Section 2713 of the Patient Protection and Affordable Care Act (ACA), codified as 42 USC 300gg-13C 300gg-13, requires all non-grandfathered group health and individual health insurance plans to cover certain preventive health services with no cost sharing (e.g., copayment, coinsurance or deductible). This includes coverage for all contraceptive methods approved by the U.S. Food and Drug Administration (FDA), except for religious exemptions and accommodations for certain employers. Over-the-counter (OTC) formulations are only required to be covered by insurance if they were prescribed.
Under the federal Health Center Program, federally qualified health centers (FQHCs) play an integral role in providing contraception to low-income and uninsured individuals.
The Title X National Family Planning Program is the only federal program specifically dedicated to supporting the delivery of family planning care. The program funds organizations in each state to distribute federal dollars to safety net clinics to provide family planning services to low-income, uninsured and underserved clients. FQHCs may also enroll in the 340B Drug Pricing Program, entitling them to purchase contraception at a discounted price.
State Policy Options
States play a role in addressing access to contraception by considering barriers such as cost, insurance coverage and provider shortages.
The majority of women who are privately insured report their insurance covers the full cost of their contraceptive care, while one in five say they pay some out-of-pocket costs. This is in part due to exceptions for certain types or brands of contraception. Some states have codified or expanded their insurance coverage requirements for contraception. Twelve states and the District of Columbia require marketplace insurance coverage for certain OTC birth control methods, such as spermicide, sponges, emergency contraception or condoms. Seven states and the District of Columbia require private insurers to cover male condoms; insurers may require enrollees to obtain a prescription to receive coverage for these OTC birth control methods.
Traditionally, Medicaid fee-for-service has issued global payments for labor and delivery, meaning providers are not reimbursed for insertion of long-acting reversible contraception (LARCs) (i.e., IUDs and implants) and/or the devices themselves if provided immediately postpartum. States can increase access to contraception during the postpartum period by unbundling the cost of LARCs from other postpartum services. For example, Utah requires the Medicaid program to reimburse providers separately for the insertion of LARC immediately after childbirth. Illinois permits health plans to allow hospitals separate reimbursement for LARC devices provided immediately postpartum before hospital discharge.
Nearly one-third of hormonal contraceptive users say they have missed taking their birth control because they were not able to get their next supply of pills. Studies suggest a 12-month supply has been associated with a 30% reduction in the odds of having an unintended pregnancy when compared with women who are dispensed less than three months of coverage. New Jersey requires public and private health plans to allow enrollees to obtain a 12-month supply of their contraceptive method at one time. Louisiana requires Medicaid plans to dispense six-month supplies of contraceptives to patients at a time, unless the patient or provider requests otherwise.
Some states require insurance plans to cover contraception prescribed by practitioners other than physicians. For example, Arizona requires health insurance plans cover pharmacist prescribing of self-administered hormonal contraceptives. Maryland permits pharmacists to bill Medicaid for the patient assessment that is required before pharmacists can prescribe.
Advanced Practice Clinicians and Pharmacists
States may consider the scope of practice of advanced practice clinicians and pharmacists to increase the number of providers who can prescribe contraception. For example, in 2021, Maryland established certification requirements and the scope of practice for certified midwives, which include family planning, well-person reproductive care and contraception prescribing. Washington permits certified nurse-midwives to prescribe and administer contraception. Utah permits physician assistants who have practiced for at least 10,000 hours to provide services and prescribe medication, including contraceptives, without supervision from a physician.
“Pharmacy access” laws authorize pharmacists to prescribe contraceptives, which can make contraceptive care more accessible and affordable by eliminating the need for a separate visit to a health care provider. Pharmacists are more likely to have extended hours than clinics and do not require an appointment to be seen. In the United States, about 89% of residents live within five miles of a pharmacy and people see their community pharmacist 12 times more frequently than their primary care provider.
At least 20 states and the District of Columbia allow pharmacists to prescribe—or dispense under a standing prescription order—hormonal contraceptives. For example, Hawaii allows pharmacists to prescribe self-administered hormonal contraceptives and West Virginia allows pharmacists to dispense self-administered hormonal contraceptives under a standing prescription order from the state health officer. In addition to prescribing and dispensing self-administered hormonal contraception, South Carolina permits pharmacists to also administer injectable hormonal contraceptives under a standing order. Nevada requires prescribing pharmacists to provide the patient with a risk assessment tool and contraceptive method counseling when prescribing and dispensing self-administered hormonal contraceptives. In 2022, Virginia expanded the ability of pharmacists to distribute contraceptives to patients through telehealth. Seven states require a patient to see a primary care provider after a specified period of time to continue receiving contraceptives from a pharmacist.
Emergency Contraceptive Access in Emergency Rooms
Emergency contraception, which significantly reduces the chance of pregnancy, is most effective the sooner it is taken. Twenty states and the District of Columbia require hospital emergency rooms to provide emergency contraception-related information or services to sexual assault victims. Wisconsin requires hospitals to provide survivors of sexual assault with medically accurate information about emergency contraception including its availability. Nevada requires any facility providing emergency care to a sexual assault survivor to give the patient information about emergency contraception—and to supply emergency contraceptive pills upon request.
NCSL acknowledges Arnold Ventures for their support of this publication.
Please note that NCSL takes no position on state legislation or laws mentioned in linked material, nor does NCSL endorse any third-party publications; resources are cited for informational purposes only.