Key Takeaways
- There’s great variability in how a lot states reimburse for abortion providers in states that use state funds to pay for abortions for his or her Medicaid enrollees (international charges for medicine abortion: $162 (RI) to $665 (NM), D&C procedures: $146 (WA) to $1,000 (NY), D&E procedures: $248 (WA) to $1,300 (NY)). IL reimburses $1,920 for a D&E process, which is a worldwide fee that features all different providers supplied with the process.
- Though scientific care is extra difficult after the primary trimester, reimbursement charges don’t enhance considerably to replicate the elevated complexity and better prices related to abortion care later in being pregnant (median reimbursements: $334 for D&C vs. $570 for D&E).
- Lately, some states, comparable to Illinois, New York, New Mexico, and Maryland have considerably boosted their Medicaid reimbursement charges to assist abortion entry of their states within the face of abortion bans and restrictions in states throughout the nation. For instance, six states have greater than doubled their reimbursement charges for D&C procedures and 5 states for D&E procedures since 2017.
Medicaid is a joint federal and state program and Medicaid fee charges, that are set by the states, have been the main target of coverage consideration since its early days. Typically talking, Medicaid reimbursement charges have traditionally been decrease than these paid by Medicare and are even decrease relative to non-public insurance coverage charges. These decrease charges have been cited as a disincentive to Medicaid supplier participation, which limits the pool of suppliers prepared to serve Medicaid enrollees and constrains their entry to care.
Underneath Medicaid, fee for abortion providers has been additional difficult by the federal Hyde Modification, which has banned the usage of any federal funds for abortion since 1977, solely permitting exceptions for pregnancies that endanger the lifetime of the pregnant individual, or that outcome from rape or incest. In 19 states and the District of Columbia the place abortion will not be banned, Medicaid packages don’t pay for any abortions past the Hyde exceptions, which means that low-income pregnant enrollees looking for abortions should pay for the providers out-of-pocket or depend on donations from abortion funds to assist cowl the prices. For the reason that Dobbs determination overturning Roe v Wade, 14 states have banned abortion with solely very restricted exceptions and almost all of the abortion suppliers in these states have both closed their providers or moved to different states.
At the moment, 17 states use their very own state funds to pay for abortions for ladies with Medicaid in circumstances past the federal limitations set within the Hyde Modification and abortion stays authorized in these states (Determine 1). In contrast to different providers utilized by Medicaid enrollees wherein the prices of care are divided between the federal and state authorities, the states bear the complete price of abortion care.
At the moment, 44% of reproductive age girls with Medicaid protection reside in states that use their very own funds to pay for abortion providers for Medicaid enrollees in circumstances past the federal Hyde limitations. A fifth (21%) of girls with Medicaid protection reside in a state the place abortion is banned, and a 3rd (35%) reside in a state the place there is no such thing as a ban, however abortion protection is at the moment restricted by the Hyde Modification.
In analysis carried out earlier than the Dobbs determination, even when Medicaid does reimburse for abortion providers, suppliers have reported decrease reimbursement charges from Medicaid in comparison with self-pay. For instance, a 2020 research reviewed 2017 Medicaid and Medicare doctor charges schedules for dilation and curettage (D&C) and dilation and evacuation (D&E) procedures for 45 states and D.C. They discovered median Medicaid reimbursement charges for a first- and second-trimester abortion would cowl 37% and 41% of what a self-pay affected person could be charged for the process, respectively. The research didn’t tackle the charges for abortions after the second trimester.
To know the state of Medicaid fee for abortion providers post-Dobbs, KFF researchers reviewed Medicaid doctor price schedules for medicine and procedural abortions in states that don’t ban abortion, together with each states that use state funds to pay for abortions for Medicaid enrollees and states that solely pay for abortions within the circumstances of pregnancies ensuing from rape, incest, or life endangerment. The reimbursement charges offered are for fee-for-service (FFS) claims, as managed care charges aren’t usually publicly accessible. Whereas many pregnant individuals lined by Medicaid are enrolled in managed care organizations (MCOs), FFS charges are an essential window for understanding reimbursement ranges, and in lots of states, the FFS charges are the minimal fee stage for MCO plans. The reimbursement charges offered on this temporary are for non-facility (e.g., outpatient clinics or doctor’s workplaces) provider-only charges (e.g., excluding any facility charges) since most abortions are carried out exterior of a hospital setting. Some states, comparable to Massachusetts and Connecticut, have completely different reimbursement charges for freestanding clinics offering household planning and abortion providers, which are sometimes increased than supplier price schedule charges, and people charges had been used when accessible.
Some states use a bundled reimbursement for abortion providers the place providers supplied with the abortion are included within the bundled fee charge, whereas different states use unbundled billing and suppliers can invoice for all extra providers supplied with the abortion. Different providers typically billed for on the day of the abortion in states that use unbundled codes might embody an ultrasound, medicine administration, a nerve block, and Rh testing, that are outlined in coding guides developed by the Reproductive Well being Entry Venture for guide vacuum aspiration abortion and medicine abortion. Median reimbursement quantities for every of those providers from state Medicaid doctor price schedules are reported under.
Remedy Abortion
In 2023, medicine abortion accounted for 63% of all abortions. The 2-drug routine is FDA permitted to terminate pregnancies as much as 10 weeks within the U.S. Regardless of the large use of medicine abortion, fewer states publicly report reimbursement charges for medicine abortion than for procedures. Remedy abortion could be billed utilizing three separate process codes and sometimes all three codes are billed on the similar time. There are codes for mifepristone/Mifeprex (S0190), misoprostol (S0191), in addition to a worldwide medicine abortion code (S0199) that features all related providers and provides (e.g., affected person counseling, workplace visits, affirmation of being pregnant by HCG, ultrasound to substantiate period of being pregnant, ultrasound to substantiate completion of abortion). Nonetheless, not all states reimburse for all three of the codes for medicine abortion. States usually take two completely different approaches to reimburse for providers offered to sufferers that obtain medicine abortion: (1) a bundled international fee utilizing the worldwide medicine abortion code (S0199) along with the drugs; or (2) fee for separate providers, like ultrasounds and Rh testing, along with the drugs. Sixteen states that use state funds to pay for abortion providers for Medicaid enrollees checklist reimbursement for no less than one of many three medicine abortion codes, with 11 reimbursing for the worldwide medicine abortion code, 13 reimbursing for mifepristone, and 13 itemizing reimbursement for misoprostol. The median Medicaid reimbursement for the worldwide medicine abortion code (S0199) is $470, starting from a low of $81 in Rhode Island to a excessive of $570 in New Mexico (Determine 2). The median reimbursement for mifepristone is $81, starting from a low of $49 in Vermont to a excessive of $99 in Maine. The median reimbursement for misoprostol, a drug that’s utilized in different obstetric procedures, is $1 and ranges from $1 to $5. If the median quantities for all three medicine abortion codes are summed, the median reimbursement for medicine abortion is $539. Nonetheless, the vary throughout states is sort of massive, from $162 in Rhode Island to $665 in New Mexico.
Whereas most states that use their very own funds to pay for abortion providers for Medicaid enrollees checklist reimbursement charges for medicine abortion, solely half of states that observe Hyde restrictions checklist reimbursement charges for medicine abortion and median reimbursement in these states is considerably decrease (see Appendix Determine 2).
For the states that don’t used the bundled code for medicine abortion, the charges for the 2 medicine vary from $68 in Alaska to $91 in New Jersey. In these states, suppliers might invoice for different providers — comparable to an workplace go to, an ultrasound, or Rh testing – which may doubtlessly add lots of of {dollars} to the quantity reimbursed, as proven in Desk 1.
Of notice, these charges are for medicine abortion provision in outpatient clinics or doctor’s workplace. At the moment, roughly 16% of all abortions are medicine abortions offered via telehealth. This report doesn’t particularly tackle the reimbursement charges for these providers that are probably completely different since they don’t embody parts of care such because the ultrasound.
D&C Procedures
Dilation and curettage (D&C) is a typical abortion process that can be utilized as much as roughly 16 weeks of gestation. Medicaid doctor price schedules for fee-for-service reimbursement charges had been printed on-line for D&C procedures in all 17 states that use state funds to reimburse for abortion providers for Medicaid enrollees (Determine 3). The median reimbursement for a D&C process in these states was $334, ranging broadly from $146 in Washington to $1,000 in New York. Some states have considerably boosted their fee charges in recent times, notably, NY, IL, CT, NM, MD and NJ have greater than doubled their fee charges since 2017 (Determine 3). Nonetheless, in lots of states, the will increase have been fairly modest over the previous 7 seven years. In states that solely reimburse for abortions in circumstances of pregnancies ensuing from rape, incest, and life endangerment, fee charges had been significantly decrease (see Appendix Determine 1).
Different providers could also be billed and reimbursed on the day of a procedural abortion, which may embody an ultrasound, medicine administration like lidocaine and methergine, or a nerve block for ache, in addition to Rh testing and Rh immunoglobulin administration. Not all states reimburse for all of those additional providers, and never all suppliers might essentially be billing for all of the doable providers (Desk 2). Some states like Illinois and New Mexico reimburse the abortion process (59840 and 59841) as a bundled code and won’t pay for different associated providers when these codes are billed. Due to this fact, Illinois and New Mexico had been faraway from the calculations within the desk under detailing median quantities for different providers which may be offered on the day of the abortion.
D&E Procedures
For a dilation and evacuation (D&E) process, which is commonly used within the second trimester, the reimbursement charges equally diverse broadly by state (Determine 4). In states that fund abortion providers for Medicaid enrollees the median reimbursement for a D&E process was $570, starting from a low of $248 in Rhode Island and Washington to a excessive of $1,920 in Illinois. States that considerably elevated D&C charges from 2017 to 2024 additionally considerably elevated D&E charges, notably Illinois elevated reimbursement charges for D&E by 860% and NY and NM greater than doubled their charges.
Just like D&C procedures, the median reimbursement for D&E procedures in states that pay for abortions for Medicaid enrollees is increased than in states that solely cowl abortions in circumstances of rape, incest, and life endangerment (see Appendix Determine 2). On condition that D&E procedures are usually offered later in being pregnant, it’s putting that some states are reimbursing the identical quantity or simply barely increased for this extra difficult process than a D&C, which is often accomplished earlier in being pregnant. Moreover, plainly some states haven’t raised their Medicaid abortion reimbursement ranges since no less than 2017 (California and Hawaii) though these states are anticipated to extend their fee charges within the close to future.
Like D&C procedures, suppliers can typically invoice for different providers supplied with the D&E process, comparable to ultrasounds, drugs, nerve blocks, and the workplace go to, if the code will not be a bundled code (Desk 3). Just like D&C procedures, Illinois and New Mexico use bundled funds for D&E procedures that embody all different providers supplied with the D&E procedures and, subsequently, aren’t included within the calculations within the desk under.
Greater than half of reproductive aged girls with Medicaid reside in states the place abortion is both banned or the circumstances below which Medicaid will cowl an abortion are extraordinarily restricted. Medicaid enrollees residing in these states might should depend on abortion funds or assist from household and mates to pay for his or her abortion providers, or they could forgo getting providers altogether. Within the Guttmacher Institute’s survey of abortion sufferers carried out between June 2021 and July 2022, they discovered 22% of abortion sufferers residing in abortion restrictive states relied on monetary subsidies from abortion funds or clinic reductions to pay for his or her abortion in comparison with 11% of abortion sufferers residing in abortion-rights protecting states. Within the 12 months after Dobbs, abortion funds reported a spike in requests for monetary assist to entry abortions, however attributable to a rise in demand and prices and a lower in donations, some abortion funds have needed to considerably cut back assist. The longer somebody has to attend to obtain abortion providers, the costlier the providers change into for individuals who should pay out of pocket. Conversely, the Guttmacher Institute discovered that greater than 4 in ten individuals acquiring abortions in protected states used Medicaid to cowl the price of their abortion, underscoring the significance of Medicaid entry in states the place the availability of abortion stays authorized.
The prices of offering abortions has additionally grown in all states as the prices of medical tools and personnel enhance yearly. As well as, there are particular bills related to offering abortion care with which different outpatient clinics do not need to contend. Abortion clinics have added safety prices to maintain their workers and sufferers protected from anti-abortion actions, comparable to additional safety guards, cameras, workers background checks, and bulletproof home windows. Elevated security considerations and prices have made it tough to retain their workforce. All of those elements of offering abortion care make ample reimbursement for abortion providers an much more essential consideration if the abortion supplier community is to be sustained in states the place abortion will not be banned.
On the Horizon
Just a few states have made efforts in recent times to bump up their reimbursement charges for abortion providers, most notably New Mexico, New York, and Illinois. These increased funds may enhance abortion suppliers’ willingness to take part in Medicaid, doubtlessly lowering the monetary boundaries skilled by individuals with decrease incomes who should pay for his or her abortion out-of-pocket or depend on monetary help from abortion funds. Nonetheless, regardless of the elevated complexity of D&E procedures, the Medicaid funds aren’t considerably increased than reimbursements for first trimester D&C procedures. And whereas reimbursement for care after the second trimester will not be addressed on this report it probably represents an much more complicated process and better prices for suppliers.
California has lately proposed rising Medi-Cal reimbursement charges for each abortion procedures and medicine abortion to $1,150 no matter methodology, which might be the very best reimbursement for medicine abortion throughout all states. Nonetheless, in different states, the shortage of ample Medicaid reimbursement for these providers might additional exacerbate reproductive entry inequities for individuals with low incomes.
In states the place abortion stays authorized, there was a large enhance within the variety of abortions. Satisfactory Medicaid reimbursement for each procedural and medicine abortions can enhance the monetary stability of clinics in these states. It may well additionally doubtlessly enhance the variety of suppliers who can serve sufferers with Medicaid protection in addition to different sufferers looking for abortions each in-state and from states the place abortion is banned or restricted.