Marketplace Pulse: Who Covers Abortion in the Individual Market?

The Marketplace Pulse series provides expert insights on timely policy topics related to the health insurance marketplaces. The series, authored by RWJF Senior Policy Adviser Katherine Hempstead, analyzes changes in the individual market; shifting carrier trends; nationwide insurance data; and more to help states, researchers, and policymakers better understand the pulse of the marketplace.

The Dobbs decision in 2022 overturned the previously established constitutional right to abortion. As a result, in the words of the majority, "the authority to regulate abortion is returned to the people and their elected representatives." Since then, there has been a flurry of activity in states to both protect and restrict access to abortion. Inevitably, this has had implications for the coverage of abortion in health insurance markets that are regulated by states, including state employee plans, fully insured group coverage, and the individual market.

Before the Dobbs decision, abortion was not uniformly covered by state-regulated health insurance plans. Some states banned coverage of abortion in public employee plans, some banned coverage of the procedure in marketplace qualified health plans, while others banned abortion in all state-regulated insurance. Since Dobbs, some states have doubled down on their restrictions, while others have sought to affirmatively protect the right to abortion by requiring that plans cover it. As it currently stands, nine states require that abortion be covered and 16 states allow plans to cover abortion—i.e. they neither require it nor prohibit it. The other half of states either ban coverage in the individual market alone or in all state-regulated health insurance markets. 

Insurance Coverage for Abortion | Tableau Public

As can be seen from an assessment of silver Marketplace plans, understanding state law on abortion coverage is just the starting point for understanding whether and how plans cover abortion care, since there is a considerable amount of plan variation within states. Sometimes this variation stems from exemptions. For example, Oregon, one of the states requiring that abortion be covered, has granted an exemption to plans sponsored by religious health systems. Accordingly, not all plans on the individual market in that state cover abortion. Another challenge is when plans do not mention their coverage policy in customer-facing documentation (in most cases the Summary of Benefits and Coverage (SBC)), even when they are doing business in a state that requires coverage. This is the case in New York state, where nearly 20% of plans do not mention that they cover abortion. In Maryland, another state that requires coverage, nearly two-thirds of plans do not mention that they cover the procedure in consumer-facing documentation.

An even more variable situation exists in those states that neither require nor prohibit the coverage of abortion. In these states, plans can choose whether to cover abortion, and how they want to communicate about it. At one end of the spectrum, 100% of Marketplace plans in Alaska and Hawaii report that they cover abortion. In Delaware, Iowa, New Hampshire, West Virginia, and Wyoming, the opposite is true: all plans report that they do not cover the procedure. This is, for all practical purposes, the case in Minnesota and Virginia, though some plans do not disclose their coverage policy. In Nevada and Colorado, most plans do not mention whether or not they cover abortion. New Mexico is unique among this group of states in that almost three-quarters of their plans report that they cover abortion.

As described in a recent blog from the Georgetown Center on Health Insurance Reforms, abortion is both relatively common and somewhat expensive. The average self-pay price for a first trimester procedural or medication abortion approached $600 in 2020. While patients with coverage may still face some out-of-pocket costs, insurance provides some financial protection, and payments would at least count toward the deductible. Some of the states that require plans to cover abortion have imposed various types of regulations designed to minimize patient obligations, and some have also taken steps to reduce or eliminate barriers such as prior authorization or lifetime limits.

Our survey of individual market plans found that even in states where coverage of abortion is required, not all plans disclose that coverage in consumer-facing documentation. Lack of clarity from plans may undermine the objective of state coverage requirements, since enrollees may not know that abortion is covered without scrutinizing complex plan documentation. This could be relevant when choosing a plan or when services are needed. In states that neither require nor prohibit the coverage of abortion, the situation is even more unsettled, as coverage policies are variable, and many plans do not disclose their policy on abortion coverage in a manner that is easy for consumers to understand. With open enrollment approaching, the benefits of uniform disclosure are clear. In the post-Dobbs environment, reproductive healthcare has become far more complex, and plans and states should jointly work to minimize confusion for consumers. One practical suggestion would be to require all plans to disclose their abortion coverage policy on the SBC. While access to abortion may be a controversial issue, access to coverage information need not be.