Planned Parenthood Federation, Planned Parenthood Action Fund Issue Joint Public Comment on Centers for Medicare & Medicaid Services Rule

WASHINGTON, July 11 -- The Planned Parenthood Federation of America, New York, and Planned Parenthood Action Fund, New York, have issued a joint public comment on the Centers for Medicare and Medicaid Services' rule entitled "Medicare and Medicaid Programs, Basic Health Program, and Exchanges: Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program". The comment was written on July 7, 2020, and posted on July 8, 2020:

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Planned Parenthood Federation of America (Planned Parenthood) and Planned Parenthood Action Fund (the Action Fund) submit these comments in response to an Interim Final Rule (IFR) issued by the U.S. Department of Health and Human Services (Department) to make certain policy and regulatory changes in response to the coronavirus disease 2019 (COVID-19) pandemic./1

As a trusted health care provider and advocate, Planned Parenthood routinely weighs in on policies that impact public health. We do so here to address the IFR's sixty-day delay in implementation of the "Separate-Billing Rule," a new regulation that will require issuers on Affordable Care Act (ACA) individual exchanges to bill separately for most abortion coverage and direct policy holders to pay for that coverage in separate transactions./2

Planned Parenthood is the nation's leading reproductive health care provider and advocate, and it is a trusted, nonprofit source of primary and preventive care for patients across the United States. Each year, Planned Parenthood's hundreds of health centers provide affordable birth control, life-saving cancer screenings, testing and treatment for sexually transmitted diseases (STDs), and other essential care to more than 2 million patients. Planned Parenthood health centers also provide abortion services and ensure that patients have accurate information about all of their reproductive health care options. One in five women in the United States has visited a Planned Parenthood health center.

Planned Parenthood patients frequently use health insurance coverage purchased through the ACA individual marketplaces, and many of them qualify for federal financial assistance to pay their premiums. Patients use their ACA-marketplace plans to obtain much-needed care from Planned Parenthood health centers. For that reason and because of our commitment to ensuring affordable health care coverage for people across the country, we have an interest in ensuring that ACA-marketplace plans provide comprehensive benefits and that people are able to access and maintain coverage under those plans. To those ends, we have been deeply engaged in the legislative and rulemaking process surrounding the ACA, including rulemakings related to the implementation of the ACA's Section 1303, which permits private marketplace plans to cover abortion care but forbids issuers offering such plans in the individual market from paying for those services with federal dollars that are prohibited for spending on abortion. Our advocacy has focused on ensuring that everyone--regardless of their income, race, gender, sexual orientation, gender identity, age, disability status, or immigration status--has coverage that meets their needs.

For the reasons previously identified in our comments to the Department, attached as Exhibit A, Planned Parenthood continues to vehemently oppose the Separate-Billing Rule. The rule is unworkable; will result in loss of health insurance benefits and increased insurance premiums for people across the country; will eviscerate abortion coverage in ACA marketplaces; and will further stigmatize sexual and reproductive health care. The rule's harms will fall disproportionately on people with low and moderate incomes, Black and Latina women, and immigrants, and the rule will result in adverse physical and mental health consequences, particularly for people who are delayed in accessing or are unable to access abortion care because of the rule. Additionally, the Separate-Billing Rule is at odds with the ACA and unlawful under the Administrative Procedure Act, and we support litigation filed by Planned Parenthood of Maryland, Inc. (a Planned Parenthood affiliate), consumers, and states to invalidate the rule./3

Planned Parenthood submits these comments to make clear that in addition to our longstanding objections, the Department's recent IFR, which provides a sixty-day delay in implementation of the Separate-Billing Rule, is woefully inadequate to address the rule's severe, negative effects on consumers, which the pandemic and recession have exacerbated. In light of these additional harms, we call on the Department to immediately suspend the Separate-Billing Rule's implementation, at least until the COVID-19 pandemic is over and the U.S. economy has recovered. Instead of wasting agency, patient, issuer, and state time in implementing this misguided rule, the Department should focus its energy on expanding, not threatening, access to health insurance and care that people across the country need now more than ever.

I. ACCESS TO COMPREHENSIVE, AFFORDABLE HEALTH INSURANCE IS CRITICAL DURING THE COVID-19 PANDEMIC AND RECESSION.

ACA marketplaces offering individual health plans have helped reduce the number of uninsured Americans by making health insurance available to individuals and families who may not have access to a group-sponsored health plan or public insurance program. Federal subsidies have also helped to make those exchange plans more affordable for people with low and moderate incomes. As a result of the individual marketplaces and other ACA reforms, nearly nine in ten women between 19 and 64 were insured in 2018./4

And by the start of the 2020 Plan Year, 11.4 million people had enrolled in an individual-market exchange plan,/5 one-third of whom lived in states where one or more plans in the ACA marketplace include abortion coverage./6

During the COVID-19 pandemic, the Department has an obligation to take steps not just to maintain this level of coverage but to expand access, including for the newly uninsured population. To date, nearly 3 million COVID-19 cases have been diagnosed in the United States./7

Treatment for the disease can require extended hospital stays and substantial, costly medical interventions. Individuals with coverage through an ACA marketplace will be able to access laboratory testing and medically necessary hospitalizations related to COVID-19 infection, thanks to the ACA's requirement that health plans cover essential health benefits. But for individuals without health coverage, these costs could be financially devastating, and they will discourage individuals from seeking care. Individuals who have been hospitalized for COVID-19 care have reported receiving hospital bills for up to hundreds of thousands of dollars, and in one instance, over one million dollars./8

The need to protect coverage during the pandemic is also critically important to minimizing the disproportionately negative effect that COVID-19 is having on Black and brown communities due to systemic racism and barriers to coverage and care./9

According to CDC data, Black and Latinx individuals are disproportionately dying from COVID-19./10

Moreover, due to environmental racism and decades of neglect, communities of color are more likely to suffer from chronic conditions that raise the risk of developing severe COVID-19 symptoms, such as asthma, cardiovascular disease, and diabetes./11

Maintaining and strengthening coverage through the individual marketplaces is also crucial for individuals who have so far been healthy but are suffering from the economic impact of what has now officially become a U.S. recession./12

Since the beginning of the pandemic, more than 40 million Americans have lost their jobs./13

For these newly unemployed individuals, ACA marketplaces offering individual plans provide a critical lifeline to health insurance. Unemployed individuals who previously had employer-sponsored health coverage may seek an individual market plan now because it is more affordable or accommodating than continuing group coverage under COBRA./14

And many unemployed people will turn to the exchanges mid-year because job loss is a basis for special enrollment in an ACA exchange throughout the plan year. 45 C.F.R. Sec. 155.420(d).

As with COVID-19 infections, the impact of the economic downturn has not been felt equally. Due to systemic structures that limit the ability of Black and brown people to access education and high-paying jobs, people of color make up the majority of low-wage earners economically harmed by the COVID-19 pandemic./15

Moreover, although women make up nearly fifty percent of the workforce, they account for most of the job losses related to COVID-19./16

Pushing a policy that will directly reduce access to care during a pandemic is unconscionable and is something that the Department should be working to address, not contributing to.

II. THE SIXTY-DAY DELAY IN IMPLEMENTATION IGNORES THE SEPARATE-BILLING RULE'S NEW COSTS.

In the IFR, the Department generally adheres to the Separate-Billing Rule's cost analysis, but it states that the rule's costs in the coming year will be lower than expected because of the sixty-day delay in implementation. The Department, therefore, asks commenters to help it identify the value of cost savings from delayed implementation.

Planned Parenthood objects to the assumptions underlying the Department's request for comment. The Department cannot simply assess "cost savings" from the delayed implementation period it selected without simultaneously addressing the massive new costs to consumers, patients, issuers, and states that are associated with implementing the Separate-Billing Rule in the middle of a global pandemic and recession. In light of these new costs, it is apparent that the sixty-day delay in implementation is woefully inadequate to address the needs of stakeholders.

A. The Department must address the Separate-Billing Rule's additional costs for consumers and patients if implemented during a pandemic and recession.

In announcing the sixty-day implementation delay, the Department completely ignored the interests of consumers and patients and did not explain how they could possibly be prepared by August 2020 to comply with the Separate-Billing Rule's requirement that they pay their abortion-related premium portion in a separate transaction.

First, the Department concluded in December 2019 that the Separate-Billing Rule would affect more than three million enrollees around the country./17

But millions of people have lost their jobs in the past few months, and many of those people will turn to the ACA's individual marketplaces to obtain health coverage. Accordingly, to assess the cost impact of a delay in implementation, the Department must recalculate the number of affected enrollees, which is likely to be far greater than the three million identified by the Department in the original rule.

Second, the IFR fails to account for the additional costs to consumers of implementing the Separate-Billing Rule at a time when people are dealing with new and substantial upheaval in their lives--from COVID-19 infection, deaths of family members, job loss, loss of health insurance, an inability to obtain child care as schools and daycare centers are closed, potential eviction or other consequences from their inability to pay bills, and COVID-related changes in residence that may delay receipt of mail. The Department has acknowledged that the Separate-Billing Rule will lead to inadvertent non-initiation and termination of coverage for some individuals confused about whether and how to pay the abortion-related portion of the premium./18

At a minimum, the Department must address the increased likelihood of these non-initiations and terminations among consumers whose lives have been further complicated by the pandemic and recession. It should also address the fact that lapses in health insurance coverage carry even greater potential for economic hardship today because of COVID-19 than they did when the Separate-Billing Rule was adopted.

Third, in assessing delayed implementation, the Department must account for consumers' rising inability to weather premium increases at this time. The Department has conceded that the Separate-Billing Rule is likely to result in increases of up to one percent annually for consumers./19

However, the COVID-19 pandemic is also likely to lead to premium increases as plans around the country experience deep losses attributable to the disease. For example, in March, Covered California predicted that one-year projected costs in the commercial market, which includes individual insurance plans, would "range from $34 billion to $251 billion for testing, treatment and care specifically related to COVID-19."/20

It concluded that premium increases in individual and employer markets in 2021 "could be 40 percent or more solely because of these unexpected COVID-19 costs in the absence of federal action, as insurers would seek to recoup unplanned [] losses from 2020 and budget for pandemic-related costs in 2021."/21

Any consideration of implementing the Separate-Billing Rule during the pandemic must consider the compounding effect of the Separate-Billing Rule's premium increases alongside COVID-19-related premium increases. Taken together, these increases are likely to impose even greater hardship on consumers and result in more enrollees dropping coverage or selecting cheaper plans that do not fully meet their needs.

Fourth, the Department must address the impact of implementing the Separate-Billing Rule at a time when individuals' needs for comprehensive and affordable health care are increasing. Most obviously, any lapses in health insurance coverage caused by the Separate-Billing Rule will have potentially catastrophic effects on the health and economic stability of individuals diagnosed with COVID-19. At least 850,000 people who have contracted COVID-19 reside in states whose individual marketplaces require plans to offer abortion coverage./22

Another 470,000 live in states that permit abortion coverage in their individual exchanges, and where one or more plans do in fact include that coverage./23

In total, nearly half of all COVID-19 cases have occurred in states where at least one individual marketplace plan will be affected by the Separate-Billing Rule./24

In addition, the Department must contend with the increasingly negative impact that the Separate-Billing Rule will have on people in need of sexual and reproductive health care. As the American College of Obstetricians and Gynecologists (ACOG) told the Department in a comment seeking delay of the Separate-Billing Rule's implementation, the rule will "result in more uninsured individuals, and compromise the ability of Americans to obtain access to care during this public health crisis."/25

The IFR did not even acknowledge this letter, much less attempt to reconcile its sixty-day implementation delay with the letter's concerns.

More recent data confirms ACOG's concerns. One new study conducted by the Guttmacher Institute found that more than one-third of women reported that they wanted to delay having a child or limit future births because of the pandemic./26

It is more critical now than ever that people have access to health insurance that makes birth control and abortion affordable, yet the Department has acknowledged that some enrollees will lose their health insurance coverage because of the Separate-Billing Rule./27

As the Guttmacher Institute found, "the number of women who will need to access abortion care may increase" because of the pandemic and changing fertility preferences./28

Moreover, many people report that raising funds for their abortion delayed obtaining care./29

Such delay is likely to only exacerbate cost, as abortion care is more expensive later in pregnancy./30

In one study, the total out-of-pocket costs (including abortion and travel) of obtaining abortion care were equivalent to more than one-third of monthly personal income for more than half of participants./31

Those numbers are undoubtedly amplified in an economic downturn like the one we are experiencing now.

For individuals for whom such costs are or become prohibitive, the deleterious impact of being unable to access abortion care is significant and long-lasting. Being denied a wanted abortion results in economic insecurity for women and their families for years to come, including nearly four-times-higher odds of being below the Federal Poverty Line./32

Women denied abortion care also report more chronic pain and rate their overall health as worse than those who are able to obtain abortions./33

Instead of addressing these harms, the Department has recognized that issuers may respond to the Separate-Billing Rule by dropping abortion coverage from their plans, where permitted by state law, which will force people to pay out of pocket for this care./34

B. The Department must evaluate the costs to issuers and states of requiring implementation of the Separate-Billing Rule during the pandemic and recession.

In addition to ignoring harms to consumers, the Department's selection of a sixty-day implementation delay is at odds with the needs of issuers and states. For this reason, as well, we urge the Department to immediately suspend implementation of the Separate-Billing Rule, at least until the pandemic is over and the economy has recovered.

Even before the COVID-19 pandemic, most issuers would have needed far longer for implementation than the Separate-Billing Rule or the IFR would provide. Blue Cross Blue Shield Association, for example, told the Department that "most issuers would need up to two years for implementation."/35

America's Health Insurance Plans likewise conducted a survey of plans and concluded that two-thirds would need at least eighteen months to comply./36

In particular, issuer representatives explained that implementation in the middle of the 2020 plan year would increase consumer confusion and leave issuers without a sufficient amount of time to test new systems required to comply with the rule and to train customer service staff./37

The National Association of Insurance Commissioners echoed that concern, explaining that "[c]onsumers can more easily adapt to new payment arrangements at the beginning of a plan year, when they expect premiums to be different and other changes to their plan to occur."/38

Issuers also described the tasks necessary to ensure compliance with the rule, including "changes to nearly every aspect of the enrollment and billing processes to identify impacted enrollees, generate and send multiple accurate invoices, collect multiple payments, and reconcile payment amounts."/39

In the IFR, the Department stated that it was delaying implementation in light of the "immediate need for . . . issuers to devote resources to respond to" the emergency caused by the pandemic./40

The delay had the effect of providing issuers eight months, instead of six, to implement the Separate-Billing Rule. On the record before it, however, the Department was plainly wrong to conclude that a sixty-day delay would provide sufficient time for issuers to respond to the COVID19 pandemic and comply with the Separate-Billing Rule. The majority of issuers will still be required to comply with the Separate-Billing Rule in the middle of a plan year, which runs from January 1 to December 31. These issuers will still have to comply with the rule at least ten months before most issuers have indicated that they would be prepared to comply. And now issuers will have to do so in the middle of what the Department has conceded is a pandemic presenting "extraordinary circumstances,"/41 which, due in large part to the Department's complete failure to take necessary steps to control it, is only going to get worse.

In addition, the Department's assertion that the IFR's August 2020 implementation deadline will be "operationally and administratively feasible" during the pandemic is completely unsupported by comments that the Department received after promulgating the Separate-Billing Rule but before issuing the IFR delaying implementation./42

The administrative record for the IFR--which one of Planned Parenthood's affiliates obtained in litigation--demonstrates that four issuers had already asked about extensions to the implementation deadline even before the Department published the IFR in early May. Two of those issuers made general inquiries, and therefore do not support the view that a sixty-day delay would be sufficient to address their concerns./43

The other two issuers requested implementation extensions until the first quarter of 2021, and July 1, 2021, respectively./44

Both periods of time are, of course, far longer than the IFR's sixty-day extension, and the requests show why that extension is inadequate given the pandemic. As one issuer explained, it is engaged in "extensive IT and Operations department efforts to configure and implement state of emergency regulations such as payment of claims for Providers credentialed at other locations; relaxation of telehealth requirements; first-dollar coverage of COVID-19 screening and testing; and[] changes to Physician Assistant billing rules."/45

That issuer also identified other impediments to timely compliance that would likely require a timeframe "far exceeding the six (6) months allotted" by the Separate-Billing Rule./46

The Department must address this contradictory evidence when it assesses the cost impact of requiring implementation by August 2020. In particular, the Department estimated in the Separate-Billing Rule that issuers would pay a fifty percent premium to prepare for implementation by the original deadline./47

That estimate, even assuming it was accurate when made, is likely an underestimate now--even with the sixty-day delay--because issuers and their vendors are also dealing with new IT and operational demands associated with the pandemic.

The IFR also failed to address the unique interests of state exchanges and agencies during this time; impacts to these stakeholders also bear on the costs associated with implementation of the Separate-Billing Rule during the pandemic and recession. For example, the Department's IFR failed to acknowledge, much less contend with, critical points made in a letter from seven state attorneys general, all of whom urged the Department to delay implementation until the COVID-19 pandemic is contained and the economy has recovered./48

The attorneys general highlighted the experience of state health and insurance regulators to justify this delay, explaining that these civil servants are focused "on the mission-critical functions of assuring access to and maintenance of health coverage for treatment and testing of COVID-19."/49

At a minimum, the Department must explain how the imposition of the Separate-Billing Rule on state exchanges and regulators at this time affects the Department's cost assessment involved in selecting the period of delayed implementation.

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The Trump administration's handling of the COVID-19 pandemic has been nothing short of disastrous. The Department should focus its time and efforts on trying to stem the pandemic and save American lives, not on denying people access to critical sexual and reproductive health services. Planned Parenthood strongly urges the Department to put the health and lives of all people in this country first. Particularly given the changed circumstances created by the pandemic and recession, the Department should suspend implementation of the Separate-Billing Rule until it can be withdrawn. The rule has always been at odds with the ACA's purpose and the best interests of people in the United States, and that remains true. At a minimum, the Department should halt implementation of the rule until the pandemic has been successfully contained and the economy has fully recovered. The Department should instead work toward fulfilling its responsibility to save lives and ensure that people can access high-quality care at affordable prices during this precarious time.

Respectfully,

Jacqueline C. Ayers

Vice President of Government Relations & Public Policy

Planned Parenthood Action Fund

Planned Parenthood Federation of America

1110 Vermont Avenue NW, Suite 300

Washington, DC 20005

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Footnotes:

1/ See Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program, Interim Final Rule, 85 Fed. Reg. 27,550 (May 8, 2020).

2/ See Patient Protection and Affordable Care Act; Exchange Program Integrity, Final Rule, 84 Fed. Reg. 71,674 (Dec. 27, 2019) (to be codified at 45 C.F.R. pts. 155, 156); Patient Protection and Affordable Care Act; Exchange Program Integrity, Notice of Correction, 85 Fed. Reg. 2,888 (Jan. 17, 2020).

3/ See Complaint for Declaratory and Injunctive Relief, Planned Parenthood of Md., Inc. v. Azar, No. 1:20-cv-00361 (D. Md. Feb. 11, 2020), ECF No. 1; see also Ex. A, Amended and Supplemental Complaint for Declaratory and Injunctive Relief, Planned Parenthood of Md., Inc. v. Azar, No. 1:20-cv-00361 (D. Md. May 19, 2020), ECF No. 39-1; Complaint for Declaratory Relief, California v. U.S. Dep't of Health & Human Servs., No. 4:20-cv-682 (N.D. Cal. Jan. 30, 2020), ECF No. 1; Washington v. Azar, No. 2:20-cv-47, 2020 WL 3620084 (E.D. Wash. Apr. 9, 2020), appeal docketed No. 20-35521 (9th Cir. June 8, 2020).

4/ Kaiser Family Found., Women's Health Insurance Coverage (2020), https://www.kff.org/womens-health-policy/factsheet/womens-health-insurance-coverage-fact-sheet/.

5/ Kaiser Family Found., Marketplace Enrollment, 2020 (2020), https://www.kff.org/health-reform/state-indicator/ marketplace-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22sc %22%7D.

6/ Calculated by summing the marketplace enrollment numbers, Kaiser Family Found., supra note 5, for the states listed in notes 22 and 23, infra.

7/ Ctrs. for Disease Control & Prevention, Coronavirus Disease 2019 (COVID-19), Cases in the U.S. (July 6, 2020), https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html [hereinafter "CDC Case Numbers"].

8/ See, e.g., Danny Westneat, Coronavirus Survival Comes with a $1.1 Million, 181-Page Price Tag, Seattle Times, June 13, 2020, https://www.seattletimes.com/seattle-news/inspiring-story-of-seattle-mans-coronavirus-survival-comes -with-a-1-1-million-dollar-hospital-bill/; Adi Guajardo, Evans Man Shocked by $139,254 Medical Bill for COVID-19 Treatment, Denver 7 ABC, May 30, 2020, https://www.thedenverchannel.com/news/local-news/evans-man-shockedby-139-254-medical-bill-for-covid-19-treatment; Joseph Goldstein, She Survived the Coronavirus. Then She Got a $400,000 Medical Bill, N.Y. Times, June 14, 2020, https://www.nytimes.com/2020/06/14/nyregion/coronavirus-billingnyc.html.

9/ William J. Barber II & William J. Barber III, Racism and COVID-19 Are a Lethal Combination, The Nation, Apr. 21, 2020, https://www.thenation.com/article/activism/environmental-racism-death-coronavirus/.

10/ Richard A. Oppel Jr., et al., The Fullest Look Yet at the Racial Inequity of Coronavirus, N.Y. Times, July 5, 2020, https://www.nytimes.com/interactive/2020/07/05/us/coronavirus-latinos-african-americans-cdc-data.html; Ctrs. for Disease Control & Prevention, COVID-19 in Racial and Ethnic Minority Groups (June 4, 2020), https://www.cdc.gov/ coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html; J. Edward Moreno, Black, Latino Communities Suffering Disproportionately from Coronavirus, Statistics Show, The Hill, Apr. 7, 2020, https://thehill.com/ homenews/state-watch/491518-black-latino-communities-suffering-disproportionately-from-coronavirus.

11/ Ctrs. for Disease Control & Prevention, People Who Are at Higher Risk for Severe Illness (May 14, 2020), https:// www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html.

12/ Nat'l Bureau of Econ. Res., Determination of the February 2020 Peak in US Economic Activity (June 8, 2020), https:// www.nber.org/cycles/june2020.pdf.

13/ Patricia Cohen, 'Still Catching Up': Jobless Numbers May Not Tell Full Story, N.Y. Times (updated June 4, 2020), https://www.nytimes.com/2020/05/28/business/economy/coronavirus-unemployment-claims.html.

14/ Rachel Garfield et al., Kaiser Family Found., Eligibility for ACA Health Coverage Following Job Loss (May 13, 2020), https://www.kff.org/coronavirus-covid-19/issue-brief/eligibility-for-aca-health-coverage-following-job-loss/. The extent to which an individual who was uninsured before job loss qualifies for a special enrollment period after job loss depends on the individual's state of residence. Id.

15/ Janell Ross, As Economy Struggles Amid Coronavirus, Low-Wage Workers of Color Taking a Major Hit, NBC News, Mar. 25, 2020, https://www.nbcnews.com/news/nbcblk/economy-struggles-amid-coronavirus-low-wage-workers-colortaking-major-n1168731.

16/ Renee Monrad, Why Are COVID-19-Related Job Losses Hitting Women Harder Than Men?, Forbes, Apr. 30, 2020, https://www.forbes.com/sites/reneemorad/2020/04/30/why-are-covid-19-related-job-losses-hitting-women-harder-than -men/#463599e61296.

17/ Patient Protection and Affordable Care Act; Exchange Program Integrity, Final Rule, 84 Fed. Reg. at 71,706.

18/ Id. at 71,686 (HHS conceding that "even with fulsome outreach and education efforts to explain the billing scheme to the policy holder, consumer confusion could still lead to inadvertent coverage losses."); see also id. at 71,703 (projecting annual issuer costs to manage "the grace period process for a higher volume of enrollees who enter a nonpayment grace period," including costs related to carrying out "termination[s]" for non-payment).

19/ Id. at 71,701 (citing "[i]ncrease in premiums beginning in plan year 2021"); id. at 71,704.

20/ Covered Cal., Covered California Releases the First National Projection of the Coronavirus (COVID-19) Pandemic's Cost to Millions of Americans With Employer or Individual Insurance Coverage (Mar. 24, 2020), https://www.covered ca.com/newsroom/news-releases/2020/03/24/covered-california-releases-the-first-national-projection-of-thecoronavirus-covid-19-pandemics-cost/.

21/ Id.

22/ Calculated by summing the case numbers as of July 6 in Maine, New York, Illinois, California, Oregon, and Washington. CDC Case Numbers, supra note 7.

23/ Calculated by summing the case numbers as of July 6 in Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New Jersey, Maryland, Montana, Colorado, Alaska, Hawaii, and the District of Columbia. CDC Case Numbers, supra note 7. See also Laurie Sobel et al., Kaiser Family Found., The Status and Likely Impact of Final Regulations on Payments for Abortion Coverage in ACA Marketplace Plans (May 4, 2020), https://www.kff.org/womens -health-policy/issue-brief/the-status-and-likely-impact-of-final-regulations-on-payments-for-abortion-coverage-in-acamarketplace-plans/ (identifying states with at least one marketplace plan that covers abortion care).

24/ Calculated by summing the case numbers as of July 6 in the seventeen states identified in footnotes 22 and 23 and the District of Columbia, and dividing by the total number of U.S. cases. See CDC Case Numbers, supra note 7.

25/ A Planned Parenthood affiliate obtained this comment, along with the rest of the IFR administrative record, in litigation. For ease of reference, we attach as Exhibit B that administrative record, which the Department has not posted online.

26/ Laura Lindberg et al., Guttmacher Inst., Early Impacts of the COVID-19 Pandemic: Findings from the 2020 Guttmacher Survey of Reproductive Health Experiences (2020), https://www.guttmacher.org/report/early-impactscovid-19-pandemic-findings-2020-guttmacher-survey-reproductive-health?utm_source=Guttmacher+Email+Alerts& utm_campaign=a8beeef774-PSRH+Covid+commentary+5-2020_COPY_01&utm_medium=email&utm_term=0_9ac8 3dc920-a8beeef774-260691229.

27/ Patient Protection and Affordable Care Act; Exchange Program Integrity, Final Rule, 84 Fed. Reg. at 71,688.

28/ Lindberg et al., supra note 26.

29/ See Sarah C.M. Roberts et al., Out-of-Pocket Costs and Insurance Coverage for Abortion in the United States, 24 Women's Health Issues e211 (2014).

30/ Jenna Jerman & Rachel K. Jones, Secondary Measures of Access to Abortion Services in the United States, 2011 and 2012: Gestational Age Limits, Cost, and Harassment, 24 Women's Health Issues e419 (2014) (In 2011 and 2012, the median cost for a procedural abortion at ten weeks gestation was $495, compared to $1,350 at twenty weeks gestation).

31/ Roberts et al., supra note 29.

32/ Diana Greene Foster et al., Socioeconomic Outcomes of Women Who Receive and Women Who Are Denied Wanted Abortions in the United States, 108 Am. J. Pub. Health 407 (2018); see also Sarah Miller et al., Nat'l Bureau of Econ. Res., Working Paper 26662: The Economic Consequences of Being Denied an Abortion (2020), https://www.nber.org/ papers/w26662.pdf.

33/ Lauren J. Ralph et al., Self-Reported Physical Health of Women Who Did and Did Not Terminate Pregnancy After Seeking Abortion Services: A Cohort Study, 171 Annals Internal Med. 328 (2019).

34/ Patient Protection and Affordable Care Act; Exchange Program Integrity, Final Rule, 84 Fed. Reg. at 71,705.

35/ Comments of Blue Cross Blue Shield Association at 4 (Jan. 7, 2019), CMS-2018-0135-74025, available at https:// www.regulations.gov/document?D=CMS-2018-0135-74025 [hereinafter "BCBSA Comment"].

36/ Comments of America's Health Insurance Plans at 11 (Jan. 7, 2019), CMS-2018-0135-73991, available at https:// www.regulations.gov/document?D=CMS-2018-0135-73991 [hereinafter "AHIP Comment"].

37/ See, e.g., AHIP Comment at 11; BCBSA Comment at 5.

38/ Comments of National Association of Insurance Commissioners at 1 (Jan. 8, 2019), CMS-2018-0135-73342, available at https://www.regulations.gov/document?D=CMS-2018-0135-73342.

39/ Patient Protection and Affordable Care Act; Exchange Program Integrity, Final Rule, 84 Fed. Reg. at 71,697.

40/ Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program, Interim Final Rule, 85 Fed. Reg. at 27,599; see also id. at 27,600.

41/ Id. at 27,599.

42/ Id. at 27,601.

43/ See Evolent Health Email, IFR-AR 000139; Softheon Email, IFR-AR 000150.

44/ See Cigna Letter at 2, IFR-AR 000152; Community Health Options ("CHO") Letter at 2, IFR-AR 000145.

45/ CHO Letter at 2, IFR-AR 000145.

46/ Id. at 2-3, IFR-AR 000145-46.

47/ Patient Protection and Affordable Care Act; Exchange Program Integrity, Final Rule, 84 Fed. Reg. at 71,689; id. at 71,697.

48/ See Att'y Gen. of N.Y., et al., Letter, IFR-AR 000153-56.

49/ Id. at 3, IFR-AR 000155; see also ACOG Letter at 1, IFR-AR 000157 (explaining that the rule would "increase costs to states . . . during this public health crisis").

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The rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0047-0001

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