Variability in Cost Charges for Abortion Companies Beneath Medicaid

Key Takeaways

  • There’s great variability in how a lot states reimburse for abortion companies in states that use state funds to pay for abortions for his or her Medicaid enrollees (world charges for remedy 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 world fee that features all different companies supplied with the process.
  • Though medical care is extra difficult after the primary trimester, reimbursement charges don’t enhance considerably to mirror 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. Usually talking, Medicaid reimbursement charges have traditionally been decrease than these paid by Medicare and are even decrease relative to private 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.

Beneath Medicaid, fee for abortion companies has been additional difficult by the federal Hyde Amendment, which has banned using any federal funds for abortion since 1977, solely permitting exceptions for pregnancies that endanger the lifetime of the pregnant individual, or that end result from rape or incest. In 19 states and the District of Columbia the place abortion is just not banned, Medicaid applications don’t pay for any abortions past the Hyde exceptions, which means that low-income pregnant enrollees in search of abortions must pay for the companies out-of-pocket or depend on donations from abortion funds to assist cowl the prices. Because the Dobbs determination overturning Roe v Wade, 14 states have banned abortion with solely very restricted exceptions and practically all of the abortion suppliers in these states have both closed their companies or moved to different states.

At the moment, 17 states use their very own state funds to pay for abortions for girls with Medicaid in circumstances past the federal limitations set within the Hyde Modification and abortion stays authorized in these states (Determine 1). Not like different companies utilized by Medicaid enrollees by which the prices of care are divided between the federal and state authorities, the states bear the complete value of abortion care.

At the moment, 44% of reproductive age ladies with Medicaid protection stay in states that use their very own funds to pay for abortion companies for Medicaid enrollees in circumstances past the federal Hyde limitations. A fifth (21%) of girls with Medicaid protection stay in a state the place abortion is banned, and a 3rd (35%) stay in a state the place there isn’t a ban, however abortion protection is at present restricted by the Hyde Modification.

In analysis performed earlier than the Dobbs determination, even when Medicaid does reimburse for abortion companies, suppliers have reported decrease reimbursement charges from Medicaid in comparison with self-pay. For instance, a 2020 study 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 can be charged for the process, respectively. The research didn’t handle the charges for abortions after the second trimester.

To know the state of Medicaid fee for abortion companies post-Dobbs, KFF researchers reviewed Medicaid doctor charge schedules for remedy 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 are usually not sometimes publicly accessible. Whereas many pregnant folks 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 degree for MCO plans. The reimbursement charges offered on this temporary are for non-facility (e.g., outpatient clinics or doctor’s places of work) provider-only charges (e.g., excluding any facility charges) since most abortions are carried out outdoors of a hospital setting. Some states, comparable to Massachusetts and Connecticut, have totally different reimbursement charges for freestanding clinics offering household planning and abortion companies, which are sometimes larger than supplier charge schedule charges, and people charges had been used when accessible.

Some states use a bundled reimbursement for abortion companies the place companies supplied with the abortion are included within the bundled fee charge, whereas different states use unbundled billing and suppliers can invoice for all further companies supplied with the abortion. Different companies typically billed for on the day of the abortion in states that use unbundled codes could embody an ultrasound, remedy administration, a nerve block, and Rh testing, that are outlined in coding guides developed by the Reproductive Health Entry Mission for manual vacuum aspiration abortion and medication abortion. Median reimbursement quantities for every of those companies from state Medicaid doctor charge schedules are reported under.

Treatment Abortion

In 2023, medication abortion accounted for 63% of all abortions. The 2-drug routine is FDA authorized to terminate pregnancies as much as 10 weeks within the U.S. Regardless of the broad use of remedy abortion, fewer states publicly report reimbursement charges for remedy abortion than for procedures. Treatment abortion could be billed utilizing three separate process codes and infrequently all three codes are billed on the identical time. There are codes for mifepristone/Mifeprex (S0190), misoprostol (S0191), in addition to a world remedy abortion code (S0199) that features all related companies and provides (e.g., affected person counseling, workplace visits, affirmation of being pregnant by HCG, ultrasound to verify period of being pregnant, ultrasound to verify completion of abortion). Nevertheless, not all states reimburse for all three of the codes for remedy abortion. States sometimes take two totally different approaches to reimburse for companies supplied to sufferers that obtain remedy abortion: (1) a bundled world fee utilizing the worldwide remedy abortion code (S0199) along with the medicines; or (2) fee for separate companies, like ultrasounds and Rh testing, along with the medicines. Sixteen states that use state funds to pay for abortion companies for Medicaid enrollees listing reimbursement for at the very least one of many three remedy abortion codes, with 11 reimbursing for the worldwide remedy abortion code, 13 reimbursing for mifepristone, and 13 itemizing reimbursement for misoprostol. The median Medicaid reimbursement for the worldwide remedy 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 remedy abortion codes are summed, the median reimbursement for remedy abortion is $539. Nevertheless, the vary throughout states is kind of giant, from $162 in Rhode Island to $665 in New Mexico.

Whereas most states that use their very own funds to pay for abortion companies for Medicaid enrollees listing reimbursement charges for remedy abortion, solely half of states that comply with Hyde restrictions listing reimbursement charges for remedy 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 remedy abortion, the charges for the 2 medication vary from $68 in Alaska to $91 in New Jersey. In these states, suppliers could invoice for different companies — comparable to an workplace go to, an ultrasound, or Rh testing – which might doubtlessly add tons of of {dollars} to the quantity reimbursed, as proven in Desk 1.

Of be aware, these charges are for remedy abortion provision in outpatient clinics or doctor’s workplace. At the moment, roughly 16% of all abortions are remedy abortions supplied by telehealth. This report doesn’t particularly handle the reimbursement charges for these companies that are probably totally different since they don’t embody elements 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 charge 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 companies 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 companies could also be billed and reimbursed on the day of a procedural abortion, which might embody an ultrasound, remedy 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 companies, and never all suppliers could essentially be billing for all of the attainable companies (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 companies when these codes are billed. Subsequently, Illinois and New Mexico had been faraway from the calculations within the desk under detailing median quantities for different companies which may be supplied on the day of the abortion.

D&E Procedures

For a dilation and evacuation (D&E) process, which is usually used within the second trimester, the reimbursement charges equally various broadly by state (Determine 4). In states that fund abortion companies 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.

Much like D&C procedures, the median reimbursement for D&E procedures in states that pay for abortions for Medicaid enrollees is larger than in states that solely cowl abortions in circumstances of rape, incest, and life endangerment (see Appendix Determine 2). Provided that D&E procedures are sometimes supplied later in being pregnant, IT is putting that some states are reimbursing the identical quantity or simply barely larger for this extra difficult process than a D&C, which is often completed earlier in being pregnant. Moreover, IT appears that some states haven’t raised their Medicaid abortion reimbursement ranges since at the very least 2017 (California and Hawaii) though these states are anticipated to increase their payment rates within the close to future.

Like D&C procedures, suppliers can typically invoice for different companies supplied with the D&E process, comparable to ultrasounds, medicines, nerve blocks, and the workplace go to, if the code is just not a bundled code (Desk 3). Much like D&C procedures, Illinois and New Mexico use bundled funds for D&E procedures that embody all different companies supplied with the D&E procedures and, due to this fact, are usually not included within the calculations within the desk under.

Greater than half of reproductive aged ladies with Medicaid stay in states the place abortion is both banned or the circumstances beneath which Medicaid will cowl an abortion are extraordinarily restricted. Medicaid enrollees residing in these states could must depend on abortion funds or assist from household and associates to pay for his or her abortion companies, or they could forgo getting companies altogether. Within the Guttmacher Institute’s survey of abortion patients performed between June 2021 and July 2022, they discovered 22% of abortion sufferers residing in abortion restrictive states relied on financial 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 scale back assist. The longer somebody has to attend to obtain abortion companies, the dearer the companies change into for individuals who must pay out of pocket. Conversely, the Guttmacher Institute discovered that greater than 4 in ten folks 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 costs of providing 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 would not have to contend. Abortion clinics have added safety prices to keep their staff and patients safe from anti-abortion actions, comparable to extra security guards, cameras, employees background checks, and bulletproof windows. Elevated security issues and prices have made IT troublesome to retain their workforce. All of those elements of offering abortion care make ample reimbursement for abortion companies an much more essential consideration if the abortion supplier community is to be sustained in states the place abortion is just not banned.

On the Horizon

Just a few states have made efforts in recent times to bump up their reimbursement charges for abortion companies, most notably New Mexico, New York, and Illinois. These larger funds might enhance abortion suppliers’ willingness to take part in Medicaid, doubtlessly decreasing the monetary limitations skilled by folks with decrease incomes who must pay for his or her abortion out-of-pocket or depend on monetary help from abortion funds. Nevertheless, regardless of the elevated complexity of D&E procedures, the Medicaid funds are usually not considerably larger than reimbursements for first trimester D&C procedures. And whereas reimbursement for care after the second trimester is just not addressed on this report IT probably represents an much more complicated process and better prices for suppliers.

California has recently 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 remedy abortion throughout all states. Nevertheless, in different states, the dearth of ample Medicaid reimbursement for these companies could additional exacerbate reproductive entry inequities for folks with low incomes.

In states the place abortion stays authorized, there was a large increase within the variety of abortions. Enough Medicaid reimbursement for each procedural and medicine abortions can enhance the monetary stability of clinics in these states. IT can even doubtlessly enhance the variety of suppliers who can serve sufferers with Medicaid protection in addition to different sufferers in search of abortions each in-state and from states the place abortion is banned or restricted.

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