Health Insurance Exchanges: Coverage of Non-excepted Abortion Services by Qualified Health Plans

What GAO Found

Under the Patient Protection and Affordable Care Act (PPACA), insurance plans offered in health insurance exchanges—known as qualified health plans (QHP)—may cover abortion services as a benefit consistent with federal and state law. Federal law applicable to QHPs for the 2014 benefit year prohibits the use of federal funds made available to offset the cost of QHP coverage to pay for abortion services except where the pregnancy is the result of rape or incest, or the life of the pregnant woman would be endangered unless an abortion is performed. QHPs may cover abortion services that do not meet that exception (referred to as non-excepted abortion services), but state law may restrict the circumstances under which coverage can be provided. For the 2014 benefit year, 17 states do not allow QHPs to provide non-excepted abortion services, and 6 states permit the coverage of such services only in certain limited circumstances. Among the remaining 28 states (including the District of Columbia) with no such laws, in 5 states all QHPs cover non-excepted abortion services; in 15 states some QHPs cover non-excepted abortion services; and in 8 states no QHPs cover non-excepted abortion services. Nationally, 1,036 QHPs in these 28 states cover non-excepted abortion services and 1,062 QHPs do not.

Of the 18 issuers from which GAO obtained information—which offered nearly one-quarter of the QHPs covering non-excepted abortion services in the 28 states—all but three issuers indicated that the benefit is not subject to any restrictions, limitations, or exclusions. All 18 issuers also indicated that their abortion services benefit is subject to the same requirements as other benefits, such as enrollee out-of-pocket costs—including deductibles, copayments, and coinsurance—and prior authorization requirements, all of which can vary depending on the location where the service is provided. To estimate the cost of the coverage of non-excepted abortion services, issuers indicated that they generally reviewed historical costs for these procedures. All but one of the issuers from which GAO obtained information estimated the cost of coverage of non-excepted abortion services to be less than $1 per enrollee per month—the minimum amount required to be estimated under PPACA for these services, and all but two of these issuers rounded the amount up to $1 to comply with PPACA. The highest cost estimated by the issuers GAO collected information from was $1.10 per enrollee per month. Fifteen issuers and a state-based exchange which bills enrollees on behalf of issuers did not itemize the premium amount associated with non-excepted abortion services coverage on enrollees’ bills nor indicate that they sent a separate bill for that premium amount. Six issuers GAO contacted indicated that they provided information about coverage for abortion services to consumers before they enrolled in QHPs, while others indicated that consumers shopping for QHPs would need to call the issuer to obtain such information.

PPACA requires QHPs to cover a package of essential health benefits. While this package does not include abortion services, QHPs may cover those services, consistent with federal and state law. GAO was asked to provide a list of QHPs that do and that do not cover abortion services and for additional information on issues related to that coverage. This report describes whether non-excepted abortion services are covered by QHPs within the 28 states with no laws restricting such coverage for the 2014 benefit year and provides additional information—such as the scope and the cost of non-excepted abortion services coverage—for selected QHPs that cover such services.

To obtain the information presented here, GAO contacted every state to determine whether states had laws restricting the circumstances under which abortion services may be provided as a covered benefit by QHPs for 2014. Based on a review of those laws and relevant federal requirements, GAO determined that 23 states have laws restricting the circumstances under which non-excepted abortion services may be provided as a covered benefit by QHPs for the 2014 benefit year. In order to report on whether non-excepted abortion services are covered by QHPs within the 28 states with no laws restricting such coverage in 2014, GAO obtained data on QHPs’ coverage of non-excepted abortion services from the Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), the agency responsible for overseeing the establishment of health insurance exchanges; private issuers of QHPs; state departments of insurance and state exchange organizations; and from officials at the Office of Personnel Management. To provide additional information regarding non-excepted abortion services for selected QHPs that cover such services, GAO interviewed and collected documentation from a non-probability sample of 18 issuers about the QHPs they offer in 10 states; while not generalizable, this sample covers almost a quarter of the QHPs covering non-excepted abortion services in these states.