If you’re one of the 3 million Americans who bought health insurance on an Affordable Care Act state exchange, you may be surprised to open up the mail this summer and find two separate monthly bills. Under a new rule finalized by the Department of Health and Human Services in December, insurers are now required to issue a separate invoice for the amount of your premium that they attribute to abortion services. So you’ll get one bill for abortion services and another for the rest of your insurance coverage.

Here’s what you need to know about the new requirements:

What is the background? Why was the change made?


The first thing to know is that federal funding for abortion has been illegal since 1976, when Congress passed a measure now known as the Hyde Amendment after its sponsor, Rep. Henry Hyde, R-Ill. (Subsequent updates included exceptions for pregnancies that are a danger to the life of the mother.)

When President Barack Obama was presenting his plans for the ACA, antiabortion lawmakers protested that it would illegally fund abortion, despite his assurances otherwise, through tax breaks and government subsidies. The ACA already requires insurers to itemize abortion coverage separately, but early on in the rollout of the plans, in 2014, a Government Accountability Office report found that many did not do so.

HHS Secretary Alex Azar said in a statement that providing separate bills is “an essential step” in remedying that issue. “The separate billing requirement fulfills Congress’ intent and reflects President Donald Trump’s strong commitment to preventing taxpayer funding of abortion coverage,” he said.

The U.S. Conference of Catholic Bishops and other groups that oppose abortion praised the change.

“Consumers have a right to know if they are paying for elective abortion. While the Affordable Care Act still allows government-subsidized plans to cover abortion, at least with this rule, Americans can now see and try to avoid complicity by choosing plans consistent with their consciences,” said Archbishop Joseph Naumann of Kansas City, Kansas, who is an official for the USCCB.

What about those who opposed the rule? What are their arguments?


There were many objections to the new rule.

Abortion rights groups argued that it would create stigma around abortion and make it more difficult for women to get insurance coverage for abortion.

Jacqueline Ayers, vice president for government relations for Planned Parenthood Federation of America, said the rule is an effort to make legal abortion more difficult to access: “This rule won’t just require separate payments, it further splits off abortion from other reproductive health care and puts up massive barriers to access.” Likewise Equity Forward’s Mary Alice Carter accused HHS of once again putting “the wishes of the antiabortion lobby ahead of what is best for the health and well-being of people in America.”

Insurers protested that the administrative requirements are burdensome. Medical groups said the rule could lead health insurance companies to drop coverage of abortion and cause people to lose coverage if they get confused and don’t pay both bills.

“Many commenters stated that the proposals would threaten the mental and physical health, well-being, and economic security of enrollees, especially women, across the country,” HHS said in the document announcing the rule, summarizing the objections of people who responded when a draft of the rule was open to public comment. “Commenters stated that health insurance should provide coverage for the full range of reproductive health care, including abortion, and that this rule threatens to take such coverage away by imposing burdensome requirements on issuers.”

There’s good reason for the concerns about making abortion more difficult to access.


A Kaiser Family Foundation analysis published in December 2018, when a draft rule was published, said it would likely result in some insurers deciding to eliminate abortion coverage. The official rule does not address the possibility of enrollees opting out of paying for abortion services, but HHS does address it in a subsequent guidance document fact sheet. HHS explains in a section that could be confusing due to the double negatives that it would not take action against a plan that “effectively allow enrollees to opt out of coverage for these services by not paying the separate bill for such services.” And the more people “opt out,” the more financial pressure there will be on insurers that offer abortion services and the more expensive it gets for those who want the coverage.

How much will the bill cost? Will people be paying more?

HHS has said the second bill should be for no less than $1 per enrollee, per month.

The total cost will not change under the new rule — that is, the abortion services coverage charges won’t be an add-on but will simply be broken out from the total bill. But there’s a big catch.

The insurance industry has said the changes would create huge burdens for them, including changing their billing software, managing double the payments and dealing with confusion from customers. HHS wrote that the total cost to insurers, exchanges and enrollees would reach $546.1 million in 2020 and then stabilize at $232.1 million in 2021, $230.7 million in 2022, and $229.3 million in 2023 and subsequent years.

Those costs will inevitably get passed on to consumers in some form, be it an increase in premiums, deductibles, co-pays or changes to coverage and doctor networks.

Where can I get more detailed information?

The HHS final rule is published in the Federal Register, and HHS has published a fact sheet at outlining some steps insurers should take to inform consumers about the legislation.