States Use Unused ACA Marketplace Premiums to Fund Abortion Services Amid CMS Guidance Debate

Some U.S. states are exploring policy options to utilize unused segregated premiums from Affordable Care Act (ACA) Marketplace insurers to finance abortion services for populations facing financial and systemic barriers such as low-income, uninsured, or underinsured individuals. The legal framework enabling these state-level initiatives is grounded in Section 1303 of the ACA, which governs abortion coverage requirements in qualified health plans. Recent guidance issued by the Centers for Medicare & Medicaid Services (CMS) regarding the use of Section 1303 funds has raised concerns about compliance with federal law, particularly in relation to the intended segregation and usage of these premiums for abortion care access programs. This analysis further discusses how civil rights protections under Title VI of the Civil Rights Act of 1964 and Section 1557 of the ACA intersect with abortion coverage access and non-discrimination mandates. The role of Medicaid presumptive eligibility mechanisms and broader health policy changes, including legislative acts impacting Medicaid enrollment, are relevant considerations for states seeking to expand abortion service funding through unused marketplace premium funds. These topics collectively provide insight into the complex regulatory and compliance environment surrounding reproductive health coverage policies affecting underserved populations.