constitutes a life-threatening situation. That means physicians in abortion-ban states may have to weigh the pregnant person’s medical risk against possible legal ramifications.
“This is less of a coverage question and more of a question of whether providers in the states that ban abortion are going to provide the care,” said Katie Keith, a Georgetown University research faculty member. “All of these laws are designed to chill behavior, to make it so unattractive or scary to providers to keep them from doing it at all.”
3. Residents of states with abortion laws that are illegal can they get coverage in other States or help with travel expenses?
In recent weeks, many large employers — including Microsoft, Bank of America, Disney, and Netflix — have said they will set up programs to help pay travel costsWorkers and other beneficiaries from states that ban abortion can travel to obtain an abortion elsewhere.
But it isn’t as straightforward as it sounds. Employers will have the responsibility of determining whether workers will stay employed. access this benefitby the health plan, or any other reimbursement method. Protecting privacyThis could also be a problem. Consultants also suggested that employers should consider whether their travel reimbursement benefits conflict with other rules. Does it violate the law if an employer covers travel to an abortion clinic but not to an eating disorder clinic? Mental Health Parity and Addiction Equity Act? Is it illegal to have abortions performed by a plan that does not have providers?
Jessica Waltman, vice-president for compliance at MZQ Consulting, stated that lawmakers must consider these conflicts. “They could be putting all the employer group plans in their state in a very precarious position if that state law would prohibit them from complying with federal law,” she said, particularly if they restrict access to benefits called for in the Pregnancy Discrimination Act.
There are other possible conflicts if the employer is located in a state that allows abortion, but the worker is in one that prohibits it. “If I’m an Oregon-based company, my insurance plan must provide for abortion coverage, but what do I do about an Oklahoma employee? I don’t know the answer,” said René ThorneJackson Lewis’ principal, where she oversees litigation that involves self insured firms.
It is not clear whether state laws are going to target employers, insurers, or other providers of benefits, such as travel or videovisits, for abortion services.
Thorne wrote that laws that restrict abortion are lawful in a white paper for clients, generally apply to the medical provider and sometimes those who “aid or abet” the abortion. Texas is one of the states that allows private citizens to sue anyone who assists in accessing or provides illegal abortions.
The courts will decide whether these laws will be applied to insurers or employers.
“We are in uncharted territory here, as we’ve never before been in a situation where plans, as well as their employer sponsors and those administering the plans, might face criminal liability in connection with a plan benefit,” said Seth PerrettaGroom Law Group principal, which advises employers, is authored by.
Answers won’t come soon, but “there will be so much litigation around this,” said Thorne.
Kaiser Health News (KHN)National newsroom that produces detailed journalism about health issues. Together with Policy Analysis and Polling KHNOne of the three main operating programs at KFF(Kaiser Family Foundation). KFF is an endowed non-profit organization that provides information to the nation on health issues.
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