Background

Contraception is crucial for helping women avoid unintended pregnancies, and it has myriad health, social and economic benefits. Since the mid-1990s, 28 states have required health insurance plans regulated by the state that provide coverage of prescription drugs and devices to also cover prescription contraceptives.

Federal law, under a provision of the Affordable Care Act of 2010, expanded on these state policies in several ways. The federal contraceptive coverage guarantee applies to most private health plans nationwide, whether sold to employers, schools or individuals, or whether offered by employers that self-insure. (An employer that self-insures shoulders the financial risks for health care costs for its employees. State laws cannot regulate self-insured employers, which cover about 60% of insured workers nationwide.)

In addition, the federal guarantee specifically requires coverage for 18 methods of contraception used by women (including female sterilization), along with related counseling and services, and it requires this coverage to be provided without any out-of-pocket costs to the patient, such as copayments or deductibles. The federal guarantee does not require similar coverage for vasectomy or male condoms. Under the guarantee, health plans may apply formularies, prior authorization requirements and similar restrictions within a method category (e.g., to encourage patients to choose one hormonal IUD over another), but they may not favor one type of method over another (e.g., oral contraceptives over contraceptive rings). 

More recently, some states have amended and expanded their own requirements to match the standard set in the federal guarantee, specifically requiring coverage for the full range of contraceptive methods, counseling and services used by women; eliminating out-of-pocket costs; and limiting other health plan restrictions. Some of these new state provisions go beyond the federal guarantee by requiring coverage for contraceptive methods that are available over the counter without requiring the patient to first obtain a prescription, ensuring that women may receive an extended supply of a method at one time (usually a one-year supply, rather than a typical one- or three-month supply), or requiring coverage of male sterilization without out-of-pocket costs.

In October 2017, the Trump administration made it much easier for an employer to exclude contraceptive coverage from any health plan it offers to its employees and their dependents. One regulation allows any employer—nonprofit or for-profit—to exclude some or all contraceptive methods and services from the health plans it sponsors if the employer has religious objections. Another regulation allows employers with moral objections to do the same, although it applies to a slightly narrower set of employers (any employer that is not a publicly traded company). Enforcement of these regulations has been blocked by the courts. Previous federal regulations are in effect that offer an exemption for a much narrower set of explicitly religious employers and provide an “accommodation” for other nonprofit and closely held for-profit employers with religious objections that allows them to avoid paying or arranging for contraceptive coverage while still ensuring that employees and dependents receive coverage seamlessly from the same insurance company. Most of the state laws that expand contraceptive coverage offer exemptions as well, although few of them are as broad as the blocked federal exemption.