Markian Hawryluk
The Bulletin

Oregon officials are concerned that a regulation proposed by the Trump administration to require separate billing for abortion coverage by plans sold on the health insurance exchange could result in consumers inadvertently losing their health coverage.

The proposed rules, issued the day after the November mid-term elections, would require health plans to send consumers two separate invoices for their health insurance premium: one to cover all of the standard health benefits and a second solely for abortion coverage. If consumers mistakenly believe the abortion premium is an optional benefit and do not submit a payment for it, they could lose their health coverage.

“Undoubtedly, a number of consumers will fail to make the nominal premium payment and will lose coverage because of nothing more than an administrative requirement,” Cameron Smith, director of Oregon’s Department of Consumer and Business Services wrote in submitted comments on the proposed rule. “In some instances, this loss of coverage will result in loss of life.”

The rule was proposed by the federal Department of Health and Human Services, which argued that regulations do not reflect the intent of Congress in the Affordable Care Act when it required separate billing for elective abortions to ensure that federal funds are not used for abortions, except in cases of rape, incest or when the health of the woman is at risk.

Under the Obama administration, HHS allowed insurers to send a single monthly invoice that separately itemizes the premium amount for abortion services, or to send the enrollee a notice at the time of enrollment that the monthly invoice will include a separate charge for such services.

The Trump administration’s proposed rule would require plans to send two monthly bills in separate envelopes or emails. One bill would cover the majority of health services, while the second bill would be only for the abortion coverage.

The cost of providing abortion coverage comes to less than $1 per person per month, but HHS requires the bill be rounded up to a full dollar. Health plans must keep those funds in a separate account to be used only for elective abortions.

Under the proposal, consumers would be instructed to submit payments for the two invoices separately, although HHS said consumers should not be penalized if they pay for both with a single payment.

Many worry, however, that the segregated billing requirement could confuse consumers and result in unpaid premiums.

“If any man or woman of not reproductive age says, “Well, I don’t need abortion coverage, why should I pay the $1?’ it could seem optional,” said Laurie Sobel, Associate Director for Women’s Health Policy at the Henry J. Kaiser Family Foundation. “If this goes through, plans are going to need to do quite a bit of outreach to explain to people that this is not optional and that you are at risk of losing your coverage if you don’t pay it.”

Most insurers use a premium threshold to determine whether to begin the termination process if a consumer hasn’t paid their entire premium. For example, a plan might use a threshold of 95 percent of the premium cost. If a consumer is billed for a $100 premium, but only pays $99, the payment will not be considered past due.

But if the shortfall continues for six months adding up to a total of $6, that consumer would drop below the 95 percent threshold. That would trigger the start of a grace period to make good on the balance and could lead to a termination of benefits.

“There are folks whose plan should be covered completely by subsidies, and they will still need to pay the $1,” Sobel said. “So they think they qualified for a zero premium plan, and then, they’re going to get billed.”

If consumers do lose coverage due to underpayment, they would not be able to enroll in coverage again until the next open enrollment period.

Sobel said in other states, plans could opt to drop abortion coverage altogether rather than deal with the administrative hassle of separate billing and collection, patient education and termination work.

Oregon, Washington, California and New York require all health plans sold on their exchanges to cover abortions. Oregon granted Providence Health Plans an exemption due to their religious affiliation.

Officials estimate Oregon plans would incur an additional $800,000 in costs to comply with the new billing requirements. They estimate the cost for a plan to collect the $1 monthly premium, including paper, printing, processing and postage costs, would likely exceed the premium itself.

It’s unclear how Oregon health plans would treat the unpaid premium amounts if the new rules go into effect.

“It is definitely on our radar, and we are evaluating how we would implement it,” said Ken Provencher, CEO of PacificSource Health Plans.

It’s also unclear when the rules would go into effect. The comment period for the proposed rule expired in early January. HHS could decide to issue a final regulations at any time, and implement the segregated billing requirement 60 days later.

The National Association of Insurance Commissioners, which hasn’t taken a formal stance on the billing requirement itself, urged the administration not to implement the new rules in the middle of a plan year. The release of the final rule could be delayed because of the government shutdown.

HHS issued another proposed rule this week that would require insurance companies offering plans that cover abortions to also offer “mirror plans” that provide the same coverage but exclude abortions. That regulation would not apply in Oregon because of state laws.

Pro-choice groups are expecting the Trump administration to issue final rules on an abortion gag clause proposed last year that would limit what information about abortion services clinics receiving federal funds could provide to patients.

The segregated billing requirement is seen by many as another attempt to roll back access to abortion.

“This is really a moral and political choice of the administration to try to reduce the number of health insurance plans that cover abortion,” said Dania Palanker, a health policy expert at the Georgetown University Center on Health Insurance Reform. “It isn’t dealing with any problem with the Affordable Care Act or with insurance.”

— Reporter: 541-633-2162,