Variability in Payment Rates for Abortion Services Under Medicaid
Key Takeaways
- There is tremendous variability in how much states reimburse for abortion services in states that use state funds to pay for abortions for their Medicaid enrollees (global rates for medication 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 procedure, which is a global payment that includes all other services provided with the procedure.
- Although clinical care is more complicated after the first trimester, reimbursement rates do not increase significantly to reflect the increased complexity and higher costs associated with abortion care later in pregnancy (median reimbursements: $334 for D&C vs. $570 for D&E).
- In recent years, some states, such as Illinois, New York, New Mexico, and Maryland have significantly boosted their Medicaid reimbursement rates to support abortion access in their states in the face of abortion bans and restrictions in states across the nation. For example, six states have more than doubled their reimbursement rates for D&C procedures and five states for D&E procedures since 2017.
Medicaid is a joint federal and state program and Medicaid payment rates, which are set by the states, have been the focus of policy attention since its early days. Generally speaking, Medicaid reimbursement rates have historically been lower than those paid by Medicare and are even lower relative to private insurance rates. These lower rates have been cited as a disincentive to Medicaid provider participation, which limits the pool of providers willing to serve Medicaid enrollees and constrains their access to care.
Under Medicaid, payment for abortion services has been further complicated by the federal Hyde Amendment, which has banned the use of any federal funds for abortion since 1977, only allowing exceptions for pregnancies that endanger the life of the pregnant person, or that result from rape or incest. In 19 states and the District of Columbia where abortion is not banned, Medicaid programs do not pay for any abortions beyond the Hyde exceptions, meaning that low-income pregnant enrollees seeking abortions have to pay for the services out-of-pocket or rely on donations from abortion funds to help cover the costs. Since the Dobbs decision overturning Roe v Wade, 14 states have banned abortion with only very limited exceptions and nearly all the abortion providers in those states have either closed their services or moved to other states.
Currently, 17 states use their own state funds to pay for abortions for women with Medicaid in circumstances beyond the federal limitations set in the Hyde Amendment and abortion remains legal in these states (Figure 1). Unlike other services used by Medicaid enrollees in which the costs of care are divided between the federal and state government, the states bear the full cost of abortion care.
Currently, 44% of reproductive age women with Medicaid coverage live in states that use their own funds to pay for abortion services for Medicaid enrollees in circumstances beyond the federal Hyde limitations. A fifth (21%) of women with Medicaid coverage live in a state where abortion is banned, and a third (35%) live in a state where there is no ban, but abortion coverage is currently restricted by the Hyde Amendment.
In research conducted before the Dobbs decision, even when Medicaid does reimburse for abortion services, providers have reported lower reimbursement rates from Medicaid compared to self-pay. For example, a 2020 study reviewed 2017 Medicaid and Medicare physician fees schedules for dilation and curettage (D&C) and dilation and evacuation (D&E) procedures for 45 states and D.C. They found median Medicaid reimbursement rates for a first- and second-trimester abortion would cover 37% and 41% of what a self-pay patient would be charged for the procedure, respectively. The study did not address the fees for abortions after the second trimester.
To understand the state of Medicaid payment for abortion services post-Dobbs, KFF researchers reviewed Medicaid physician fee schedules for medication and procedural abortions in states that do not ban abortion, including both states that use state funds to pay for abortions for Medicaid enrollees and states that only pay for abortions in the cases of pregnancies resulting from rape, incest, or life endangerment. The reimbursement rates presented are for fee-for-service (FFS) claims, as managed care rates are not typically publicly available. While many pregnant people covered by Medicaid are enrolled in managed care organizations (MCOs), FFS rates are an important window for understanding reimbursement levels, and in many states, the FFS rates are the minimum payment level for MCO plans. The reimbursement rates presented in this brief are for non-facility (e.g., outpatient clinics or physician’s offices) provider-only rates (e.g., excluding any facility rates) since most abortions are performed outside of a hospital setting. Some states, such as Massachusetts and Connecticut, have different reimbursement rates for freestanding clinics providing family planning and abortion services, which are often higher than provider fee schedule rates, and those rates were used when available.
Some states use a bundled reimbursement for abortion services where services provided with the abortion are included in the bundled payment rate, while other states use unbundled billing and providers can bill for all additional services provided with the abortion. Other services often billed for on the day of the abortion in states that use unbundled codes may include an ultrasound, medication administration, a nerve block, and Rh testing, which are outlined in coding guides developed by the Reproductive Health Access Project for manual vacuum aspiration abortion and medication abortion. Median reimbursement amounts for each of these services from state Medicaid physician fee schedules are reported below.
Medication Abortion
In 2023, medication abortion accounted for 63% of all abortions. The two-drug regimen is FDA approved to terminate pregnancies up to 10 weeks in the U.S. Despite the wide use of medication abortion, fewer states publicly report reimbursement rates for medication abortion than for procedures. Medication abortion can be billed using three separate procedure codes and often all three codes are billed at the same time. There are codes for mifepristone/Mifeprex (S0190), misoprostol (S0191), as well as a global medication abortion code (S0199) that includes all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion). However, not all states reimburse for all three of the codes for medication abortion. States typically take two different approaches to reimburse for services provided to patients that receive medication abortion: (1) a bundled global payment using the global medication abortion code (S0199) in addition to the medications; or (2) payment for separate services, like ultrasounds and Rh testing, in addition to the medications. Sixteen states that use state funds to pay for abortion services for Medicaid enrollees list reimbursement for at least one of the three medication abortion codes, with 11 reimbursing for the global medication abortion code, 13 reimbursing for mifepristone, and 13 listing reimbursement for misoprostol. The median Medicaid reimbursement for the global medication abortion code (S0199) is $470, ranging from a low of $81 in Rhode Island to a high of $570 in New Mexico (Figure 2). The median reimbursement for mifepristone is $81, ranging from a low of $49 in Vermont to a high of $99 in Maine. The median reimbursement for misoprostol, a drug that is used in other obstetric procedures, is $1 and ranges from $1 to $5. If the median amounts for all three medication abortion codes are summed, the median reimbursement for medication abortion is $539. However, the range across states is quite large, from $162 in Rhode Island to $665 in New Mexico.
While most states that use their own funds to pay for abortion services for Medicaid enrollees list reimbursement rates for medication abortion, only half of states that follow Hyde restrictions list reimbursement rates for medication abortion and median reimbursement in these states is substantially lower (see Appendix Figure 2).
For the states that do not used the bundled code for medication abortion, the rates for the two drugs range from $68 in Alaska to $91 in New Jersey. In these states, providers may bill for other services — such as an office visit, an ultrasound, or Rh testing – which could potentially add hundreds of dollars to the amount reimbursed, as shown in Table 1.
Of note, these rates are for medication abortion provision in outpatient clinics or physician’s office. Currently, approximately 16% of all abortions are medication abortions provided through telehealth. This report does not specifically address the reimbursement rates for these services which are likely different since they do not include components of care such as the ultrasound.
D&C Procedures
Dilation and curettage (D&C) is a common abortion procedure that can be used up to approximately 16 weeks of gestation. Medicaid physician fee schedules for fee-for-service reimbursement rates were published online for D&C procedures in all 17 states that use state funds to reimburse for abortion services for Medicaid enrollees (Figure 3). The median reimbursement for a D&C procedure in these states was $334, ranging widely from $146 in Washington to $1,000 in New York. Some states have substantially boosted their payment rates in recent years, notably, NY, IL, CT, NM, MD and NJ have more than doubled their payment rates since 2017 (Figure 3). Nonetheless, in many states, the increases have been quite modest over the past 7 seven years. In states that only reimburse for abortions in cases of pregnancies resulting from rape, incest, and life endangerment, payment rates were considerably lower (see Appendix Figure 1).
Other services may be billed and reimbursed on the day of a procedural abortion, which could include an ultrasound, medication administration like lidocaine and methergine, or a nerve block for pain, as well as Rh testing and Rh immunoglobulin administration. Not all states reimburse for all of these extra services, and not all providers may necessarily be billing for all the possible services (Table 2). Some states like Illinois and New Mexico reimburse the abortion procedure (59840 and 59841) as a bundled code and will not pay for other related services when these codes are billed. Therefore, Illinois and New Mexico were removed from the calculations in the table below detailing median amounts for other services that may be provided on the day of the abortion.
D&E Procedures
For a dilation and evacuation (D&E) procedure, which is often used in the second trimester, the reimbursement rates similarly varied widely by state (Figure 4). In states that fund abortion services for Medicaid enrollees the median reimbursement for a D&E procedure was $570, ranging from a low of $248 in Rhode Island and Washington to a high of $1,920 in Illinois. States that substantially increased D&C rates from 2017 to 2024 also significantly increased D&E rates, notably Illinois increased reimbursement rates for D&E by 860% and NY and NM more than doubled their rates.
Similar to D&C procedures, the median reimbursement for D&E procedures in states that pay for abortions for Medicaid enrollees is higher than in states that only cover abortions in cases of rape, incest, and life endangerment (see Appendix Figure 2). Given that D&E procedures are typically provided later in pregnancy, it is striking that some states are reimbursing the same amount or just slightly higher for this more complicated procedure than a D&C, which is typically done earlier in pregnancy. Additionally, it seems that some states have not raised their Medicaid abortion reimbursement levels since at least 2017 (California and Hawaii) although these states are anticipated to increase their payment rates in the near future.
Like D&C procedures, providers can often bill for other services provided with the D&E procedure, such as ultrasounds, medications, nerve blocks, and the office visit, if the code is not a bundled code (Table 3). Similar to D&C procedures, Illinois and New Mexico use bundled payments for D&E procedures that include all other services provided with the D&E procedures and, therefore, are not included in the calculations in the table below.
More than half of reproductive aged women with Medicaid live in states where abortion is either banned or the cases under which Medicaid will cover an abortion are extremely limited. Medicaid enrollees living in these states may have to rely on abortion funds or help from family and friends to pay for their abortion services, or they may forgo getting services altogether. In the Guttmacher Institute’s survey of abortion patients conducted between June 2021 and July 2022, they found 22% of abortion patients living in abortion restrictive states relied on financial subsidies from abortion funds or clinic discounts to pay for their abortion compared to 11% of abortion patients living in abortion-rights protective states. In the year after Dobbs, abortion funds reported a spike in requests for financial support to access abortions, but due to an increase in demand and costs and a decrease in donations, some abortion funds have had to significantly reduce support. The longer someone has to wait to receive abortion services, the more expensive the services become for those who have to pay out of pocket. Conversely, the Guttmacher Institute found that more than four in ten people obtaining abortions in protected states used Medicaid to cover the cost of their abortion, underscoring the importance of Medicaid access in states where the provision of abortion remains legal.
The costs of providing abortions has also grown in all states as the costs of medical equipment and personnel increase annually. In addition, there are specific expenses associated with providing abortion care with which other outpatient clinics do not have to contend. Abortion clinics have added security costs to keep their staff and patients safe from anti-abortion activities, such as extra security guards, cameras, staff background checks, and bulletproof windows. Increased safety concerns and costs have made it difficult to retain their workforce. All of these aspects of providing abortion care make adequate reimbursement for abortion services an even more important consideration if the abortion provider network is to be sustained in states where abortion is not banned.
On the Horizon
A few states have made efforts in recent years to bump up their reimbursement rates for abortion services, most notably New Mexico, New York, and Illinois. These higher payments could increase abortion providers’ willingness to participate in Medicaid, potentially reducing the financial barriers experienced by people with lower incomes who have to pay for their abortion out-of-pocket or rely on financial assistance from abortion funds. However, despite the increased complexity of D&E procedures, the Medicaid payments are not substantially higher than reimbursements for first trimester D&C procedures. And while reimbursement for care after the second trimester is not addressed in this report it likely represents an even more complex procedure and higher costs for providers.
California has recently proposed increasing Medi-Cal reimbursement rates for both abortion procedures and medication abortion to $1,150 regardless of method, which would be the highest reimbursement for medication abortion across all states. However, in other states, the lack of adequate Medicaid reimbursement for these services may further exacerbate reproductive access inequities for people with low incomes.
In states where abortion remains legal, there has been a sizable increase in the number of abortions. Adequate Medicaid reimbursement for both procedural and medication abortions can improve the financial stability of clinics in these states. It can also potentially increase the number of providers who can serve patients with Medicaid coverage as well as other patients seeking abortions both in-state and from states where abortion is banned or restricted.