Federal Support for Reproductive Health Services: Frequently Asked Questions
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Federal Support for Reproductive Health
Services: Frequently Asked Questions
Updated October 4, 2024
Congressional Research Service
https://crsreports.congress.gov
R46785
SUMMARY
Federal Support for Reproductive Health
Services: Frequently Asked Questions
Federal support for reproductive health services—preventive, diagnostic, and treatment services
related to reproductive systems, functions, and processes—is administered in different ways,
largely because federal agencies, departments, and programs have different missions.
R46785
October 4, 2024
Alexa C. DeBoth,
Coordinator
Analyst in Health Policy
Congress has considered bills related to various aspects of reproductive health care. This includes
bills that expand or restrict the types of reproductive health services available, how they are paid
for or provided, and the restrictions in place on paying for or providing certain types of reproductive health services. The
Supreme Court’s recent decisions regarding Dobbs v. Jackson Women’s Health Organization; the consolidated cases U.S.
Food and Drug Administration (FDA) v. Alliance for Hippocratic Medicine and Danco Laboratories L.L.C. v. Alliance for
Hippocratic Medicine; and Moyle v. United States have raised questions about access to contraception and abortion services.
This report provides answers to frequently asked questions concerning the coverage, funding, and provision of reproductive
health services in the United States. Specifically, it discusses six categories of reproductive health services with regard to
whether the federal government pays for these services, requires certain health insurance plans to cover them, or provides
them. The six categories addressed in this report are
1.
2.
3.
4.
5.
6.
contraception;
abortion and abortion counseling;
infertility-related services;
maternity services;
reproductive health screening, preventive services, and treatment; and
gender-affirming services.
After providing an overview of the reproductive health services discussed, the report
•
•
describes the services that federal payment programs will cover when provided to enrolled beneficiaries;
•
describes whether and how federal programs that provide health services directly to a set of beneficiaries
deliver or pay for the six types of reproductive health services; and
•
provides short summaries of various federal programs that administer grants to nongovernmental entities to
provide specific types of reproductive health services.
answers questions about federal requirements for private health insurance coverage of reproductive health
services;
Congressional Research Service
Federal Support for Reproductive Health Services: Frequently Asked Questions
Contents
Introduction ..................................................................................................................................... 1
General Questions ........................................................................................................................... 2
What Are Reproductive Health Services? ................................................................................. 2
What Are Contraceptive Services?............................................................................................ 2
What Are Abortions and Abortion Counseling Services? ......................................................... 7
Can Federal Funds Be Used to Pay for Abortions or Abortion Counseling? ............................ 8
What Are Infertility Services? ................................................................................................... 9
What Are Maternity Services? ................................................................................................ 10
What Are Reproductive Health Prevention and Treatment Services? ...................................... 11
What Are Gender-Affirming Services? ................................................................................... 15
Medicaid ........................................................................................................................................ 17
Does Medicaid Cover Reproductive Services? ....................................................................... 19
Comparing Medicaid Traditional Benefit Coverage of Reproductive Health
Services to ABPs............................................................................................................ 22
Where Do Medicaid Enrollees Receive Reproductive Health Care Services? ................. 23
Does Medicaid Cover Contraceptive Services? ...................................................................... 24
Does Medicaid Cover Abortions or Abortion Counseling?..................................................... 27
Does Medicaid Cover Infertility Services? ............................................................................. 28
Does Medicaid Cover Maternity Services? ............................................................................. 28
Medicaid Eligibility Pathways .......................................................................................... 29
Benefit Coverage .............................................................................................................. 30
Comparing Medicaid Maternity Coverage Across Coverage Types ................................. 31
Does Medicaid Cover Reproductive Health Screening and Preventive Services? .................. 32
Traditional Benefits........................................................................................................... 32
ABPs ................................................................................................................................. 33
Comparing Medicaid Reproductive Health Screenings and Preventive Services
Across Coverage Types.................................................................................................. 33
Does Medicaid Cover Gender-Affirming Services? ............................................................... 33
Medicare ........................................................................................................................................ 34
Does Medicare Cover Reproductive Health Services? ........................................................... 34
Does Medicare Cover Contraceptive Services? ...................................................................... 34
Does Medicare Cover Abortions or Abortion Counseling?..................................................... 35
Does Medicare Cover Infertility Services? ............................................................................. 35
Does Medicare Cover Maternity Services? ............................................................................. 35
Does Medicare Cover Reproductive Health Screening, Prevention, and Treatment
Services? .............................................................................................................................. 36
Does Medicare Cover Gender-Affirming Services? ............................................................... 36
Federal Regulation of Private Health Insurance ............................................................................ 37
Does Federal Law Require Private Health Insurance Coverage of Reproductive
Health Services?................................................................................................................... 38
Overview: Coverage of the Essential Health Benefits (EHB) .......................................... 38
Overview: Coverage of Certain Preventive Services Without Cost Sharing .................... 39
Does Federal Law Require Private Health Insurance Coverage of
Contraceptive Services? ....................................................................................................... 41
Does Federal Law Require Private Health Insurance Coverage of Abortions or
Abortion Counseling? .......................................................................................................... 45
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Federal Support for Reproductive Health Services: Frequently Asked Questions
Does Federal Law Require Private Health Insurance Coverage of Infertility Services? ........ 47
Does Federal Law Require Private Health Insurance Coverage of Maternity Services? ........ 48
Does Federal Law Require Private Health Insurance Coverage of Reproductive
Health Screening, Prevention, and Treatment Services?...................................................... 50
Does Federal Law Require Private Health Insurance Coverage of Gender-Affirming
Services? .............................................................................................................................. 52
Federal Employees Health Benefits Program (FEHB) .................................................................. 53
Do FEHB Plans Cover Reproductive Health Services? .......................................................... 54
Do FEHB Plans Cover Contraceptive Services?..................................................................... 55
Do FEHB Plans Cover Abortions or Abortion Counseling? ................................................... 56
Do FEHB Plans Cover Infertility Services? ............................................................................ 56
Do FEHB Plans Cover Maternity Services? ........................................................................... 56
Do FEHB Plans Cover Reproductive Health Screening, Prevention, and Treatment
Services? .............................................................................................................................. 57
Does FEHB Cover Gender-Affirming Services? .................................................................... 57
Federal Agencies and Departments ............................................................................................... 58
Bureau of Prisons (BOP) ......................................................................................................... 58
Does BOP Provide Reproductive Health Services? .......................................................... 60
Does BOP Provide Contraceptive Services?..................................................................... 60
Does BOP Provide Abortions or Abortion Counseling? ................................................... 60
Does BOP Provide Infertility Services? ............................................................................ 61
Does BOP Provide Maternity Services? ........................................................................... 61
Does BOP Provide Reproductive Health Screening, Prevention, and
Treatment Services? ....................................................................................................... 61
Does BOP Provide Gender-Affirming Services? .............................................................. 62
Department of Defense (DOD) ............................................................................................... 63
Does DOD Provide Reproductive Health Services? ......................................................... 63
Does DOD Provide Contraceptive Services?.................................................................... 63
Does DOD Provide Abortions or Abortion Counseling? .................................................. 64
Does DOD Provide Infertility Services? ........................................................................... 64
Does DOD Provide Maternity Services? .......................................................................... 66
Does DOD Provide Reproductive Health Screening, Prevention, and Treatment
Services? ........................................................................................................................ 66
Does DOD Provide Gender-Affirming Services? ............................................................. 66
U.S. Immigration and Customs Enforcement (ICE) Noncitizen Detention ............................ 67
Does ICE Provide Reproductive Health Services? ........................................................... 68
Does ICE Provide Contraceptive Services? ...................................................................... 68
Does ICE Provide Abortions or Abortion Counseling? .................................................... 68
Does ICE Provide Infertility Services? ............................................................................. 68
Does ICE Provide Maternity Services? ............................................................................ 68
Does ICE Provide Reproductive Health Screening, Prevention, and
Treatment Services? ....................................................................................................... 69
Does ICE Provide Gender-Affirming Services? ............................................................... 70
Indian Health Service (IHS) .................................................................................................... 70
Does IHS Provide Reproductive Health Services? ........................................................... 70
Does IHS Provide Contraceptives? ................................................................................... 71
Does IHS Provide Abortions or Abortion Counseling? .................................................... 72
Does IHS Provide Infertility Services? ............................................................................. 72
Does IHS Provide Maternity Services? ............................................................................ 73
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Federal Support for Reproductive Health Services: Frequently Asked Questions
Does IHS Provide Reproductive Health Screening, Prevention, and
Treatment Services? ....................................................................................................... 73
Does IHS Provide Gender-Affirming Services? ............................................................... 74
The U.S. Coast Guard (USCG) ............................................................................................... 74
Does USCG Provide Reproductive Health Services? ....................................................... 75
Does USCG Provide Contraceptive Services?.................................................................. 75
Does USCG Provide Abortions or Abortion Counseling? ................................................ 76
Does USCG Provide Infertility Services? ......................................................................... 76
Does USCG Provide Maternity Services? ........................................................................ 76
Does USCG Provide Reproductive Health Screening, Prevention, and Treatment
Services? ........................................................................................................................ 76
Does USCG Provide Gender-Affirming Services? ........................................................... 77
Department of Veterans Affairs (VA) ...................................................................................... 77
Does the VA Provide Reproductive Health Services? ....................................................... 77
Does the VA Provide Contraceptive Services? ................................................................. 77
Does the VA Provide Abortions or Abortion Counseling? ................................................ 78
Does the VA Provide Infertility Services? ........................................................................ 78
Does the VA Provide Maternity Services? ........................................................................ 80
Does the VA Provide Reproductive Health Screening, Prevention, and Treatment
Services? ........................................................................................................................ 80
Does the VA Provide Gender-Affirming Services? ........................................................... 81
Grant Programs Focused on Reproductive Health ........................................................................ 81
The Title X Family Planning Program .................................................................................... 81
Do Title X Projects Provide Reproductive Health Services? ............................................ 83
Do Title X Projects Provide Contraceptive Services? ...................................................... 83
Do Title X Projects Provide Abortions or Abortion Counseling? ..................................... 85
Do Title X Projects Provide Infertility Services?.............................................................. 85
Do Title X Projects Provide Maternity Services? ............................................................. 86
Do Title X Projects Provide Reproductive Health Screening, Prevention, and
Treatment Services? ....................................................................................................... 87
Do Title X Projects Provide Gender-Affirming Services? ................................................ 88
What Are Adolescent Pregnancy Prevention Programs? ........................................................ 89
Do Adolescent Pregnancy Prevention Programs Provide Reproductive
Health Services? ............................................................................................................ 90
Do Adolescent Pregnancy Prevention Programs Provide Contraceptive Services? ......... 91
Do Adolescent Pregnancy Prevention Programs Provide Abortions or
Abortion Counseling? .................................................................................................... 91
Do Adolescent Pregnancy Prevention Programs Provide Infertility Services?................. 91
Do Adolescent Pregnancy Prevention Programs Provide Maternity Services? ................ 92
Do Adolescent Pregnancy Prevention Programs Provide Reproductive Health
Screening, Prevention, and Treatment Services? ........................................................... 92
Do Adolescent Pregnancy Prevention Programs Provide Gender-Affirming
Services? ........................................................................................................................ 92
What Federal Grant Programs Address Sexually Transmitted Infections (STIs)? .................. 92
What Centers for Disease Control and Prevention (CDC) Programs
Address STIs? ................................................................................................................ 92
What Is the Ryan White HIV/AIDS Program? ................................................................. 93
What Is the National Breast and Cervical Cancer Early Detection Program? .................. 94
Grant Programs That May Be Used to Support Reproductive Health Services ............................ 95
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Federal Support for Reproductive Health Services: Frequently Asked Questions
How Does the Federal Health Center Program Support Reproductive
Health Services? ............................................................................................................ 95
How Does the Title V Maternal Child Health State Block Grant Support
Reproductive Health Services? ...................................................................................... 96
How Does the Social Services Block Grant Program Support Reproductive
Health Services? ............................................................................................................ 97
How Does the Healthy Start Program Support Reproductive Health Services? ............... 98
How Does the Maternal, Infant, and Early Childhood Home Visiting (MIECHV)
Program Support Reproductive Health Services?.......................................................... 98
How Did the Pregnancy Assistance Fund (PAF) Program Support Reproductive
Health Services? ............................................................................................................ 99
Tables
Table 1. Contraceptive Methods: Effectiveness and Definitions..................................................... 4
Table 2. Examples of Reproductive Health Prevention and Treatment Services .......................... 13
Table 3. Infertility Services Offered by the VA ............................................................................. 78
Table A-1. Federal Requirements on Private Health Insurance Coverage of Reproductive
Health Services......................................................................................................................... 102
Table B-1. Acronyms Used in This Report.................................................................................. 109
Appendixes
Appendix A. Federal Requirements on Private Health Insurance Coverage of
Reproductive Health Services .................................................................................................. 101
Appendix B. Acronyms Used in This Report .............................................................................. 109
Appendix C. Policy Experts and Other Points of Contacts Table ................................................ 113
Contacts
Author Information....................................................................................................................... 114
Congressional Research Service
Federal Support for Reproductive Health Services: Frequently Asked Questions
Introduction
Reproductive health services are preventive, diagnostic, and treatment services related to
reproductive systems, functions, and processes. Federal support for these services is administered
in different ways because federal agencies, departments, and programs have different missions.
This report first defines six different types of reproductive health services that may receive
federal support, noting restrictions where relevant. The six types of reproductive health services
discussed in this report are
1.
2.
3.
4.
5.
6.
contraception;
abortion and abortion counseling;
infertility-related services;
maternity services;
reproductive health screening, preventive services, and treatment; and
gender-affirming services.1
The report next describes the role that the federal government has in paying for services provided
to beneficiaries enrolled in federal health insurance programs, requiring payment for services by
certain private health insurance plans, and providing domestic reproductive health services
through federal agencies and programs.2 The report then discusses grant programs that focus on
one or more specific reproductive health topics (e.g., breast cancer screening) and grant programs
that have a broader focus but may provide or pay for some types of reproductive health services.
The report concludes with three appendixes: Appendix A presents a table of federal statutory
coverage requirements of private health insurance; Appendix B identifies acronyms used in this
report; Appendix C lists CRS experts on the various reproductive health topics discussed in this
report.
On June 24, 2022, the U.S. Supreme Court issued its opinion in Dobbs v. Jackson Women’s
Health Organization, concluding that the U.S. Constitution does not confer a right to an
abortion.3 During subsequent terms, the Court heard and issued decisions on several cases
regarding reproductive health care.4 The Court’s decisions have raised questions about access to
contraception, abortion, and reproductive health services, and Congress has considered legislation
on reproductive health care in a new federal landscape.
Throughout this report, CRS has taken the primary approach of using gendered terms in the same
manner as the terms are used in the statute, rules, regulations, and guidance of specific agencies
and grant programs. That is to say, the usage of the terms such as “woman,” “man,” “female,”
“male,” “pregnant woman,” “pregnant person,” and “individuals who are pregnant,” in each
Gender-Affirming Services are medical and surgical interventions designed to help match an individuals’ primary and
secondary sex characteristics with their gender identity. Services include, but are not limited to, hormone therapy and
surgical procedures. For more information, see “What Are Gender-Affirming Services?” in this report.
2 The enrollment estimates provided for federal programs covered in this report are not additive, as individuals can
have multiple types of health coverage. In addition, the methodological approaches used to determine the estimates
may limit comparisons between different coverage types.
3 CRS Legal Sidebar LSB10768, Supreme Court Rules No Constitutional Right to Abortion in Dobbs v. Jackson
Women’s Health Organization.
4 See, for example, CRS Legal Sidebar LSB11196, Supreme Court Allows Emergency Abortions in Idaho but Leaves
Litigation Unresolved, and CRS Legal Sidebar LSB11183, Medication Abortion Access Remains Unchanged as
Supreme Court Rejects Legal Challenge on Standing Grounds.
1
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section have been made consistent with each federal agency’s or grant program’s official
terminology.5
General Questions
What Are Reproductive Health Services?
Reproductive health services are preventive, diagnostic, and treatment services related to
reproductive systems, functions, and processes. These services include, but are not exclusive to,
those related to family planning; sexually transmitted infections (STIs)/sexually transmitted
diseases (STDs);6 screening and treatment for diseases, including cancers, of the reproductive
organs and breast tissues; and gender-affirming services.7
Family planning services, which are a subset of reproductive health services, include healthpromoting preventive, diagnostic, and treatment services that help individuals and/or families
decide on whether or when to become pregnant. Such services may include using contraceptives,
infertility treatments, preconception care, pregnancy counseling, and counseling on healthy
sexual behaviors.8
What Are Contraceptive Services?
Contraceptive services include contraceptive counseling services and use of contraceptive
products or methods to prevent or delay pregnancy. Contraceptive counseling includes a health
care provider’s assessment of a client in determining which methods are safe, effective, and
available for the client; counseling of the client in determining whether a contraceptive method
will meet the client’s need and, if so, which method to choose; education of the client on how to
use the method consistently and correctly; the provision of the contraceptive product or method;
and follow-up care.9
A contraceptive is a product or method intended to lower the possibility of becoming pregnant.10
Contraceptive products vary in type and include drugs (e.g., oral contraceptives) and medical
5 For more information about terminology related to gender and gender identity, see the following resource: Centers for
Disease Control and Prevention (CDC), Division of Adolescent and School Health, “Terminology,” December 23,
2022, https://www.cdc.gov/healthyyouth/terminology/sexual-and-gender-identity-terms.htm.
6 Some assert there to be a distinction between sexually transmitted infections (STIs) and sexually transmitted diseases
(STDs). Others use the terms interchangeably. The federal programs described in this report use the terms
interchangeably. As a result, this report presents either term as it is used in the program being discussed, without
suggesting a distinction between the terms. The difference between the two is that an STI is a “virus, bacteria, fungus,
or parasite people can get through sexual contact.” All STDs start out as infections, but not all STIs develop into
diseases. For example, a Human Papillomavirus Virus (HPV) infection is classified as an STI, but if it develops into
genital warts or cervical cancer, it is then considered an STD. See CDC, “About Sexually Transmitted Infections
(STIs),” March 25, 2024, https://www.cdc.gov/sti/about/index.html#cdc_disease_basics_overview-sti-or-std.
7 Department of Health and Human Services (HHS), Office of the Assistant Secretary of Health (OASH), Office of
Population Affairs (OPA), Reproductive Health, https://opa.hhs.gov/reproductive-health.
8 Loretta Gavin, Susan Moskosky, and Marion Carter et al., “Providing Quality Family Planning Services:
Recommendations of CDC and the U.S. Office of Population Affairs,” Morbidity and Mortality Weekly Report, vol. 63,
no. RR-4 (April 25, 2014), https://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf. Adoption is not discussed in this report
because, although it is included as a family planning service, it is not an explicit health service.
9 Ibid.
10 Some types of contraceptives may also reduce risk of contracting certain STIs. STIs are discussed in the “What Are
Reproductive Health Prevention and Treatment Services?” section of this report.
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Federal Support for Reproductive Health Services: Frequently Asked Questions
devices (e.g., internal condom). Some contraceptive products have both a drug and device
component (e.g., contraceptive patch). Prior to commercial availability in the United States,
contraceptive products are reviewed by the Food and Drug Administration (FDA) of the U.S.
Department of Health and Human Services (HHS). Federal funding or payment for contraception
is generally limited to certain medical or surgical procedures and to those products that are FDAapproved, cleared, or authorized for marketing. Contraceptive methods can include fertility
awareness-based family planning methods. These utilize fertility-awareness tracking through
monitoring of symptoms and biological markers to determine periods during the menstrual cycle
when the possibility of pregnancy is lowest.11 Fertility-awareness tracking can be tracked
manually or with the assistance of a mobile medical application (app).12
For contraceptive drugs, FDA approves those products that demonstrate substantial evidence that
the drug is safe and effective for the purpose stated in the new drug application.13 For high-risk
(class III) contraceptive devices, FDA approves those products that demonstrate reasonable
assurance of safety and effectiveness. For moderate-risk (class II) contraceptive devices, FDA
clears those products that demonstrate substantial equivalence to a device already on the market
(a predicate device).14
FDA has identified 19 different contraceptive methods.15 (See Table 1, which lists those methods
from those most effective at preventing pregnancy to those least effective and provides a
description for each method.)16 For example, for each of the first five methods listed, according to
FDA, less than one pregnancy per 100 women per year would be expected, in contrast to the last
method listed (spermicide alone), in which up to 28 pregnancies per 100 women per year would
be expected under typical use.17 Intrauterine devices (IUDs) and implants are long-acting
reversible contraceptives (LARCs) and are highly effective in preventing pregnancy and can last
for several years. FDA has approved emergency contraceptives (EC), which may be used if the
regular form of birth control fails (e.g., condom breakages). FDA states that EC “prevents about
55-85% of predicted pregnancies,” and “should not to be used as a regular form of birth
control.”18 FDA also states that approved contraceptive methods, including EC and IUDs, are not
11 CDC, “Contraception and Birth Control Methods,” August 6, 2024, https://www.cdc.gov/contraception/about/.
12 FDA, “FDA allows marketing of first direct-to-consumer app for contraceptive use to prevent pregnancy,” press
release, August 10, 2018, https://www.fda.gov/news-events/press-announcements/fda-allows-marketing-first-directconsumer-app-contraceptive-use-prevent-pregnancy.
13 For more information, see CRS Report R41983, How FDA Approves Drugs and Regulates Their Safety and
Effectiveness, and CRS In Focus IF11083, Medical Product Regulation: Drugs, Biologics, and Devices.
14 CRS Report R42130, FDA Regulation of Medical Devices. Examples of contraceptive devices that are class III (high
risk) include some intrauterine devices (IUDs), tubal occlusion devices (such as Essure, which was discontinued by
Bayer in 2018), and the female condom. Examples of contraceptive devices that are class II (moderate risk) include the
diaphragm and the male condom. For IUD regulation, see 21 C.F.R. §884.5360; for tubal occlusion device regulation,
see 21 C.F.R. §884.5380; for female condom regulation, see 21 C.F.R. §884.5330.; for diaphragm regulation, see 21
C.F.R. §884.5350; and for condom regulation, see 21 C.F.R. §884.5300.
15 Note that FDA approves, clears, and grants marketing authorization for individual contraceptive products, not
methods. For purposes of this report, which includes birth control options broader than products, such as sterilization,
the term methods is used.
16 FDA, Birth Control Guide, May 10, 2024, https://www.fda.gov/media/150299/download.
17 Ibid.
18 Ibid.
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abortifacients19 within the meaning of federal law.20 These contraceptive products, including EC
pills, are not effective if the patient is already pregnant (where pregnancy “encompasses the
period of time from implantation until delivery.”)21 Table 1 displays the FDA’s descriptions of
contraceptive methods and their effectiveness, and language reflects that of the FDA birth control
resources. Effectiveness estimates are the number of women per 100 who become pregnant over
the course of one year using the same method given typical use of that method.
Table 1. Contraceptive Methods: Effectiveness and Definitions
Number of
Pregnancies
Expected
(per 100 women
over one year)
Method
Description
Sterilization surgery
for women
Less than 1
Tubal ligation (cutting or tying of fallopian tubes); sealing of fallopian
tubes with clips, clamps, rings, or with an instrument that uses
electric current.
Sterilization surgery
for men
Less than 1
Vasectomy; blocking of vas deferens (tubes that carry seminal fluid).
Intrauterine device
(IUD) copper
Less than 1
T-shaped copper device inserted into the uterus; prevents sperm
from reaching the egg and may prevent implantation. Can be used for
a maximum of 10 years.
IUD with progestin
Less than 1
T-shaped device containing the hormone progestin inserted into the
uterus; prevents sperm from reaching the egg and thins the lining of
the uterus. Can last eight years or more depending on the type.
Implantable rod
Less than 1
Small progestin-containing rod placed under the skin of the upper
arm; stops ovaries from releasing eggs; thickens cervical mucus
(preventing sperm from reaching the egg). Can be used for up to
three years.
Shot/Injection
4
Intramuscular or subcutaneous injection of the hormone progestin;
one shot is needed every three months.
Oral contraceptive
(combined pill)
7
Daily pill containing estrogen and progestin hormones; prevents
ovaries from releasing eggs; thickens cervical mucus (preventing
sperm from reaching the egg). Taken for three weeks with a week
break in between.
Oral contraceptive
(progestin only)
7
Daily pill containing progestin hormones; thickens cervical mucus
(preventing sperm from reaching the egg); some types may prevent
ovaries from releasing eggs, but these types are less common. Some
types are taken continuously, while others are taken for three weeks
with a week break in between.
19Abortifacient drugs are those for which the main or side effect is a medical abortion. EC, for instance, prevents
pregnancy by delaying ovulation and will not affect an existing pregnancy. For additional information on how EC
works, see, for example, FDA, “Plan B One-Step (1.5 mg levonorgestrel) Information,” December 23, 2022,
https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/plan-b-one-step-15-mglevonorgestrel-information. For more information on medical abortions, see the section of this report titled “What Are
Abortions and Abortion Counseling Services?”
20 FDA, “Prescription Drug Products; Certain Combined Oral Contraceptives for Use as Postcoital Emergency
Contraception,” 62 Federal Register 8610-8612, February 25, 1997.
21 45 C.F.R. §46.202(f).
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Number of
Pregnancies
Expected
(per 100 women
over one year)
Method
Description
Patch
7
Skin patch containing estrogen and progestin hormones that is worn
on the upper arm, upper back, lower abdomen, or buttocks;
prevents ovaries from releasing eggs; thickens cervical mucus
(preventing sperm from reaching the egg). Each new patch is worn
for three weeks at a time, with a week break in between.
Vaginal
contraceptive ring
7
Flexible ring worn intravaginally that releases progestin and estrogen
hormones; prevents ovaries from releasing eggs; thickens cervical
mucus (preventing sperm from reaching the egg). Each new ring is
worn for three weeks at a time, with a week break in between.
Software application
for contraception
7-8
Medical software application (app) that can be used as a method of
contraception to prevent pregnancy by predicting fertile days using
information entered by the user such as daily basal body temperature
and menstrual cycle information; recommends when to refrain from
unprotected sex or to use contraception.
Male condom
13
Thin film sheath placed over the penis; over-the-counter barrier
method that prevents sperm from reaching the egg.
Diaphragm with
spermicide
17
Dome-shaped flexible disk worn intravaginally to cover the cervix,
with spermicide foam, cream, or jelly inside of it; barrier method that
prevents sperm from reaching the egg; spermicide kills sperm cells.
Worn for a maximum of 24 hours.
Sponge with
spermicide
17
Disk-shaped sponge-like device worn intravaginally, with spermicide
foam, cream, or jelly inside of it; barrier method that prevents sperm
from reaching the egg; spermicide kills sperm cells. Worn for a
maximum of 30 hours.
Cervical cap with
spermicide
22-23
Latex or silicon cup that covers the cervix, with spermicide foam,
cream, or jelly inside of it; barrier method that prevents sperm from
reaching the egg; spermicide kills sperm cells. Worn for a maximum
of 48 hours.
Internal (female)
condom
21
Thin lubricated pouch placed inside the vagina; over-the-counter
barrier method that prevents sperm from reaching the egg.
Spermicide alone
21-28
Sperm cell killing foam, cream, jelly, film, or tablet placed
intravaginally; over-the-counter product.
Emergency
Contraceptives
(EC)
EC (Levonorgestrel
1.5mg [one pill] or
Levonorgestrel
0.75mg [two pills])
Pregnancies
Prevented
7 out of every 8
women who would
have gotten pregnant
will not become
pregnant after taking
this EC.
Congressional Research Service
Description
Progestin hormone pill(s); should be taken within 72 hours of birth
control failure or unprotected sex; primarily works to stop or delay
ovaries from releasing eggs.
Levonorgestrel 1.5mg (one pill) is available over-the-counter for
patients without age restrictions (e.g., Plan B One Step, Next Choice
One Dose)
Levonorgestrel 0.75mg (two pills) is available over-the-counter for
patients 17 years old or older, and by prescription for patients under
age 17.
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Federal Support for Reproductive Health Services: Frequently Asked Questions
Method
EC (Ulipristal
Acetate)
Number of
Pregnancies
Expected
(per 100 women
over one year)
6 or 7 out of every 10
women who would
have gotten pregnant
will not become
pregnant after taking
this EC.
Description
Pill that blocks progesterone hormone; should be taken within 120
hours of unprotected sex; works primarily by stopping or delaying
ovaries from releasing eggs; may also work by changing the lining of
the uterus that may affect implantation; available by prescription (e.g.,
Ella).
Sources: FDA, “Birth Control,” May 10, 2024, https://www.fda.gov/consumers/womens-health-topics/birthcontrol. FDA, “Plan B One-Step (1.5 mg levonorgestrel) Information,” December 23, 2022,
https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/plan-b-one-step-15-mglevonorgestrel-information. FDA, “ella (ulipristal acetate) tablet,” full prescribing information, August, 2010,
https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022474s000lbl.pdf.
Notes: Table language reflects that of the FDA Birth Control resources and chart. It is organized from most to
least effective contraceptive (sterilization is most effective; ECs are least effective). Number of pregnancies
prevented per 100 people using that method over the course of a year is not available for EC because EC is not
meant for routine or continuous use like other methods included in this table.
Though not mentioned in the FDA “Birth Control Guide,” other forms of sterilization surgery
exist and may be used as a primary form of contraception. These procedures include
hysterectomy (removal of uterus)22 and bilateral salpingectomy (removal of fallopian tubes),
often with bilateral oophorectomy (removal of both ovaries).23 These surgeries are also
commonly used to treat medical conditions, such as reproductive cancers.
22 U.S. National Library of Medicine, “Hysterectomy,” January 26, 2021, https://medlineplus.gov/hysterectomy.html.
23 Harvard Health Publishing, “Will removing your fallopian tubes reduce your risk of ovarian cancer?,” October 13,
2020, https://www.health.harvard.edu/womens-health/will-removing-your-fallopian-tubes-reduce-your-risk-of-ovariancancer. Salpingectomy and oophorectomy may also be used to prevent or treat certain reproductive cancers.
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Opill: First Over-the-Counter Birth Control Pill
In July 2023, FDA approved the first over-the-counter (OTC) birth control pill, Opill (norgestrel). Opill is a daily
oral contraceptive and the first in the United States to be approved for use without a prescription. This progestinonly oral contraceptive can be purchased without a prescription at pharmacies, drug stores, and online. The
efficacy of norgestrel was previously established with the original approval of the drug in 1973. The manufacturer
of norgestrel applied to switch the product from prescription-only to over-the-counter. In order for the product
to be approved for OTC use, FDA requires the manufacturer to demonstrate the product can be used safely and
effectively in a nonprescription setting and without the supervision from a health care professional. In a decisional
memo, FDA found “the potential benefits of an increase in the ability for consumers to prevent unintended
pregnancy (with its attendant medical, economic, and societal harms) outweigh the potential risks of the product
in the nonprescription setting” and ultimately approved the drug to be available OTC. Some contraceptives,
including condoms and ECs, are available without a prescription.
Sources: FDA, “FDA Approves First Nonprescription Daily Oral Contraceptive,” press release, July 13, 2023,
https://www.fda.gov/news-events/press-announcements/fda-approves-first-nonprescription-daily-oralcontraceptive. FDA, “Decisional Memorandum, New Drug Application 17031 Supplement 41 Application for Full
Prescription-to-Nonprescription Switch of Norgestrel Tablets 0.075 mg,” decisional memo, July 13, 2023,
https://www.accessdata.fda.gov/drugsatfda_docs/nda/2023/017031Orig1s041SumR.pdf. FDA, “Prescription-toNonprescription (Rx-to-OTC) Switches,” May 06, 2022, https://www.fda.gov/drugs/drug-application-processnonprescription-drugs/prescription-nonprescription-rx-otc-switches.
Note: The availability and price of Opill are determined by the manufacturer.
What Are Abortions and Abortion Counseling Services?
An abortion, which is used to terminate a pregnancy, may be medically induced or surgically
performed. A medically induced abortion (also called a medical abortion) is a nonsurgical
intervention that is effective within the first 10 weeks of a pregnancy.24 To terminate a pregnancy
medically, mifepristone (also known as RU-486) and misoprostol are prescribed25 in
combination.26 Mifepristone is a progesterone hormone blocker and is FDA-approved for the
termination of pregnancy,27 and misoprostol is used off-label to induce uterine contractions,
though its approved use is to prevent stomach ulcers.28 This intervention can include a follow-up
appointment with a health care provider to confirm termination of the pregnancy. Surgical
24 FDA, “Information about Mifepristone for Medical Termination of Pregnancy Through Ten Weeks Gestation,”
March 23, 2023, https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/informationabout-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation. The administration of medication or
medications to induce an abortion, at less than 10 weeks’ gestation, typically involves the use of mifepristone and
misoprostol; at more than nine weeks’ gestation, medication abortion typically involves the use of vaginal
prostaglandins. Katherine Kortsmit, Antoinette T. Nguyen, Michele G. Mandel, et al., “Abortion Surveillance —
United States, 2021,” Morbidity and Mortality Weekly Report, vol. 72, no. SS-9 (November 24, 2023), pp. 1-29.
25 Mifepristone is subject to restricted distribution pursuant to the drug’s FDA-mandated Risk Evaluation and
Mitigation Strategies (REMS) program. Formerly, the drug could be prescribed only by certified health care providers
and dispensed only in-person at specially certified health care settings, among other requirements. In 2021, FDA
reviewed the Mifepristone REMS program and determined that certain elements of the program would be updated. The
REMS program was updated to remove the in-person drug-dispensing requirement. Additionally, the update allows for
the dispensing of Mifepristone in certified pharmacies subject to manufacturers’ proposals. See FDA, “Information
about Mifepristone for Medical Termination of Pregnancy Through Ten Weeks Gestation,” March 23, 2023,
https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/mifeprex-mifepristoneinformation.
26 Mifepristone is the generic form of Mifeprex. FDA, “Questions and Answers on Mifeprex,” September 1, 2023,
https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answersmifeprex.
27 Mifeprex (mifepristone) label, https://www.accessdata.fda.gov/drugsatfda_docs/label/2000/20687lbl.pdf.
28 FDA, “Misoprostol (marketed as Cytotec) Information,” press release, July 10, 2015, https://www.fda.gov/drugs/
postmarket-drug-safety-information-patients-and-providers/misoprostol-marketed-cytotec-information.
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abortion procedures vary depending on which week of pregnancy a patient is in. These
procedures can include aspiration of the uterus, dilation of the cervix, and evacuation
procedures.29
Abortion counseling, sometimes called all-options pregnancy counseling, is, in general, a
discussion between a clinician and a patient about abortion as a potential option in pregnancy
decisionmaking.30 Abortion services may be affected by state laws limiting abortion based on
gestational age or other determinations. For a survey of laws restricting or prohibiting abortion,
see CRS Report R47595, State Laws Restricting or Prohibiting Abortion.
Can Federal Funds Be Used to Pay for Abortions or
Abortion Counseling?
Federal funds are available under limited circumstances to pay for abortion. Specifically, under
federal law, certain federal funds may only be used to pay for abortions in cases of rape, incest, or
endangerment of a mother’s life. This restriction is the result of statutory and legislative
provisions such as the Hyde Amendment (see text box), which has been added to the annual
appropriations measure for the Departments of Labor, HHS, and Education, and Related Agencies
(LHHS) since 1976.31 Similar provisions exist in the appropriations measures for foreign
operations, the District of Columbia, the Treasury, and the Department of Justice (DOJ).32 Other
codified restrictions limit the use of funds made available to the Department of Defense (DOD),
the Department of Veterans Affairs (VA), and the Indian Health Service (IHS).33
These provisions and agency guidance may additionally specify conditions under which abortion
counseling may or may not be offered by federal agencies and grant programs.34
Hyde Amendment
Following the Supreme Court’s Roe v. Wade decision, some of the first federal legislative responses involved
restrictions on the use of federal funds to pay for abortions. In 1976, Representative Henry J. Hyde offered an
amendment to the Departments of Labor and Health, Education, and Welfare, Appropriation Act, 1977, that
restricted the use of appropriated funds to pay for abortions provided through the Medicaid program. In 1980, the
Supreme Court upheld the validity of the Hyde Amendment, concluding that the funding restriction was
constitutional. Under this provision, federal funds may only be used to pay for abortions in cases of rape, incest, or
endangerment of a mother’s life.
Sources: P.L. 94-439, §209, 90 Stat. 1418, 1434 (1976).
Notes: For additional discussion of abortion funding restrictions, see CRS Report RL33467, Abortion: Judicial
History and Legislative Response.
29 Katherine Kortsmit, Antoinette T. Nguyen, Michele G. Mandel, et al., “Abortion Surveillance — United States,
2021,” Morbidity and Mortality Weekly Report, vol. 72, no. SS-9 (November 24, 2023), pp. 1-29.
30 American College of Obstetricians and Gynecologists, Pregnancy Choices: Raising the Baby, Adoption, and
Abortion, FAQ, April 2024, https://www.acog.org/womens-health/faqs/pregnancy-choices-raising-the-baby-adoptionand-abortion.
31 See P.L. 94-439, §209, 90 Stat. 1418, 1434 (1976).
32 For additional discussion of abortion funding restrictions, see CRS Report RL33467, Abortion: Judicial History and
Legislative Response, and CRS In Focus IF12167, The Hyde Amendment: An Overview.
33 See, for example, 10 U.S.C. §1093(a) (“Funds available to the Department of Defense may not be used to perform
abortions except where the life of the mother would be endangered if the fetus were carried to term or in a case in
which the pregnancy is the result of an act of rape or incest.”).
34 See, for example, 42 C.F.R. §59.5 (“Each project supported under [Part 59] must: ... not provide abortion as a
method of family planning. A project must: offer pregnant clients the opportunity to be provided information and
counseling regarding each of the following options: prenatal care and delivery; infant care, foster care, or adoption, and
pregnancy termination.”).
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What Are Infertility Services?
Infertility is a reproductive health disorder generally defined as the inability to conceive
pregnancy after a certain time period that is age dependent of attempting to conceive.35 Infertility
affects people of all genders and can be caused by reproductive organ damage, hormone
imbalance, genetic disorders, or certain medical treatments.36 Treatments for infertility thus may
involve surgery, hormone/medication therapy, genetic counseling, or medical procedures such as
intrauterine insemination (IUI).37 Treatment may also involve Assisted Reproductive
Technologies (ARTs), which are generally defined as “all fertility treatments in which either eggs
or embryos are handled.”38 In Vitro Fertilization (IVF), the most commonly used ART, is a
procedure designed to help initiate a pregnancy via transfer of fertilized embryo(s) into a uterus.39
Other ARTs include gamete and zygote intrafallopian transfer40 and elective single embryo
transfer.41
The three federal agencies that currently regulate the use of ARTs are the Centers for Disease
Control and Prevention (CDC),42 the Centers for Medicare & Medicaid Services (CMS), and the
FDA. According the American Society of Reproductive Medicine, the professional organization
that represents ART providers and clinics, the agencies’ roles are as follows:
The Centers for Disease Control and Prevention (CDC) collects and publishes data on ART
procedures. The Food and Drug Administration (FDA) controls approval and use of drugs,
biological products, and medical devices and has jurisdiction over screening and testing of
reproductive tissues, such as donor eggs and sperm. The Centers for Medicare and
35 CDC, “Infertility: Frequently Asked Questions,’ May 15, 2024, https://www.cdc.gov/reproductive-health/infertility-
faq/.
36 Ibid.
37 CDC, “What is Infertility?,” April 20, 2022, https://www.cdc.gov/reproductivehealth/features/what-is-infertility/
index.html. “Intrauterine insemination (IUI) is an infertility treatment that is often called artificial insemination. In this
procedure, specially prepared sperm are inserted into the woman’s uterus. Sometimes the woman is also treated with
medicines that stimulate ovulation before IUI.”
38 CDC, “What is Assisted Reproductive Technology?,” October 8, 2019, https://www.cdc.gov/art/whatis.html. IVF is
traditionally administered in “cycles.” In a single cycle, one egg or many eggs are retrieved from an ovary and
externally fertilized. The fertilized embryo or embryos are implanted into the uterus and monitored for development.
More than one cycle may be necessary to achieve pregnancy.
39 American Society of Reproductive Medicine, “What is In Vitro Fertilization (IVF)?” infographic,
https://www.reproductivefacts.org/globalassets/_rf/news-and-publications/infographics/invitro-fertilization/ivfinfographic.png.
40 CDC, “2021 Assisted Reproductive Technology: Fertility and National Summary Report,” 2023,
https://www.cdc.gov/art/reports/2021/pdf/Report-ART-Fertility-Clinic-National-Summary-H.pdf. Gamete and zygote
intrafallopian transfers are procedures in which “gametes or zygotes [are] transferred into the fallopian tubes rather than
the uterus.”
41 CDC, “Single Embryo Transfer,” August 3, 2017, https://www.cdc.gov/art/patientresources/transfer.html. CDC
defines this procedure as follows: “Elective single-embryo transfer (eSET) is a procedure in which one embryo,
selected from a larger number of available embryos, is placed in the uterus or fallopian tube. The embryo selected for
eSET might be from a previous IVF cycle (e.g., cryopreserved embryos [frozen]) or from the current fresh IVF cycle
that yielded more than one embryo. The remaining embryos may be set aside for future use or cryopreservation.”
42 P.L. 102-493 mandates CDC surveillance of Assisted Reproductive Technologies and, “Requires each assisted
reproductive technology program to report annually to the Secretary of Health and Human Services (Secretary),
through the Centers for Disease Control, regarding: (1) pregnancy success rates; and (2) each embryo laboratory used
by the program and whether it is certified (or has applied for certification) under this Act.” In the years following the
statute’s enactment, Congress changed the agency’s name to the “Centers for Disease Control and Prevention.”
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Medicaid Services (CMS) is responsible for implementation of the Clinical Laboratory
Improvement Act to ensure the quality of laboratory testing.43
What Are Maternity Services?
Maternity services, also referred to in this report as maternal health services, encompass a range
of preventive, diagnostic, and treatment services to monitor the health of the pregnant individual
and the fetus. These services include interventions provided during pregnancy (i.e., prenatal or
antepartum care), services provided during labor and delivery (i.e., intrapartum care), and
services provided after birth (i.e., postpartum or postnatal care).44 Other maternity services may
include support provided by entities such as doulas45 or lactation specialists, as well as other care
coordination and educational services (e.g., childbirth preparation classes). Specific services and
the timing and frequency of visits can vary based on the needs of the pregnant individual and the
fetus, as well as the maternity care setting.
Prenatal care services monitor the pregnant individual’s physical and psychological health as
well as the overall health of the fetus. Prenatal services typically include the routine monitoring of
vital signs such as maternal blood pressure and temperature, as well as physical and laboratory
assessments to screen, diagnose, and manage maternal or fetal risks, conditions, disorders, or
infections.46 Patient education is provided on a range of topics, including nutrition and the use of
prenatal vitamins (e.g., folic acid supplementation47), counseling against the use of harmful
substances, and referrals to relevant medical or social services.48 Ultrasonographic technology
(i.e., ultrasound) is typically used to confirm pregnancy and assess the overall health and growth
of the fetus.49
43 American Society for Reproductive Medicine, Oversight of Assisted Reproductive Technology, Birmingham, AL,
Updated 2021, https://www.asrm.org/globalassets/asrm/asrm-content/about-us/pdfs/oversiteofart.pdf.
44 Although not formally part of maternity care, preconception care, defined as a woman’s health before she becomes
pregnant, is considered the first step in planning a healthy pregnancy. The goal of preconception care (also referred to
as pre-pregnancy care), is to identify health conditions, lifestyle factors, and other risk factors that may affect the
health of a future pregnancy. For more information, see Office of the Assistant Secretary for Health (OASH): Office on
Women’s Health, Preconception health, February 22, 2021, https://www.womenshealth.gov/pregnancy/you-getpregnant/preconception-health, and ACOG, Good Health Before Pregnancy: Prepregnancy Care, January 2024,
https://www.acog.org/womens-health/faqs/good-health-before-pregnancy-prepregnancy-care.
45 A doula is a trained nonmedical professional who can provide physical, emotional, and informational support to a
birthing person and their family before, during, and after childbirth. See DONA International, “What is a Doula,”
https://www.dona.org/what-is-a-doula-2/.
46 Sharon Murray et al., “Antepartum Assessment, Care, and Education,” in Foundations of Maternal-Newborn and
Women's Health Nursing, 8th ed. (St. Louis, MI: Elsevier, 2023), pp. 123-139. Women's Preventive Services Initiative
(WPSI), Recommendations for well-woman care: clinical summary tables, ACOG Foundation, Washington, DC, 2024,
pp. 38-44, https://www.womenspreventivehealth.org/wp-content/uploads/FINAL-WPSI-Clinical-Summary-Tables2024.pdf.
47 U.S. Preventive Services Task Force, “Folic Acid Supplementation to Prevent Neural Tube Defects: Preventive
Medication,” August 1, 2023, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-forthe-prevention-of-neural-tube-defects-preventive-medication. See text box below for more information about the U.S.
Preventive Services Task Force.
48 Russell S. Kirby and Sarah Verbiest, “The Reproductive and Perinatal Health of Women, Pregnant Persons, and
Infants,” in Kotch’s Maternal and Child Health: Problems, Programs, and Policy in Public Health, 4th ed. (Burlington,
MA: Jones & Bartlett, LLC, 2022), pp. 185-187.
49 Sharon Murray et al., “Prenatal Diagnosis and Fetal Assessment During the Antepartum Period,” in Foundations of
Maternal-Newborn and Women's Health Nursing, 8th ed. (St. Louis, MI: Elsevier, 2023), pp. 177-180.
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Intrapartum care includes the range of services provided from the onset of labor through the
delivery of the newborn.50 These services include the monitoring of various maternal and fetal
vital signs, the management of pain and other conditions that may arise during labor, and services
specific to the method of delivery (e.g., vaginal vs. Cesarean section birth).51
Postpartum care broadly includes services provided immediately after delivery, as well as those
provided anywhere from six weeks to one year after birth. Postpartum services may include
mental health screenings (e.g., those that identify perinatal depression), physical health exams,
social assessments, counseling and/or initiation of contraception, and the management of other
chronic medical conditions that may have been initiated or exacerbated by pregnancy.52
In June 2022, the Biden Administration released the “White House Blueprint for Addressing the
Maternal Health Crisis,” which outlines a whole-of-government approach toward improving
maternal morbidity and mortality rates. Among the five priority goals is Goal 1: “Increase access
to and coverage of comprehensive high-quality maternal health services, including behavioral
health services.”53 Under this goal, the Blueprint prioritizes the expansion of insurance coverage
for maternity services from pregnancy up to a minimum of one year postpartum, emphasizes the
importance of obstetric readiness in areas without hospital-based obstetric services and linkages
to specialized maternity services, and describes the importance of expanding access to family
planning services, including contraceptive services and pre-pregnancy care.54
What Are Reproductive Health Prevention and Treatment Services?
Prevention and screening services in reproductive health seek to prevent, detect, or treat
infections, cancers, and other disorders involving the reproductive system. Common reproductive
infections include STIs 55 such as chlamydia, gonorrhea, human immunodeficiency virus (HIV)/
acquired immune deficiency syndrome (AIDS), and human papillomavirus (HPV).56 Other
reproductive disorders include malignant cancers of the reproductive tract and breast, benign
cysts and tumors, and infertility.57
50 For the purposes of this report, postnatal services provided to the infant following delivery are not considered part of
the broader definition of maternity services.
51 The American College of Obstetricians and Gynecologists (ACOG), “Labor & Delivery,” https://www.acog.org/
womens-health/pregnancy/labor-and-delivery.
52 WPSI, Recommendations for well-woman care: clinical summary tables, ACOG Foundation, Washington, DC, 2024,
pp. 38-44, https://www.womenspreventivehealth.org/wp-content/uploads/FINAL-WPSI-Clinical-Summary-Tables2024.pdf. ACOG, “Optimizing Postpartum Care: Committee Opinion No. 736,” 2018, https://www.acog.org/clinical/
clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care (reaffirmed 2021).
53 The White House, “Fact Sheet: President Biden’s and Vice President Harris’s Maternal Health Blueprint Delivers for
Women, Mothers, and Families,” press release, June 24, 2022, https://www.whitehouse.gov/briefing-room/statementsreleases/2022/06/24/fact-sheet-president-bidens-maternal-health-blueprint-delivers-for-women-mothers-and-families/.
54
The White House, White House Blueprint for Addressing the Maternal Health Crisis, June 2022, pp. 19-26,
https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf.
55 CDC, “About Sexually Transmitted Infections,” March 25, 2024, https://www.cdc.gov/sti/about/. “Sexually
transmitted diseases (STDs), also known as sexually transmitted infections or STIs, are very common. Millions of new
infections occur every year in the United States.”
56 CDC, “About Genital HPV Infection,” February 6, 2024, https://www.cdc.gov/sti/about/about-genital-hpvinfection.html. Human immunodeficiency virus (HIV) and human papillomavirus (HPV) infections can cause certain
cancers.
57 CDC, “Common Reproductive Health Concerns for Women,” May 15, 2024, https://www.cdc.gov/reproductivehealth/women-health/common-concerns.html, and CDC, “Prostate Cancer Basics,” August 27, 2024,
https://www.cdc.gov/prostate-cancer/about/index.html.
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In health care, prevention occurs along a continuum, depending on the outcomes to be
prevented.58 For example, vaccinations can prevent infectious diseases, chemotherapy can prevent
a cancer-related death, and hospice care can prevent pain and distress.59 In common usage, health
care services are generally described as either prevention or treatment, as follows:
•
•
Preventive services, which are furnished in the absence of symptoms, are
sometimes called primary prevention and secondary prevention. Primary
prevention includes interventions that are typically applied to the whole
population, such as vaccinations that decrease the risk for illness. Secondary
prevention consists of screening—diagnostic tests that detect disease early, when
treatment may be more likely to achieve remission or cure—and post-exposure
prophylaxis (PEP)—usually a drug(s) or vaccine given following exposure to an
infectious disease to prevent illness.60 For example, women planning to become
pregnant or who are early in pregnancy can take a folic acid supplement for the
purpose of preventing birth defects.61 The United States Preventive Services Task
Force (USPSTF; see text box below) evaluates evidence and makes
recommendations for the effective use of preventive services in primary care
settings.
Treatment services are surgical and medical (including pharmaceutical)
interventions to control or cure a disease, manage its symptoms, or both.
Treatment services are sometimes referred to as tertiary prevention. They are
furnished to patients who have symptoms or diagnostic findings of actual illness.
Monitoring, the use of diagnostic services to track the course of a disease or
remission, is considered a form of treatment, thus it is not discussed separately in
this report.
Clinical Preventive Services Recommendations: Key Advisory Bodies
Several nonfederal panels make clinical preventive service recommendations, including the U.S. Preventive Services
Task Force (USPSTF) and the Women’s Prevention Services Initiative (WPSI), which inform clinical practice and
are referenced in federal law to define certain requirements for coverage of or payment for clinical preventive
services.
U.S. Preventive Services Task Force (USPSTF)
The U.S. Preventive Services Task Force is an independent, volunteer panel of experts in prevention, evidencebased medicine, and epidemiology that makes evidence-based recommendations about clinical preventive services
such as screenings, counseling services, and preventive medications. Depending on available evidence,
recommendations are tailored to specific populations, such as age groups.
USPSTF recommendations “apply only to people without recognized signs or symptoms of the disease or health
condition, focus on screening to identify disease early and interventions to prevent the onset of disease, [and]
address services offered in the primary care setting or services to which patients can be referred by primary care
professionals.”
The USPSTF assigns grades to preventive services based on evidence of effectiveness balanced against potential
harm. A and B grade recommendations are given to those services that the task force most highly recommends
58 CRS Video WVB00063, Public Health 101: Overview of the U.S. System and Review of Federal Vaccine Policy,
slide 7 and accompanying audio.
59 Health programs and payers may categorize these services differently than prevention services, such as screening,
diagnostic, or treatment services.
60 CDC, Prevention: Picture of America, April 19, 2016, p. 1, https://stacks.cdc.gov/view/cdc/142637/cdc_142637_
DS1.pdf.
61 American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice and American Society
for Reproductive Medicine, “Committee Opinion: Prepregnancy Counseling,” Obstetrics and Gynecology, vol. 133,
no. 1 (January 2019).
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implementing for preventive care. These preventive services have a high or moderate net benefit for patients
based on available evidence.
Women’s Preventive Services Initiative (WPSI)
The Women’s Preventive Services Initiative is a coalition of health professional organizations representing
women’s health care clinicians and patient advocates with expertise in women’s health. WPSI is tasked with
developing, reviewing, and updating the Women’s Preventive Services Guidelines (Guidelines), which were initially
established in 2011 to provide evidence-based recommendations specific to women’s health in addition to
recommendations made by USPSTF. WPSI reviews the Guidelines at least once every five years, or upon the
availability of new evidence, as well as new preventive services topics.
The Guidelines aim to serve as a basis of recommendations to improve women’s health across the lifespan, and to
complement, build upon, and fill gaps in existing guidelines provided by the USPSTF. The Guidelines also serve as
the basis for which preventive services should be covered by certain insurers without cost-sharing, notably
contraceptive services and supplies.
Sources: USPSTF, “About the USPSTF,” https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf.
USPSTF, “Scope of Work,” Procedure Manual, Section 1.4, pp. 1-2, May, 2021,
https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/2023-11/procedure-manual-2023.pdf.
USPSTF, “13th Annual Report To Congress: High-Priority Evidence Gaps for Clinical Prevention Services”
November, 2023, https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/reports-congress/thirteenthannual-report-congress-high-priority-evidence-gaps-clinical-preventive-services. Health Resources and Services
Administration (HRSA), “Women’s Preventive Services Guidelines,” March, 2024, https://www.hrsa.gov/womensguidelines. HRSA, “Women’s Preventive Services Initiative” Factsheet, 2023,
https://www.womenspreventivehealth.org/wp-content/uploads/FINAL-2023-WPSI-Factsheet.pdf.
Notes: USPSTF is supported by the HHS Agency for Healthcare Quality and Research (AHRQ). WPSI is
supported by a cooperative grant under Health Resources and Services Administration (HRSA).
A given reproductive health service may be either a preventive service, a treatment service, or
both. For example, mammography may be a preventive service when used to screen for breast
cancer in asymptomatic patients with no history of the disease, or a treatment service when used
to monitor a breast cancer patient’s treatment progress or remission. Considering the definitions
above, health care services may be considered preventive or treatment services based on their
use.62 Often, the use (or purpose) of a service determines how it is financed. Table 2 lists
examples of diseases or conditions and their respective prevention and treatment services and
their uses.
Table 2. Examples of Reproductive Health Prevention and Treatment Services
Prevention
Disease or
Condition
Primary
Prevention
Screening/PostExposure
Prophylaxis (PEP)
Treatment
Monitoring
Medical/Surgical
Treatment
Breast cancera
None known,
although some
healthy behaviors
may lower incidence
Mammography,a
genetic counseling and
testing
Mammography
Mastectomy/lumpectomy, chemotherapy,
immunotherapy,
radiation
Cervical cancer
Human
papillomavirus (HPV)
vaccine
Visual exam, cervical
cytology (Pap smear),
HPV testing
Visual exam, cervical
cytology (Pap smear)
Surgery,
chemotherapy
62 These services additionally may be used as a diagnostic service for someone with symptoms or increased risk for a
disease. Similarly, the purpose of the service such as a diagnostic test may inform how a service is provided, covered,
or paid for.
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Prevention
Screening/PostExposure
Prophylaxis (PEP)
Treatment
Disease or
Condition
Primary
Prevention
Monitoring
Medical/Surgical
Treatment
Human
immunodeficiency
virus (HIV)
Pre-exposure
prophylaxis (PrEP),b
counseling regarding
safe sexual practices,
bloodborne
pathogens
protectionsc
Human
immunodeficiency
virus (HIV) testing,
PEPd
Viral load testing,
other bloodwork,
retesting following
exposure
Combination drug
therapy, management
of HIV-associated
conditions
Gonorrheae
Counseling regarding
safe sexual practices
Testing following
Repeat testing,
possible exposure or if especially for
at risk, PEP
antibiotic-resistant
strains
Antibiotic therapy
Source: Prepared by CRS.
Notes: This table provides illustrative examples only and is not intended to be comprehensive.
a. CDC, “Breast Cancer Basics,” February 22, 2024, https://www.cdc.gov/breast-cancer/about/index.html.
b. CDC, “Preventing HIV with PrEP,” January 18, 2024, https://www.cdc.gov/hiv/prevention/prep.html. “PrEP is
for adults and adolescents without HIV who may be exposed to HIV through sex or injection drug use.
PrEP may be an option to help protect pregnant people and their babies from getting HIV while trying to
get pregnant, during pregnancy, or while breastfeeding.” There are currently three medications with FDA
approval for use as PrEP: Truvada, Descovy, and Apretude.
c. Occupational Safety and Health Administration (OSHA), “Bloodborne Pathogens and Needlestick
Prevention,” https://www.osha.gov/bloodborne-pathogens.
d. CDC, “Preventing HIV with PEP,” January 25, 2024, https://www.cdc.gov/hiv/prevention/pep.html. HIV PEP
medications should be started within 72 hours of a possible exposure.
e. CDC, “About Gonorrhea” February 15, 2024, https://www.cdc.gov/gonorrhea/about/index.html.
On December 17, 2020, HHS released a National Strategic Plan for improving STI education,
prevention, and treatment in the United States for 2021-2025.63 This action plan specifically
targets rising rates of chlamydia, gonorrhea, syphilis, and HPV through five main objectives: (1)
STI prevention; (2) reduction of adverse outcomes through expanded prevention and health care
delivery; (3) accelerate progress in STI research, technologies, and innovations; (4) reduction of
STI-related health disparities and inequalities; and (5) integration of existing STI prevention
programs. On June 8, 2023, HHS released the STI Federal Implementation Plan to detail how
federal departments and agencies will carry out the objectives in the National Strategic Plan.64 In
addition to the STI Federal Implementation Plan, HHS, FDA, CDC, and other federal
departments and agencies implement task forces, issue programmatic guidance, and provide
training on emerging STI issues, like the recent increase in cases of infants born with syphilis,
known as congenital syphilis.65
63 HHS, “Sexually Transmitted Infections National Strategic Plan for the United States: 2021–2025,” 2020,
https://www.hhs.gov/sites/default/files/STI-National-Strategic-Plan-2021-2025.pdf.
64 HHS, “HHS Releases First-Ever STI Federal Implementation Plan,” press release, June 8, 2023,
https://www.hhs.gov/about/news/2023/06/08/hhs-releases-first-ever-sti-federal-implementation-plan.html.
65 See for instance, the report from the National Syphilis and Congenital Syphilis Syndemic Federal Task Force,
Considerations for the Implementation of Point of Care (POC) Tests for Syphilis , HHS, June 2024,
https://www.hhs.gov/sites/default/files/nscss-considerations-for-the-implementation-of-syphilis-poc-tests.pdf.
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Federal Support for Reproductive Health Services: Frequently Asked Questions
What Are Gender-Affirming Services?
Gender-affirming services, also known as gender-affirming care, are medical, surgical, mental
health, and nonmedical interventions designed to help align an individuals’ physical traits with
their gender identity.66 Although gender-affirming services do not always involve reproductive
health care services, they are covered by this report because services can involve care affecting
reproductive organ systems, and because these health services are of legislative interest to
Congress. Gender affirmation refers to the process of recognizing or affirming people in their
gender identity.67 Gender affirmation is not only something experienced by transgender and
gender diverse (TGD) individuals but also by individuals whose sex assigned at birth aligns with
their gender identity. Sex assigned at birth refers to a person’s sex usually being assigned or
determined at birth based on the appearance of external genitalia.68 Gender-identity refers to an
individual’s deeply felt, internal, intrinsic sense of their own gender.69 Although health services
that are gender-affirming are not synonymous with transition-related care, this report uses the
terms “gender-affirming services” or “gender-affirming care” to refer to such services unless
specified in relevant statute, rules, regulations, and guidance.
Use of gender-affirming services may stem from a diagnosis of gender dysphoria, a feeling of
significant discontent with their biological sex and/or birth gender, although not all individuals
who experience feelings of distress related to their gender or who have a diagnosis stemming
from that distress seek or receive gender-affirming services.70 Additionally, not all TGD
individuals experience gender dysphoria or feelings of distress. TGD individuals may still seek
out or receive gender-affirming care. Gender-affirming care is highly individualized and TGD
people may vary in the gender-affirming and transition-related services they do or do not seek out
with consultation from their health care provider(s).
Gender-affirming care treatment includes primary care, mental health services, hormone therapy,
and surgical and postoperative care.71 Gender-affirming primary care is primary care with specific
attention to the sometimes unique needs of TGD individuals and can involve appropriate
preventive services such as cancer screenings, mental health screenings, and ongoing hormone
therapy support depending on the provider’s scope of care and knowledge. Clinical guidance for
the care and treatment of TGD individuals in the primary care setting recommends that the
general health of TGD individuals should be attended to within the primary care setting, without
differentiation from services offered to people who are not TGD for physical and mental health
issues. Depending on the scope of the health provider and their knowledge of providing gender-
66 Office of Population Affairs (OPA), OASH, “Gender-Affirming Care and Young People,” https://opa.hhs.gov/sites/
default/files/2022-03/gender-affirming-care-young-people-march-2022.pdf. Not all gender-affirming services are
intended to align an individual’s sex with their gender and may support a person in feeling less distressed about a
potential misalignment of their sex and gender.
67 E. Coleman, A.E. Radix, W.P. Bouman, et al., “Standards of Care for the Health of Transgender and Gender Diverse
People, Version 8,” International Journal of Transgender Health, vol. 23 (2022), p. S252.
https://www.wpath.org/publications/soc.
68 Ibid.
69 Ibid.
70 HHS, OPA, OASH, “Gender-Affirming Care and Young People,” https://opa.hhs.gov/sites/default/files/2022-03/
gender-affirming-care-young-people-march-2022.pdf.
71 E. Coleman, A.E. Radix, W.P. Bouman, et al., “Standards of Care for the Health of Transgender and Gender Diverse
People, Version 8,” International Journal of Transgender Health, vol. 23 (2022),
https://www.wpath.org/publications/soc.
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Federal Support for Reproductive Health Services: Frequently Asked Questions
affirming care, transition-related care, such as hormone therapy, is also possible in primary care.72
Although some care for TGD individuals can take place in primary care setting, gender-affirming
care can require the coordination of multiple health care specialists. TGD individuals seeking care
may be referred to multidisciplinary gender clinics where providers of varying specialties can
coordinate an individual’s gender-affirming care treatment and services.73
Being transgender or gender diverse is not in itself a mental health disorder. As mentioned earlier
in this section, TGD individuals may experience gender dysphoria or feelings of prolonged
distress related to feelings of gender incongruence. Gender-affirming mental health care can
involve the treatments and management of prolonged feelings of distress and other mental health
issues.74 Gender-affirming surgical interventions and postoperative care can involve altering
physical features to align an individual’s gender identity.75 Surgeries include, but are not limited
to, those that alter the face, the chest/breasts, or genitals. The availability of gender-affirming
treatments may vary and depend on a health care provider’s training and knowledge in providing
gender-affirming treatments, state scope of practice laws, professional guidance, and laws
specifying access of such care.
Section 1557 of the Patient Protection and Affordable Care Act (ACA)76
Section 1557 of the ACA (§1557) prohibits discrimination on the basis of race, color, national origin, sex, disability,
and age in programs and activities administered by an executive agency or a state or federal health insurance
exchange, as well as in federally funded health programs and activities.77 HHS has primary rulemaking authority for
implementing Section 1557. HHS issued Section 1557 regulations in 2016, 2020, and 2024.78 Each administration
since the ACA’s passage has taken a different approach to implementing the law. Administrations have disagreed
on, among other things, which entities the law covers and on whether Section 1557 prohibits discrimination on
the basis of gender identity, sexual orientation, or termination of pregnancy. HHS appears to have consistently
interpreted Section 1557 to prohibit discrimination on the basis of pregnancy and related medical conditions (with
some variation as to how HHS has approached discrimination on the basis of pregnancy termination). In its most
recent rulemaking, finalized in May 2024, HHS interpreted Section 1557 to prohibit discrimination on the basis of
gender identity, sexual orientation, and pregnancy and related conditions, including pregnancy termination.79
In some circumstances, Section 1557 may require covered entities, including federal health and health insurance
programs, to provide or cover certain reproductive health services, including gynecological services, genderaffirming care, fertility services, or contraceptive services. The circumstances in which such services or coverage
would be required under Section 1557 are fact specific and beyond the scope of this report. According to HHS, a
72 Kevan Wylie, Gail Knudson, Sharful Islam Khan, et al., “Serving transgender people: clinical care considerations
and service delivery models in transgender health,” The Lancet, vol. 388, no. 10042 (2016), pp. 401-411.
73 Rebecca M. Warwick and Daniel E. Shumer, “Gender-affirming multidisciplinary care for transgender and nonbinary children and adolescents,” Children's Health Care, vol. 52, no. 1 (2021), pp. 91-155.
74 “Conversion” therapy aimed at attempting to change a person’s gender identity is not recognized as valid clinical
treatment of gender dysphoria by health professional organizations, and the American Psychological Association
recommends against the use of gender identity change efforts and that such efforts put TGD individuals at significant
risk of harm. See American Psychological Association, “Serving transgender people: clinical care considerations and
service delivery models in transgender health,” February 2021, https://www.apa.org/about/policy/guidelinespsychological-assessment-evaluation.pdf.
75 University of Michigan Medicine, “Gender Confirmation Surgery,” (accessed July 1, 2022),
https://www.uofmhealth.org/conditions-treatments/transgender-services/gender-confirmation-surgery.
76 Questions from congressional clients regarding legal issues addressed in this textbox may be directed to Abigail A.
Graber, CRS Legislative Attorney, who authored solely this textbox.
77 42 U.S.C. §18116.
78 HHS, “Nondiscrimination in Health Programs and Activities,” 89 Federal Register 37522, May 6, 2024 (“2024
Section 1557 Rule”); HHS, “Nondiscrimination in Health Programs and Activities,” 85 Federal Register 37160,
August 18, 2020; HHS, “Nondiscrimination in Health Programs and Activities,” 81 Federal Register 31376, May 18,
2016.
79 2024 Section 1557 Rule, supra footnote 78, at 37556, 37699.
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Federal Support for Reproductive Health Services: Frequently Asked Questions
covered entity’s refusal to provide, cover, or refer for abortions does not, in and of itself, violate Section 1557.
For more on Section 1557, see CRS Legal Sidebar LSB11169, HHS Finalizes Rule Addressing Section 1557 of the
ACA’s Incorporation of Title IX (May 28, 2024 version).
Medicaid
Medicaid, authorized in SSA Title XIX, is a federal-state program that jointly finances primary
and acute medical services, as well as long-term services and supports (LTSS) to a diverse lowincome population, including eligible children, pregnant women, adults, individuals with
disabilities, and people aged 65 and older.80 Participation in Medicaid is voluntary for states; all
states, the District of Columbia, and five U.S. territories choose to participate.
Medicaid is jointly financed by states and the federal government. States must follow federal
rules to receive federal matching funds, but states have the flexibility to design their own versions
of Medicaid within the federal statute’s framework. This flexibility results in variability across
state Medicaid programs in terms of eligibility and covered benefits, among other criteria. In
FY2023, Medicaid provided health care services to an estimated 97 million individuals81 at a total
cost of approximately $894 billion (including federal and state expenditures).82
Medicaid provides a health care safety net for low-income populations, playing a more significant
role for certain subpopulations.83 For example, in 2022 approximately 21% of the U.S. population
received Medicaid coverage.84 In that same year, Medicaid provided health coverage for
approximately 60% of all nonelderly individuals with incomes below 100% of the federal poverty
level (FPL).85 For some types of services (including reproductive health services), Medicaid is a
significant payer. For instance, Medicaid paid for approximately 41% of all births in the United
States in 2022.86 According to the most recent data available, Medicaid provided 75% of all
public expenditures on family planning services in FY2015.87
80 For more information about the Medicaid program, see CRS Report R43357, Medicaid: An Overview.
81 This enrollment figure is measured according to average monthly enrollment and represents the number of
beneficiaries with full and partial benefits who are enrolled on an average monthly basis. This enrollment measure
differs from person-year equivalents, which represent the average program enrollment over the course of a year and
from ever-enrolled counts, which measure the number of people covered by Medicaid for any period of time during the
year. Congressional Budget Office (CBO) Baseline Projections, Medicaid, June 2024, at https://www.cbo.gov/system/
files/2024-06/51301-2024-06-medicaid.pdf.
82 CMS, Form CMS-64 data as of May 29, 2024, athttps://www.medicaid.gov/medicaid/financial-management/stateexpenditure-reporting-for-medicaid-chip/expenditure-reports-mbescbes/index.html.
83 The health care safety net consists of those organizations and programs, in both the public and private sectors, with a
legal obligation or a commitment to provide direct health care services to uninsured and underinsured populations.
84
U.S. Census Bureau, American Community Survey Tables for Health Insurance Coverage, Table HI-05_ACS,
Health Insurance Coverage Status and Type of Coverage by State and Age for All Persons: 2022, at
https://www.census.gov/data/tables/time-series/demo/health-insurance/acs-hi.html.
85 KFF, Health Insurance Coverage of the Nonelderly (0-64) with Incomes below 100% Federal Poverty Level (FPL),
as of 2022, State Health Facts, accessed June 18, 2024, at https://www.kff.org/other/state-indicator/nonelderly-up-to100-fpl/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
86 Osterman MJK, Hamilton BE, Martin JA, Driscoll AK, Valenzuela CP. Births: Final data for 2022. National Vital
Statistics Reports; vol 73, no 2. Hyattsville, MD: National Center for Health Statistics, at https://dx.doi.org/10.15620/
cdc:145588.
87 Guttmacher Institute, Publicly Supported Family Planning Services in the United States, October 2019, at
https://www.guttmacher.org/sites/default/files/factsheet/publicly-supported-fp-services-us.pdf.
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Federal Support for Reproductive Health Services: Frequently Asked Questions
The State Children’s Health Insurance Program (CHIP)
CHIP is a federal-state program that provides health coverage to certain uninsured, low-income children and
pregnant individuals in families that have annual income above Medicaid eligibility thresholds but do not have
health insurance. Like Medicaid, CHIP is jointly financed by the federal government and the states and is
administered by the states. In FY2023, CHIP covered health care services for an estimated 7 million individuals at
an estimated cost of $23 billion, with the federal government paying approximately $17 billion of that total.
Participation in CHIP is voluntary, and all states, DC, and five territories participate. As with Medicaid, the federal
government sets basic requirements for CHIP, but states have the flexibility to design their own versions of CHIP
within the federal government’s basic framework. As a result, there is significant variation across CHIP programs.
CHIP Program Design
States may design their CHIP programs in one of three ways: a CHIP Medicaid expansion, a separate CHIP
program, or a combination approach in which the state operates a CHIP Medicaid expansion and one or more
separate CHIP programs concurrently. CHIP benefit coverage depends on program design. CHIP Medicaid
expansions must follow the federal Medicaid rules for benefits. For separate CHIP programs, benefits are
permitted to look more like private health insurance.
Under separate CHIP programs, child health assistance is defined at 42 C.F.R. §457.402 and includes services such
as physician and surgical services, prenatal care, and pre-pregnancy family planning services and supplies. The law
requires separate CHIP programs to cover certain services, including emergency services, well baby and well-child
care (including age-appropriate immunizations), and dental services. If offered, mental health services must meet
federal mental health parity requirements. As with Medicaid, federal funds may not be used for abortion services,
except in the case of a pregnancy resulting from rape or incest, or when necessary to save the mother’s life.
According to a 2017 study that looked at the types of reproductive health services covered under separate CHIP
plans, states generally provide routine gynecologic exams and obstetric care, STI/STD screening and treatment,
age-appropriate sexuality education, family planning, pregnancy testing, and pregnancy care, among other services.
CHIP Coverage of Pregnant Individuals
Under separate CHIP programs, states may extend CHIP coverage to uninsured low-income pregnant individuals
through various authorities: (1) the CHIP state plan option for pregnant individuals, (2) the Section 1115 waiver
authority, and/or (3) the unborn child pathway. Under the state plan option, states are permitted to cover
pregnant individuals through a state plan amendment when certain conditions are met. The period of coverage
associated with the state plan option includes pregnancy through the postpartum period (through 60 days
postpartum), and benefits include all services available to CHIP children in the state as well as prenatal, delivery,
and postpartum care. States are permitted to provide different benefits to pregnant individuals than CHIP children.
Under CHIP-funded pregnancy-related Section 1115 demonstration waivers, with CMS approval, states define the
eligibility criteria and benefit coverage (including duration of postpartum care), among other waiver features.
States may target the benefit coverage to meet particular health care needs (e.g., treatment for pregnant women
with substance use disorders).
States also are permitted to provide CHIP coverage to pregnant individuals (including individuals aged 19 and
older) by extending coverage to unborn children as permitted through federal regulation. Coverage available to
such individuals may be limited to prenatal and delivery services but still is used in a number of states because it
permits the extension of CHIP coverage to a pregnant individual regardless of that person’s immigration status.
The American Rescue Plan Act of 2021 (ARPA; P.L. 117-2 ) permits states to offer 12 months of continuous
postpartum coverage, regardless of changes in circumstances (with exceptions), under Medicaid and CHIP. States
that elect this option under Medicaid must elect the parallel state plan option under CHIP. Coverage includes
CHIP child health assistance available under the CHIP state plan for targeted low-income children or targeted lowincome pregnant individuals through the 12-month postpartum period. However, states are permitted to provide
more generous postpartum coverage.
Sources: CHIP average monthly enrollment from CBO, “CHIP Baseline Projections,” June 2024, at
https://www.cbo.gov/system/files/2024-06/51296-2024-06-chip.pdf. CHIP expenditures estimates from CMS, Form
CMS-64 Data and Net CHIP Expenditures, May 29, 2024, at https://www.medicaid.gov/medicaid/financialmanagement/state-expenditure-reporting-for-medicaid-chip/expenditure-reports-mbescbes/index.html. For more
on the types of reproductive health services covered under separate CHIP plans, see National Health Law
Program, CHIP Provides Critical Reproductive Health Care to Adolescents and Pregnant Women, September 12, 2017, at
https://healthlaw.org/chip-provides-critical-reproductive-health-care-to-adolescents-and-pregnant-women/.
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Federal Support for Reproductive Health Services: Frequently Asked Questions
Does Medicaid Cover Reproductive Services?
Medicaid coverage includes a variety of primary and acute-care services, including a wide range
of reproductive health services. Not all Medicaid enrollees have access to the same set of
services. An enrollee’s eligibility pathway (i.e., the eligibility category listed in statute)
determines the available services, and the services available to enrollees vary by state. In general,
federal law provides two primary benefit packages for state Medicaid programs: (1) traditional
benefits and (2) alternative benefit plans (ABPs).88 For certain subgroups, states may offer a
targeted benefit package (e.g., individuals eligible only for family planning services and supplies,
certain low-income pregnant women who are entitled to limited pregnancy-related services, and
women needing treatment for breast or cervical cancer). In addition, states can use waiver
authority89 to tailor benefit packages to specified Medicaid subgroups or to offer services outside
of those permitted under the Medicaid statute (e.g., Section 1115 demonstration waivers for
individuals living with or at risk for HIV and hepatitis, and Section 1115 demonstrations to
extend family planning services to otherwise ineligible women who lose Medicaid coverage after
the 60-day postpartum period).
Traditional Benefits
Under traditional Medicaid, states are required to cover a wide array of mandatory services90 for
all categorically needy individuals.91 In addition, states may provide optional services—that is,
services that states can choose whether to provide under their state plans.92 Examples of
mandatory service categories likely to include reproductive health services are inpatient hospital
services; physician services; family planning services; and early and periodic screening,
diagnosis, and treatment (EPSDT) for persons under age 21 (this benefit is described in more
detail below). Examples of optional service categories likely to encompass reproductive health
services include clinic services; prescription drugs; and other diagnostic, screening, preventive,
and rehabilitative services.
Some Medicaid service categories have an obvious connection to reproductive health, while
others do not. This is because many of the benefit categories listed in statute identify a type of
provider or care setting rather than a type of service. For example, a wide variety of qualified
providers may deliver reproductive health services under Medicaid, including different types of
physicians (e.g., obstetricians, gynecologists, anesthesiologists, maternal-fetal medicine
specialists) and other qualified providers identified by the state as participating in Medicaid (e.g.,
nurse midwives). Moreover, enrollees may access reproductive health services in a variety of
settings, such as a hospital, an outpatient setting, or a rural health clinic.
88 SSA §1937 [42 U.S.C. §1396u-7].
89 SSA authorizes several waiver and demonstration authorities that allow states to operate their Medicaid programs
outside of federal rules. The primary Medicaid waiver authorities include Section 1115, Section 1915(b), and Section
1915(c).
90 SSA §§1902(a)(10)(A) before (i) [42 U.S.C. §§1396a(a)(10)(A) before (i)]; 1905(a)(1)-(5), (17), (21), (28), (29) [42
U.S.C. §§1396d(a)(1)-(5), (17), (21), (28), (29)]; 42 C.F.R. §§440.210; 440.220.
91 Categorically needy refers to certain groups of families and children, aged, blind, or disabled individuals, and
pregnant women listed in SSA §1902(a)(10)(A) [42 U.S.C. §§1396a(a)(10)(A)], who comprise required and optional
Medicaid eligibility groups. 42 C.F.R. §435.4.
92 SSA §1905(a)(6)-(16), (18)-(20), (22)-(27) [42 U.S.C. §§1396d(a)(6)-(16), (18)-(20), (22)-(27)]; 42 C.F.R. §440.225.
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Federal Support for Reproductive Health Services: Frequently Asked Questions
Within the general Medicaid service categories listed in statute, states define the specific features
of each covered benefit within four broad federal guidelines.93 The breadth of coverage for a
given benefit can, and does, vary from state to state, even for mandatory services.
Under these broad categories, states offer several Medicaid services to meet a person’s
reproductive health needs, including
•
•
•
•
•
•
•
•
•
•
•
well-care visits,
breast and cervical cancer screenings,
HIV screening and treatment,
counseling and treatment for STIs,
domestic violence screening,
breastfeeding services and supplies,
smoking cessation programs,
contraception,
medically necessary hysterectomies,
reproductive health-related education and outreach activities, and
infertility treatments.
(Information on Medicaid coverage of specific types of reproductive health services appears
below.)
Medicaid-eligible children under age 21 are entitled to EPSDT,94 which includes health
screenings and services such as assessments of a child’s physical and mental health development,
laboratory tests, appropriate immunizations, and health education, among others. States are
required to provide all federally allowed treatment to address problems identified through
screenings, even if the required treatment is not otherwise covered under a given state’s Medicaid
plan. Reproductive health services, which are part of the screening and treatment services
available under ESPDT, include screenings and treatment for STIs, coverage of the HPV vaccine,
family planning services and supplies and related services, and sexuality education and
counseling.95
93 First, each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose. States may
place appropriate limits on a service based on such criteria as medical necessity. Second, within a state, services
available to the various population groups must be equal in amount, duration, and scope. This requirement is the
comparability rule. Third, with certain exceptions, the amount, duration, and scope of benefits must be the same
statewide, referred to as the statewideness rule. Fourth, with certain exceptions, enrollees must have freedom of choice
among health care providers or managed care entities participating in Medicaid.
94 See generally SSA §1905(a)(4)(B) [42 U.S.C. §1396d(a)(4)(B)], SSA §1902(a)(43) [42 U.S.C. 1396a(a)(43)], SSA
§1905(r) [42 U.S.C. §1396d(r)] and 42 C.F.R. Part 441, Subpart B, CMS, EPSDT: A Guide for States, June 2014, at
https://www.medicaid.gov/medicaid/benefits/downloads/epsdt_coverage_guide.pdf.
95 CMS identifies the American Academy of Pediatrics (AAP) “Bright Futures” guidelines as an example of a
recognized and accepted clinical practice guideline for EPSDT screenings. Bright Futures encourages providers to offer
reproductive and sexual health services, including STI screening, HPV vaccines, sexuality education and counseling,
and pregnancy testing. For more information, see Joseph F. Hagan Jr., et al., Bright Futures: Guidelines for Health
Supervision of Infants, Children, and Adolescents, AAP, 4th Edition, 2017, at https://www.aap.org/en/practicemanagement/bright-futures/bright-futures-materials-and-tools/bright-futures-guidelines-and-pocket-guide/.
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Federal Support for Reproductive Health Services: Frequently Asked Questions
Alternative Benefit Plans (ABPs)
As an alternative to providing the mandatory and selected optional benefits listed in statute under
traditional Medicaid, states can enroll specified groups in ABPs. However, states that choose to
implement the ACA (P.L. 111-148, as amended) Medicaid expansion are required to enroll
individuals newly eligible for Medicaid through the expansion in ABPs (with exceptions for
selected special-needs subgroups).96
Under ABPs, states must provide comprehensive benefit coverage that is based on one of three
commercial insurance products, including (1) the standard Blue Cross/Blue Shield preferred
provider option service plan offered through the Federal Employees Health Benefit Programequivalent health insurance coverage; (2) the commercial health maintenance organization with
the largest insured commercial, non-Medicaid enrollment in the state; or (3) the health benefits
plan offered to state employees. A fourth option, “Secretary-approved,” coverage is also available
to states.97
ABPs must qualify as either benchmark, where the benefits are at least equal to one of the
statutorily specified benchmark plans (listed above), or benchmark-equivalent, which means the
benefits include certain specified services and the overall benefits are at least actuarially
equivalent to one of the statutorily specified benchmark coverage packages. In addition, ABPs
must include a variety of specific services, including services under Medicaid’s EPSDT benefit98
and family planning services and supplies for individuals of reproductive age.99 Finally, states are
generally permitted to offer additional benefits beyond those required by law.
Unlike traditional Medicaid benefit coverage, ABPs must cover at least the 10 categories of
health care services—known as the essential health benefits (EHBs)—as defined in ACA Section
1302(b).100 However, as with traditional Medicaid, states generally specify the amount, duration,
and scope of benefit coverage within these broad categories in the Medicaid state plan.
Certain EHB categories are particularly relevant to coverage of reproductive health services. For
example, under the “maternity and newborn care” category, states are required to cover prenatal
care, labor and delivery, and postpartum care services. Under the “preventive and wellness
services and chronic disease management” EHB category, states are required to cover specified
preventive services without beneficiary cost sharing.101 (Information on Medicaid coverage of
specific types of reproductive health services appears below.)
96 For more information, see CRS In Focus IF10399, Overview of the ACA Medicaid Expansion.
97 For more information, see CRS Report R45412, Medicaid Alternative Benefit Plan Coverage: Frequently Asked
Questions.
98 SSA §1937(a)(1)(A)(ii) [42 U.S.C. §1396u-7(a)(1)(A)(ii)].
99 SSA §1937(b)(7) [42 U.S.C. §1396u-7(b)(7)]; 42 C.F.R. §440.345(b).
100 Federal requirements related to the EHBs generally apply to certain private health insurance plans. The 10
categories of EHB are (1) ambulatory patient services, (2) emergency services, (3) hospitalization, (4) maternity and
newborn care, (5) mental health and substance use disorder services (including behavioral health treatment), (6)
prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and
wellness services and chronic disease management, and (10) pediatric services, including oral and vision care. For
more information about private health insurance EHB requirements, see the “Overview: Coverage of the Essential
Health Benefits (EHB)” section of this report. For Medicaid ABP requirements regarding the EHBs, see SSA
§1937(b)(5) [42 U.S.C. §1396u-7(b)(5)]; 42 C.F.R. §440.347.
101 Under Medicaid, cost-sharing protections listed in SSA §§1916 and 1916A [42 U.S.C. §1396o and 42 U.S.C.
§1396o-1] generally apply to preventive services provided in ABPs. In addition, cost sharing may not be applied to
preventive services that are within the definition of EHBs (described in 45 C.F.R. 147.130). For more information, see
CMS, “Medicaid and Children’s Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans,
(continued...)
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Under ABPs, states are permitted to waive the statewideness and comparability requirements that
apply to traditional Medicaid benefits. This flexibility allows states to define the populations
served and the specific benefit packages that apply. 102 States can design different ABPs for
different beneficiary subgroups.
Comparing Medicaid Traditional Benefit Coverage of Reproductive Health
Services to ABPs
It is difficult to compare the ways in which coverage of reproductive health under traditional
Medicaid benefits are similar to and different from ABP benefits. Although both coverage types
offer many of the same benefits, the scope of coverage under each type may vary from state to
state. This variability largely reflects the choices permitted by federal law in defining the amount,
duration, and scope of benefits offered under the state plan. (The sections below, where possible,
highlight key differences in the federal requirements regarding the scope of traditional Medicaid
benefits and ABP benefits.) For example, while both coverage types require states to cover family
planning services, under traditional Medicaid, states generally have the discretion to identify the
specific services they will cover. By contrast, under ABPs, states are required to provide all of the
FDA-approved contraceptive methods (see Table 1 in the “What Are Contraceptive Services?”
section of this report), as prescribed, to meet the Medicaid EHB preventive services
requirement.103 (For more information, see the “Does Medicaid Cover Contraceptive Services?”
section of this report.)
State coverage of a specific benefit may also vary depending on a given enrollee’s eligibility
pathway. For example, under traditional Medicaid, federal requirements permit states to cover the
HPV vaccine for adults aged 22 and older at state option. By contrast, under ABPs, states are
required to cover the HPV vaccine for adults aged 22 and older under the Medicaid EHB
preventive health service requirement. Finally, regardless of coverage type, states are required to
cover the HPV vaccine for most children through age 21 (as age-appropriate) under EPSDT. (For
more information, see the “Does Medicaid Cover Reproductive Health Screening and Preventive
Services?” section of this report.)
In addition, states are permitted to rely on different statutory authorities to direct federal Medicaid
funds to pay for certain services. In the case of doula services,104 for example, Minnesota105
covers doulas under Medicaid’s traditional mandatory pregnancy-related services category, while
Oregon106 covers them under Medicaid’s traditional optional preventive services category. New
York, by contrast, covers doula services for certain enrollees under Medicaid’s optional other
diagnostic, screening, preventive and rehabilitative services benefit category.107 In each of these
Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and
Enrollment; Final Rule,” Federal Register, vol. 78, no. 135, July 15, 2013. The preventive services that must be
covered are listed in their entirety at Healthcare.gov, “Preventive health services,” at https://www.healthcare.gov/
coverage/preventive-care-benefits/.
102 SSA §1937(a)(1) [42 U.S.C. §1396u-7(a)(1)].
103 CMS, “Re: Medicaid Family Planning Services and Supplies,” State Health Officials (SHO) letter, SHO # 16-008,
June 14, 2016, at https://www.medicaid.gov/federal-policy-guidance/downloads/sho16008.pdf.
104 See footnote 45 for additional details.
105 See Minnesota CHIP state plan Attachment 3.1-A, Page 66i, at
https://www.medicaid.gov/medicaid/spa/downloads/MN-23-0018.pdf.
106 See Oregon CHIP state plan, Transmittal # 22-0019, Attachment 4.19-B, Page 1a.6, at https://www.medicaid.gov/
medicaid/spa/downloads/OR-22-0019.pdf.
107 Anoosha Hasan, State Medicaid Approaches to Doula Service Benefits, National Academy for State Health Policy,
(continued...)
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scenarios, different federal requirements shape how these states incorporate this provider type
under their state plan.
Where Do Medicaid Enrollees Receive Reproductive Health Care Services?
Medicaid enrollees receive reproductive health care from a range of Medicaid providers,
including private physicians, nurse midwives, birth attendants, and other health professionals
working within their scope of practice under state law.108 Medicaid beneficiaries access
reproductive health services in various types of facilities, including health departments,
community health centers, certain school-based health clinics, urgent care or retail clinics,
emergency rooms and other clinics.109
In general, under Medicaid’s “freedom of choice of provider” requirement, states must permit
enrollees to receive services from any willing Medicaid-participating provider,110 and states
cannot exclude providers solely on the basis of the range of services they provide.111 Medicaid
managed care enrollees may be restricted to providers in a given managed care plan network,112
except in the case of family planning services.113 Medicaid enrollees (regardless of whether they
receive services through the managed care delivery system or not) may obtain family planning
services from the provider of their choice (as long as the provider participates in the Medicaid
program), even if they are not considered “in-network” providers.114
April 16, 2024, at https://nashp.org/state-tracker/state-medicaid-approaches-to-doula-service-benefits/. See also New
York CHIP state plan, Attachment 3.1-A Supplement, at https://www.medicaid.gov/medicaid/spa/downloads/NY-240003.pdf.
108 For example, see SSA §1905(a)(17) [42 U.S.C. §1396d(a)(17)] and 42 C.F.R. §§440.165, 441.21 for rules regarding
Medicaid coverage of services provided by a nurse-midwife.
109 Michelle Long, Brittni Frederiksen, Usha Ranji, et al., Experiences with Health Care Access, Cost, and Coverage:
Findings from the 2022 KFF Women’s Health Survey, KFF, December 20, 2022, https://www.kff.org/womens-healthpolicy/report/experiences-with-health-care-access-cost-and-coverage-findings-from-the-2022-kff-womens-healthsurvey/.
110 Under federal law, Medicaid enrollees may obtain medical services “from any institution, agency, community
pharmacy, or person, qualified to perform the service or services required ... who undertakes to provide him such
services.” This provision is often referred to as the “any willing provider” or “free choice of provider” provision. (SSA
§1902(a)(23) [42 U.S.C. §1396a(a)(23)]; 42 C.F.R. §431.51.
111 SSA §1902(a)(23) [42 U.S.C. §1396a(a)(23)]; 42 C.F.R. §431.51. See also Center for Medicaid, CHIP and Survey
& Certification (CMCS), “Re: Update on Medicaid/CHIP,” CMCS Informational Bulletin, June 1, 2011, at
http://www.medicaid.gov/Federal-Policy-Guidance/downloads/6-1-11-Info-Bulletin.pdf.
112 Medicaid enrollees generally receive benefits via one of two service delivery systems: fee-for-service (FFS) or
managed care. Under FFS, health care providers are paid by the state Medicaid program for each service provided to a
Medicaid enrollee. Under managed care, Medicaid enrollees get most or all of their services through a managed care
organization under contract with the state.
113 SSA §1902(a)(23)(B) [42 U.S.C. §1396a(a)(23)(B)]; 42 C.F.R. §431.51(b)(2); and 42 C.F.R. Part 438.
114 42 C.F.R. §431.51.
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Does Medicaid Cover Contraceptive Services?
States are required115 to provide family planning services and supplies to prevent or delay
pregnancy under both traditional and ABP benefit coverage for most individuals116 of
reproductive age (including minors) who desire such services and supplies.117 States are not
permitted to charge point-of-service cost sharing (e.g., copays, coinsurance) for Medicaid family
planning services and supplies, regardless of the type of coverage.118 Family planning services
and supplies must be available to Medicaid enrollees without undue burden, coercion, or mental
pressure.119 Such state plan services include education and counseling on methods of
contraception. States are required to cover follow-up care and services necessary to stop or
modify birth control methods, such as the removal of LARCs.120 States may pay for sterilization
services only if certain specified conditions are met.121 In addition, Medicaid beneficiaries must
be free to choose the provider of their choice and the method of family planning to be used.122
Although the term “family planning services” is not defined in Medicaid statute or program
regulations, the Medicaid program distinguishes between items and procedures for family
planning purposes (i.e., contraceptive care) and family planning-related services (i.e., services
provided in a family planning setting as part of or as follow-up to a family planning visit) to
determine the federal reimbursement rate (i.e., the federal medical assistance percentage [FMAP]
rate) available to states for these services.123 Specifically, states may receive a 90% FMAP rate for
items and procedures for family planning purposes (e.g., counseling services and patient
education, examination and treatment by medical professionals, laboratory examinations and
tests, medically approved methods, procedures, pharmaceutical supplies and devices to prevent
115 SSA §1902(a)(10)(A) in the matter before (i), [42 U.S.C. §1396a(a)(10)(A) in the matter before (i)], and
1905(a)(4)(C) [42 U.S.C. §1396d(a)(4)(C)]. “Under section 1905(a)(4)(C) of the Social Security Act (the Act), family
planning services and supplies must be included in the standard Medicaid benefit package and in alternative benefit
plans (ABPs).” (See HHS, CMS, “Re: Medicaid Family Planning Services and Supplies,” SHO letter, SHO#16-008,
June 14, 2016, at https://www.medicaid.gov/federal-policy-guidance/downloads/sho16008.pdf.)
116 SSA §1902(a)(10)(C) [42 U.S.C. §1396a(a)(10)(C)] permits states to offer family planning services and supplies to
medically needy Medicaid enrollees at state option. Medically needy individuals are individuals who are otherwise
eligible for Medicaid but who have incomes too high to qualify for Medicaid. These individuals may qualify for
Medicaid by meeting the medically needy income standard, or by spending down their income to the medically needy
income standard by incurring and paying for medical expenses.
117 For more information, see HHS, CMCS Informational Bulletin, SUBJECT: Medicaid Family Planning Services and
Supplies: Requirements and Best Practices, August 8, 2024, at https://www.medicaid.gov/federal-policyguidance/downloads/cib08082024.pdf. In FY2015, Medicaid accounted for 75% of U.S. public family planning
expenditures. Guttmacher Institute, Publicly Supported Family Planning Services in the United States, October 2019, at
https://www.guttmacher.org/sites/default/files/factsheet/publicly-supported-fp-services-us.pdf.
118 SSA §§1916(a)(2)(D), 1916(b)(2)(D), and 1916A(b)(3)(B)(vii) [42 U.S.C. §§1396o(a)(2)(D), 1396o(b)(2)(D),
1396o–1(b)(3)(B)(vii)]; 42 C.F.R. §447.56(a)(2)(ii).
119 SSA §1905(a)(4)(C) [42 U.S.C. §1396d(a)(4)(C)]; 42 C.F.R. §441.20.
120 For more information, see HHS, CMS, “Re: Medicaid Family Planning Services and Supplies,” SHO letter,
SHO#16-008, June 14, 2016, at https://www.medicaid.gov/federal-policy-guidance/downloads/sho16008.pdf. Also see
CMS, Frequently Asked Questions (FAQs), “Medicaid Family Planning Services and Supplies,” January 11, 2017, at
https://www.medicaid.gov/sites/default/files/federal-policy-guidance/downloads/faq11117.pdf.
121 42 C.F.R. §§441.253-441.256.
122 SSA §1902(a)(23) [42 U.S.C. §1396a(a)(23)]; 42 C.F.R. §441.20, and 42 C.F.R. §431.51.
123 For more information on the types of family planning benefits covered under state Medicaid programs, see Usha
Ranji, Ivette Gomez, Alina Salganicoff, et al., Medicaid Coverage of Family Planning Benefits: Findings from a 2021
State Survey, KFF, February 17, 2022, at https://www.kff.org/womens-health-policy/report/medicaid-coverage-offamily-planning-benefits-findings-from-a-2021-state-survey/. See also HHS, CMS, “Re: Medicaid Family Planning
Services and Supplies,” SHO letter, SHO#16-008, June 14, 2016, at https://www.medicaid.gov/federal-policyguidance/downloads/sho16008.pdf.
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conception, and infertility services, including sterilizations and sterilization reversals),124 and for
related administrative costs.125 By contrast, family planning-related services are reimbursable at
the state’s regular FMAP rate.126 Family planning-related services generally align more with
reproductive health and screening services (e.g., medical diagnosis, treatment, and preventive
services) and are provided because they were identified, or diagnosed, during a family planning
visit.127 (Family planning-related services are discussed in more detail in the “Does Medicaid
Cover Reproductive Health Screening and Preventive Services?” section of this report.)
The specific benefits that states offer under the family planning service category vary. For
Medicaid enrollees who receive traditional state plan coverage, states may identify the specific
services and supplies they cover (including EC),128 as long as the services meet basic federal
requirements (e.g., they are determined by CMS to be sufficient in amount, duration, and scope to
reasonably achieve their purpose,129 and beneficiaries are permitted to choose which family
planning method to use). States generally cover a broad range of medically approved methods,
procedures (e.g., sterilization), and devices to prevent conception under traditional Medicaid,
including over-the-counter contraceptive methods (e.g., male/female condoms, spermicide, the
sponge, EC) and prescription contraceptives (e.g., oral contraceptives, LARCs, patch, diaphragm,
injectable, IUDs).130
Prescription drugs are considered an optional Medicaid service, but all states cover them.131 State
coverage of various FDA-approved prescription contraceptives under traditional Medicaid is
generally established through national drug rebate agreements between drug manufacturers and
124 SSA §1903(a)(5) [42 U.S.C. §1396b(a)(5)]; CMS, State Medicaid Manual §4270.B.1 at https://www.cms.gov/
regulations-and-guidance/guidance/manuals/paper-based-manuals-items/cms021927.
125 42 C.F.R. §433.15(b)(2).
126 For FY2024, states’ regular FMAP rates range from 50.00% to 77.27%, depending on the state’s per capita income
as compared with the national average. FMAPs may also vary by population (e.g., services to some persons newly
eligible under the ACA Medicaid expansion are reimbursed at a 90% FMAP rate for 2020 and subsequent years). See
CRS Report R43847, Medicaid’s Federal Medical Assistance Percentage (FMAP).
127 CMS, “Re: Family Planning Services Option and New Benefit Rules for Benchmark Plans,” SHO Letter,
SMDL#10-013 ACA# 4, July 2, 2010, at http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/
SMD10013.pdf, and HHS, CMS “Re: Family Planning and Family Planning Related Services Clarification,” SHO
Letter, SMDL#14-003 ACA# 31, April 16, 2014, at https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/
SMD-14-003.pdf.
128 For more information on state coverage of emergency contraception (EC) as of July 1, 2021, see Usha Ranji, Ivette
Gomez, Alina Salganicoff, et al., Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State Survey,
KFF, February 17, 2022, at https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-family-planningbenefits-findings-from-a-2021-state-survey/.
129 CMS, State Medicaid Manual §4270.B.1, at https://www.cms.gov/regulations-and-guidance/guidance/manuals/
paper-based-manuals-items/cms021927.
130 For more on the range of family planning benefits covered by states under traditional Medicaid, see Usha Ranji,
Ivette Gomez, Alina Salganicoff, et al., Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State
Survey, KFF, February 17, 2022, at https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-familyplanning-benefits-findings-from-a-2021-state-survey/.
131 States are also permitted to cover over-the-counter (OTC) drugs, including oral contraception and emergency
contraception under Medicaid. As family planning services and supplies described in SSA §1905(a)(4)(C) [42 U.S.C.
§1396d(a)(4)(C)], Medicaid coverage of OTC oral contraception and emergency contraception must be provided
without enrollee cost sharing, as per SSA §§1916(a)(2)(D), 1916(b)(2)(D), and 1916A(b)(3)(B)(vii) [42 U.S.C.
§§1396o(a)(2)(D), 1396o(b)(2)(D), 1396o–1(b)(3)(B)(vii)]; 42 C.F.R. §447.56(a)(2)(ii) and 42 C.F.R. § 438.108). For
more information, see HHS, CMCS Informational Bulletin, SUBJECT: Medicaid Family Planning Services and
Supplies: Requirements and Best Practices, August 8, 2024, at https://www.medicaid.gov/federal-policyguidance/downloads/cib08082024.pdf.
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the HHS Secretary under the Medicaid Drug Rebate program.132 States are permitted to rely on
utilization controls, such as preferred drug lists and prior authorization, to encourage providers to
prescribe certain drugs over others. However, in general, Medicaid covers most FDA-approved
drugs produced by manufacturers that enter into rebate agreements with HHS, which results in
enrollee access to a wide range of prescription drugs.133
For Medicaid enrollees who receive ABP coverage, states must cover family planning services
and supplies that meet Medicaid EHB preventive services requirements, including coverage of at
least one form of contraception within each of the contraceptive methods, as prescribed, approved
by FDA (see Table 1 in “What Are Contraceptive Services?”),134 and all of the services
recommended by the USPSTF (e.g., counseling on STIs and HIV and screening for breast and
cervical cancers). (See the USPSTF text box in the “What Are Reproductive Health Prevention
and Treatment Services?” section).135 In addition, states may provide targeted family planning
services under Medicaid for populations who are not otherwise eligible for traditional Medicaid
(e.g., nonpregnant, nondisabled childless adults) through special waivers of federal law (i.e.,
Section 1115 family planning waivers).136 States have discretion to determine the populations and
benefits covered under Section 1115 family planning waivers. However, such coverage is timelimited and must be budget-neutral to the federal government, whereby the estimated federal
spending under the waiver cannot exceed the estimated federal cost of the state’s Medicaid
program without the waiver.
The ACA established an optional Medicaid eligibility group for family planning services so that
states no longer have to rely on time-limited waiver authority to extend limited benefit coverage
for family planning services and supplies to targeted eligibility groups (including groups who
were not traditionally eligible for Medicaid).137 The ACA family planning eligibility group
includes individuals (men and women) (1) who are not pregnant and (2) whose income does not
132 Drug manufacturers enter into national rebate agreements with the HHS Secretary under the Medicaid Drug Rebate
Program. The program requires a drug manufacturer to enter into, and have in effect, a national rebate agreement with
the HHS Secretary to rebate a portion of the Medicaid payment for the drug to the states based on a statutory formula.
States then share the rebate they receive from pharmaceutical manufacturers with the federal government as a way to
offset the costs of prescription drugs under the Medicaid program in exchange for state Medicaid coverage of most of
the manufacturer’s drugs. For more information, see CRS Report R43778, Medicaid Prescription Drug Pricing and
Policy.
133 Rachel Dolan, Understanding the Medicaid Prescription Drug Rebate Program, KFF, Issue Brief, November 2019,
at http://files.kff.org/attachment/Issue-Brief-Understanding-the-Medicaid-Prescription-Drug-Rebate-Program.
134 For more information, see CMS, “RE: Family Planning and Family Planning Related Services Clarification,” State
Medicaid Directors Letter (SMDL), SMDL#14-003 ACA# 31, April 16, 2014, at https://www.medicaid.gov/FederalPolicy-Guidance/Downloads/SMD-14-003.pdf. See also CMS, “Re: Medicaid Family Planning Services and Supplies,”
SHO letter, SHO # 16-008, June 14, 2016, at https://www.medicaid.gov/federal-policy-guidance/downloads/
sho16008.pdf.
135 For more on the range of family planning benefits covered by states under Medicaid ABPs, see Usha Ranji, Ivette
Gomez, Alina Salganicoff, et al., Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State Survey,
KFF, February 17, 2022, at https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-family-planningbenefits-findings-from-a-2021-state-survey/.
136 Section 1115 targeted family planning waivers may offer a limited set of services (i.e., family planning services and
supplies and related services) to a specific population identified in the waiver special terms and conditions. These
individuals may not be eligible for full Medicaid state plan services. As of January 2024, eleven states have CMS
approval for Medicaid Section 1115 family planning waivers. For more information, see, KFF, State Health Facts,
“States That Have Expanded Eligibility for Coverage of Family Planning Services Under Medicaid,” at
https://www.kff.org/medicaid/state-indicator/family-planning-services-waivers/.
137 As of January 2024, 18 states have CMS approval for Medicaid family planning state plan amendments. For more
information, see KFF, State Health Facts, “States That Have Expanded Eligibility for Coverage of Family Planning
Services Under Medicaid,” at https://www.kff.org/medicaid/state-indicator/family-planning-services-waivers/.
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exceed the highest income eligibility level established by the state for pregnant women.138
Benefits for this eligibility group are limited to family planning services and supplies and related
medical diagnosis and treatment services.139 Unlike Section 1115 family planning demonstration
waivers, family planning coverage under the state plan authority is not time-limited or subject to
budget neutrality.
Comparing family planning coverage across the various types of Medicaid benefit coverage (i.e.,
traditional Medicaid, ABP coverage, Section 1115 family planning waivers, or the optional ACA
family planning eligibility group) reveals a key difference: under ABPs, states must comply with
the Medicaid EHB preventive service requirements that establish a federal coverage floor of
FDA-approved contraceptives (see Table 1 in “What Are Contraceptive Services?”) and the
USPSTF services.140 Under the other coverage types, states have more discretion when defining
covered benefits. The multiple eligibility pathways and related service coverage options make it
difficult to assess the relative richness of the benefit coverage within and across states. However,
findings from a 2021 50-state survey of Medicaid fee-for-service (FFS) coverage of select family
planning services highlight the mandatory nature of various types of contraceptive coverage
under ABPs, as well as state choices in offering different types of contraception under the other
coverage types. The survey also captures differences across coverage types in terms of utilization
controls (e.g., whether prescription required, brand/type restrictions, quantity or frequency limits,
medical necessity requirements), which states use to control costs or otherwise influence how
beneficiaries use the benefit.141
Does Medicaid Cover Abortions or Abortion Counseling?
Like other HHS programs, Medicaid is subject to the Hyde Amendment, which prohibits the use
of federal funds for abortions, except in the cases of rape, incest, or endangerment of a woman’s
life (for more information on the Hyde Amendment, see the “Can Federal Funds Be Used to Pay
for Abortions or Abortion Counseling?” section of this report). The Hyde Amendment does not
restrict federal funding for the cost of treating a physical disorder, injury, or illness, including a
life-endangering condition that is caused by or arises from pregnancy, that would, as certified by
a physician, place the woman in danger of death unless an abortion is performed. Moreover,
Medicaid program regulations permit federal reimbursement for the termination of ectopic
pregnancies, which are nonviable and endanger the life of the mother.142
In addition, the Hyde Amendment does not prohibit a “state, locality, entity, or private person”
from paying for abortion services, or managed care providers from offering abortion coverage,
138 SSA §1902(a)(10) in subdivision (XVI) after (G) [42 U.S.C. §1396a(a)(10) in subdivision (XVI) after (G)].
139 “Family planning related services are medical, diagnostic, and treatment services provided pursuant to a family
planning visit that address an individual’s medical condition and may be provided for a variety of reasons including,
but not limited to: treatment of medical conditions routinely diagnosed during a family planning visit, such as treatment
for urinary tract infections or sexually transmitted infection; preventive services routinely provided during a family
planning visit, such as the HPV vaccine; or treatment of a major medical complication resulting from a family planning
visit.” See CMS, “Re: Medicaid Family Planning Services and Supplies,” SHO letter, SHO # 16-008, June 14, 2016, at
https://www.medicaid.gov/federal-policy-guidance/downloads/sho16008.pdf.
140 For a summary of federal coverage requirements for Medicaid family planning services, by coverage type, see Usha
Ranji, Yali Bair, and Alina Salganicoff, Medicaid and Family Planning: Background and Implications of the ACA,
Kaiser Family Foundation, February 2016, p. 18, at http://files.kff.org/attachment/issue-brief-medicaid-and-familyplanning-background-and-implications-of-the-aca.
141 For more information, see Usha Ranji, Ivette Gomez, Alina Salganicoff, et al., Medicaid Coverage of Family
Planning Benefits: Findings from a 2021 State Survey, KFF, February 17, 2022, at https://www.kff.org/womens-healthpolicy/report/medicaid-coverage-of-family-planning-benefits-findings-from-a-2021-state-survey/.
142 42 C.F.R. §441.207.
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nor does it affect a state’s or locality’s ability to contract with a managed care provider for such
coverage with state-only funds (as long as such funds are not the state share of Medicaid
matching funds).143 Some states rely on state-only funds to pay for abortions that do not meet the
Hyde amendment exceptions.
Through program regulations,144 and later revised through program guidance, Medicaid enrollees
and providers may be required to comply with reasonable documentation requirements to ensure
that the abortion meets the Hyde amendment criteria and is eligible for Medicaid federal
reimbursement. However, such documentation requirements may not prevent or impede coverage
for abortions and may be waived if the treating physician certifies that the patient was unable to
comply.145
Following the U.S. Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization,146
coverage of Hyde-permissible abortions under Medicaid has shifted. According to a recent study,
abortion remains legal (subject to specified criteria such as gestational age) in 36 states and the
District of Columbia. Among these states as of March 2024, 19 states and the District of
Columbia follow the Hyde Amendment restrictions when paying for abortion services for
Medicaid enrollees, and 17 states use state-only funds to pay for abortions beyond the Hyde
Amendment limitations (nine of which do so pursuant to a court order).147
Does Medicaid Cover Infertility Services?
States are permitted to cover fertility diagnosis services (e.g., lab tests, semen analysis, and
imaging studies) and infertility treatment services (e.g., medications, surgeries, ARTs such as IUI
or IVF) at state option under all coverage types (i.e., traditional Medicaid, ABPs, Section 1115
Medicaid family planning waivers, and the optional ACA family planning eligibility group).148
Although state Medicaid programs are required to cover most manufacturers’ prescription drugs
to receive rebates under the Medicaid Drug Rebate Program, states are permitted to exclude or
otherwise restrict coverage of outpatient fertility drugs.149
Does Medicaid Cover Maternity Services?
Medicaid is a significant payer of maternal health services and births in the United States.
According to CDC, Medicaid paid for approximately 41% of all births in the United States in
143 Department of Labor, Health and Human Services, and Education and Related Agencies Appropriations Act, 1998,
(P.L. 105-78) Section 509 and 510. These restrictions have been continued in the HHS Appropriations Acts, most
recently through the enactment of the Further Consolidated Appropriations Act, 2022 (P.L. 117-103). See also HHS,
Health Care Financing Administration (HCFA), Center for Medicaid and State Operations (CMSO), SMDL, February
12, 1998, at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd021298.pdf.
144 42 C.F.R. §§441.203, 441.206 and 441.208.
145 HHS, HCFA, CMSO, SMDL, February 12, 1998, at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/
smd021298.pdf.
146 For more information, see CRS Legal Sidebar LSB10768, Supreme Court Rules No Constitutional Right to Abortion
in Dobbs v. Jackson Women’s Health Organization.
147 Alina Salganicoff, Laurie Sobel, Ivette Gomez, et al., The Hyde Amendment and Coverage for Abortion Services
Under Medicaid in the Post-Roe Era, KFF, March 14, 2024, at https://www.kff.org/womens-health-policy/issue-brief/
the-hyde-amendment-and-coverage-for-abortion-services-under-medicaid-in-the-post-roe-era/.
148 For more information of state coverage of fertility services by program type, see Usha Ranji, Ivette Gomez, Alina
Salganicoff, et al., Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State Survey, KFF, February
17, 2022, at https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-family-planning-benefitsfindings-from-a-2021-state-survey/.
149 SSA §1927(d)(2)(B) [42 U.S.C. §1396r-8(d)(2)(B)].
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2022.150 In general, Medicaid benefits for pregnant women can differ by eligibility pathway
across and within states.151
Medicaid Eligibility Pathways
Medicaid’s mandatory poverty-related pregnant women pathway provides access to pregnancy
coverage under traditional Medicaid for pregnant women with incomes less than 133% of FPL,152
and up to 185% of FPL at state option.153 As of July 2023,154 the Medicaid upper-income
eligibility threshold for pregnant women ranged from 133% of FPL in four states (Idaho,
Louisiana, Oklahoma, and South Dakota) to 375% of FPL (in Iowa).155 Coverage for these
women may include full Medicaid benefit coverage, or states may limit services to those related
to pregnancy.156 In either case, coverage generally begins at the time of application and ends after
60 days postpartum. While states may impose cost sharing in the form of program participation
fees (e.g., premiums) for pregnant women with incomes above 150% FPL, pregnant women are
exempt from point-of-service cost sharing (e.g., copays, coinsurance) for pregnancy-related
services, including tobacco cessation counseling.157
Women who are otherwise eligible for Medicaid (e.g., who meet the financial eligibility criteria
of a state’s former Aid to Families with Dependent Children [AFDC] program, or who are eligible
through a family coverage pathway) and become pregnant are generally permitted to retain their
150 Osterman MJK, Hamilton BE, Martin JA, Driscoll AK, and Valenzuela CP, Births: Final data for 2022, National
Vital Statistics Reports, vol 73, no 2, Hyattsville, MD: National Center for Health Statistics, at https://dx.doi.org/
10.15620/cdc:145588.
151 For more information on Medicaid’s pregnancy coverage, see Medicaid and CHIP Payment and Access
Commission (MACPAC), MACPAC Report to the Congress, Chapter 3: Issues in Pregnancy Coverage under Medicaid
and Exchange Plans, March 2014, at https://www.macpac.gov/wp-content/uploads/2014/03/Issues-in-PregnancyCoverage-under-Medicaid-and-Exchange-Plans.pdf. See also Maggie Clark, Medicaid and CHIP Coverage for
Pregnant Women: Federal Requirements, State Options, Georgetown University Health Policy Institute, Center for
Children and Families, November 5, 2020, at https://ccf.georgetown.edu/2020/11/05/medicaid-and-chip-coverage-forpregnant-women-federal-requirements-state-options/.
152 SSA §§1902(a)(10)(A)(i)(III) [42 U.S.C. §1396a(a)(10)(A)(i)(III)]; 1902(a)(10)(A)(i)(IV) [42 U.S.C.
§1396a(a)(10)(A)(i)(IV)]; 1902(l)(2)(A) [42 U.S.C. §1396a(l)(2)(A)]; and 1905(n) [42 U.S.C. §1396d(n)].
153 SSA §§1902(a)(10)(A)(ii)(I) [42 U.S.C. §1396a(a)(10)(A)(ii)(I)]; 1902(a)(10)(A)(ii)(IV) [42 U.S.C.
§1396a(a)(10)(A)(ii)(IV)]; 1902(a)(10)(A)(ii)(IX) [42 U.S.C. §1396a(a)(10)(A)(ii)(IX)]; and 1902(l)(2)(A)(ii)(I) [42
U.S.C. §1396a(l)(2)(A)(ii)(I)].
154 MACPAC, MACStats, EXHIBIT 35. Medicaid and CHIP Income Eligibility Levels as a Percentage of the FPL for
Children and Pregnant Women by State, July 2023, at https://www.macpac.gov/wpcontent/uploads/2023/12/EXHIBIT-35.-Medicaid-and-CHIP-Income-Eligibility-Levels-as-a-Percentage-of-the-FPLfor-Children-and-Pregnant-Women-July-2023.pdf.
155 Prior to the enactment of the ACA, states had the flexibility to determine what types of income to include or
disregard when determining Medicaid income eligibility for most nondisabled Medicaid eligibility groups, and income
counting rules varied greatly across Medicaid eligibility categories and across states. Under the ACA, states are
required to transition to a new Medicaid eligibility income-counting rule based on Modified Adjusted Gross Income
(MAGI) to establish uniform standards for what income to include or disregard in determining Medicaid eligibility for
most Medicaid eligibility categories. In transitioning to MAGI, states converted their old income-counting rules to
MAGI-based income standards set by each state in coordination with CMS. As a result, the upper-income eligibility
thresholds for pregnant women is effectively higher than 185% of FPL statutory maximum in a number of states. For
more information, see CRS Report R43861, The Use of Modified Adjusted Gross Income (MAGI) in Federal Health
Programs.
156 SSA §§1902(a)(10) in subdivisions (V), (VII) after (G) [42 U.S.C. §1396a(a)(10) in subdivisions (V), (VII) after
(G)], see also MACPAC, Pregnant Women, at https://www.macpac.gov/subtopic/pregnant-women/.
157 SSA §1902(e)(5) [42 U.S.C. §1396a(e)(5)].
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existing full Medicaid state plan coverage (whether provided under traditional Medicaid or ABP
coverage) until that individual’s next eligibility redetermination (up to 12 months).158
States have the option, when certain conditions are met, to extend full Medicaid benefit coverage
during pregnancy and throughout the 12-month postpartum period to women who received
Medicaid coverage while pregnant. In addition to any available pregnancy-related services and
60-day postpartum care that a woman might be entitled to under the Medicaid state plan (or
waiver), pregnancy and postpartum coverage under this state plan option includes the full
Medicaid benefit coverage that is available to other mandatory eligibility groups (or substantially
equivalent benefit coverage as determined by the HHS Secretary). Such coverage is available
during the pregnancy through the last day of the month of the 12-month period beginning on the
last day of the individual’s pregnancy.159
Many qualified aliens, such as Legal Permanent Residents who entered the United States after
August 22, 1996,160 are prohibited from receiving Medicaid for five years (often referred to as the
five-year bar).161 States are permitted to provide Medicaid coverage to certain lawfully residing
pregnant women within the five-year waiting period when certain conditions are met (e.g., the
state offers coverage to all such individuals who meet the definition of lawfully residing, or
applicants meet state residency requirements).
For nonpregnant women who would be eligible for Medicaid but for their citizenship status,
states are required to pay for services to treat an emergency medical condition under emergency
Medicaid.162 For pregnant women, emergency Medicaid includes services covered under the state
plan, including routine prenatal care, labor and delivery, and routine postpartum care. States may
provide additional services to treat conditions that may complicate the pregnancy or the
delivery.163
Benefit Coverage
Medicaid’s pregnancy-related benefit under traditional Medicaid covers services that are
“necessary for the health of a pregnant woman and fetus, or have become necessary as a result of
158 Women who are otherwise eligible for Medicaid (under the ACA Medicaid expansion pathway, for example) and
who become pregnant are generally permitted to retain their existing Medicaid benefit coverage unless the woman selfidentifies as pregnant and requests a change in her Medicaid coverage category. In this example, the individual would
be entitled to ABP coverage, and such coverage would continue until her next eligibility redetermination (i.e., coverage
may extend after the 60-day postpartum period). Source: CMS, “Medicaid Program; Eligibility Changes,” 77 Federal
Register 17149, March 23, 2012.
159 As of May 10, 2024, the District of Columbia, the United States Virgin Islands and 46 states (Alabama; Alaska;
Arizona; California; Colorado; Connecticut; Delaware; Florida; Georgia; Hawaii; Illinois; Indiana; Kansas; Kentucky;
Louisiana; Maine; Maryland; Massachusetts; Michigan; Minnesota; Mississippi; Missouri; Montana; Nebraska;
Nevada, New Hampshire; New Jersey; New Mexico; New York; North Carolina; North Dakota; Ohio; Oklahoma;
Oregon; Pennsylvania; Rhode Island; South Carolina; South Dakota; Tennessee; Texas, Utah, Vermont; Virginia;
Washington; West Virginia; and Wyoming) have CMS approval to extend Medicaid and CHIP coverage from 60 days
to 12 months postpartum under the “extended postpartum coverage option.” For more information, see National
Academy for State Health Policy, State Tracker, State Efforts to Extend Medicaid Postpartum Coverage, Updated
5/10/2024, at https://nashp.org/state-tracker/view-each-states-efforts-to-extend-medicaid-postpartum-coverage/.
160 Qualified aliens in statute (8 U.S.C. §1641(b)) are Legal Permanent Residents, refugees, aliens paroled into the
United States for at least one year, aliens granted asylum or related relief, certain abused spouses and children, and
Cuban-Haitian entrants. For more information, see CRS Report RL34500, Unauthorized Aliens’ Access to Federal
Benefits: Policy and Issues.
161 8 U.S.C. §1613.
162 SSA §1903(v)(3) [42 U.S.C. §1396b(v)(3)].
163 42 C.F.R. §440.255(b)(2).
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the woman having been pregnant.”164 Coverage varies by state. States use the targeted pregnancy
benefit coverage that is available through Medicaid’s poverty-related pregnant women pathways
to provide enhanced pregnancy-related benefits (e.g., prenatal vitamins, genetic counseling,
smoking cessation services, nutrition counseling, dental care, child birth education classes, doula
services, depression screening, breastfeeding support and supplies, case management, postpartum
home visits).165 States also rely on various Medicaid waiver authorities to undertake
demonstration projects that in the HHS Secretary’s judgement further the goals of the Medicaid
program by providing targeted benefits to pregnant women (e.g., Substance Use Disorder Section
1115 demonstrations that target pregnant and postpartum women, among other populations).166
Finally, states rely on a number of Medicaid care delivery models (e.g., pregnancy medical home)
and payment initiatives (e.g., value-based payment) to promote positive health outcomes for
pregnant women and newborns.167
Pregnant women are among the groups who are exempt from mandatory enrollment in ABPs;
however, special federal rules apply to those who are eligible for and choose to participate in such
coverage. Specifically, ABPs must cover at least the 10 categories of health care services—known
as the EHBs—as defined in Section 1302(b) of the ACA (for more information, see the text box
“Section 1557 of the Patient Protection and Affordable Care Act (ACA)” in the “What Are
Gender-Affirming Services?” section of this report).168 Under the maternity and newborn care and
preventive services EHB coverage categories, Medicaid ABPs must cover several services related
to maternity care at no cost to the enrollee, including but not limited to prenatal visits, folic acid
supplements, and breastfeeding support services.
Comparing Medicaid Maternity Coverage Across Coverage Types
Coverage of Medicaid maternity services can and does vary within and across states based on
enrollees’ eligibility pathways. According to a 2015 survey of Medicaid FFS pregnancy and
perinatal benefits by coverage type (i.e., traditional Medicaid, ABP coverage, and pregnancy-only
Medicaid), most states cover basic prenatal services such as ultrasounds, prenatal vitamins,
prenatal genetic testing, and postpartum visits. However, coverage of maternity-related services
after delivery (e.g., parenting classes, breastfeeding and lactation support services) is less
164 42 C.F.R. §440.210(a)(2)(i).
165 For more information on the kinds of pregnancy benefits that states offer under their Medicaid programs, Usha
Ranji, Ivette Gomez, Alina Salganicoff, et al., Medicaid Coverage of Pregnancy-Related Services: Findings from a
2021 State Survey, KFF, May 2022, at https://files.kff.org/attachment/Report-Medicaid-Coverage-of-PregnancyRelated-Services-Findings-from-a-2021-State-Survey.pdf. See also CMS, SHO# 21-007 RE: Improving Maternal
Health and Extending Postpartum Coverage in Medicaid and the Children’s Health Insurance Program (CHIP),
December 7, 2021, at https://www.medicaid.gov/federal-policy-guidance/downloads/sho21007.pdf.
166 For more information, see CMS, “Section 1115 Demonstrations,” at https://www.medicaid.gov/medicaid/section1115-demonstrations/index.html.
167 For examples of state efforts to improve maternal and child health outcomes, see MACPAC, Report to the
Congress, Chapter 5: Medicaid’s Role in Maternal Health June 2020, at https://www.macpac.gov/wp-content/uploads/
2020/06/June-2020-Report-to-Congress-on-Medicaid-and-CHIP.pdf. Also see, CMS, SHO# 21-007 RE: Improving
Maternal Health and Extending Postpartum Coverage in Medicaid and the Children’s Health Insurance Program
(CHIP), December 7, 2021, at https://www.medicaid.gov/federal-policy-guidance/downloads/sho21007.pdf.
168 Federal requirements related to the EHBs generally apply to certain private health insurance plans. The 10
categories of EHB are (1) ambulatory patient services, (2) emergency services, (3) hospitalization, (4) maternity and
newborn care, (5) mental health and substance use disorder services (including behavioral health treatment), (6)
prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and
wellness services and chronic disease management, and (10) pediatric services, including oral and vision care. For
more information about private health insurance EHB requirements, see the “Does Federal Law Require Private Health
Insurers to Cover Reproductive Health Services?” section of this report. For Medicaid ABP requirements regarding the
EHBs, see SSA §1937(b)(5) [42 U.S.C. §1396u-7(b)(5)]; 42 C.F.R. §440.347.
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common. The survey also found that while coverage requirements differ across eligibility
pathways, in general, states aligned their pregnancy and perinatal benefit coverage across the
coverage types captured in the survey (i.e., traditional Medicaid, ABP coverage, and pregnancyonly Medicaid).169
Does Medicaid Cover Reproductive Health Screening and
Preventive Services?
In general, Medicaid covers a wide array of reproductive health screenings, preventive services,
and treatment of conditions identified during screenings. Coverage varies within and across
states.
Traditional Benefits
An enrollee’s eligibility pathway determines the reproductive health screenings, preventive
services, and treatments for conditions identified during these screenings that are available.
Different federal rules may apply, depending on the eligibility pathway and/or service category
under which the benefit is offered. States are permitted to rely on different statutory authorities to
direct federal Medicaid funds to pay for similar services.
For example, states must cover certain screening services (e.g., mammograms, cervical cancer
screenings and diagnostic services) as a mandatory family planning benefit without enrollee cost
sharing for individuals eligible under Medicaid’s pregnancy-related eligibility pathways and
traditional Medicaid, or under EPSDT for children through age 21. These screenings may be
offered at state option as a targeted benefit under a Section 1115 family planning waiver, or under
the optional ACA family planning eligibility group.
In each case, states define the specific features of each covered benefit within the broad federal
rules that apply for each eligibility pathway and covered benefit. The breadth of coverage for a
given benefit can, and does, vary from state to state, even for mandatory services. Examples of
Medicaid services that states offer as a part of reproductive health screenings, preventive services,
and treatment of conditions identified during screenings under traditional Medicaid include
physicians visits; well-care visits; breast and pelvic exams; laboratory tests; medical diagnosis,
screening, and treatment services for conditions including breast and cervical cancer, HIV/AIDS,
and STI; domestic violence screening and related treatment; EPSDT services; and preventive
services routinely provided during a family planning visit, such as the HPV vaccine.170
169 For more information on Medicaid state coverage of routine prenatal services, counseling and support services,
delivery and postpartum care, and breastfeeding supports by coverage type, see Kathy Gifford, Jenna Walls, Usha
Ranji, et al., Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a State Survey, Kaiser Family
Foundation (KFF), April 27, 2017, at https://www.kff.org/womens-health-policy/report/medicaid-coverage-ofpregnancy-and-perinatal-benefits-results-from-a-state-survey/. For more recent survey data tracking Medicaid state
coverage of pregnancy-related services, see Usha Ranji, Ivette Gomez, Alina Salganicoff, et al., Medicaid Coverage of
Pregnancy-Related Services: Findings from a 2021 State Survey, KFF, May 19, 2022, at https://www.kff.org/reportsection/medicaid-coverage-of-pregnancy-related-services-findings-from-a-2021-state-survey-report/. However, this
source does not track coverage differences across Medicaid coverage types.
170 For examples of the types of Medicaid services that states offer as a part of reproductive health screenings,
preventive services, and treatment of conditions identified during screenings, see Kaiser Family Foundation, Issue
Brief, Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey,
March 13, 2018, at https://www.kff.org/womens-health-policy/issue-brief/womens-sexual-and-reproductive-healthservices-key-findings-from-the-2017-kaiser-womens-health-survey/.
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ABPs
For program enrollees who receive care through ABPs, the “preventive and wellness services and
chronic disease management” EHB category requires states to cover all preventive services
without enrollee cost-sharing per Public Health Service Act (PHSA) Section 2713 (See
“Overview: Coverage of Certain Preventive Services Without Cost Sharing”). These EHB
coverage requirements represent a floor for all ABP benefit coverage. Examples of ABP
reproductive health screening, preventive services, and treatment for conditions identified under
these screenings under this EHB coverage category include screening, counseling and treatment
for STIs, universal HIV screening and treatment, breast and cervical cancer screenings and
follow-up treatment, gynecological exams and Pap smears, well-woman visits, vaccines (e.g.,
HPV), and domestic and interpersonal violence screenings and related treatment.
Comparing Medicaid Reproductive Health Screenings and Preventive Services
Across Coverage Types
Comparing reproductive health screenings and preventive services coverage across the various
types of Medicaid benefit coverage (i.e., traditional Medicaid, ABP coverage, Section 1115
family planning waivers, or the optional ACA family planning eligibility group) reveals a key
difference: under ABPs, states must comply with the EHB requirement for states to cover all
required preventive services without beneficiary cost sharing. Under the other coverage types,
states have more discretion when defining covered benefits. As with many of the other
reproductive health benefits addressed in this report, Medicaid’s multiple eligibility pathways and
service coverage options make it difficult to assess the differences in coverage of these benefits
within and across states.171
Does Medicaid Cover Gender-Affirming Services?
Medicaid benefits are subject to Section 1557 of the ACA, which prohibits discrimination based
on race, color, national origin, sex, disability, and age in programs and activities administered by
an executive agency or a state or federal health insurance exchange, as well as in federally funded
health programs and activities, (see text box “Section 1557 of the Patient Protection and
Affordable Care Act” in section “What Are Gender-Affirming Services?”).172 Medicaid covers a
broad range of medically necessary physical and mental health care services for transgender,
nonbinary, and gender-nonconforming individuals. Like other Medicaid benefits, coverage of
such services may vary state by state and within states across eligibility pathways, benefit
categories, and by coverage type.173 Examples of Medicaid-covered services for such individuals
include surgical interventions, speech and language interventions, behavioral health services,
hormone therapy, fertility services, and hair removal.174 A 2022 study identified 25 states and the
171
For more information, see Assistant Secretary for Planning and Evaluation, Office of Health Policy, Access to
Preventive Services without Cost-Sharing: Evidence from the Affordable Care Act, Issue Brief, January 11, 2022, at
https://aspe.hhs.gov/sites/default/files/documents/786fa55a84e7e3833961933124d70dd2/preventive-services-ib2022.pdf.
172 For more information, see CRS Video WVB00695, Section 1557 and Medical Care for Transgender People: Select
Legal Issues, May 2, 2024.
173 For more information, see Movement Advancement Project, Health Care Laws and Policies: Medicaid Coverage
for Transition-Related Care, at https://www.lgbtmap.org/img/maps/citations-medicaid.pdf.
174 For more information on the types of gender-affirming care that are covered under Medicaid and a list of states that
cover these services under their Medicaid programs, see Ivette Gomez, Usha Ranji, Alina Salganicoff, et al., Update on
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District of Columbia as including (or in the process of extending coverage for) gender-affirming
care under Medicaid, seven states expressly exclude such coverage, and Medicaid coverage of
gender-affirming care is unclear in 18 states.175
Medicare
Medicare is a federal program that pays for covered health care services for qualified
beneficiaries, namely individuals aged 65 and older and permanently disabled individuals under
the age of 65. It consists of four parts (A through D), which cover hospitalizations, physician
services, prescription drugs, skilled
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