CurrentMedicarePolicy N/A

FAQs on Coverage of Abortion for which Public Funding is Prohibited by Qualified Health Plan (QHP) Issuers in the Individual Market

Guidance for Qualified Health Plan (QHP) issuers in the individual market regarding coverage, segregation of funds, and cost-sharing for abortion services for which public funding is prohibited, including reference to statutory and regulatory requirements (ACA Section 1303 and 45 CFR 156.280).

Policy Summary

PayerMedicare

PolicyFAQs on Coverage of Abortion for which Public Funding is Prohibited by Qualified Health Plan (QHP) Issuers in the Individual Market

Policy CodePolicy N/A

Change TypeInformational guidance (no material change)

Effective Date

Next Review Date

Key ActionIf offering coverage for abortions for which federal funding is prohibited, segregate a minimum $1 PMPM into a separate account used exclusively to pay for those abortions in accordance with Section 1303 of the ACA and 45 CFR 156.280.

POLICY UPDATE CHANGES

No material changes — federal guidance reiterates existing segregation and coverage rules after Dobbs.

1Required segregated PMPM

statutory/regulatory referencesCitations referenced

Policy overview and scope

Post-Dobbs guidance reiterates that federal regulations governing Qualified Health Plan (QHP) issuers' handling of abortion services for which public funding is prohibited remain unchanged: issuers may offer coverage consistent with state law but must follow existing statutory and regulatory requirements. The relevant authorities cited are ACA Section 1303 and 45 CFR 156.280.

Offering abortion coverage without cost sharing or as a pre-deductible benefit is permitted where consistent with state law, and issuers may use accumulated segregated funds to provide more comprehensive coverage. However, if a QHP covers a service without cost sharing or as pre-deductible in a manner not permitted under IRC section 223(c)(2), the plan cannot qualify as a high deductible health plan (HDHP), which would affect enrollee Health Savings Account (HSA) eligibility.

Issuer permissibility and requirements

Guidance statements regarding issuer actions and obligations:

ALL of the following

QHP issuers may provide abortion coverage in the individual market if consistent with state law.
Issuers that offer coverage of abortion services for which public funding is prohibited must segregate funds used for those services pursuant to Section 1303 of the ACA and 45 CFR 156.280.
Abortion services for which federal funding is prohibited are defined based on law in effect as of the date six months before the beginning of the plan year involved.
Issuers that offer such coverage may provide it without cost sharing where consistent with state law, and some states require such coverage.
Issuers must segregate a minimum $1 per member per month (PMPM) premium into a separate account used exclusively to pay for abortions for which public funding is prohibited.
Issuers may use accumulated segregated funds to provide more comprehensive coverage of prohibited abortions and may adjust benefits to align actual costs closer to the $1 PMPM statutory minimum (e.g., cover without cost sharing or make pre-deductible).
If a QHP covers a service without cost sharing or as pre-deductible contrary to IRC section 223(c)(2), the QHP cannot qualify as a high deductible health plan (HDHP), affecting enrollee HSA eligibility.

Thresholds and definitions

Segregated premium minimum$1 per member per month (PMPM)

Abortion services for which public funding is prohibitedAbortions for which the use of federal funds appropriated for HHS is not permitted, determined based on law as in effect six months before the plan year begins.

Segregated accountA separate account consisting solely of the $1 PMPM segregated premium and used exclusively to pay for abortions for which public funding is prohibited.

Operational actions for issuers / administrators

Documentation Required

Segregate prohibited-funding abortion funds

If offering coverage for abortions for which federal funding is prohibited, segregate a minimum $1 per member per month into a separate account used exclusively to pay for those abortions in accordance with Section 1303 of the ACA and 45 CFR 156.280.

Billing Rule

Use segregated funds for covered abortions

Use balances in the segregated account to provide coverage for abortions for which public funding is prohibited, including offering coverage without cost sharing or as a pre-deductible benefit where consistent with state law.

Denial Risk

HSA eligibility risk if pre-deductible/no cost sharing

If a QHP covers abortion services without cost sharing or characterizes benefits as pre-deductible other than as permitted under IRC section 223(c)(2), the plan cannot qualify as a high deductible health plan and enrollees would not be eligible to contribute to a health savings account.

Frequently asked questions

Q: Can QHP issuers offer abortion coverage after Dobbs? A: Yes, if doing so is consistent with state law; issuers that offer such coverage must segregate funds for abortions for which federal funding is prohibited.

Q: Have federal regulations changed after Dobbs? A: No, issuers must continue to adhere to Section 1303 of the ACA and 45 CFR 156.280 for segregation and administrative requirements.

Q: May issuers provide abortion coverage without cost sharing? A: Yes, where consistent with state law; issuers may also offer it as a pre-deductible benefit and must still segregate at least $1 PMPM. Note that providing coverage without cost sharing or as pre-deductible in a way inconsistent with IRC section 223(c)(2) prevents the plan from qualifying as an HDHP and would make enrollees ineligible to contribute to an HSA.