# Federal Support for Reproductive Health Services: Frequently Asked Questions > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/crs%3AR46785 ## Record - **Collection:** Congressional research report - **Document type:** CRS Report - **Published:** October 4, 2024 - **Citation:** R46785 ## Text 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 Congressional Research Service 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 Congressional Research Service 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 Congressional Research Service 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 Congressional Research Service 1 Federal Support for Reproductive Health Services: Frequently Asked Questions 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. Congressional Research Service 2 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. Congressional Research Service 3 Federal Support for Reproductive Health Services: Frequently Asked Questions 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). Congressional Research Service 4 Federal Support for Reproductive Health Services: Frequently Asked Questions 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. 5 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. Congressional Research Service 6 Federal Support for Reproductive Health Services: Frequently Asked Questions 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. Congressional Research Service 7 Federal Support for Reproductive Health Services: Frequently Asked Questions 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.”). Congressional Research Service 8 Federal Support for Reproductive Health Services: Frequently Asked Questions 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.” Congressional Research Service 9 Federal Support for Reproductive Health Services: Frequently Asked Questions 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. Congressional Research Service 10 Federal Support for Reproductive Health Services: Frequently Asked Questions 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. Congressional Research Service 11 Federal Support for Reproductive Health Services: Frequently Asked Questions 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). Congressional Research Service 12 Federal Support for Reproductive Health Services: Frequently Asked Questions 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. Congressional Research Service 13 Federal Support for Reproductive Health Services: Frequently Asked Questions 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. Congressional Research Service 14 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. Congressional Research Service 15 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. Congressional Research Service 16 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. Congressional Research Service 17 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/. Congressional Research Service 18 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. Congressional Research Service 19 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/. Congressional Research Service 20 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...) Congressional Research Service 21 Federal Support for Reproductive Health Services: Frequently Asked Questions 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...) Congressional Research Service 22 Federal Support for Reproductive Health Services: Frequently Asked Questions 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. Congressional Research Service 23 Federal Support for Reproductive Health Services: Frequently Asked Questions 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. Congressional Research Service 24 Federal Support for Reproductive Health Services: Frequently Asked Questions 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 [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/crs%3AR46785. Public record. Not legal advice.