DEPARTMENT OF HEALTH & HUMAN SERVICES 
Health Care Financing Administration  
 Center for Medicaid and State Operations 
7500 Security Boulevard 
Baltimore, MD 21244-1850 
February 12, 1998   
Dear State Medicaid Director:   
The purpose of this letter is to notify you about a recent congressionally enacted revision to the "Hyde 
Amendment" which affects the Medicaid program and to tell you how this revision in the law is to be 
implemented.   
Effective November 13, 1997, as part of the Department of Labor, Health and Human Services, and Education 
and Related Agencies Appropriations Act, 1998, Public Law Number 105-78 (1997), Congress passed a 
revision of the Hyde Amendment pertaining to Federal funding of abortions under the Medicaid program. As 
enacted in section 509, the provision states:   
 (a) None of the funds appropriated under this Act shall be expended for any abortion.   
 (b) None of the funds appropriated under this Act shall be expended for health benefits coverage that includes 
coverage of abortion.   
 (c) The term health benefits coverage' means the package of services covered by a managed care provider or 
organization pursuant to a contract or other arrangement.   
  
Section 510 continues as follows:   
 (a) The limitations established in the preceding section shall not apply to an abortion--  
 (1) if the pregnancy is the result of an act of rape or incest; or   
 (2) In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a 
life-endangering physical condition caused by or arising from the pregnancy itself that would, as certified by a 
physician place the woman in danger of death unless an abortion is performed.   
 (b) Nothing in the preceding section shall be construed as prohibiting the expenditure by a State, locality, 
entity, or private person of State, local, or private funds (other than a State's or locality's contribution of 
Medicaid matching funds).   
 (c) Nothing in the preceding section shall be construed as restricting the ability of any managed care provider 
from offering abortion coverage or the ability of a State or locality to contract separately with such a provider 
for such coverage with State funds (other than a State's or locality's contribution of Medicaid matching funds).   
  
Current regulations at 42 CFR 441.203 and 441.206 require that before Federal financial participation (FFP) can 
be made available, the State must obtain a signed physician's certification that, based on the professional 
judgment of the physician, the abortion was necessary to save the life of the mother. Because the language of 
the current Hyde Amendment differs from its predecessors (by requiring that the abortion be necessary due to a 
physical disorder, injury, or illness, including a life-endangering physical condition caused by or arising from 
the pregnancy itself, that would place the woman in danger of death unless an abortion is performed) the State 
must change the wording of the physician's certification to comport with the current statutory language.   
As with the language in effect since October 1, 1993, the revised Hyde Amendment provides for funding for 
abortions if the pregnancy is the result of an act of rape or incest. As discussed in my December 28, 1993 letter, 
all abortions covered by the Hyde Amendment, including those abortions related to rape or incest, are medically 
necessary services and are required to be provided by states participating in the Medicaid program. States may  continue to impose reasonable reporting or documentation requirements on recipients or providers as may be 
necessary to assure them that an abortion was for the purpose of terminating a pregnancy caused by an act of 
rape or incest. However, those reporting or documentation requirements may not serve to deny or impede 
coverage for abortions. To insure that reporting requirements do not prevent or impede coverage for these 
covered abortions, any such reporting requirements must be waived and the procedure considered being 
reimbursable if the treating physician certifies that in his or her professional opinion, the patient was unable, for 
physical or psychological reasons, to comply with the requirements.   
The new Hyde Amendment language precludes payment for any "health benefits coverage" that includes 
abortions other than those specifically permitted by the terms of the Hyde Amendment. Therefore, a managed 
care provider or organization that provides abortions in addition to those reimbursed under the Hyde 
Amendment pursuant to a contract or other arrangement with the Medicaid agency are not eligible for any 
Federal funding for any of the services covered by that contract or arrangement. If a state wishes to reimburse 
managed care providers or organizations to provide additional abortions, it must do so under a separate contract 
or arrangement using monies unrelated to Federal, state or local Medicaid matching dollars. However, this 
should not be construed as restricting the ability of any managed care provider to offer abortion coverage or the 
ability of a State or locality to contract separately with such a provider for such coverage with State funds (other 
than a state's or locality's contribution of Medicaid matching funds).   
As you know, it is necessary for States to adhere to all conditions for Federal Medicaid funding. As part of its 
ongoing State assessment and audit programs, HCFA may include reviews of abortion claims, if necessary, to 
assure compliance with these conditions.   
Please call my office if you have any questions about this matter.   
 
Sincerely yours,   
/s/ 
Sally K. Richardson, Director  
Center for Medicaid and State Operations   
 
cc:  
All Regional Administrators  
All HCFA Associate Regional Administrators Division of Medicaid and State Operations  
Lee Partridge - American Public Welfare Association  
Joy Wilson - National Council of State Legislature  
Jennifer Baxendell - National Governor's Association