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Some group health plans on state health exchange will cover 'elective' abortions; individual plans will cover only if "medically necessary"

New Hampshire Sunday News

September 28. 2013 9:20PM

The individual health insurance plans that Anthem Blue Cross and Blue Shield will unveil in the state's new health exchange on Tuesday will cover only abortions that are "medically necessary," a company spokesman said Friday.

That's because of a prohibition on using federal funds for abortion, a ban reinforced in the Affordable Care Act.

Christopher Dugan, senior director of public relations for Anthem in New Hampshire, said small-group plans offered in the exchange also will cover "elective" abortion services. But not the plans that individuals will be able to purchase, he said.

Oct. 1 is the start of open enrollment for the new health-care plans created under the ACA, also known as Obamacare.

Previously, individual customers could purchase a rider from Anthem for maternity coverage, and elective abortion was included in that, Dugan said. But in the new plans, he said, "Our decision was to exclude elective abortions because federal funds could not be used, under the new (health reform) law, for that."

Anthem is currently the only insurer offering medical coverage through the state insurance exchange, the New Hampshire Health Insurance Marketplace. Northeast Delta Dental will offer a variety of dental plans through the exchange starting on Tuesday.

Harvard Pilgrim has said it will join the Marketplace in the future.

State's decision

The Affordable Care Act allows the states to decide whether to include abortion coverage in their exchanges, but it specifically prohibits use of federal funds for abortion services except in cases of rape or incest, or when the life of the woman is endangered.

President Barack Obama reiterated that ban, known as the Hyde Amendment, in an executive order he signed on March 24, 2010. "The Act specifically prohibits the use of tax credits and cost-sharing reduction payments to pay for abortion services," the order said.

"The Act also imposes strict payment and accounting requirements to ensure that Federal funds are not used for abortion services in exchange plans . and requires State health insurance commissioners to ensure that exchange plan funds are segregated by insurance companies . ," the order stated.

However, asked whether Anthem would segregate funds used to cover abortions in the small-group plans offered in the Marketplace, Dugan said, "It is our understanding that segregation does not apply to small-group coverage."

So what does "medically necessary" mean?

Clear rules

According to the coverage certificate for the new plans provided by Dugan, that is defined as "health care services or products provided to an enrollee for the purposes of preventing, stabilizing, diagnosing, or treating an illness, injury or disease, or the symptoms of an illness, injury or disease."

Such care must be clinically appropriate, "consistent with generally accepted standards of medical practice," demonstrated to improve health outcomes and "not primarily for the convenience of the enrollee or provider."

According to the National Conference of State Legislatures, at least 17 states have banned coverage of abortion services in their exchange plans.

New Hampshire law is silent on the issue.

The state's Joint Healthcare Reform Oversight Committee met a year ago to decide on the "essential health benefits" that will be offered in exchange plans.

The committee had to choose a "benchmark" plan that would cover 10 categories of services required under the ACA: hospitalization, prescription drugs, prevention and wellness, mental health and substance abuse, laboratory services, pediatrics including oral and vision care, rehabilitation, ambulatory patient care, emergency services, and maternity and newborn care.

Abortion coverage is not part of those "essential" health benefits, according to Jennifer Patterson, health legal counsel for the state Insurance Department.

And even when the joint committee chose as its benchmark an Anthem plan, Matthew Thornton Blue, that does provide abortion coverage, Patterson advised lawmakers that does not mean carriers that participate in the exchange have to offer such coverage. "That's one thing the committee was really concerned about: If we choose this and it has the coverage, does that become part of the package?" she said. "And it does not."

Carriers' decision

Because lawmakers here did not address the issue of abortion coverage in legislation, Patterson said, "It's up to the carriers to decide what services are covered by any particular plan."

"If it's in Anthem's plan that they're offering, it's there because they chose to put it in, not because it's required to be put in," she said.

The Legislature still could act on the issue, and Patterson said insurers that offer plans through the exchange would have to abide by what lawmakers decide.

"If New Hampshire wanted to take a position on it, the Legislature would have to pass a law that says, one way or another: You can't cover it; you have to cover it," she said.

And under Section 1303 of the Affordable Care Act, Patterson said, "If the state chooses to make a law with respect to abortion, then that law won't be preempted by the ACA."

Paula Rogers, a former insurance commissioner who is now director of government relations for Anthem, said if lawmakers were to take up a measure to ban abortion coverage in the state Marketplace, her company probably would stay out of the debate.

"That's a policy decision at the state level, and we'd be required to address it and comply," she said.

Last year, the Legislature passed a law (RSA 420-N:7) that prohibits creating a state-based health exchange. Instead, the law allows state agencies to "interact with the federal government with respect to the creation of a federally facilitated exchange."

And that's what begins on Tuesday.The same New Hampshire law states that any activities related to the exchange should promote preservation of the "private, commercial delivery of health coverage" and minimize "interference with the operation of commercial markets."

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