Out-of-Pocket Costs for Abortion Care Among Individuals Enrolled in Employer Sponsored Insurance Plans
In recent years, insurance coverage of abortion has been the focus of state lawmakers in their efforts to either restrict or expand access to abortion services. Since the passage of the ACA in 2010, many of the states that now have moved to ban or restrict abortion have banned state regulated plans sold through their state exchanges from covering abortion. However, since 2022 when Roe v Wade was overturned, many states that support abortion rights enacted laws requiring coverage, typically free of cost-sharing, to support access to services.
Even before these state actions, many women did not use their insurance to pay for abortions, even when it was covered, because of the highly confidential and stigmatized nature of abortion care. As a result, most people with private insurance end up paying the full costs of abortion that can range from $563 for medication abortion to upwards of $895 for second-trimester abortion. The result has been that those full costs have been borne by women even when they are insured, and insurance has not had to pay for a service that is often covered.
Data Analysis of Healthcare Claims
To get a better understanding of how much private plans are reimbursing health care providers for abortion and related services and document the out-of-pocket spending that people incur when they use their insurance, we conducted an analysis of the 2023 Merative Marketscan claims database. This analysis utilized a large national sample of healthcare claims for people enrolled in employer sponsored insurance plans in both the state-regulated and self-insured markets.
Our findings indicate that most females who used their private insurance to pay for their abortion had out-of-pocket costs for their services, including 62% of those who accessed medication abortion, 68% of those who obtained a D&C procedure, and 76% of those who received a D&E procedure. Below is a summary of the financial data identified in the study:
| Service Type | Median Reimbursement | Median Out-of-Pocket Cost |
|---|---|---|
| Medication Abortion | $562 | Less than $100 |
| D&C Procedure | $1,046 | Less than $100 |
| D&E Procedure | $4,872 | Over $200 |
For those with coverage through employer sponsored insurance plans, a quarter of females with private insurance paid more than $100 for medication abortion and D&C procedures, and close to $1,000 for D&E procedures, which are typically done later in pregnancy. Furthermore, out-of-pocket costs were substantially higher for D&C and D&E procedures provided in ambulatory/outpatient hospital settings than office-based settings.
The Impact of State Policies
In their efforts to shore up and protect access to abortion and reproductive rights after the Dobbs decision, a handful of states have enacted policies, requiring first dollar coverage for abortion services for people enrolled in state regulated plans. The intent of these policies is to reduce financial barriers to abortion by making the services more affordable.
In the five states that had policies eliminating cost-sharing for abortion services in place in 2023, the share of women with cost-sharing for an abortion decreased substantially from 82% in 2022 to 60% in 2023. In contrast, this share was unchanged in states that permit cost-sharing for abortion, recorded at 80% in 2022 and 79% in 2023.
Ancillary Services and Billing Methods
Regarding medication abortion, there are typically two different approaches to billing for services provided: (1) billing the medications plus any ancillary services; or (2) billing the medications plus the global medication abortion code (S0199), a bundled code that includes all associated services and supplies. For abortion procedures such as D&Cs and D&Es, most providers bill for the procedure plus any associated services and supplies.
Commonly billed ancillary services include:
- Ultrasound: These were commonly billed with a D&C procedure (71%) and D&E procedure (69%); 44% of medication abortions also include a separate ultrasound claim.
- Pain Medication/Sedation: A claim for pain medication and/or sedation was billed with many D&E procedures (73%) and over half of D&C procedures.
- Laboratory and Testing: Services include Rh testing and/or treatment, specimen handling, and the surgical tray.
- Office Visits: General office visits and cervical dilators are also frequently part of the billing.
It is important to note that ultrasound is not a medical requirement for first-trimester abortion care but is required by some state laws. Research suggests that medication abortion without ultrasonography has been shown to be as effective and safe as medication abortion with ultrasonography.