Contraception is basic preventive health care that should be affordable and accessible for everyone. Under a provision of the Affordable Care Act (ACA) known as the federal contraceptive coverage guarantee, most private health insurance plans in the United States must cover the full range of contraceptive methods, services and counseling without patients’ incurring out-of-pocket costs such as copayments or deductibles. A substantial body of evidence confirms that the contraceptive coverage guarantee has had a positive impact since it took effect in 2012—dramatically reducing patients’ costs and helping them to effectively use the birth control method of their choice. This suggests that federal policymakers should strengthen contraceptive coverage protections and extend them to everyone in the United States, regardless of how they get health insurance.
How the contraceptive coverage guarantee works
- The federal contraceptive coverage guarantee is a part of a broader requirement under the ACA for most private health plans to cover a wide range of preventive services without copayments, deductibles or other out-of-pocket costs. In 2011, the Health Resources and Services Administration (HRSA) adopted expert recommendations for what must be covered as women’s preventive services, a list that included the full range of contraceptive methods, counseling and services. Since 2011, HRSA has updated these recommendations several times:
- Contraception was reaffirmed as preventive care in the updated recommendations adopted by HRSA in 2016.
- In 2019, HRSA expanded the coverage guarantee to include to the full range of “female-controlled” contraceptive methods approved by the U.S. Food and Drug Administration (FDA), as well as related counseling, initiation and follow-up care. This coverage includes a wide spectrum of contraceptive options designed to prevent unintended pregnancies and improve birth outcomes, from sterilization and long-acting reversible contraceptives to emergency contraception and fertility awareness-based methods.
- In 2021, male condoms were included as options that must be covered without cost-sharing. While the guarantee now covers male condoms, it continues to exclude vasectomy, and some health plans and entities remain exempt from the requirement. In 2024, the Biden administration proposed a rule to address remaining exclusions—including coverage of over-the-counter contraception without prescription or cost-sharing requirements—but withdrew it before it was finalized and the Trump administration took office. A large majority of private health plans are subject to the contraceptive coverage requirement, including most offered by employers, schools, and unions, and those offered through the ACA’s health insurance marketplaces.
- Some plans or entities are exempt from the contraceptive coverage requirement:
- “Grandfathered plans,” which are exempt from many ACA requirements and which enrolled 14% of covered workers in 2020.
- “Church plans,” which are established by houses of worship and other religiously affiliated nonprofits; they are exempt from federal enforcement under the ACA’s preventive services requirement.
- An employer or university claiming a religious or moral objection to covering contraception can exclude such coverage from health plans offered to employees or students.
- The HRSA guidance requires health plans subject to the federal contraceptive coverage guarantee to cover each distinct method deemed “female controlled” by the FDA (e.g., oral contraceptive pills and IUDs), as well as related counseling, services needed to initiate or discontinue use, and follow-up care. Federal guidance specifically prohibits covered entities from denying coverage for services based on an individual’s sex assigned at birth, gender identity, or gender as recorded by the insurer. It also limits plans’ ability to use gatekeeping “medical management techniques,” such as formularies or prior authorization requirements, that make it difficult for enrollees to obtain their preferred products or services. However, health plans have not always complied with these rules.
- In addition to the federal ACA requirement, 31 states and the District of Columbia have their own contraceptive coverage requirements for private insurers, which must comply with both federal and state laws. While state laws apply to a smaller subset of health plans (most notably, they do not apply to employers that “self-insure” instead of buying traditional insurance), some states go beyond the federal guarantee by requiring coverage for vasectomy or for an extended (e.g., 12-month) supply of a method at one time.
Impact of the contraceptive coverage guarantee
- Contraceptive methods and services can be prohibitively expensive for many patients. Eliminating these costs through insurance coverage can help people use their preferred methods. That, in turn, can facilitate effective contraceptive use and protect against contraceptive coercion, in which patients may be pressured to use methods they do not prefer.
- Numerous studies confirm that the federal contraceptive coverage guarantee has dramatically reduced patients’ out-of-pocket spending. Following the ACA’s implementation, the proportion of privately insured women paying nothing for contraception increased substantially. For example, between fall 2012 and spring 2014 (the period during which the coverage guarantee went into wide effect), the proportion of privately insured women who paid nothing out of pocket for the contraceptive pill increased from 15% to 67%, with similar changes for injectable contraceptives, the vaginal ring and the IUD.
