There are three things to know about insurance coverage for abortion

Will your health plan now pay for the abortion that the Supreme Court has overturned Rowe vs. Wade?

Even before the June 24 verdict, insurance coverage for abortion changed dramatically. Now the problem is more complicated because states have set different rules – about half are expected to limit or ban abortion in almost all situations.

To be clear, though, the question of whether an insurance plan covers abortion is not the same as whether abortion is allowed in a state. Coverage issues are more complex and controlled by a variety of factors, including the level of access to abortion that a state allows.

How dense is a bush? Abortion can be covered by a health plan, but if no provider is available, patients do not have access. However, people with insurance that do not cover abortion can still get one – but only if it is available in their state or they can travel and pay out of pocket. There are also many unanswered questions about whether the legal authority to target abortion coverage in employer plans limits abortion.

These issues will remain before the court for the next few years.

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

In the meantime, here are the answers to three common questions.

1. Should health plans – or employers – provide coverage for optional abortions?

The simple answer is “no.”

“There is no law that requires a health plan, employer-based or anything else, to cover an elective abortion,” Fuse Brown said.

Whether they will do it is more complicated.

Some job-based health plans cover alternative abortions. Patients can search their plan documents or call their insurers directly.

Plans proposed by self-insured employers are more likely to have coverage because a federal pension law generally prioritizes state control over those health plans. Self-funded employers, as they get older, pay medical bills, although they usually hire a third party, sometimes a health insurer, to handle claims and administrative work.

Still, millions of Americans work for small employers who tend to buy plans directly from health insurers, who then pay the medical bills. These plans, known as “fully insured,” are subject to state law, whose abortion coverage methods have changed over time.

According to the KFF, eleven states prevent those individual plans from covering abortions in most situations, although some states allow consumers to purchase an insurance rider that will cover the cost of abortion.

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

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

For the more than 14 million Americans who purchase their coverage through Affordable Care Act marketplaces, their living conditions are important.

Twenty-six states limit abortion coverage to ACA plans, while seven states require it as a planning facility, according to the KFF. These states are California, Illinois, Maine, Maryland, New York, Oregon and Washington.

The rules for the federal-state health program Medicaid for low-income people also change. Thirty-four states and the District of Columbia follow the so-called Hyde Amendment, which barred federal funds from paying for abortions, rape or incest, or saving a mother’s life, although some states allow coverage for other treatments. Necessary abortion.

For all these reasons, it is not surprising that a study published in the Journal of Health in April noted that patients paid out-of-pocket for most abortions (69% in one study). The researchers found that the average cost of a drug abortion was $ 560 and abortion methods ranged from an average of $ 575 in the first trimester to $ 895 in the second.

2. What about coverage for pregnancy-related complications that require treatment such as abortion?

Insurance policies must cover the care of essential health services, including medically necessary pregnancy care and abortion when abortion endangers a patient’s life.

Under the Pregnancy Discrimination Act of 1978 and other regulations, Fuse Brown said, “Pregnancy and prenatal care, including high-risk pregnancies, and maternity care in general need to be covered.”

In an ectopic pregnancy – when a fertilized egg is implanted outside the uterus – the fetus is not effective, and the condition is usually life-threatening for the mother without treatment. Many other conditions can be effective, including situations where a woman has an abortion but not all the tissue is removed, potentially leading to a dangerous infection.

Although all state laws currently restricting abortion include an exception to save the mother’s life, it is not always clear what creates a life-threatening situation. This means that physicians in abortion-prohibited states may have to weigh a pregnant person’s medical risks against the potential legal implications.

“This is less of a coverage question and more of a question about whether state providers that prohibit abortion will care,” said Katie Keith, a research faculty member at Georgetown University’s Center on Health Insurance Reforms. “All of these laws are designed to cool the behavior, to make it so attractive or intimidating to prevent providers from doing it altogether.”

3. Can residents of states where abortion is illegal get coverage in another state 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 for travel expenses so that workers or other beneficiaries in the state can travel for abortions elsewhere with restrictions.

But it’s not as easy as it sounds. Employers need to find out if employees will receive this benefit through a health plan or some other compensation method. Protecting privacy can also be a problem. Some consultants also say employers need to consider whether their travel reimbursement benefits conflict with other rules. If an employer, for example, covers travel for an abortion procedure but not for an eating disorder clinic, does this violate the Mental Health Parity and Addiction Equity Act? If a provider of a plan is unwilling or unable to perform an abortion, does it violate any state or federal network adequacy rules?

Lawmakers need to think about these conflicts, says Jessica Waltman, vice president for the approval of employee benefits firm MZQ Consulting. “They could throw the plans of all employer groups in their state into a very precarious position if that state law prohibits them from complying with federal law,” he said, especially if they limit access to the benefits stated in the Pregnancy Discrimination Act.

There are other potential conflicts if an employer is in a state that allows abortion but a worker is in a situation that limits it. “If I were an Oregon-based company, my insurance plan would certainly pay for abortion coverage, but what about Oklahoma employees? I don’t know the answer,” said Rene Thorne, a principal at Jackson Lewis, where he works with self-insured companies. Supervised the case involved.

It is also uncertain whether state laws will target insurers, employers or others providing benefits, including travel or television for abortion services.

Laws that restrict abortion, Thorne wrote in a white paper for clients, generally apply to medical providers and sometimes to those who “assist or support” abortion. Some states, including Texas, allow private citizens to sue for $ 10,000 if someone provides an illegal abortion or helps a person access an abortion.

Whether those laws apply to employers or insurers will undoubtedly end up in court.

“We’re in an unfamiliar area here because we’ve never been in a situation where the plan, as well as the sponsor of their employer and those who manage the plan, could face criminal liability for the benefit of a plan,” said Seth Pereta, president of a Groom Law group. Which advises employers.

The answer won’t come soon, but “there will be a lot of lawsuits around it,” Thorne said.

KHN (Kaiser Health News) is a national newsroom that creates in-depth journalism about health issues. KHN is one of the three major operating programs of KFF (Kaiser Family Foundation), including policy analysis and polling. KFF is a non-profit organization that provides health information to the nation.

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