V. REIMBURSEMENT CONSIDERATIONS

Adding medication and/or aspiration abortion and EPL management into your practice should not cost you money in the long term. In time, all costs should be recoverable through proper billing and appropriate fee setting.

Financial analysis for integrating EPL and abortion services involves three main components: cost, revenue, and profit or loss. In addition, integrating these services has many intangible benefits, including improved continuity of care, patient retention, and enhanced relationships with  patients.

1. Cost

There are several one-time expenses for aspiration procedures including equipment and supplies and possible ultrasound equipment. As a result, you may not be able to show a profit in the first year of service, especially if you are seeing a low volume of patients. However, over 2 to 3 years, the variable supply costs should be very low, especially if using group purchasing programs (for example, in the U.S. through NAF membership, Afaxys, or HRSA 340b pricing for contraceptive supplies). In addition, ultrasound equipment can be used for other purposes, such as prenatal care or urgent care, so its cost can be shared across a larger pool of patients. Some sites may need to purchase liability insurance to cover abortion services.

U.S. facilities receiving federal funding, such as Title X or Section 330 funding (Federally Qualified Health Centers), may face domestic gag rules, and be prohibited from using federal funds for abortion care. These facilities need to establish clear financial and administrative systems to ensure that abortion expenses and revenues are properly segregated from their federally funded services. The following administrative guide outlines the key administrative and financial issues that federally funded facilities must take into account as they integrate abortion services. Sites that were built, purchased, or renovated with federal funding may have additional restrictions that need to be explored before abortion services can be provided on site.

When incorporating medication abortion services (either in person and via telehealth) there will be little upfront cost to the organization. Expenses may include the purchase of mifepristone and optional cost of an ultrasound machine. Based on where you practice, ultrasound may be readily available on-site or through the radiology department. However, point of care ultrasound dramatically decreases the cost and increases the convenience for the patient.

2. Revenue

Knowing how much you can expect to be paid for EPL and abortion services is another important step in developing your budget. While EPL services should be more broadly reimbursed by all payers, including U.S. Medicaid programs, some public and/or private insurance plans will reimburse for abortion services while others will not. Review of the Guttmacher State Policy Guide may help determine the insurance coverage in your setting or state.

If your patients have insurance, it will be beneficial to research if and how much those insurance plans will reimburse for EPL and abortion services. If you encounter plans that will not reimburse, consider negotiating contracts with those insurance companies with which you already have relationships. Be prepared to dedicate staff time to identifying and establishing new contracts. See FP Insurance Letter as a blueprint for contacting an insurance company.

Regarding abortion services, while some of your patients may be insured, it is important to note that approximately 40% of patients who have insurance decline to use it for abortion services for privacy reasons.

3. Billing

When billing Medicaid or private insurance, use of proper billing codes is very important to get accurate reimbursement. A list of the most common ICD-10 codes used for diagnosing and billing for early pregnancy loss, manual vacuum aspiration for abortion, medication abortion, and contraception provision can be found here.

4. Fee Setting

There are three key considerations when setting your fee for patients:

• What are your actual costs?
• What are your competitors charging?
• What is the value placed on it by patients?

In setting your fees, make sure to consider including the following:

• Lab tests (if using)
• Medications
• Ultrasound (if using)
• Contraception (if patient desires it to be dispensed or placed at the same visit)

The staff making the appointment should be able to articulate all the services covered in the visit. Consider additional services provided at the same visit including: contraceptive counseling and provision, pap test, STI screening, even flu, COVID and HPV vaccination. Some practices offering medication abortion will choose to bill for the abortion medications and part of the provider time under the abortion part of the visit, and bill the rest as they would any primary care visit.

Cost is an important factor in people’s decision around abortion modality. High fees create barriers to care, and can lead to people being forced to continue undesired pregnancies. Consider charging the minimum fee needed to cover costs of delivering the service and unbundling optional services to lower the total cost of care for self-pay patients. Consider offering sliding scale fee structures, subsidized by abortion funds (see below). While some clinics offer the same fee for medication and procedural abortion, this may drive up the cost of care for telehealth and in-person MAB patients, adding barriers to access.

5. Helping Patients Pay For Their Abortion

Paying for abortion services can be a financial challenge for some patients. Patients who may be paying out of pocket include those who do not have insurance, patients who have insurance in a state or setting that limits coverage for abortion services, and patients who are keeping the visit confidential from those on the same insurance plan. With bans and state-based restrictions, patients are now increasingly traveling for abortion care. This increases the costs to the patient to include travel, overnight accommodations, time off from work, and childcare.

Providers can connect with local, regional or national abortion funds to help patients pay for their abortion care. The National Network of Abortion Funds (NNAF) maintains a helpful (but non-exhaustive)  listing of U.S. state-based abortion funds. If providing telehealth medication abortion the Abortion Freedom Fund is another resource to help people pay for their telehealth abortions.Your staff can become familiar with helping patients access supportive services (such as travel support) through Apiary for Practical Support (.e.g., brigidalliance.org). Patients can also reach out to Planned Parenthood and National Abortion Federation for financial support to help cover abortion-related costs.

Global gag rules may impact abortion funding sources globally for non-governmental organizations (NGOs) that receive U.S. global health assistance, prohibiting these organizations from using their own, non-U.S. funds to provide abortion services, information, counseling or referrals, or to participate in abortion-related advocacy (Guttmacher 2025).

6. Professional Liability Insurance

Obtaining affordable liability coverage is currently a challenge for clinicians in every area of medicine, and abortion services in particular. Although the financial risk to the insurer for abortion services is approximately one third that of obstetric services, insurance companies often “bundle” abortion with general Ob-Gyn coverage, despite much lower complication rates (Dehlendorf 2008). ACOG released a committee opinion that early pregnancy care (including EPL and abortion care) should fall under the scope of gynecologic care and as such, individuals may choose not to carry professional liability coverage for obstetrics. Many insurance companies do not yet recognize abortion as a service that falls safely within the scope of practice of primary care providers, despite significant safety and efficacy data.

Providers who do not have coverage for EPL and abortion services under their institutions’ professional liability insurance can obtain supplemental malpractice insurance. Providers working at FQHCs will need to obtain this supplemental insurance, as the Federal Tort Claims Act excludes abortion related services.

Advocacy for improved insurance industry regulation could help ensure that clinicians trained and willing to provide services to their patients are not limited by the decisions of liability insurers.

The Access Delivered toolkit has a useful table on liability insurance. The graph below provides information on different malpractice insurance options. States differ on which insurers they consider to be legitimate. If you plan to purchase individual insurance, check with your state insurance commissioner that your carrier is on the approved list. Whichever option you choose, assure the coverage is adequate for your services. The Abortion Coalition for Telemedicine (ACT) may have coverage for telehealth providers.