• Medicaid is a major source of coverage for contraceptive care for millions of people. Many Medicaid patients rely on a range of safety net providers including Planned Parenthood clinics, community health centers, state and local health departments, and Indian Health Services for their contraceptive care. The composition of the safety net and the relative role of the different providers vary considerably from state to state.
• Safety net providers served over four in ten (43%) female Medicaid enrollees seeking contraceptive care nationally, but there were considerable variations by state in the share of patients they served. While the safety net plays an important role for Medicaid enrollees, over half (54%) of female Medicaid enrollees had their last contraceptive visit at an office-based provider or outpatient clinic. 
• Community health centers (CHC) accounted for 18% of recent contraceptive visits but the state range was sizable with 46% of female patients in DC had their last contraceptive visit of 2023 at a CHC and 38% in Rhode Island. In contrast to only 4% in Wisconsin and 6% in Utah, North Dakota, North Carolina and Minnesota were seen at a CHC.
• Planned Parenthood was also an important source of contraceptive care for Medicaid enrollees (18%) but ranged widely by state. In California, 47% of female Medicaid enrollees had their last contraceptive visit of 2023 at a Planned Parenthood, compared to none in Arkansas, Mississippi, North Dakota, Wyoming, West Virginia and Texas.
• Health departments (6%) and Indian Health Services (1%) often play a smaller role nationally, but these shares can mask the important role they play in some states as a major provider of contraceptive care. For example, 39% of female Medicaid enrollees in Alabama got their last contraceptive visit of 2023 at a health department and 37% of enrollees in Alaska through Indian Health Services. 
• The relative role of safety providers is likely to change in the coming years spurred by the Federal Medicaid payment ban on Planned Parenthood, uncertainty regarding the future of Title X, growth in the uninsured projected as result of the 2025 Federal Budget Reconciliation law.

For millions of low-income people, Medicaid is a major source of coverage for their contraceptive care. It is the largest national, publicly funded program that finances family planning care and provides a key source of revenue for the vast network of safety net providers that provide reproductive and sexual health care services. Over the past year, a combination of actions by the Trump Administration, Supreme Court rulings, and new federal laws have begun to constrict the resources available to many of the providers that comprise this network. These actions have considerable implications for the future of this safety net and ultimately for access to contraceptive care for low-income people. 

The reproductive health safety net is composed of clinics that receive public funds to provide sexual and reproductive health services, and includes Community Health Centers (CHCs), health departments, Planned Parenthood clinics, Indian Health Services, and other publicly funded clinics. These sites provide family planning services including contraception, sexually transmitted infection (STI) testing and treatment, and cervical and breast cancer screening and serve large populations of low-income individuals on Medicaid billing the program for the sexual and reproductive health services they provide to enrollees. Many of these sites also receive funding support from federal programs to serve low-income uninsured individuals including the Title X family planning program, federal Health Center Program and the Indian Health Service.

The most immediate impact on funding for safety net providers has been through the Courts and Congress and has disproportionately but not exclusively affected Planned Parenthood clinics. In June 2025, the Supreme Court ruling in Medina v Planned Parenthood opened the door for states to choose to disqualify Planned Parenthood clinics from participating as a Medicaid provider. This ruling was followed by the July 2025 enactment of the 2025 Federal Budget Reconciliation Law which stripped federal Medicaid funding for one year to Planned Parenthood clinics as well as a handful of other family planning providers that also offered abortion services to their patients. The provision of the new law is being legally challenged in three separate cases making their way through federal courts, but currently, the funding ban is in effect across the country. In addition to actions directed to providers, the new law will also require certain Medicaid enrollees to meet work requirements as a condition of eligibility, a new policy that is estimated by the Congressional Budget Office to increase the number of uninsured by millions in the next ten years. 

Using the 2023 Transformed Medicaid Statistical Information System Research Files (TAF), a database of all Medicaid claims, KFF conducted an analysis to look at where reproductive age females received their last contraceptive care service by state with the goal of better understanding the role of the different types of reproductive health safety net providers in providing contraceptive care to females with Medicaid. Since people can receive contraceptive care at multiple locations in the span of a year, this analysis focused on the last location where Medicaid enrollees who received contraceptive care got their services in 2023. Since contraceptive patients can have multiple visits in the same year, this approach eliminates duplication in counting enrollees for one calendar year. This analysis specifically examines the number of Medicaid enrollees who obtained their most recent contraceptive visit at the following sites: Planned Parenthood, health centers including federally qualified health centers (FQHCs) and Look-alike health centers, state and local health departments, Indian Health Services, other sites (i.e., emergency room, retail clinics, pharmacies), and office-based providers/outpatient clinics (i.e., offices, independent clinics, outpatient hospital clinics, ambulatory surgical centers, and birthing centers). We then looked at the distribution of place of service for contraceptive care by state. Detailed methods are presented in Appendix 1. 

U.S. Profile

Nationally, Medicaid enrollees rely on a broad range of safety net providers for their contraceptive care. Over four in ten (43%) received their last contraceptive visit of 2023 at a safety net provider, including a Planned Parenthood clinic, a community health center, a state and local health department, or Indian Health Services (Figure 1).

Planned Parenthood

Planned Parenthood clinics are specialized reproductive health providers that provide the full range of contraceptive methods, STI testing, pap smears, breast exams, preventive care, and often abortion services. Despite the fact that there are fewer Planned Parenthood clinics than other safety net providers such as community health centers and state health departments, research has shown that they provide this specialized care to a high volume of patients relative to other providers. Not all states have Planned Parenthood clinics. Many states, with the support of abortion opponents, have tried to exclude Planned Parenthood clinics from their Medicaid program, largely due to opposition to including a health care provider that also provides abortion. While these efforts have been challenged by the health care provider, the Supreme Court’s June 2025 decision in Medina v Planned Parenthood South Atlantic has opened the door for states to ban Planned Parenthood from participating in their Medicaid programs. This was followed in July 2025 with the enactment of the 2025 Federal Reconciliation Bill which imposed a one year ban on Federal Medicaid funding that had a direct impact on Planned Parenthoods’ ability to participate in Medicaid for one year. In recent years, many Planned Parenthood sites have closed due to funding cuts, low Medicaid reimbursement levels, state abortion policies, and a loss of federal funds with more closures anticipated in the coming years if federal funds are not restored.

The share of female Medicaid recipients who received their last contraceptive visit of 2023 at a Planned Parenthood clinic was 18% across the U.S. and ranged from 0% in states that do not have a Planned Parenthood presence or ban Planned Parenthood from participating in their Medicaid program (Arkansas, Mississippi, North Dakota, Texas, Wyoming) to almost half (47%) of California female Medicaid recipients who received their last contraceptive visit of 2023 at a Planned Parenthood clinic (Figure 2). California has the largest Medicaid enrollment in the country and the nation’s largest Planned Parenthood clinic network but has also seen the largest number of Planned Parenthood clinic closures this year, with 6 clinics closing since the start of 2025. Some states like Louisiana have seen all of their Planned Parenthood clinics close this year. In Wisconsin, one in three (32%) female Medicaid clients received their last contraceptive care in 2023 at a Planned Parenthood clinic. Planned Parenthood clinics also provide contraceptive services to 20% Medicaid patients in Connecticut, Oregon and Washington State. As clinics have closed across the U.S. in the last several years, the share of Medicaid enrollees that rely on Planned Parenthood has likely decreased since 2023.

Community Health Centers

Community health centers comprise a national network of safety net providers that receive federal grants to provide a range of primary health services as well as other services including dental and mental health care to low-income people. Community health centers as defined in this analysis include mostly federally qualified health centers (FQHCs), as well as FQHC look-alike clinics. Although the network is vast (nearly 18,000 service sites across the U.S.), not all these sites provide contraceptive care or may not provide the full range of contraceptive services to their patients. Previous research finds that only 1 in 4 community health centers offer their patients onsite access to all of the most effective family planning methods. Community health centers have historically served much smaller volumes of contraceptive clients, and it is estimated they would have to increase their contraceptive client caseloads by 56% to make up for the loss of Planned Parenthood clinics as a site of care for Medicaid enrollees.

The share of female Medicaid recipients who received their last contraceptive visit of 2023 at a community health center across the U.S. was 18% and ranged from a low of 4% in Wisconsin to a high of 46% in D.C. (Figure 3). In states where smaller shares of Medicaid patients rely on community health centers, these providers may face difficulties in ramping up the availability of services to meet a higher demand for time-sensitive services if there are fewer options for contraceptive care when other clinics close or when they are faced with an increasing number of uninsured patients due to coverage loses through ACA enrollment decreases and Medicaid disenrollment.

State and Local Health Departments

State and local health departments comprise another important part of the reproductive health safety net in several states, and many, particularly in the South, receive Title X funding to provide family planning services to low-income and insured people in their community. Health departments have historically made up a smaller percentage of publicly supported family planning clinics and served fewer patients than Planned Parenthood clinics and federally qualified health centers (FQHCs). Of the 4.7 million women who obtained contraceptive care from publicly supported clinics in 2020, 13% received care from a health department. Similar to FQHCs, health departments are also less likely to provide the full range of contraceptive methods. However, recent research has shown that health departments perform as well or better than FQHCs on providing patient-centered contraceptive care, like prescribing at least 12 months of oral contraception at initial visit and providing same-day IUDs and implants.

This analysis finds that the role of health departments in providing contraceptive services to Medicaid enrollees nationally was 6%, it varied considerably from state to state, ranging from a high of 39% in Alabama to 0% in a number of states where health departments either do not provide or bill for health services or contraceptive care (Figure 4). Alabama’s entire Title X network is comprised of health departments, as are most of South Carolina and Louisiana’s Title X networks, which may explain the large share of Medicaid recipients who get their contraceptive care at a health department. In general, states in the Southeastern U.S. provided contraceptive care to larger shares of female Medicaid enrollees through health departments than in other parts of the country.

Indian Health Services

Indian Health Services (IHS) may not play a large role in providing contraceptive care across the U.S., but in states with larger American Indian and Alaska Native populations, they play a major role. Federal regulations require IHS to cover health promotion and disease prevention services, which include family planning services and STI services with no cost-sharing to members or descendants of federally recognized Tribes who live on or near federal reservations.

In Alaska, more than one in three (37%) female Medicaid enrollees received their last contraceptive visit of 2023 at an Indian Health Services site (Figure 5). One in six (16%) female Medicaid enrollees received their last contraceptive care at Indian Health Services in South Dakota. Indian Health Services also played a larger role in Arizona, New Mexico, Wyoming, and Montana. Many of these sites bill Medicaid for services provided to Native Americans in addition to grant funding they receive through IHS. Reductions in Medicaid enrollment anticipated as a result of the Medicaid work requirements in the 2025 Federal Reconciliation law and subsequent increases in the share of patients who are uninsured means that these sites could have fewer resources to provide contraceptive services to their patients.

Office-Based Providers/Outpatient Clinics

Given the vast proliferation of managed care in the Medicaid program, providers including those in private practice, independent clinics, outpatient or inpatient hospital departments, or ambulatory surgical centers or birthing centers provide the majority of contraceptive care to Medicaid enrollees. Most individuals with Medicaid go to an office-based provider or outpatient clinic that accepts Medicaid patients for their contraceptive care. With a weakening of the reproductive health safety net and fewer options for Medicaid enrollees to receive contraceptive care, office-based providers and outpatient clinics may see an influx of patients who can no longer go to their usual contraceptive care provider or be seen in a timely way.

The national share of female Medicaid enrollees receiving contraceptive care at an office-based provider/outpatient clinic was 54%. This ranged from a low of 25% in California, which has a large network of reproductive health safety net providers, to a high of 86% in Arkansas (Figure 6). It should be noted that office-based/outpatient providers may see a decrease in Medicaid patients in the future if enrollees start to lose Medicaid coverage due to work requirements and administrative lapses in coverage. Also, care at these sites may be unaffordable for those who are uninsured. A 2024 KFF survey found that 20% of uninsured females reported that they had to stop using a method of birth control because of cost.

Looking Ahead

Recent policy changes under the current Trump Administration have resulted in cuts to federal funding for reproductive health safety net providers through Title X and Medicaid. This has made it challenging for some of these clinics to continue operating at full capacity, and in some cases stay open. In April 2025, 16 of the 86 Title X grantees, including all the Planned Parenthood grantees had their Title X funding withheld by the Trump Administration. While some grantees eventually received partial funding months later, many clinics went several months without any Title X funds and Planned Parenthood grantees have not received any Title X funds this year. This funding uncertainty has left some of these clinics facing difficult decisions regarding their ability to continue to operate without knowing when or if they would ever receive their Title X funding. In addition, the future of the Title X family planning program is unclear. Nearly all the staff of the federal program have been laid off during the shutdown, and the Trump administration did not include any support for the program in its FY 2026 budget proposal to Congress earlier this year. 

With the June 2025 Supreme Court ruling in Medina v. Planned Parenthood South Atlantic, the door was opened for states to disqualify Planned Parenthood from participating as providers in their Medicaid programs. While this case narrowly focused on South Carolina, it is anticipated that many states, even those where abortion is banned, will drop Planned Parenthood from their Medicaid programs because they provide abortion services in other states. Federal Medicaid funds have been prohibited from paying for abortion services for decades under the Hyde Amendment, and this case allows states to choose to block Planned Parenthood from participating in Medicaid for providing other services, including contraceptive and preventive care. This state choice was effectively nationalized by the 2025 Federal Budget Reconciliation Law which prohibits “specialized” reproductive health clinics that are classified as essential community providers, provide abortion services, and received over $850,000 in Medicaid revenues from receiving any federal Medicaid reimbursement for providing non-abortion-related family planning services to individuals with Medicaid. This includes nearly all Planned Parenthood clinics as well as Maine Family Planning and Health Imperatives in Massachusetts. While this law is currently being challenged in multiple lawsuits, federal Medicaid funding is currently blocked and no longer flows to these providers for any services they provide to Medicaid enrollees. Some states have provided funds to Planned Parenthood and other affected safety net providers, but there is no guarantee that the funding will continue in future years, and funding levels often do not fill the gap. Finally, while this is a one year ban, there are already efforts in place by abortion opponents to extend this policy next year through another reconciliation vehicle. 

The 2025 Federal Budget Reconciliation Law is also projected to increase the number of individuals without insurance by 10 million over the next 10 years, which is expected to place increased pressure on the remaining reproductive health care safety net given its role providing care to uninsured patients. Combined, these policies and cuts to funding for family planning care are expected to have a direct impact on the availability of affordable and effective contraception to those who want or need it and will likely increase the number of individuals living in contraceptive deserts and who potentially experience an undesired pregnancy. The impacts of these policies will vary considerably from state to state by provider type.

Medicaid Claims Data: This analysis used two files from the 2023 T-MSIS Analytic Files (TAF): Other Header and Other Line Files (outpatient services). The analysis was limited to outpatient services because place of service (POS_CD) is only included in the Other Header File. Some patients who received their last contraceptive care while in an inpatient setting are not captured by this analysis. 

State Exclusion Criteria: Georgia and Illinois were excluded due to data quality issues with NPI.

Identifying Contraceptive Care in Medicaid Claims Data: Contraceptive claims from the Other Line file were included if they could be linked by CLM_ID to the Other Header File. We looked for all contraceptive diagnosis and procedure codes from the Other Header and Other Line File (codes available upon request).

Defining Site of Care in Medicaid Claims Data: Then the following codes were used to define the site of care on the contraceptive claim: BLG_PRVDR_NPI, DRCTNG_PRVDR_NPI, RFRG_PRVDR_NPI, SPRVSNG_PRVDR_NPI, SRVC_PRVDR_NPI, POS_CD, PGM_TYPE_CD, and BNFT_TYPE_CD. A hierarchy of contraceptive care sites was created because a single claim can have multiple codes describing different sites. There were a number of instances where contraceptive claims had laboratory as a place of service because contraceptive counseling was provided with the lab service, such as a sexually transmitted infection test. Therefore, we applied the hierarchy to all of the claims on a service day for that individual to capture whether an individual went to another location on the same day that would have likely ordered the lab service.

Office-based providers/Outpatient clinics were classified after all other sites of care were identified. The following hierarchy and codes were used to define each site of care (see Appendix Figure 1 for distributions by state): 

• Planned Parenthood: any Planned Parenthood NPI as identified through the NPPES Registry included in BLG_PRVDR_NPI, DRCTNG_PRVDR_NPI, RFRG_PRVDR_NPI, SPRVSNG_PRVDR_NPI, SRVC_PRVDR_NPI. 
• Community Health Centers: POS_CD 50 (Fed Qualified Health Ctr.), PGM_TYPE_CD 04 (Federally Qualified Health Centers (FQHC)), BNFT_TYPE_CD 004 (FQHC services), BLG_PRVDR_NPPES_TXNMY_CD 261QF0400X (Clinic/Center – Federally Qualified Health Center (FQHC)), BLG_PRVDR_TXNMY_CD 261QF0400X (Clinic/Center – Federally Qualified Health Center (FQHC)), or an FQHC or FQHC look alike NPI from the HRSA Health Center Directory or NPPES Registry with taxonomy 261QF0400X (Clinic/Center – Federally Qualified Health Center (FQHC)) for BLG_PRVDR_NPI, DRCTNG_PRVDR_NPI, RFRG_PRVDR_NPI, SPRVSNG_PRVDR_NPI, SRVC_PRVDR_NPI 
• Health Department: POS_CD 71 (Public Health Clinic) or 72 (Rural Health Clinic), PGM_TYPE_CD 03 (Rural Health Clinic (RHC)), or BNFT_TYPE_CD 003 (Rural health clinic services) 
• Indian Health Services: POS_CD 05 (Indian Health Service – Free-standing Facility), 06 (Indian Health Service – Provider-based Facility), 07 (Tribal 638), 08 (Tribal 638 Provider-based Facility); PGM_TYPE_CD 05 (Indian Health Services (IHS)); BNFT_TYPE_CD 061 (Indian Health Services and Tribal Health Facilities); or TOS_CD 127 (Indian Health Service (IHS)) 
• Other: Other services include places like retail clinics, pharmacies, urgent care, schools, telehealth, and laboratories. Across the states, the percentage of female Medicaid enrollees who received their last contraceptive visit in an “other” location ranged from 0% to 9%. 
• Office-based Providers/Outpatient Clinics: POS_CD: 11 (Office), 19 (Off Campus – Outpatient Hospital), 21 (Inpatient Hospital), 22 (Outpatient Hospital), 24 (Ambulatory Surgical Center), 25 (Birthing Center), 49 (Independent Clinic)

Access to contraception is a key element in shaping health and well-being for many women in their reproductive years. The Affordable Care Act (ACA) created a minimum set of benefits for most health plans regulated by the federal government and states, requiring most private plans to cover, without any cost sharing, the full range of FDA-approved contraceptives and services as a preventive service. In the years since its implementation in 2012, there has been a sharp decrease in the share of privately insured women who pay out of pocket costs for their prescribed contraceptives. Despite its impact reducing costs for women, the contraceptive coverage requirement has been one of the most contentious elements of the ACA leading to heated policy debates and multiple lawsuits, including three cases that reached the Supreme Court. Since the passage of the ACA, Presidential administrations have taken divergent approaches to the regulations that affect how this provision is implemented. For example, during the first Trump administration, the Department of Health and Human Services (HHS) and other related agencies promulgated a regulation that provided a broad exception to the contraception requirement to employers or plan with religious or moral objections to contraception. The Biden administration issued a proposed regulation, that was ultimately withdrawn, that would have expanded contraceptive coverage to include over-the-counter methods.

It is not known what, if any, actions the current Trump administration will make regarding contraceptive coverage. With major plans for reorganization of agencies within HHS including HRSA, the agency that has issued the contraceptive coverage requirement under the ACA rules, as well as actions to dismantle and restructure federal advisory committees, the future of contraceptive coverage is not clear. Concern about the future of this provision has spurred multiple efforts by Congressional Democrats and some state legislatures to enshrine the right to contraception, especially since Roe v Wade was overturned by the Supreme Court. This issue brief explains the rules for private insurance coverage of contraceptives at the federal and state level, the exemptions and accommodations available for certain employers, gaps in coverage for contraceptives obtained outside of the traditional clinical setting, and how changes in the agencies responsible for making contraceptive recommendations may affect coverage for contraceptives.

Use of Contraception

Contraceptive care is an important component of overall health care for many people in their reproductive years, and most women use contraception at some point in their lifetime. The majority (82%) of women of reproductive age (18 to 49) say they used some form of contraception in the past 12 months (Figure 1) and three quarters say that preventing a pregnancy is very or somewhat important to them. While most women who use contraception use it to prevent pregnancy (65%), one in five (20%) use it to both prevent pregnancy and for some other reason (such as managing a medical condition or preventing a sexually transmitted infection) and 14% use it solely for reasons outside of preventing pregnancy (such as to regulate their periods or manage acne). Among women who use contraception, nearly half (48%) report using more than one kind of contraceptive method in the past 12 months. Three in 10 (31%) women rely on permanent methods (either their own sterilization or their partner’s) and one in four (24%) used long-acting reversible methods (LARCS) like intrauterine devices (IUDs) or contraceptive implants. Four in ten (40%) women use short acting hormonal methods, with three in 10 (29%) relying on oral contraceptive pills.

Despite the fact that the ACA has been in place for 15 years, there are still gaps in awareness that federal law requires most private plans to cover the full cost of contraceptives. Among women of reproductive age, less than half (43%) know that plans are required to cover all FDA approved prescribed contraceptives. Higher shares of Black women are aware of this requirement compared to White women (49% vs. 42%). Notably, less than half (44%) of women with private insurance coverage, for whom this requirement applies, are aware that most insurance plans are required to pay the full cost of birth control for women.

ACA Federal Requirements for Contraceptive Coverage and State Laws

The Affordable Care Act requires most private plans to cover a range of recommended preventive health services provided by in-network health care providers, including contraceptives, without any cost-sharing (such as copays, deductibles or co-insurance). This requirement applies to all private plans—fully insured and self-insured plans in the individual, small group, and large group markets, except those that maintain “grandfathered” status. Individual, small, and large group plans are regulated by the state, whereas self-insured plans are regulated by the federal government under the Employee Retirement Income Security Act (ERISA). The required preventive health services for adults are those that: receive an A or B recommendation by the U.S. Preventive Services Task Force (USPSTF); are recommended by the Health Resources and Services Administration (HRSA) currently based on guidelines issued by the Women’s Preventive Services Initiative (WPSI), the expert body currently commissioned by HRSA to issue and update preventive clinical recommendations for women; and vaccine recommendations for children and adults made by the Advisory Committee on Immunization Practices (ACIP).

The HRSA contraceptive services and counseling recommendation requires plans to cover all FDA-approved, -granted, or -cleared contraceptive methods, as well as sterilization procedures, and patient screening, education, and counseling for all adolescent and adult women. This also includes any follow-up care that is required, as well as insertion and removal of implants and IUDs. The initial 2011 HRSA recommendation included the language “as prescribed” in reference to the coverage requirement for contraception. When WPSI updated the contraceptive coverage recommendation in 2021, it did not include a prescription requirement for coverage of contraception. HRSA subsequently dropped the prescription requirement in its language when the preventive services guidelines were updated and posted. While “as prescribed” is only referenced in the U.S. Departments of Labor, Health and Human Services, and Treasury (“tri-agency”) federal FAQs, plans are “encouraged” but are not required to cover over-the-counter methods, and very few do without a prescription.

Over the years, the federal tri-agency has released additional guidance clarifying the contraceptive coverage requirement. Some of this guidance has been adopted into the updated versions of the contraceptive recommendation, such as the requirement that plans must cover without cost-sharing at least one product within each FDA -approved, granted, or cleared contraceptive method category. Federal guidance clarifications include:

• Clarifying that plans must cover any contraceptives that are deemed “medically necessary” by a health care provider for an individual, including brand name drugs if a generic is not available, a clinician-recommended brand name product, and contraceptive products that are not specifically identified by HRSA, such as new contraceptive products approved by the FDA.
• Requiring plans to have an exceptions process in place for individuals whose health care provider has determined that a different contraceptive within a category (including a brand name or a different generic), that is not the one covered without cost-sharing by the plan, is “medically appropriate” for them. The exceptions process must be easily accessible and timely for patients and providers to request coverage for a medically necessary contraceptive.
• As an alternative to covering one method within each contraceptive category without cost-sharing, plans can also choose to cover all products within a contraceptive category that have no therapeutic equivalents (with the same active ingredients, dosage form, route of administration, and strength). For example, plans could choose to cover all types of hormonal IUDs currently available in the US, since none of them has a therapeutic equivalent.

Plans can use reasonable medical management to control costs and promote efficient delivery of contraceptive care. Within the categories of contraceptives that must be covered, plans may limit coverage in these categories to generic drugs and can impose cost-sharing for equivalent branded drugs. However, as noted above, plans must cover with no cost-sharing any brand names or therapeutically equivalent products that a health provider deems as “medically appropriate” for an individual. Federal guidance has also clarified that plans are not allowed to require individuals to first fail using some methods (like oral contraceptive pills) before covering a different method (such as IUDs) and cannot require that individuals first fail using certain products within a category (e.g. requiring a person to first fail using pill A before covering pill B). Plans cannot impose age limits to contraceptive services, since the recommendation applies to women with reproductive capacity.

Since the implementation of the ACA’s contraceptive coverage provision, fewer women are paying out of pocket for contraceptives. Research has found that the share of women with employer sponsored coverage who pay $0 for oral contraceptives, injectables, vaginal rings and IUDs has dramatically increased since the contraceptive coverage requirement took effect. However, a significant share of privately insured women are still paying out of pocket. Among privately insured contraceptive users, one in four (24%) report paying out-of-pocket for some or all of their contraception because their plan did not cover the full cost (Figure 2). Reasons for having out-of-pocket costs could include being enrolled in a grandfathered plan, working for an employer that has a religious objection to covering contraception, going to an out of network provider, or using a brand name method that has a generic alternative.

Before the ACA, coverage for prescription contraceptives was generally widespread in the private and public sectors, but not universal, and typically subject to cost-sharing. Unless a state had a contraceptive coverage mandate, insurers and employers could choose whether or not to provide coverage for contraception. In 2000, a ruling by the Employment Equal Opportunity Commission found that employers that covered preventive prescription drugs and services, but did not cover prescription contraceptives were in violation of the Civil Rights Act. Currently, 31 states and DC have laws requiring insurance plans to cover contraceptives and 19 states and DC prohibit cost sharing (Figure 3). State laws, however, fall short of universal coverage. They only apply to state regulated plans (Table 1), but not self-funded plans where 67% of covered workers are insured and many of these state laws also do not require plans to cover the full range of contraceptive products or do not prohibit cost-sharing (Appendix Table 1). If the ACA preventive services requirement were invalidated by the courts, only individuals with fully-insured state plans living in states with laws requiring contraceptive coverage would be guaranteed some sort of coverage.

Exemptions and Accommodations to the Contraceptive Coverage Requirement

While most employers are required to include contraceptive coverage in their plans, houses of worship can choose to be exempt from the requirement if they have religious objections. This exception means that women workers and female dependents of exempt employers do not have guaranteed coverage for either some or all FDA -approved, -granted, or -cleared contraceptive methods if their employer has an objection. Meanwhile, religiously- affiliated nonprofits and closely held for-profit corporations are not eligible for an exemption but can choose an accommodation (Figure 4). This option was first offered to religiously-affiliated nonprofit employers and then extended to closely held for-profits after the Supreme Court ruling in Burwell v. Hobby Lobby. The accommodation allows these employers to opt out of providing and paying for contraceptive coverage in their plans by either notifying their insurer, third party administrator (TPA), or the federal government of their objection. The insurers are then responsible for covering the costs of contraception, which assures that their workers and dependents have contraceptive coverage while relieving the employers of the requirement to pay for it. Because the federal government does not track this information, it is not known how many employers or plans do not cover or only provide partial coverage for contraceptive services and supplies. 

Despite its far-reaching impact, the ACA’s requirement for contraceptive coverage has been challenged in the courts on multiple occasions, with three cases reaching the Supreme Court. The earlier cases, Burwell v. Hobby Lobby (2014) and Zubik v. Burwell (2016), challenged the Obama Administration’s regulations implementing the contraceptive coverage requirement, contending that the requirement violated some employers’ religious rights. The most recent cases, Little Sisters of the Poor v. Pennsylvania (2020) and Trump v. Pennsylvania (2020), involved regulations issued by the first Trump Administration in 2018. These regulations allowed any nonprofit or for-profit employers, including private institutions of higher education, with religious objections to contraception coverage and all but publicly-traded employers with moral objections to qualify for an exemption and exclude contraceptive coverage from their plans.

In August 2025, a U.S. District Court issued a ruling in Commonwealth of Pennsylvania v. Trump in favor of Pennsylvania vacating the 2018 Trump regulations. The court found the regulations are arbitrary and capricious and were promulgated in excess of Defendants’ statutory authority and in violation of the Administrative Procedure Act’s (“APA”). The Trump administration has appealed this ruling to the Third Circuit Court of Appeals. While the Obama regulations allowing only houses of worship to be exempt are now in effect, it is not clear whether employers that dropped some or all contraceptive coverage under the Trump regulations are now in compliance or whether the Trump administration will enforce these regulations while the litigation proceeds.

Gaps in Coverage for Contraceptives Outside of the Traditional Clinical Setting

Over the past 15 years there have been efforts to broaden contraceptive availability outside of traditional clinical settings, including through commercial apps that use telehealth platforms, state efforts to allow pharmacists to prescribe birth control, and, most recently, over-the-counter (OTC) access to contraceptives without a traditional prescription. However, because the ACA’s contraceptive requirement only applies to contraception prescribed by in-network health care providers as well as challenges working getting insurance providers to work with non-traditional venues, it has been nearly impossible for individuals to obtain contraception at no cost from these new avenues using their insurance or Medicaid.

Telecontraception: A variety of online platforms are providing a new option for people to conveniently obtain contraceptive supplies that need a prescription without the need for an in-person visit (“telecontraception”). While these platforms offer a variety of brands and generic equivalents, and most offer a $10 to $15 per month oral contraception option, many report barriers working with private insurance companies. Companies that accept insurance have reported that private insurance companies are sometimes unwilling to cover contraceptive mail order deliveries beyond the first few months, likely due to pharmacy contract limitations and competition by the private insurance companies’ internal mail orders. Companies have also experienced issues with Pharmacy Benefit Managers (PBM) placing limits on refills from the telecontraception company and requiring patients to use their insurance companies PBM mail order program. One company also reported that they are considered an out-of-network provider, which means that their clients can be charged copays.

Over-the-Counter Contraceptives: In July 2023, the FDA approved the progestin-only Opill for over the counter (OTC) use, making it the first OTC daily oral contraceptive pill available for over-the-counter purchase in the U.S. without age restriction in stores and online. The suggested retail price of Opill is $19.99 for one month’s supply or $49.99 for a three-month supply. While the ACA currently requires most private plans to cover contraceptives without cost-sharing, as discussed earlier, plans typically require a prescription to trigger coverage, even for contraceptive methods that are available OTC without a prescription (such as emergency contraception). Currently, eight states (CA, CO, DE, MD, NJ, NM, NY, and WA) have laws or regulations requiring state-regulated private health insurance plans to cover, without cost sharing, some or all OTC contraception without a prescription. Requiring all plans to cover non-prescribed contraceptives would require legislation at the federal level or administrative changes to the ACA’s preventive services policy. Federal FAQs from July 2022 encourage, but do not require, plans to cover without cost sharing OTC emergency contraceptive products that are purchased without a prescription. In October 2024, the Biden Administration proposed a new rule that would have required most private plans to cover OTC methods purchased without a prescription from an in-network pharmacy and would have required plans to disclose to enrollees that OTC products were included in their coverage. In January 2025, days before the end of their presidential term, the Biden administration withdrew the proposed regulation.

Pharmacist Prescribing:  Thirty-five states and D.C. have passed laws to allow pharmacists to prescribe certain self-administered contraceptives to women, such as oral contraceptives, emergency contraception, the patch and the vaginal ring. In these states pharmacist prescribing helps reduce barriers to accessing contraception by removing the need to visit a clinician to obtain a prescription, and for people without insurance, it can be less expensive than getting a prescription from a clinician. However, challenges remain for women seeking a prescription for contraception from a pharmacist. For example, pharmacies typically charge consultation fees, which some reports suggest can be as high as $50 in certain areas. While insurers are generally required to cover contraceptives without cost sharing, they are not obligated to cover this fee. This lack of payment can lead to pharmacies charging patients a consultation fee.

The Future of Contraceptive Coverage

Changes in the Department of HHS and the agencies responsible for making women’s preventive health services recommendations may affect access and coverage to contraceptives. HHS under the Trump Administration has announced a proposal that would make major changes go through a “transformation to Make American Healthy Again.” Should this proposal be implemented, they could result in elimination of many positions and significant restructuring and consolidation of the divisions within HHS. HRSA, along with the Office of the Assistant Secretary for Health (OASH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Agency for Toxic Substances and Disease Registry (ATSDR), and the National Institute for Occupational Safety and Health (NIOSH) would be combined to form a new division, the Administration for a Health America (AHA). The statutory language in the ACA specifically names HRSA as the division responsible for making preventive services recommendations for women and it is unclear how or whether this new consolidated agency would be able to make updates or make new recommendations given the specificity of HRSA as the agency responsible for issuing the coverage guidelines for women’s preventive services in section governing coverage of preventive services in the ACA law.

The American College of Obstetricians and Gynecologists (ACOG), the organization that convenes the WPSI panel of leading medical and health professional organizations that make recommendations to for women’s preventive services to HRSA, has publicly announced that it will stop accepting federal funds for any continuation of its current contracts following changes in federal funding guidelines by the Trump administration, citing that “Recent changes in federal funding laws and regulations significantly impact ACOG’s program goals, policy positions, and ability to provide timely and evidence-based guidance and recommendations for care.” In their letter, ACOG has stated that they will continue the work, but the decision to withdraw was applauded by a Trump administration spokesman. Prior to this announcement, Project 2025 and other anti-abortion advocates had called for the federal government to cut ties with ACOG.  It is not clear how the Trump Administration will proceed after the ACOG contract expires. Whether HRSA or a new AHA agency would contract with a different organization or convene its own panel is unknown. HHS could convene a new panel to make new contraceptive recommendations or make changes to the existing one. Project 2025 and other anti-abortion organizations have called for removing IUDs and the emergency contraception pill Ella from the contraceptive coverage requirement, based on the false claim they prevent the implantation of a fertilized embryo. Research has consistently found that emergency contraception pills do not terminate a pregnancy, stop the implantation of a fertilized egg, nor affect a developing embryo and is stated on the product information available on the FDA website.

In addition, the courts continue to litigate different aspects of the ongoing preventive health services case Braidwood v. Kennedy. A federal district court is currently considering whether the Secretary of Health and Human Services’ ratification of HRSA and ACIP recommendations violates the Administrative Procedure Act and thus invalidates the preventive services issued by these agencies, including contraceptive coverage. In the original case, filed in 2022, the respondents claimed that the preventive services requirements for private health insurance are unconstitutional and that the requirement to cover pre-exposure prophylaxis treatment (PrEP) (medication to prevent getting HIV from sex or injection drug use for those at risk) violates the Religious Freedom Restoration Act (RFRA). The Supreme Court ruled in June 2025 that the ACA requirement that most private insurers and Medicaid expansion programs cover preventive services recommended by USPSTFwith no cost-sharing is constitutional. Depending on how the District Court rules regarding HRSA and ACIP and whether there are appeals to the ruling, this case may end up before the Supreme Court once again.