While there is not a similar certification  requirement for federal funding of abortions in cases of rape or incest,  CMS guidance specifies that states may impose certain additional  requirements on providers and beneficiaries as a condition of Medicaid  payment for abortions eligible for federal funding, provided such  requirements are reasonable and do not deny or impede coverage for  such abortions. States  claiming federal funding for Medicaid services, including abortions, are  required to report quarterly expenditures to CMS on the form CMS-64. Medicaid beneficiaries may experience further challenges accessing  abortions in some states due to variation in Medicaid abortion coverage  and related payment requirements. Providers and Literature Pointed to Multiple Factors that Could Present Challenges to Women Accessing Abortions across States

We identified seven key factors as potential challenges to women  accessing abortions based on our interviews with eight selected  providers: (1) gestational limits; (2) mandatory counseling; (3) out-of- pocket costs; (4) parental involvement; (5) provider availability; (6) stigma  and harassment; and (7) waiting periods. In addition, a factor could be more challenging in one state versus  another, depending on the details of the factor and other factors present. Variation in State Coverage and Payment Requirements Could Further Challenge Medicaid Beneficiaries’ Access to Abortions

In responding to our survey, 29 states reported limiting abortion coverage  for Medicaid beneficiaries to the three circumstances required under  federal law—rape, incest, and life endangerment—while 21 states  reported broader abortion coverage. The remaining state, South Dakota,  reported that it limits abortion coverage for Medicaid beneficiaries to  circumstances when the pregnancy endangers the life of the woman, and  does not cover abortions in cases of rape or incest. States also varied in the extent to which their Medicaid programs covered  Mifeprex, the prescription drug most commonly used for medical  abortions. CMS  officials were not aware that these states did not cover Mifeprex, and thus  the agency had not taken any action to address states’ non-compliance. Information on Abortions Eligible for Federal Medicaid Funding Is Incomplete, but Showed a Wide Range in the Number of Procedures Covered across States

The usefulness of federal information—namely CMS-64 data—for  identifying the number of abortions eligible for federal Medicaid funding is  limited, which could hamper CMS’s efforts to ensure proper payments  and states’ coverage of abortions in cases of rape, incest, or life  endangerment. In addition, because state Medicaid programs use the CMS-64 to claim  federal funding for services provided, the form does not include  information from states that covered abortions for Medicaid beneficiaries  in circumstances of rape, incest, or life endangerment, but did not seek  federal funding for those costs. Similarly, the 8 states we  identified as incorrectly reporting their FFS abortions on the CMS-64  reported the number of such abortions to us, and these states accounted  for half of all FFS abortions for which states reported claiming federal  funding in our survey. Conclusions

CMS has a central role in monitoring states’ compliance with federal  requirements for coverage of abortions eligible for federal funding in the  Medicaid program. Finally, incomplete federal data on the number of abortions  eligible for federal Medicaid funding—in part, due to inaccuracies that we  identified in the reporting of these expenditures by eight states—limit the  agency’s ability to ensure that states are covering such abortions and that  federal payments are made appropriately. Appendix I: Literature Review

To identify studies examining factors that may present challenges to  women, including Medicaid beneficiaries, accessing abortions, we  conducted a literature review of recently published studies.
Why GAO Did This Study

While federal law prohibits federal funding for abortions in most circumstances, state Medicaid programs are required to cover abortions in limited circumstances. CMS is responsible for monitoring state compliance with federal requirements. However, concerns have been raised about challenges women may face obtaining Medicaid coverage for abortions eligible for federal funding, as well as with abortion access more broadly.
GAO was asked to review issues related to abortion access. This report examines (1) factors that may present challenges to women, including Medicaid beneficiaries, accessing abortions; and (2) federal and state information on the number of abortions eligible for federal Medicaid funding. GAO reviewed federal laws, regulations, and data sources; surveyed and received responses from Medicaid program officials in all 50 states and the District of Columbia; conducted a literature review; and interviewed CMS officials and eight abortion providers selected based on factors such as variation in Medicaid abortion coverage and geography.

What GAO Found

Women could face various challenges accessing abortions depending on where they live, and Medicaid beneficiaries may face additional challenges in some states. GAO identified seven key factors that could pose challenges to women accessing abortions, based on its interviews with providers and review of the literature: gestational limits, mandatory counseling, out-of-pocket costs, parental involvement requirements, provider availability, stigma and harassment, and waiting period requirements. The presence of these factors and their effect on abortion access—such as delays in care or increased costs—varied by state.
GAO also found that state variation in Medicaid abortion coverage and payment requirements could further complicate access for program beneficiaries. State Medicaid programs are generally required to cover abortions and can seek federal funding for such coverage when the pregnancy is the result of an act of rape or incest, or the life of the pregnant woman would be endangered unless an abortion is performed. States may also cover abortions under other circumstances, but federal funds may not be used. In GAO's survey, one state reported not covering abortions in cases of rape or incest, and 14 states reported not covering the drug used in medical abortions, which they are generally required to cover if the abortion is otherwise eligible for federal funding. Officials from the Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicaid, were unaware that these states were not covering the drug, and thus, have not taken any actions to address states' non-compliance.
Federal information on the number of abortions eligible for federal Medicaid funding is incomplete, limiting CMS's ability to ensure proper payments and states' coverage of such abortions. For example, the form CMS-64, which states use to report Medicaid expenditures, does not collect information on the number of abortions paid for by managed care—the delivery system serving most Medicaid beneficiaries. It also does not include this information from 8 states that GAO identified as incorrectly reporting abortion costs on the form. While also not complete, state information reported in GAO's survey was more comprehensive, and showed a wide range in the number of abortions eligible for federal funding covered across the 42 states that reported such information.

What GAO Recommends

GAO is making three recommendations to CMS to ensure state compliance with federal requirements for Medicaid abortion coverage, including coverage of the drug used for medical abortions. The Department of Health and Human Services concurred with these recommendations.