Federal Support for Reproductive Health Services: Frequently Asked Questions

Federal Support for Reproductive Health
April 14, 2023
Services: Frequently Asked Questions
Elayne J. Heisler,
Federal support for reproductive health services—preventive, diagnostic, and treatment services
Coordinator
related to reproductive systems, functions, and processes—is administered in different ways,
Specialist in Health
largely because federal agencies, departments, and programs have different missions.
Services

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 delivered, and the restrictions in place on paying for or providing certain types of
reproductive health services. The Supreme Court’s June 2022 decision regarding Dobbs v. Jackson Women’s Health
Organization
may raise questions about access to contraception and abortion services.
This report provides answers to frequently asked questions concerning the provision, funding, and coverage of reproductive
health services in the United States. Specifically, it discusses six categories of reproductive health services with regard to
whether the federal government provides these services, pays for them, or requires certain health insurance plans to cover
them. The six categories are
1. contraception;
2. abortion and abortion counseling;
3. infertility-related services;
4. maternity services;
5. reproductive health screening, preventive services, and treatment; and
6. gender-affirming services.
After providing an overview of the reproductive health services discussed, the report
 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;
 describes the services that federal payment programs will reimburse when services are provided to enrolled
beneficiaries;
 answers questions about federal requirements for private health insurance coverage 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.

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Contents
Introduction ..................................................................................................................................... 1
General Questions ........................................................................................................................... 1

What Are Reproductive Health Services? ................................................................................. 1
What Are Contraceptive Services? ............................................................................................ 2
What Are Abortions and Abortion Counseling Services? ......................................................... 5
Can Federal Funds Be Used to Pay for Abortions or Abortion Counseling? ............................ 6
What Are Infertility Services? ................................................................................................... 7
What Are Maternity Services? .................................................................................................. 8
What Are Reproductive Health Prevention and Treatment Services? ....................................... 8
What Are Gender-Affirming Services? .................................................................................... 11
Federal Agencies and Departments ............................................................................................... 12
Bureau of Prisons (BOP) ......................................................................................................... 12
Does BOP Provide Reproductive Health Services? .......................................................... 13
Does BOP Provide Contraceptive Services? ..................................................................... 13
Does BOP Provide Abortions or Abortion Counseling? ................................................... 14
Does BOP Provide Infertility Services? ............................................................................ 14
Does BOP Provide Maternity Services? ........................................................................... 14
Does BOP Provide Reproductive Health Screening, Prevention, and Treatment
Services? ........................................................................................................................ 15
Does BOP Provide Gender-Affirming Services? .............................................................. 15
Department of Defense (DOD) ............................................................................................... 16
Does DOD Provide Reproductive Health Services? ......................................................... 16
Does DOD Provide Contraceptive Services? .................................................................... 17
Does DOD Provide Abortions or Abortion Counseling? .................................................. 17
Does DOD Provide Infertility Services? ........................................................................... 18
Does DOD Provide Maternity Services? .......................................................................... 19
Does DOD Provide Reproductive Health Screening, Prevention, and Treatment

Services? ........................................................................................................................ 19
Does DOD Provide Gender-Affirming Services? ............................................................. 19
U.S. Immigration and Customs Enforcement (ICE) Noncitizen Detention ............................ 20
Does ICE Provide Reproductive Health Services? ........................................................... 21
Does ICE Provide Contraceptive Services? ...................................................................... 21
Does ICE Provide Abortions or Abortion Counseling? .................................................... 21
Does ICE Provide Infertility Services? ............................................................................. 21
Does ICE Provide Maternity Services? ............................................................................ 22
Does ICE Provide Reproductive Health Screening, Prevention, and

Treatment Services? ....................................................................................................... 22
Does ICE Provide Gender-Affirming Services? ............................................................... 23
Indian Health Service (IHS) .................................................................................................... 23
Does IHS Provide Reproductive Health Services? ........................................................... 23
Does IHS Provide Contraceptives? ................................................................................... 24
Does IHS Provide Abortions or Abortion Counseling? .................................................... 25
Does IHS Provide Infertility Services? ............................................................................. 25
Does IHS Provide Maternity Services? ............................................................................ 26
Does IHS Provide Reproductive Health Screening, Prevention, and Treatment

Services? ........................................................................................................................ 26
Does IHS Provide Gender-Affirming Services? ............................................................... 27
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The U.S. Coast Guard (USCG) ............................................................................................... 27
Does USCG Provide Reproductive Health Services? ....................................................... 27
Does USCG Provide Contraceptive Services?.................................................................. 27
Does USCG Provide Abortions or Abortion Counseling? ................................................ 28
Does USCG Provide Infertility Services? ......................................................................... 29
Does USCG Provide Maternity Services? ........................................................................ 29
Does USCG Provide Reproductive Health Screening, Prevention, and Treatment

Services? ........................................................................................................................ 29
Does USCG Provide Gender-Affirming Services? ........................................................... 29
Department of Veterans Affairs (VA) ...................................................................................... 29
Does the VA Provide Reproductive Health Services? ....................................................... 30
Does the VA Provide Contraceptive Services? ................................................................. 30
Does the VA Provide Abortions or Abortion Counseling? ................................................ 31
Does the VA Provide Infertility Services? ........................................................................ 31
Does the VA Provide Maternity Services? ........................................................................ 32
Does the VA Provide Reproductive Health Screening, Prevention, and Treatment
Services? ........................................................................................................................ 33
Does the VA Provide Gender-Affirming Services? ........................................................... 33
Federal Health Insurance Programs ............................................................................................... 33
Medicaid .................................................................................................................................. 34
Does Medicaid Cover Reproductive Services? ................................................................. 35
Does Medicaid Cover Contraceptive Services? ................................................................ 40
Does Medicaid Cover Abortions or Abortion Counseling? .............................................. 43
Does Medicaid Cover Infertility Services? ....................................................................... 44
Does Medicaid Cover Maternity Services? ...................................................................... 45
Does Medicaid Cover Reproductive Health Screening and Preventive Services? ........... 48
Does Medicaid Cover Gender-Affirming Services? ......................................................... 50
Medicare .................................................................................................................................. 50
Does Medicare Cover Reproductive Health Services? ..................................................... 51
Does Medicare Cover Contraceptive Services? ................................................................ 51
Does Medicare Cover Abortions or Abortion Counseling? .............................................. 51
Does Medicare Cover Infertility Services? ....................................................................... 52
Does Medicare Cover Maternity Services? ...................................................................... 52
Does Medicare Cover Reproductive Health Screening, Prevention, and Treatment

Services? ........................................................................................................................ 52
Does Medicare Cover Gender-Affirming Services? ......................................................... 52
Federal Regulation of Private Health Insurance ............................................................................ 53
Does Federal Law Require Private Health Insurance Coverage of Reproductive
Health Services? ............................................................................................................ 54
Does Federal Law Require Private Health Insurance Coverage of
Contraceptive Services? ................................................................................................. 57
Does Federal Law Require Private Health Insurance Coverage of Abortions or
Abortion Counseling? .................................................................................................... 59
Does Federal Law Require Private Health Insurance Coverage of
Infertility Services? ........................................................................................................ 61
Does Federal Law Require Private Health Insurance Coverage of
Maternity Services? ....................................................................................................... 61
Does Federal Law Require Private Health Insurance Coverage of Reproductive
Health Screening, Prevention, and Treatment Services? ............................................... 63
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Does Federal Law Require Private Health Insurance Coverage of Gender-
Affirming Services? ....................................................................................................... 64
Grant Programs Focused on Reproductive Health ........................................................................ 71
The Title X Family Planning Program .................................................................................... 71
Do Title X Projects Provide Reproductive Health Services? ............................................ 72
Do Title X Projects Provide Contraceptive Services? ...................................................... 72
Do Title X Projects Provide Abortions or Abortion Counseling? ..................................... 74
Do Title X Projects Provide Infertility Services? .............................................................. 74
Do Title X Projects Provide Maternity Services? ............................................................. 75
Do Title X Projects Provide Reproductive Health Screening, Prevention, and
Treatment Services? ....................................................................................................... 76
Do Title X Projects Provide Gender-Affirming Services? ................................................ 77
What Are Teen Pregnancy Prevention Programs?................................................................... 78
Do Teen Pregnancy Prevention Programs Provide Reproductive Health Services? ......... 78
Do Teen Pregnancy Prevention Programs Provide Contraceptive Services?.................... 79
Do Teen Pregnancy Prevention Programs Provide Abortions or

Abortion Counseling? .................................................................................................... 79
Do Teen Pregnancy Prevention Programs Provide Infertility Services? ........................... 80
Do Teen Pregnancy Prevention Programs Provide Maternity Services? .......................... 80
Do Teen Pregnancy Prevention Programs Provide Reproductive Health

Screening, Prevention, and Treatment Services? ........................................................... 80
Do Teen Pregnancy Prevention Programs Provide Gender-Affirming Services? ............. 80
What Federal Grant Programs Address Sexually Transmitted Infections (STIs)? .................. 80
What Centers for Disease Control and Prevention (CDC) Programs
Address STIs? ................................................................................................................ 81
What Is the Ryan White HIV/AIDS Program? ................................................................. 81
What Is the National Breast and Cervical Cancer Early Detection Program? .................. 82
Grant Programs That May Be Used to Support Reproductive Health Services ............................ 83
How Does the Federal Health Center Program Support Reproductive
Health Services? ............................................................................................................ 83
How Does the Title V Maternal Child Health Services Block Grant Support
Reproductive Health Services? ...................................................................................... 84
How Does the Social Services Block Grant Program Support Reproductive
Health Services? ............................................................................................................ 84
How Does the Maternal, Infant, and Early Childhood Home Visiting (MIECHV)
Program Support Reproductive Health Services? .......................................................... 85
How Does the Pregnancy Assistance Fund (PAF) Program Support Reproductive
Health Services? ............................................................................................................ 86

Tables
Table 1. Contraceptive Methods Definitions ................................................................................... 4
Table 2. Examples of Reproductive Health Prevention and Treatment Services .......................... 10
Table 3. Infertility Services Offered by the VA ............................................................................. 31
Table 4. Federal Requirements on Private Health Insurance Coverage of Reproductive
Health Services ........................................................................................................................... 65

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Table A-1. Acronyms Used in This Report .................................................................................... 88

Appendixes
Appendix A. Acronyms Used in This Report ................................................................................ 88
Appendix B. Policy Experts Table ................................................................................................ 92

Contacts
Author Information ........................................................................................................................ 93


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Introduction
Human 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 report first discusses services related to
fertility, then discusses screening, prevention, and treatment of reproductive health conditions,
and concludes with a discussion of gender-affirming services.1 The six types of reproductive
health services are
1. contraception;
2. abortion and abortion counseling;
3. infertility-related services;
4. maternity services;
5. reproductive health screening, preventive services, and treatment; and
6. gender-affirming services.
The report next describes the role that federal agencies and programs have in providing domestic
reproductive health services directly, paying for services provided to beneficiaries enrolled in
federal health insurance programs, and requiring payment for services by certain private health
insurance plans. The report then discusses grant programs that may focus on a specific type of
reproductive health service (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 two appendixes: Appendix A identifies acronyms used in this report; Appendix
B
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
, a case challenging the constitutionality of Mississippi’s Gestational Age
Act, which generally prohibits an abortion once a fetus’s gestational age is greater than 15 weeks.
A majority of the Court not only upheld the Mississippi law but also overruled the Court’s prior
decisions in Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania v. Casey,
concluding that the U.S. Constitution does not confer a right to an abortion.2 The Court’s decision
in Dobbs may raise questions about access to contraception and abortion services.
General Questions
What Are Reproductive Health Services?
Human 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

1 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 CRS Legal Sidebar LSB10768, Supreme Court Rules No Constitutional Right to Abortion in Dobbs v. Jackson
Women’s Health Organization
.
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diseases (STDs),3 screening and treatment for cancers of the reproductive organs and breast
tissues, and gender-affirming services.4
Family planning services, which are a subset of reproductive health services, include health-
promoting preventive, diagnostic, and treatment services that help individuals and/or families
decide on whether or when to become pregnant. Such services may include contraceptives,
infertility treatments, resources about adoptions5 and abortions, and counseling on healthy sexual
behaviors.6 Individuals may also choose to use Fertility Awareness-Based family planning
methods, which involve monitoring the menstrual cycle calendar and other symptoms/markers to
determine periods of least and greatest fertility.7
What Are Contraceptive Services?
A contraceptive is a product or method intended to lower the risk of becoming pregnant.8 Prior to
marketing 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 reimbursement for contraception is generally limited to certain medical or surgical
procedures and to products that are FDA-approved or cleared for marketing. Such products vary
in type, and include drugs, medical devices, or combinations of the two.

3 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 STIs “are infections that have not yet
developed into diseases”. 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 Tulane University School of Public Health and Tropical Medicine, “STI vs.
STD: Key Differences and Resources for College Students,” press release, March 16, 2020,
https://publichealth.tulane.edu/blog/sti-vs-std/.
4 World Health Organization (WHO), “Reproductive health,” 2022, https://www.who.int/westernpacific/health-topics/
reproductive-health.
5 Adoption is not discussed in this report because, although it is included as a family planning service, it is not an
explicit health service.
6 Centers for Disease Control and Prevention (CDC), “Update: Providing Quality Family Planning Services—
Recommendations from CDC and the U.S. Office of Population Affairs, 2015,” March 11, 2016, https://www.cdc.gov/
mmwr/volumes/65/wr/mm6509a3.htm.
7 CDC, “Classifications for Fertility Awareness-Based Methods,” February 1, 2017, https://www.cdc.gov/
reproductivehealth/contraception/mmwr/mec/appendixf.html.
8 Some types of contraceptives may also reduce risk of contracting certain STIs. STIs are discussed in the “What Are
Reproductive Health Prevention and Treatment Services?”
section of this report.
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For contraceptive drugs, FDA approves those
Contraceptive Methods Identified
products that demonstrate substantial evidence
by FDA
that the drug is safe and effective for the
purpose stated in the new drug application.9
1. Sterilization surgery for women
For high-risk (class III) contraceptive devices,
2. Sterilization surgery for men
FDA approves those products that
3. Intrauterine device (IUD) copper
demonstrate reasonable assurance of safety
4. IUD with progestin
and effectiveness. For moderate-risk (class II)
5. Implantable rod
contraceptive devices, FDA clears those
6. Shot/injection
products that demonstrate substantial
7. Oral contraceptives (combined pil )
equivalence to a device already on the market
8. Oral contraceptives extended/continuous use
(a predicate device).10 FDA has identified 18
9. Oral contraceptives (progestin only)
different methods of contraception (see the
10. Patch
text box, which lists those methods from
11. Vaginal contraceptive ring
those most effective at preventing pregnancy
12. Diaphragm with spermicide
to those least effective).11 For example, for
13. Sponge with spermicide
each of the first five methods listed, according
14. Cervical cap with spermicide
to FDA, less than one pregnancy per 100
15. Male condom
women per year would be expected, in
contrast to the last method listed (spermicide
16. Female condom
alone), in which 28 pregnancies per 100
17. Spermicide alone
women per year would be expected.12 FDA

has approved emergency contraceptives (EC),
Other Contraceptive Methods:
which may be used if the regular form of birth
18. Emergency contraception (EC)
control fails (e.g., condom breakages,
Source: FDA, “Birth Control Guide,” undated,
unprotected sex). FDA states that EC
https://www.fda.gov/media/135111/download.
“prevents about 55-85% of predicted
pregnancies,” and “should not to be used as a regular form of birth control.”13 FDA also states
that approved contraceptive methods, including EC and intrauterine devices (IUDs), are not
abortifacients14 within the meaning of federal law.15 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”).16 Table 1 displays the FDA’s definitions of the
18 contraceptive methods.

9 CRS Report R41983, How FDA Approves Drugs and Regulates Their Safety and Effectiveness.
10 CRS Report R42130, FDA Regulation of Medical Devices. Examples of contraceptive devices that are class III (high
risk) include 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 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 female condom 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.
11 FDA, “Birth Control Guide,” https://www.fda.gov/media/135111/download.
12 Ibid.
13 Ibid.
14Abortifacient drugs are those for which the main or side effect is a medical abortion. See, e.g., Liza Gibson, “WHO
puts abortifacients on its essential drug list,” BMJ, vol. 331, no. 7508 (July 9, 2005). For more information on medical
abortions, see the section of this report titled “What Are Abortions and Abortion Counseling Services?”
15 FDA, “Prescription Drug Products; Certain Combined Oral Contraceptives for Use as Postcoital Emergency
Contraception,” 62 Federal Register 8610-8612, February 25, 1997.
16 45 C.F.R. §46.202.
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Federal Support for Reproductive Health Services: Frequently Asked Questions

Table 1. Contraceptive Methods Definitions
Method
Definition
Sterilization surgery for women
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
Vasectomy; blocking of vas deferens (tubes that carry seminal fluid).
Intrauterine device (IUD) copper
T-shaped copper device inserted into the uterus; prevents sperm from
reaching the egg and may prevent the egg from implanting in the uterus.
Can be used for a maximum of 10 years.
IUD with progestin
T-shaped device containing the hormone progestin inserted into the
uterus; prevents sperm from reaching the egg and prevents egg from
implanting in the uterus. Can be used for a maximum of three to five years.
Implantable rod
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 a maximum of three years.
Shot/Injection
Intramuscular or subcutaneous injection of the hormone progestin; one
shot is needed every three months.
Oral contraceptive (combined pil )
Daily pil 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)
Daily pil 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.
Patch
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
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.
Diaphragm with spermicide
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 kil s sperm cells. Worn for a
maximum of 24 hours.
Sponge with spermicide
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 kil s sperm cells. Worn for a maximum of 30
hours.
Cervical cap with spermicide
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 kil s sperm cells. Worn for a maximum of 48 hours.
Male condom
Thin film sheath placed over the penis; over-the-counter barrier method
that prevents sperm from reaching the egg.
Female condom
Thin lubricated pouch placed inside the vagina; over-the-counter barrier
method that prevents sperm from reaching the egg.
Spermicide alone
Sperm cell kil ing foam, cream, jelly, film, or tablet placed intravaginally;
over-the-counter product.
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Federal Support for Reproductive Health Services: Frequently Asked Questions

Method
Definition
Emergency contraceptive (EC)
Progestin hormone pil (s); should be taken within 72 hours of birth control
(Levonorgestrel 1.5mg [one pil ] or
failure or unprotected sex; primarily works to stop ovaries from releasing
Levonorgestrel 0.75mg [two pil s])
eggs; may prevent egg from implanting in the uterus.
Levonorgestrel 1.5mg (one pil ) is available over-the-counter for patients of
all ages (e.g., Plan B One Step, Next Choice One Dose)
Levonorgestrel 0.75mg (two pil s) is available over-the-counter for patients
17 years old or older, and by prescription for patients under age 17.
EC (Ulipristal Acetate)
Pil that blocks progesterone hormone; should be taken within 120 hours
of unprotected sex; stops or delays ovaries from releasing eggs; available by
prescription (e.g., El a).
Source: FDA, "Birth Control,” June 18, 2021, https://www.fda.gov/consumers/free-publications-women/birth-
control.
Notes: Table language reflects that of the FDA Birth Control resource and chart. It is organized from most to
least effective contraceptive (sterilization is most effective; ECs are least effective).
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)17 and bilateral salpingectomy (removal of fallopian tubes),
often with bilateral oophorectomy (removal of both ovaries).18 These surgeries are also
commonly used to treat medical conditions, such as reproductive cancers.
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 nine weeks of a pregnancy.19 To terminate a
pregnancy medically, mifepristone (also known as RU-486) and misoprostol are prescribed20 in
combination.21 Mifepristone is a progesterone hormone blocker and is FDA-approved for the
termination of pregnancy,22 and misoprostol is used off-label to induce uterine contractions,

17 U.S. National Library of Medicine, “Hysterectomy,” January 26, 2021, https://medlineplus.gov/hysterectomy.html.
18 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-ovarian-
cancer. Salpingectomy and oophorectomy may also be used to prevent or treat certain reproductive cancers.
19 CDC, “Reproductive Health: Data and Statistics,” November 25, 2020, https://www.cdc.gov/reproductivehealth/
data_stats/index.htm.
20 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. In response to FDA’s
modifications, Mifepristone manufacturers must now prepare proposals on how the REMS modifications will be
implemented to the FDA. See FDA, “Approved Risk Evaluation and Mitigation Strategies (REMS): Mifepristone,”
December 26, 2021, https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/mifeprex-
mifepristone-information.
21 FDA, “Questions and Answers on Mifeprex,” December 26, 2021, https://www.fda.gov/drugs/postmarket-drug-
safety-information-patients-and-providers/questions-and-answers-mifeprex.
22 Mifeprex (mifepristone) label, https://www.accessdata.fda.gov/drugsatfda_docs/label/2000/20687lbl.pdf.
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though its approved use is to prevent stomach ulcers.23 This intervention typically necessitates a
follow-up physician appointment to confirm termination of the pregnancy. Surgical abortion
procedures vary depending on which trimester of pregnancy a patient is in. These procedures in
general seek to evacuate fetal tissue from the uterus using gynecological tools.24
Abortion counseling is, in general, a discussion between a clinician and a patient about abortion
as a potential option in pregnancy decisionmaking. Abortion counseling may also involve a
discussion of future fertility decisions.25
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, 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 HHS since 1976.26 Similar provisions exist in the appropriations
measures for foreign operations, the District of Columbia, the Treasury, and the Department of
Justice (DOJ).27 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).28
These provisions may additionally restrict abortion counseling for federal agencies and grant
programs.
Hyde Amendment
Fol owing 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
.

23 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.
24 CDC, “Abortion Surveillance—United States, 2018,” November 27, 2020, https://www.cdc.gov/mmwr/volumes/69/
ss/ss6907a1.htm?s_cid=ss6907a1_x.
25 J.D. Asher, “Abortion counseling,” American Journal of Public Health, vol. 62, no. 5 (May 1972), pp. 686-688.
26 See P.L. 94-439, §209, 90 Stat. 1418, 1434 (1976).
27 For additional discussion of abortion funding restrictions, see CRS Report RL33467, Abortion: Judicial History and
Legislative Response
.
28 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.”)
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What Are Infertility Services?
Infertility is a reproductive health disorder generally defined as the inability to conceive
pregnancy after at least one year of attempting to conceive.29 Infertility affects people of all
genders and can be caused by reproductive organ damage, hormone imbalance, or genetic
disorders. Treatments for infertility thus may involve surgery, hormone/medication therapy,
genetic counseling, or medical procedures such as intrauterine (artificial) insemination (IUI).30
Treatment may also involve Assisted Reproductive Technologies (ARTs), which are generally
defined as “all fertility treatments in which either eggs or embryos are handled.”31 In Vitro
Fertilization (IVF), the most notable example of an ART, is a procedure designed to help initiate a
pregnancy via artificial implantation of fertilized embryo(s) into a uterus. IVF is a last resort
pregnancy option for those with clinical infertility issues or those with heritable genetic
conditions. Other ARTs include gamete and zygote intrafallopian transfer32 and elective single
embryo transfer.33
The three federal agencies that currently regulate the use of ARTs are the Centers for Disease
Control and Prevention (CDC),34 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
Medicaid Services (CMS) is responsible for implementation of the Clinical Laboratory
Improvement Act to ensure the quality of laboratory testing.35

29 CDC, “Infertility FAQs,” March 1, 2022, https://www.cdc.gov/reproductivehealth/infertility/index.htm.
30 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.”
31 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.
32 CDC, “2019 Assisted Reproductive Technology: Fertility and National Summary Report, 2021,
https://www.cdc.gov/art/reports/2019/pdf/2019-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.
33 CDC, “Single Embryo Transfer,” August 3, 2017, https://www.cdc.gov/art/patientresources/transfer.html. CDC
defines this procedures 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.”
34 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.”
35 American Society for Reproductive Medicine, Oversight of Assisted Reproductive Technology, Birmingham, AL,
2010, https://www.asrm.org/globalassets/asrm/asrm-content/about-us/pdfs/oversiteofart.pdf.
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What Are Maternity Services?
Maternal health services include a broad range of interventions to support pregnant individuals.
These interventions include care during “the intrapartum hospital stay, such as practices related to
immediate prenatal care, care during labor and birthing, and postpartum care”; hospital in this
case refers to “hospitals, birthing clinics, and freestanding birth centers.”36 Prenatal care37 usually
takes the form of routine monitoring and support, including administration of prenatal vitamins,
medication counseling, drug and alcohol counseling, and management of obstetric conditions that
may arise (e.g., ectopic pregnancies, which are nonviable and life-threatening for the mother).38
Prenatal care may also include care for chronic medical conditions that may make an otherwise
normal pregnancy high risk (e.g., diabetes, cardiovascular disease, obesity). Recent
Administrations have focused on improving maternal health. Specifically, the Biden
Administration released its “Blueprint for Addressing the Maternal Health Crisis” in June 2022.
The blueprint includes goals to improve maternal health services, improve birthing services,
advance data collection, expand and improve the diversity of the perinatal workforce, and
strengthen economic and social supports before, during, and after birth.39 In 2020, the Trump
Administration, through HHS, developed a Maternal Health Action Plan that included similar
foci. Specifically, that plan aimed to improve health outcomes for women of reproductive age,
achieve healthy pregnancies and births, optimize postpartum health, improve data, and bolster
research in this area.40
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 of the reproductive organs. Common reproductive
infections include STDs 41 such as chlamydia, gonorrhea, human immunodeficiency virus (HIV)/
acquired immune deficiency syndrome (AIDS), and human papillomavirus (HPV).42 Other

36 CDC, “The CDC Guide to Breastfeeding Interventions,” 2005, https://www.cdc.gov/breastfeeding/pdf/
breastfeeding_interventions.pdf.
37 CDC, “During Pregnancy,” October 1, 2020, https://www.cdc.gov/pregnancy/during.html.
38 American College of Obstetricians and Gynecologists, “ACOG Practice Bulletin No. 191: Tubal Ectopic
Pregnancy,” Obstetrics & Gynecology, vol. 131, no. 2 (February 2018), pp. 65-77. An ectopic pregnancy is one in
which a fertilized egg implants outside the uterus. Ectopic pregnancies most often occur in the fallopian tube, but can
also be found in the abdominal cavity, cervix, or ovary. Ruptured ectopic pregnancy was the leading cause of
hemorrhage-related mortality in 2011-2013 (excess bleeding to the point of death). This pregnancy is terminated
through surgery or use of the medication methotrexate; it is not treated with mifepristone (also known as RU-486).
39 White House, White House Blueprint for Addressing the Maternal Health Crisis, Washington, DC, June 2022,
https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf.
40 HHS, Health Women, Health Pregnancies, Health Futures: Action Plan to Improve Maternal Health in America,
https://aspe.hhs.gov/sites/default/files/private/aspe-files/264076/healthy-women-healthy-pregnancies-healthy-future-
action-plan_0.pdf.
41 Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP),
CDC, “Diseases & Related Conditions,” December 8, 2021, https://www.cdc.gov/std/general/default.htm. “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. STDs are passed from one person to another through sexual activity
including vaginal, oral, and anal sex. They can also be passed from one person to another through intimate physical
contact, such as heavy petting, though this is not very common.”
42 CDC, “Sexually Transmitted Diseases,” https://www.cdc.gov/std/default.htm. Human immunodeficiency virus (HIV)
and human papillomavirus (HPV) infections can cause certain cancers.
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reproductive disorders include malignant cancers of the reproductive tract and breast, benign
cysts and tumors, and infertility.43
In health care, prevention occurs along a continuum, depending on the outcomes to be
prevented.44 For example, vaccinations can prevent infectious diseases, chemotherapy can prevent
a cancer-related death, and hospice care can prevent pain and distress. 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,
encompass primary prevention and secondary prevention. Primary prevention
includes interventions such as vaccinations that remove a risk factor 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.45 For example, “Well
Woman” visits give a patient and provider an opportunity to review risk factors
and plan the delivery of prevention and screening services.46 The United States
Preventive Services Task Force (USPSTF; see text box below) evaluates
evidence and makes recommendation 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.

43 CDC, “Common Reproductive Health Concerns for Women,” April 27, 2018, https://www.cdc.gov/
reproductivehealth/womensrh/healthconcerns.html, and “Prostate Cancer,” August 18, 2020, https://www.cdc.gov/
cancer/prostate/.
44 CRS Video WVB00063, Public Health 101: Overview of the U.S. System and Review of Federal Vaccine Policy,
slide 7 and accompanying audio.
45 CDC, Prevention: Picture of America, undated, p. 1, https://www.cdc.gov/pictureofamerica/pdfs/
picture_of_america_prevention.pdf.
46 American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice and Catherine Witkop,
MD, MPH, “Well-Woman Visit: Committee Opinion,” Obstetrics and Gynecology, vol. 132, no. 4 (October 2018), pp.
181-186. A well-woman visit encompasses, among other things, screenings and diagnostics appropriate to age and risk
factors, counseling with respect to a reproductive life plan and minimizing health risks, immunizations appropriate to
age and risk factors, and comprehensive history-taking.
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U.S. Preventive Services Task Force (USPSTF)
The U.S. Preventive Services Task Force (USPSTF) is an independent, volunteer panel of experts in prevention,
evidence-based medicine, and epidemiology that makes evidence-based recommendations about clinical preventive
services such as screenings, counseling services, and preventive medications. USPSTF recommendations inform
clinical practice and are referenced in federal law to define certain requirements for coverage of or payment for
clinical preventive services. Depending on available evidence, recommendations are tailored to specific
populations, such as age groups. However, evidence is often insufficient to tailor recommendations for specific
subpopulations, such as racial and ethnic groups.
The USPSTF defines preventive services as fol ows: “[USPSTF] recommendations focus on interventions to
prevent disease, so they only apply to persons without signs or symptoms of the disease or condition under
consideration. USPSTF recommendations address services offered in the primary care setting or services 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
implementing for preventive care and that are relevant for implementing certain coverage requirements in the
Affordable Care Act. These preventive services have a high or moderate net benefit for patients.
Several services recommended for use by the USPSTF, such as screenings for cancers of the reproductive organs,
are discussed as reproductive health preventive services in this report. These services are furnished to individuals
in clinical settings and are distinct from public health prevention activities, such as sex education in schools.
The USPSTF does not evaluate the use of vaccines, although they are also clinical preventive services. Rather, the
USPSTF defers to another federal advisory group, the Advisory Committee on Immunization Practices (ACIP).
Certain vaccines (e.g., those for hepatitis B and human papil omavirus [HPV]) can prevent sexual transmission of
these diseases; those vaccines are also discussed as reproductive health preventive services in this report.
Sources: U.S. Preventive Services Task Force (USPSTF), “About the USPSTF,”
https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf. U.S. Preventive Services Task Force, “Scope of
Work,” Procedure Manual, Section 1.4, pp.1-2, December, 2015, https://www.uspreventiveservicestaskforce.org/
uspstf/sites/default/files/inline-files/procedure-manual-2020_3.pdf. Advisory Committee on Immunization Practices
(ACIP), https://www.cdc.gov/vaccines/acip/index.html.
Notes: The task force is supported by the HHS Agency for Healthcare Quality and Research (AHRQ). The ACIP
is supported by CDC.
A given reproductive health service may be either a preventive or treatment service. 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. 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
Treatment
Screening/Post-
Disease or
Primary
Exposure
Medical/Surgical
Condition
Prevention
Prophylaxis (PEP)
Monitoring
Treatment
Breast cancera
None known,
Mammography,a
Mammography
Mastectomy,
although some
genetic counseling and
chemotherapy,
healthy behaviors
testing
immunotherapy
may lower incidence
Cervical cancer
Human
Visual exam, cervical
Visual exam, cervical
Surgery,
papil omavirus (HPV) cytology (Pap smear),
cytology (Pap smear)
chemotherapy
vaccine
HPV testing
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Prevention
Treatment
Screening/Post-
Disease or
Primary
Exposure
Medical/Surgical
Condition
Prevention
Prophylaxis (PEP)
Monitoring
Treatment
Human
Pre-exposure
Human
Viral load testing,
Combination drug
immunodeficiency prophylaxis (PrEP),b
immunodeficiency
other bloodwork,
therapy, management
virus (HIV)
counseling regarding virus (HIV) testing,
retesting fol owing
of HIV-associated
safe sexual practices, PEPd
exposure
conditions
bloodborne
pathogens
protectionsc
Gonorrheae
Counseling regarding Testing fol owing
Repeat testing,
Antibiotic therapy
safe sexual practices
possible exposure or if especial y for
at risk, PEP
antibiotic-resistant
strains
Source: Prepared by CRS.
Notes: This table provides il ustrative examples only and is not intended to be comprehensive.
a. CDC, “Basic Information About Breast Cancer,” September 14, 2020, https://www.cdc.gov/cancer/breast/
basic_info/index.htm.
b. CDC, “About PrEP,” June 3, 2022, https://www.cdc.gov/hiv/basics/prep/about-prep.html. “PrEP (pre-
exposure prophylaxis) is medicine people at risk for HIV take to prevent getting HIV from sex or injection
drug use.” 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, “HIV PEP,” October 21, 2020, https://www.cdc.gov/hiv/basics/pep.html. HIV PEP medications should
be started within 72 hours of a possible exposure.
e. CDC, “Gonorrhea–CDC Fact Sheet (Detailed Version),” January 19, 2021, https://www.cdc.gov/std/
gonorrhea/stdfact-gonorrhea-detailed.htm.
On December 17, 2020, HHS released a National Strategic Plan for improving STI education,
prevention, and treatment in the United States for 2021-2025.47 This action plan specifically
targets rising rates of chlamydia, gonorrhea, syphilis, and HPV through four main objectives: (1)
STI prevention, (2) reduction of adverse outcomes through acceleration of STI research, (3)
reduction of STI-related health disparities and inequalities, and (4) integration of existing STI
prevention programs.
What Are Gender-Affirming Services?
Gender-affirming services are medical and surgical interventions designed to help match an
individuals’ primary and secondary sex characteristics with their gender identity.48 Use of these
services may stem from a diagnosis of gender dysphoria (previously known as gender identity
disorder [GID]), defined by CMS as an individual’s “significant discontent with their biological
sex and/or gender assigned at birth.”49

47 HHS, “STI National Strategic Plan Overview,” press release, December 17, 2020, https://www.hhs.gov/programs/
topic-sites/sexually-transmitted-infections/plan-overview/index.html.
48 Office of Population Affairs, OASH, “Gender Affirming Care and Young People,” https://opa.hhs.gov/sites/default/
files/2022-03/gender-affirming-care-young-people-march-2022.pdf.
49 CMS, “Decision Memo for Gender Dysphoria and Gender Reassignment Surgery (CAG-00446N),” August 30, 2016,
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Medical interventions primarily take the form of hormone therapy but may also involve treatment
of behavioral health conditions related to stigma and discrimination, as well as other types of
treatment.50 Surgical interventions, commonly known as sex reassignment surgeries (SRS) or
gender reassignment surgeries (GRS), typically involve altering physical features to match an
individual’s gender identity.51 Surgeries include, but are not limited to, those that target the face,
the chest/breasts, or genitals.
A Note About Gender References in This Report
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 “women,” “man,” “female,” and “male,” in each section have been made consistent
with each federal agency’s or grant program’s official terminology.

Notes: For more information about terminology related to gender and gender identify, see the fol owing
resources:
CDC, "HIV and Transgender People: Terminology," April 15, 2021, https://www.cdc.gov/hiv/group/gender/
transgender/terminology.html.
WHO, "Gender, equity and human rights: Glossary of terms and tools," 2011, https://www.who.int/gender-equity-
rights/knowledge/glossary/en/.
Federal Agencies and Departments
Several federal agencies provide health services directly to specific service populations. These
agencies, the populations they serve, and the reproductive services they provide or pay for are
discussed below. Agencies are organized alphabetically by agency name.
Bureau of Prisons (BOP)
The Bureau of Prisons (BOP) within the Department of Justice (DOJ) operates the federal prison
system, which includes 122 facilities in 35 states. BOP was established in 1930 to house federal
prisoners, professionalize the prison service, and ensure consistent and centralized administration
of the federal prison system.52 BOP must confine any offender convicted and sentenced to a term
of imprisonment in a federal court. As of the end of FY2021, there were approximately 156,000
prisoners under BOP’s jurisdiction.53 BOP provides medically necessary health care treatment to
all prisoners housed in BOP-operated facilities, including medically necessary reproductive
health services.54 Most of this treatment is provided through health care clinics operated in each
BOP facility. Most clinics have examination rooms, treatment rooms, dental clinics, radiology

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=282.
50 CDC, “Patient-Centered Care for Transgender People: Recommended Practices for Health Care Settings,” February
18, 2022, https://www.cdc.gov/hiv/clinicians/transforming-health/health-care-providers/affirmative-care.html.
51 University of Michigan Medicine, “Gender Confirmation Surgery,” (accessed July 1, 2022),
https://www.uofmhealth.org/conditions-treatments/transgender-services/gender-confirmation-surgery.
52 U.S. Department of Justice (DOJ), Bureau of Prisons (BOP), About the Bureau of Prisons, June 2015, p. 1.
53 DOJ, BOP, “Statistics,” https://www.bop.gov/about/statistics/population_statistics.jsp#old_pops (data on the federal
prison population was accessed on June 29, 2022).
54 DOJ, BOP, FY 2023 Performance Budget, Congressional Submission, Salaries and Expenses, p. 25 (hereinafter,
“BOP FY2023 S&E budget justification”).
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and laboratory areas, a pharmacy, and administrative offices.55 When services cannot be provided
at a BOP facility, it transports prisoners to a community health care facility or provider (e.g., a
hospital). Generally, each BOP facility maintains its own contract with health care facilities or
providers and sets the rate to be paid for providing medical treatment to inmates.56 For prisoners
with acute or chronic long-term care needs that cannot be managed through in-prison clinics,
BOP transfers these patients to one of its Federal Medical Centers.57
All prisoners serving a period of incarceration are given an intake medical examination within 14
days of their arrival at their designated facility. This intake includes
 compiling a complete medical, mental health, and substance abuse history and
conducting a physical examination;
 conducting a dental examination; and
 ordering appropriate laboratory and diagnostic tests, if medically indicated (e.g.,
screenings for hepatitis, sickle cell anemia, and STDs).58
BOP policy requires facilities to make age-appropriate medical screening available to all
prisoners.
Does BOP Provide Reproductive Health Services?
BOP provides medically necessary health care treatment to all prisoners housed in BOP-operated
facilities, including medically necessary reproductive health services.59
In addition to the intake medical examination mentioned above, BOP policy requires facilities to
provide age-appropriate medical screening, which may include reproductive health screening, to
all prisoners.
Does BOP Provide Contraceptive Services?
BOP policy requires medical staff to provide female prisoners with information related to birth
control, if requested.60 Female prisoners have access to birth control while incarcerated, but it is
usually prescribed only for regulating menstruation and for hormone replacement therapy in
postmenopausal women, as clinically indicated.61 Birth control can be prescribed for other
reasons, but only if a clinician believes it is medically appropriate and the prescription is
approved by BOP’s medical director.62

55 U.S. Government Accountability Office (GAO), Bureau of Prisons: Better Planning and Evaluation Needed to
Understand and Control Rising Inmate Health Care Costs
, GAO-17-379, June 2017, p. 8 (hereinafter, “GAO BOP
rising inmate health care costs report”).
56 GAO BOP rising inmate health care costs report, p. 11.
57 Examples of services provided at Federal Medical Centers include dialysis for inmates with chronic renal failure;
oncology treatment (i.e., chemotherapy and radiation therapy); inpatient and forensic mental health; surgery (i.e.,
limited orthopedic and general surgery procedures); prosthetics and orthotics; long-term ventilator-dependent
management; dementia care; and end-of-life care. BOP FY2023 S&E budget justification, p. 26.
58 DOJ, BOP, Patient Care, Program Statement 6031.04, p. 24 (hereinafter “Patient Care”).
59 BOP FY2023 S&E budget justification, p. 25.
60 Patient Care, p. 28.
61 Ibid.
62 The medical director is a part of the executive staff of BOP’s Health Services Division, which is responsible for
overseeing the programs, operations, and delivery of health care at all BOP facilities.
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BOP does not provide sterilization to male or female prisoners except for bona fide medical
indications (e.g., as the result of surgical treatment for cancer of the reproductive organs).63
Does BOP Provide Abortions or Abortion Counseling?
BOP does not directly provide abortions; however, it will permit pregnant prisoners to terminate
their pregnancies, with certain conditions.64 Wardens are required to offer pregnant prisoners
medical, religious, and social counseling to help them decide whether to carry a pregnancy to
term. If the prisoner chooses to terminate the pregnancy, the prisoner is required to sign a
statement to that effect.65 Upon receipt of the signed statement, the facility’s clinical director
arranges for an abortion.66 BOP assumes the cost of the procedure only when the mother’s life is
endangered by carrying the pregnancy to term or in the case of rape or incest.67 In all other cases,
the prisoner must arrange payment for the procedure.68 However, in cases where the prisoner pays
for the procedure, BOP may use its funds to transport the prisoner to a facility outside of the
institution where the procedure will be performed.69
Does BOP Provide Infertility Services?
BOP’s policies regarding prisoner health care and regarding health care for female prisoners,
specifically, do not address infertility services.
Does BOP Provide Maternity Services?
BOP has several programs that provide parenting assistance.70 With regard to maternity services,
the most relevant program is the Mothers and Infants Nurturing Together (MINT) program.
MINT is a community-based residential program where pregnant prisoners are allowed to give
birth and spend time bonding with their newborn outside of a secure facility. To be eligible for the
MINT program, prisoners must be pregnant when they begin their period of incarceration, must
have an expected delivery date prior to their scheduled release date, must have less than five
years of incarceration remaining, must be eligible for halfway house placement, and must assume

63 Patient Care, p. 42.
64 Traditionally, as a part of the annual Commerce, Justice, Science, and Related Agencies Appropriations Act,
Congress places limitations on how BOP can use its funding to provide abortion services to prisoners. For example, the
Commerce, Justice, Science, and Related Agencies Appropriations Act, 2022 (Division B of P.L. 117-103), states that
“none of the funds appropriated by [Title II of Division B] shall be available to pay for an abortion, except where the
life of the mother would be endangered if the fetus were carried to term, or in the case of rape or incest: Provided, That
should this prohibition be declared unconstitutional by a court of competent jurisdiction, this section shall be null and
void. None of the funds appropriated under this title shall be used to require any person to perform, or facilitate in any
way the performance of, any abortion. Nothing in the preceding section shall remove the obligation of the Director of
the Bureau of Prisons to provide escort services necessary for a female inmate to receive such service outside the
Federal facility: Provided, That nothing in this section in any way diminishes the effect of section 203 intended to
address the philosophical beliefs of individual employees of the Bureau of Prisons.”
65 DOJ, BOP, Female Offender Manual, Program Statement 5200.07, p. 16 (hereinafter, “Female Offender Manual”).
66 Clinical directors are responsible for clinical care provided at each BOP facility. The clinical director provides
clinical oversight of health care services and is responsible for all health care delivered.
67 Female Offender Manual, p. 17.
68 Ibid.
69 Ibid.
70 For a description of BOP’s national parenting from prisons program, see DOJ, BOP, First Step Act Approved
Programs Guide
, July 2022, p. 26.
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financial responsibility for child care.71 Prisoners in the MINT program are transferred to a
Residential Reentry Center (RRC) (BOP’s term for a halfway house) during the last two months
of pregnancy, and they are allowed to stay at the RRC for at least three months, though BOP
policy recommends a minimum of six months.72 Once they complete the program, prisoners are
returned to their designated facility to serve the remainder of their sentences.
Does BOP Provide Reproductive Health Screening, Prevention, and Treatment
Services?

All federal prisoners receive a medical screening upon intake at a BOP facility, which includes
ordering appropriate laboratory and diagnostic tests, if medically indicated. Such tests include
age-appropriate preventive health examinations (e.g., Pap smears). BOP policy also requires
medical staff to counsel prisoners regarding any necessary follow-up treatment or testing within a
clinically appropriate time frame.73 BOP provides medically necessary treatment, including
treatment for reproductive health, to all federal prisoners.74 BOP is responsible for providing
medically necessary care in a manner consistent with the standards of care for nonprisoners.75
In addition, BOP policy requires facilities to make age-appropriate medical screening available to
all prisoners.
In general, BOP tests for STIs when there is a clinical indication that a prisoner has an STI.76
BOP has special procedures related to testing for HIV. If a prisoner who is sentenced to six
months or more has risk factors for HIV, or if there is a clinical indication that the prisoner has
HIV, then HIV testing is mandatory.77 HIV testing is also mandatory when there is a well-founded
belief that a prisoner has transmitted HIV to BOP employees or to other non-BOP employees
working in the facility.78 In addition, BOP conducts HIV testing, as necessary, to collect
information on the prevalence of HIV in the prison population (i.e., surveillance testing). BOP
provides HIV testing to prisoners upon request; such tests are limited to one per 12-month period,
unless BOP determines that additional testing is warranted.79 BOP provides pre- and post-test
counseling to all prisoners who are tested for HIV, regardless of the test results.80
Does BOP Provide Gender-Affirming Services?
BOP provides prisoners who have a possible diagnosis of GID with medical and mental health
evaluations. The evaluations are administered by staff who have experience with diagnosing
recognized sexual disorders and who have participated in BOP’s GID training. The evaluation

71 DOJ, Office of the Inspector General, Review of the Federal Bureau of Prisons’ Management of Its Female Inmate
Population
, Evaluation and Inspections Division 18-05, September 2018, p. 9.
72 Female Offender Manual, p. 18.
73 Patient Care, p. 26.
74 The GAO notes, “Multiple U.S. courts over the years have determined that inmates have a constitutional right to
adequate medical and mental health care.” GAO BOP rising inmate health care costs report, p. 2.
75 GAO BOP rising inmate health care costs report, p. 8.
76 DOJ, BOP, Infectious Disease Management, Program Statement 6190.04, p. 11 (hereinafter, “Infectious Disease
Management
”).
77 Infectious Disease Management, p. 5.
78 Ibid.
79 Infectious Disease Management, p. 6.
80 Ibid.
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includes an assessment of the prisoner’s treatment and life experiences prior to incarceration, as
well as experiences during incarceration (including hormone therapy, completed or in-process
surgical interventions, real life experience consistent with the prisoner’s gender identity, private
expressions that conform to the preferred gender, and counseling).81
If a prisoner is diagnosed with GID, BOP develops a treatment plan, which is not solely
dependent on services provided or the prisoner’s life experiences prior to incarceration. The
treatment plan may include elements or services that were, or were not, provided prior to
incarceration, including, but not limited to, those elements of the real life experience consistent
with the prison environment, hormone therapy, and counseling. Treatment plans are reviewed
regularly and updated as necessary.
BOP uses all current, accepted standards of care as a reference for developing treatment plans for
prisoners with GID. Each treatment plan or denial of treatment must be reviewed by BOP’s
medical director or the prison’s chief psychiatrist.82
Department of Defense (DOD)
DOD administers a statutory health benefit (10 U.S.C. Chapter 55) through the Military Health
System (MHS). The MHS offers health care benefits and services through its TRICARE program
to approximately 9.6 million beneficiaries, comprising members and retirees of the uniformed
services and their family members.83 TRICARE offers a range of health care services, including
reproductive health services, in military hospitals and clinics (also known as military treatment
facilities, or MTFs) and from participating civilian health care providers.84 With the exception of
active duty servicemembers, beneficiaries are subject to certain cost-sharing requirements based
on beneficiary category, health plan or benefit program, and the sponsor’s initial enlistment or
appointment date to military service.85
Does DOD Provide Reproductive Health Services?
By law, DOD is required to offer certain primary and preventive health services to all active duty
servicemembers and retirees.86 Eligible family members of servicemembers and retirees may also
access these services. Primary and preventive health services are generally offered at no cost to
beneficiaries; however, some services may be subject to certain cost-sharing requirements.

81 Patient Care, p. 41.
82 Each prison has a chief psychiatrist, chosen by the warden with the approval of BOP’s medical director. The chief
psychiatrist is responsible for supervising the prison’s psychiatric program.
83 Military Health System (MHS), “Beneficiary Population Statistics,” accessed November 5, 2020,
https://www.health.mil/I-Am-A/Media/Media-Center/Patient-Population-Statistics. The term uniformed services
includes the Armed Forces (Army, Navy, Air Force, Marine Corps, and Coast Guard), the commissioned corps of the
Public Health Service, and the commissioned corps of the National Oceanic and Atmospheric Administration. For
additional information about the MHS, see CRS In Focus IF10530, Defense Primer: Military Health System.
84 For more on the MHS, see CRS In Focus IF10530, Defense Primer: Military Health System.
85 For more on TRICARE’s cost-sharing features, see CRS Report R45399, Military Medical Care: Frequently Asked
Questions
(“Question 6. What are the Different TRICARE Plans?”). A sponsor refers to a servicemember or military
retiree. For more on sponsors and family members, see https://www.tricare.mil/Plans/Eligibility.
86 The Patient Protection and Affordable Care Act (ACA; P.L. 111-148) requires most insurance programs and plans to
cover women’s preventive health services. Those requirements do not apply to the TRICARE program; however, 10
U.S.C. §1074d does require TRICARE to include similar preventive health services. For more information on the
ACA’s requirements, see “Coverage of Certain Preventive Services Without Cost Sharing.”
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Does DOD Provide Contraceptive Services?
DOD offers contraceptive services as part of its family planning benefit.87 Counseling and
contraception methods are offered in accordance with Section 718 of National Defense
Authorization Act (NDAA) for FY2016 (P.L. 114-92) and CDC’s medical eligibility criteria and
selected practice recommendations for contraceptive use.88 DOD offers or covers only methods
of contraception recognized by FDA (see text box in “What Are Contraceptive Services?”)
including the following:
 Short-Acting Reversible Contraceptives (SARCs): oral contraceptive, patch,
vaginal ring, injection.
 Long-Acting Reversible Contraceptives (LARCs): intrauterine device (IUD),
implantable rod.
 Barriers: diaphragm, cervical cap, sponge, male/female condom.
 Sterilization: male/female surgical sterilization, permanent implant.
 Emergency Contraceptives (ECs): Plan B One Step/Next Choice One Dose,
Ella.89
Deployed servicemembers may also receive prescribed contraceptives (up to 180-day supply)
prior to their departure and while in-theater (90-day supply increments) when subscribed to the
Deployed Prescription Program (DPP).90 In-theater military health care providers are authorized
to issue new or renewal prescriptions that would be filled through the DPP.
Does DOD Provide Abortions or Abortion Counseling?
Title 10, Section 1093, of the U.S. Code prohibits the DOD from directly providing or paying for
abortion services, 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.91 DOD
may provide medically necessary care and services (including behavioral health care) when
related to a covered abortion. Abortion counseling, referral, preparation, and follow-up care for
noncovered abortions are not available in MTFs or paid for by TRICARE.92

87 Ibid. For additional information about Department of Defense (DOD) contraceptive services, see CRS In Focus
IF11109, Defense Health Primer: Selected Contraceptive Services.
88 Defense Health Agency (DHA) Procedural Instruction 6200.02, Comprehensive Contraceptive Counseling and
Access to the Full Range of Methods of Contraception
, May 13, 2019, p. 6, https://go.usa.gov/x79gj. The FY2016
National Defense Authorization Act (NDAA) requires DOD to establish and disseminate clinical guidelines on
contraception and contraception counseling, as well as to make annual and pre-and postdeployment contraceptive
counseling available to female members of the Armed Forces.
89 Ibid., p. 14. A list of FDA-approved contraceptive methods is available at https://www.fda.gov/consumers/free-
publications-women/birth-control-chart.
90 The Deployed Prescription Program (DPP) delivers prescription medications to deployed servicemembers via the
military mail system (i.e., Army Post Office, Fleet Post Office). DOD civil service employees and DOD contractors
without other health insurance are also eligible for DPP. For more information on the DPP, see https://tricare.mil/dpp.
91 32 C.F.R. §199.4(e)(2) further specifies that “abortions performed for suspected or confirmed fetal abnormality (e.g.,
ancephalic) or for mental health reasons (e.g., threatened suicide) do not fall within the exceptions” permitted in statute.
92 See Chapter 4, Section 18.3 of the TRICARE Policy Manual 6010.60-M, April 1, 2015, https://manuals.health.mil/
pages/DisplayManualHtmlFile/2021-01-20/ChangeOnly/tp15/c4s18_3.html.
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Does DOD Provide Infertility Services?
DOD offers certain counseling and treatment services for infertility, when medically necessary
and combined with natural conception, including
 correction of any physical cause of infertility;
 erectile dysfunction resulting from a physical cause; and
 diagnostic services (e.g., semen analysis, hormone evaluation, chromosomal
studies, immunologic studies, special and sperm function tests, and bacteriologic
investigation).93
In general, DOD does not offer or cover other types of infertility services or ART.94 Excluded
services include artificial intrauterine insemination (IUI), costs related to donors or sperm banks,
reversal of tubal ligation or vasectomy (unless medically necessary), erectile dysfunction
resulting from psychological causes, or noncoital reproductive procedures (e.g., IVF, gamete or
zygote intrafallopian transfer, tubal embryo transfer).95
DOD also offers limited ART services to seriously or severely ill or injured active duty
servicemembers and their spouses with qualifying diagnosis (i.e., infertility).96 Limited ART
services include sperm or egg retrieval; IVF; artificial insemination; and egg, sperm, or embryo
cryopreservation.97 Six DOD hospitals offer these services to eligible servicemembers and their
spouses:
 Madigan Army Medical Center (Tacoma, WA);
 Naval Medical Center San Diego (San Diego, CA);
 San Antonio Military Medical Center (San Antonio, TX);
 Tripler Army Medical Center (Honolulu, HI);
 Walter Reed National Military Medical Center (Bethesda, MD); and
 Womack Army Medical Center (Fayetteville, NC).98
Most of these services are provided at no cost to the patient; however, the cost of
cryopreservation and storage up to three years is shared between the patient and DOD.99

93 See Chapter 4, Sections 15.1 and 17.1 of the TRICARE Policy Manual 6010.60-M, April 1, 2015. For more on DOD
infertility services, see CRS In Focus IF11504, Infertility in the Military.
94 For more on assisted reproductive technologies (ART), see https://tricare.mil/CoveredServices/IsItCovered/
AssistedReproductiveServices. Noncoital refers to sexual or reproductive activities that do not involve heterosexual
intercourse.
95 See Chapter 7, Section 2.3 of the TRICARE Policy Manual 6010.60-M, April 1, 2015.
96 10 U.S.C. §1074(c) authorizes DOD to provide extended care benefits to servicemembers who “incur a serious injury
or illness on active duty.”
97 DOD, Report to Congress: Efforts to Treat Infertility of Military Families, December 2015, pp. 7-8,
https://go.usa.gov/x79Ww.
98 Ibid., p. 7.
99 DOD policy authorizes cost sharing of embryo cryopreservation and storage for no more than three years or when the
servicemember separates/retires, whichever comes first. For more on ART for ill or injured servicemembers, see
Assistant Secretary of Defense for Health Affairs Memorandum, “Policy for Assisted Reproductive Services for the
Benefit of Seriously or Severely Ill/Injured (Category II or III) Active Duty Service Members,” April 3, 2012.
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Does DOD Provide Maternity Services?
DOD offers and pays for medically necessary maternity care, including “care and treatment
related to conception, delivery, abortion,100 including prenatal and postnatal care (generally
through the 6th postdelivery week), and also including treatment of the complications of
pregnancy.”101 Maternity care for pregnancies resulting from noncoital reproductive procedures or
surrogacy are also covered.102
Does DOD Provide Reproductive Health Screening, Prevention, and
Treatment Services?

DOD offers a wide-range of clinical preventive services, including certain reproductive health
screening and preventive services.103 These services include, but are not limited to, screening and
counseling of breast, cervical, colon, gynecological, testicular, and prostate cancers; family
planning; menopause; STIs or STDs; PrEP for HIV; and physical or psychological conditions
resulting from an act of violence.104 DOD also offers medically necessary treatment or therapy
options to eligible beneficiaries with a reproductive health issue identified during a clinical
screening.105
Does DOD Provide Gender-Affirming Services?
DOD offers or pays for medically necessary nonsurgical treatment (i.e., hormone therapy,
pubertal suppression, or psychotherapy) for gender dysphoria.106 According to TRICARE
coverage policy, beneficiaries with gender dysphoria diagnosed by a mental health provider and
who meet certain clinical indications may access these services.107 With regard to surgical
treatment of gender dysphoria (i.e., SRS), Title 10, Section 1079(a)(11), of the U.S. Code
prohibits DOD from directly providing or paying for surgical treatment of gender dysphoria (i.e.,
SRS) for nonactive duty beneficiaries.
All active duty servicemembers diagnosed with gender dysphoria may receive nonsurgical
treatment, as described above. In addition, DOD may cover surgical treatment options for
servicemembers who entered military service prior to April 12, 2019, and who were either (1)
“medically qualified” in their preferred gender at the time of accession or (2) diagnosed with
gender dysphoria by a military medical provider.108 DOD refers to these individuals as exempt

100 The DOD will only pay for abortions in limited circumstances. For more information see “Does DOD Provide
Abortions or Abortion Counseling?”
in this report.
101 32 C.F.R. §199.2 and §199.4.
102 For more on TRICARE coverage of maternity care, see Chapter 4, Section 18.1 of the TRICARE Policy Manual,
April 1, 2015.
103 For more on DOD’s provision of clinical preventive services, see Chapter 7, Sections 2.1 and 2.22 of the TRICARE
Policy Manual, April 1, 2015.
104 32 C.F.R. §199.4(e)(3) defines DOD’s family planning benefit as certain “services and supplies related to preventing
contraception.”
105 For more on DOD administered/sponsored medically necessary treatment or therapy options, see 32 C.F.R. §199.4.
106 For more on TRICARE coverage of gender dysphoria services, see Chapter 7, Section 1.2 of the TRICARE Policy
Manual, April 1, 2015.
107 Ibid.
108 DOD Instruction 1300.28, Military Service By Transgender Persons and Persons with Gender Dysphoria,
September 4, 2020, p. 11, https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/130028p.pdf? ver=2020-
09-04-115910-477.
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servicememembers.109 DOD policies require exempt servicemembers to meet certain clinical and
administrative requirements prior to receiving approval for surgical treatment.110
U.S. Immigration and Customs Enforcement (ICE)
Noncitizen Detention
The Department of Homeland Security’s (DHS’s) Immigration and Customs Enforcement’s
(ICE’s) mission “is to protect America from the cross-border crime and illegal immigration that
threaten national security and public safety.”111 ICE’s Enforcement and Removal Operations
(ERO) is responsible for immigration enforcement in the interior of the United States, including
managing and overseeing the immigrant detention system.112
ICE detention standards were originally developed in 2000 and have been updated several times,
resulting in various sets of standards that incorporate different laws and regulations and vary in
terms of scope and rigor. Although there are different sets of standards, all facilities housing
noncitizen detainees must generally comply with one of the sets of ICE detention standards,
including health care standards. Contracts or agreements between ICE and detention facilities
specify which set of standards facilities are required to follow.113
Two sets of detention standards are applied at facilities that house the majority of the adult
detained population: the 2011 Performance-Based National Detention Standards (PBNDS)114 and
the 2000/2019 National Detention Standards (NDS).115 The 2011 PBNDS and 2019 NDS provide

109 Ibid. Medically qualified refers to being capable of “satisfactorily completing required training and initial period of
contracted service” and “performing duties without aggravating existing physical defects or medical conditions.” For
more information, see DOD Instruction 6130.03, Medical Standards For Appointment, Enlistment, or Induction into
the Military Services
, May 6, 2018, pp. 4-5, https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/
613003p.pdf.
110 Clinical and administrative requirements include a period of patient stability during cross-sex hormone therapy; full-
time, continuous real life experience in the preferred gender; gender marker change in DOD’s personnel database (i.e.,
Defense Enrollment Eligibility Reporting System); unit commander endorsement; and a DHA waiver to authorize
payment for surgical care by a designated civilian health care provider. For more on these requirements and approval
process, see Assistant Secretary of Defense for Health Affairs Memorandum, Guidance for Treatment of Gender
Dysphoria for Active and Reserve Component Service Members
, July 29, 2016, https://go.usa.gov/x7X3f, and DHA
Memorandum, Interim Defense Health Agency Procedures for Reviewing Requests for Waivers to Allow Supplemental
Health Care Program Coverage of Sex Reassignment Surgical Procedures
, November 13, 2017, https://go.usa.gov/
x7Xc3.
111 Department of Homeland Security (DHS), Immigration and Customs Enforcement (ICE), at https://www.dhs.gov/
topic/immigration-and-customs-enforcement.
112 The law provides ICE with broad authority to detain noncitizens while awaiting a determination of whether they
should be removed from the United States, and mandates that certain categories of noncitizens are subject to mandatory
detention (e.g., when the noncitizen is removable on account of certain criminal or terrorist activity). See 8 U.S.C.
§§1225, 1226, 1226a, 1231, and 1357.
113 ICE owns and operates some of its own facilities, and it has arrangements through contracts with private companies
that operate immigration detention facilities. In addition, immigrant detention facilities owned by state or local
governments or private entities operate through intergovernmental agreements. (GAO, ICE Should Enhance Its Use of
Facility Oversight Data and Management of Detainee Complaints
, 20-596, August 2020, pp. 6-7.)
114 The 2011 Performance-Based National Detention Standards (PBNDS) was revised in 2016 to meet detention
standards consistent with federal legal and regulatory requirements, as well as prior ICE policies and policy statements.
The 2011 PBNDS is an updated version of the 2008 PBNDS; some facilities have contracts agreeing to adhere to the
2008 version. (GAO, ICE Should Enhance Its Use of Facility Oversight Data and Management of Detainee
Complaints
, 20-596, August 2020.)
115 The 2019 National Detention Standards (NDS) is a modified version of the 2000 NDS. The data provided by GAO
do not distinguish between the facilities utilizing 2000 and 2019 NDS. (GAO, ICE Should Enhance Its Use of Facility
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identical guidance on certain standards, including many health care standards. In the frequently
asked questions section that follows, the two sets of standards provide the same guidance unless
otherwise noted. The following sections present these standards as enumerated in ICE guidance.
There are multiple DHS Office of Inspector General (OIG) and GAO reports that indicate
inadequate compliance with these standards.116
Does ICE Provide Reproductive Health Services?
ICE provides certain reproductive health services to noncitizens in detention. Detained
noncitizens are entitled to medical care per Title 42, Section 249, of the U.S. Code and Title 42,
Section 34.7(a), of the Code of Federal Regulations. Medical care standards are outlined in ICE’s
detention standards; those related to reproductive health services are discussed in the sections
below.
Does ICE Provide Contraceptive Services?
According to ICE guidance, detainees are entitled to impartial family planning and contraceptive
consultations with medical personnel. Detainees may receive “medically appropriate” medical
contraception.117
Does ICE Provide Abortions or Abortion Counseling?
ICE provides abortion services in certain circumstances. ICE assumes the cost of terminating the
pregnancy “if the life of the mother would be endangered by carrying a fetus to term, or in the
case of rape or incest.”118 In all other circumstances, the detainee bears the cost of terminating the
pregnancy. In all instances, ICE arranges transportation to the medical appointment at no cost to
the detainee and, if requested, to religious or social counseling.
Does ICE Provide Infertility Services?
ICE detention standards are silent on the provision of infertility services. CRS confirmed with
ICE that it does not “generally provide infertility services.”119

Oversight Data and Management of Detainee Complaints, 20-596, August 2020.)
116 For example, see DHS OIG, Concerns about ICE Detainee Treatment and Care at Detention Facilities, OIG-18-32,
December 11, 2017; DHS OIG, ICE Does Not Fully Use Contracting Tools to Hold Detention Facility Contractors
Accountable for Failing to Meet Performance Standards
, OIG-19-18, January 29, 2018; DHS OIG, Management Alert
– Issues Requiring Action at the Adelanto ICE Processing Center in Adelanto, California,
OIG-18-87, September 27,
2018; DHS OIG, Concerns about ICE Detainee Treatment and Care at Four Detention Facilities, OIG-19-57, June 3,
2019; DHS OIG, Capping Report: Observations of Unannounced Inspections of ICE Facilities in 2019, OIG-20-45,
July 1, 2020; U.S. GAO, Immigrant Detention: Additional Actions Needed to Strengthen Management and Oversight of
Detainee Medical Care
, GAO-16-321, February 2016; GAO Immigrant Detention: Care of Pregnant Women in DHS
Facilities
, GAO-20-330, March 2020; GAO, Immigrant Detention: ICE Should Enhance Its Use of Facility Oversight
Data and Management of Detainee Complaints
, GAO-20-956, August 2020.
117 2011 PBDNS, “4.4 Medical Care (Women)” and 2019 NDS “4.3 Medical Care.”
118 ICE, Performance-Based National Detention Standards 2011 (hereinafter, “2011 PBNDS”), “4.4 Medical Care
(Women)”; ICE, National Detention Standards for Non-Dedicated Facilities, revised 2019 (hereinafter, “2019 NDS”),
“4.3 Medical Care.”
119 CRS communication with ICE on October 21, 2020.
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Does ICE Provide Maternity Services?
ICE provides maternity services to detainees. ICE considers pregnant detainees one of its
vulnerable populations. According to ICE guidance, “pregnant detainees shall have access to
prenatal and specialized care, and comprehensive counseling on topics including, but not limited
to, nutrition, exercise, complications of pregnancy, prenatal vitamins, labor and delivery,
postpartum care, lactation, family planning, abortion services and parenting skills.”120 In addition,
ICE accommodates a pregnant individual’s special needs, such as an additional pillow or a
special diet, as identified by a medical professional. Finally, if a health care practitioner identifies
pregnant detainees as being high risk, they “shall be referred to a physician specializing in high
risk pregnancies.”121
Does ICE Provide Reproductive Health Screening, Prevention, and
Treatment Services?

All detainees are to be provided “comprehensive, routine and preventive health care, as medically
indicated.”122 The 2011 PBNDS guidance states that “detainees shall have access to a continuum
of health care services, including screening, prevention, health education, diagnosis and
treatment.”123 Similarly, the 2019 NDS guidance states that “all detainees shall have access to
appropriate medical, dental, and mental health care, including emergency services.”124
For detained women, ICE offers routine preventive screening services, such as pelvic and breast
examinations, Pap smears, testing for STIs, and mammograms.
In addition, ICE’s initial health assessment for women entering detention collects information
regarding
 “pregnancy testing for detainees aged 18-56 and documented results;
 if the detainee is currently nursing (breastfeeding);
 use of contraception;
 reproductive history (number of pregnancies, number of live births, number of
spontaneous/elective abortions, pregnancy complications, etc.);
 menstrual cycle;
 history of breast and gynecological problems;
 family history of breast and gynecological problems; and
 any history of physical or sexual victimization and when the incident
occurred.”125
Although ICE detention standards are silent on men’s reproductive health screening and
preventive services specifically, according to correspondence with CRS, “ICE offers routine age-
and gender-appropriate preventive health services and examinations for all male and female

120 2011 PBDNS, “4.4 Medical Care (Women)” and 2019 NDS “4.3 Medical Care.”
121 Ibid.
122 2011 PBDNS, “4.3 Medical Care” and 2019 NDS “4.3 Medical Care.”
123 2011 PBDNS, “4.3 Medical Care.”
124 2019 NDS “4.3 Medical Care.”
125 2011 PBDNS, “4.4 Medical Care (Women)” and 2019 NDS “4.3 Medical Care.”
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detainees annually. Testing for STIs is available upon detainee request and as clinically
indicated.”126
Does ICE Provide Gender-Affirming Services?
ICE provides gender-affirming services, though unlike the aforementioned services, the 2011
PBNDS and the 2019 NDS differ in terms of their guidance about transgender detainees’ health
care. (See the “U.S. Immigration and Customs Enforcement (ICE) Noncitizen Detention” section
above for a discussion of the different sets of detention standards.)
Per the 2011 PBNDS guidance, transgender detainees have access to the hormone therapy they
were receiving prior to being detained. Furthermore, “all transgender detainees shall have access
to mental health care, and other transgender-related health care and medication based on medical
need.”127 The guidance also states that their “treatment shall follow accepted guidelines regarding
medically necessary transition-related care,” though it does not reference specific guidelines.
The 2019 NDS guidance states that the detention facility and ICE/ERO should coordinate care
“based on [the] medical needs” of self-identified transgender detainees.128
Indian Health Service (IHS)
IHS provides health care directly or provides funds for Indian tribes or tribal organizations to
operate health care facilities.129 It provides services free of charge to approximately 2.7 million
eligible American Indians and Alaska Natives in 37 states.130 IHS does not have a standard
medical benefit that includes or excludes certain services.131 The agency generally focuses on
primary and preventive services and does so through a network of more than 600 facilities, which
include hospitals (46), health centers (370), and small health stations (104). Other facility types
include school health centers, youth regional treatment centers, and Alaska village clinics.132
Does IHS Provide Reproductive Health Services?
IHS does not have a standard medical benefit that includes or excludes certain services, but some
facilities provide reproductive health services and maternity care services. Among other services,

126 CRS communication with ICE on October 21, 2020.
127 2011 PBDNS, “4.3 Medical Care”
128 2019 NDS, “4.3 Medical Care.”
129 The Indian Health Service (IHS) also provides grants to Urban Indian Organizations (UIOs) that operate smaller
health facilities in urban areas. These facilities vary in terms of the services available; some provide comprehensive
services, while others provide information and referral services. The following discussion does not include UIOs
because as grantees they have more flexibility in the services they provide. Outside of the grants they receive, UIOs are
generally not eligible to receive funds from the overall IHS budget, with some exceptions. See discussion in CRS
Report R43330, The Indian Health Service (IHS): An Overview.
130 U.S. Department of Health and Human Services (HHS), IHS, Fiscal Year 2023 Indian Health Service Justification
of Estimates
, https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/
FY2023BudgetJustificaton.pdf.
131 CRS Report R43330, The Indian Health Service (IHS): An Overview.
132 U.S. Department of Health and Human Services (HHS), IHS, Fiscal Year 2023 Indian Health Service Justification
of Estimates
, https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/
FY2023BudgetJustificaton.pdf, p. 275.
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IHS provides specific women’s health services, such as mammograms and other preventive
services.
Specific reproductive health services may or may not be available at IHS because it has limited
funding and some facilities serve small populations. As such, not all facilities offer reproductive
health services, and the services available vary. In addition, IHS’s ability to pay for services
outside of its system is limited. IHS receives annual appropriations for its purchased referred care
program (PRC),133 which enables the agency to pay for outside services. PRC funds are limited
and may not be available later in any given fiscal year. IHS reports that it denied or deferred
169,953 services in FY2021 because of these funding limitations.134 Moreover, only a subset of
the IHS population is eligible for PRC, as eligibility is restricted to IHS-eligible individuals who
live in certain geographic areas. PRC funds are authorized only for services in instances when the
PRC-eligible individual does not have an alternate resource (e.g., Medicaid).
PRC will pay for services, to the extent that funds are available, based on medical priorities
ranging from priority one (services necessary to save life, limb, or sense, which are almost always
paid) to priority five (services considered elective or experimental).135 Reproductive health
services are generally included in levels one and two. Priority level one includes services that are
emergency and acute, including maternity services such as delivery and acute prenatal care.
Routine prenatal care and screening services, such as mammograms or HIV testing, are included
in priority level two, which encompasses preventive care services. IVF and gender-affirming
surgery are listed as examples of priority level five—excluded services that are not paid for by
PRC. PRC programs are managed locally, and these local programs determine what priority level
will be paid and may add or remove services within specific priority levels. In FY2021, IHS-
operated PRC programs were able to pay for priority level one and 94% of priority level two
services.136
Does IHS Provide Contraceptives?
As mentioned, IHS does not have a standard medical benefit package, so services provided vary
by facility. Most facilities offer pharmaceutical services that include contraception. IHS uses a
National Core Formulary, which individual facilities can supplement with additional drugs
depending on facility needs. The formulary includes oral contraceptives, IUDs, and implants.137
As with other IHS services, pharmaceuticals are provided to eligible American Indians and
Alaska Natives free of charge.
IHS provides EC (Plan B One-Step [Levonorgestrel]) through its pharmacies, emergency
departments, and health clinics. The June 2013 FDA approval of Plan B One-Step as an over-the-
counter drug presented a challenge for IHS, because the agency generally does not dispense drugs
without a provider order.138 This issue was resolved in October 2015, when IHS amended its

133 HHS, IHS, “Purchased Referred Care,” https://www.ihs.gov/prc/. In FY2022, the program received an appropriation
of $984.8 million in P.L. 117-103.
134 HHS, IHS, Fiscal Year 2023 Indian Health Service Justification of Estimates, https://www.ihs.gov/sites/
budgetformulation/themes/responsive2017/display_objects/documents/FY2023BudgetJustificaton.pdf, p. 127.
135 For more information, see HHS, IHS, “Purchased Referred Care, Requirements: Priorities of Care,”
https://www.ihs.gov/prc/eligibility/requirements-priorities-of-care/.
136 HHS, IHS, Fiscal Year 2023 Indian Health Service Justification of Estimates, https://www.ihs.gov/sites/
budgetformulation/themes/responsive2017/display_objects/documents/FY2023BudgetJustificaton.pdf, pp. 127- 128.
137 HHS, IHS, “National Core Formulary,” https://www.ihs.gov/nptc/formularysearch/.
138 See, for example, Mary Annette Pember, “Emergency Contraception Finally Available Through All IHS Facilities,”
Indian Country, October 19, 2015, http://indiancountrytodaymedianetwork.com/2015/10/19/emergency-contraception-
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internal policies to make EC available without a provider visit or a requirement that patients
register with the facility.139
IHS does provide sterilization services if requested, but it must follow HHS procedures when
doing so.140 This service permits only tubal ligation or vasectomy and prohibits the use of a
hysterectomy for purposes of sterilization. It also prohibits providing these procedures to anyone
under the age of 21 or anyone incapable of giving consent.141
Does IHS Provide Abortions or Abortion Counseling?
IHS is generally prohibited from using any of its appropriated funds to perform or pay for
abortion services.142 IHS funds may be used in cases where the mother’s life is endangered, or if
the pregnancy is the result of an act of rape or incest. IHS has developed and implemented
protocols for its physicians to determine and certify cases when an abortion may be paid for; the
pregnancy criteria described must be met to merit this circumstance.143 In addition, IHS will
provide health services necessary to terminate an ectopic pregnancy144—a pregnancy that occurs
outside the womb (uterus)—which is life-threatening to the mother.145
IHS policies do not discuss abortion counseling, thus it is unclear whether the agency will provide
such services. It is also unclear which of the tiered IHS PRC medical priority groups abortion
counseling would fit into if it were to be offered.
Does IHS Provide Infertility Services?
IHS provides some limited infertility services when obstetrician/gynecologist (OB/GYN)
specialists are available at an IHS facility. In addition, each IHS area or specific facility may
develop its own specific protocols. According to IHS’s program manual (the agency’s document
governing its care),
[t]he basic elements should be provided to women and men when requested and indicated,
including history and exam, basal temperature charting, semen analysis and post coital
testing, and serum progesterone assay. Endometrial biopsy, hysterosaipingography [sic]
and diagnostic laparoscopy should be made available in those facilities with OB/GYN
specialists on-site. Specific clinical protocols can be developed by consultation with
gynecological consultants within each Area/Program.146

finally-available-through-all-ihs-facilities-162134.
139 HHS, IHS, Indian Health Manual: Part 1- General, Chapter 15-Emergency Contraception,” https://www.ihs.gov/
IHM/index.cfm?module=dsp_ihm_pc_p1c15.
140 42 C.F.R. 50. 205 (b).
141 HHS, IHS, Indian Health Manual: Part 1- General, Chapter 13-Maternal and Child Health” https://www.ihs.gov/
IHM/pc/part-3/p3c13/#3-13.12F5.
142 25 U.S.C. §1676.
143 HHS, IHS, Indian Health Manual: Part 1- General, Chapter 13-Maternal and Child Health” https://www.ihs.gov/
IHM/index.cfm?module=dsp_ihm_pc_p3c13#3-13.14.
144 Ibid.
145 National Institutes of Health, National Library of Medicine, MedlinePlus Medical Encyclopedia,
http://www.nlm.nih.gov/medlineplus/encyclopedia.html.
146 HHS, IHS, Indian Health Manual: Part 1- General, Chapter 13-Maternal and Child Health” https://www.ihs.gov/
ihm/pc/part-3/p3c13/#3-13.12F4. A hysterosalpingography is a contrast X-ray of the uterus and fallopian tubes.
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IHS is limited in terms of payments for infertility services under PRC. As noted, IHS specifically
includes IVF under priority group five, which is an excluded service.147
Does IHS Provide Maternity Services?
IHS does not have a standard medical benefit that includes or excludes certain services, but some
facilities provide reproductive health services and maternity care services. The IHS system
includes 46 hospitals that offer inpatient care;148 however, specific data on the number of
hospitals performing deliveries are not available IHS has funded maternal health initiatives and
proposes to focus on improving maternal health in the FY2023 budget request to attempt to
address high levels of maternal mortality among its service population.149
IHS facilities that have access to obstetric services provide more comprehensive maternity
services. In instances where these services are not available at the facility, PRC will pay for
deliveries and acute prenatal care as a priority level one (emergency) service. Routine prenatal
care is considered a priority level two service. Such care is generally paid for, but it may be
subject to available funding.150
Does IHS Provide Reproductive Health Screening, Prevention, and Treatment
Services?

As noted above, the services available at IHS facilities vary, but some facilities may provide
reproductive screening, preventive services, and treatment for conditions identified within the
facility. Preventive screenings, such as mammography, may be paid for under PRC and are
considered to be priority level two (preventive services); however, treatment for an acute or
emergent condition (which may be identified during a screening) would be considered priority
level one.151 IHS also funds or operates programs to screen individuals at risk of HIV/AIDS and
to provide treatment services as necessary.152 These activities are coordinated through IHS’s
National HIV/AIDS Program, which coordinates the HIV/AIDS specific medical care delivered
throughout the IHS system and undertakes public health activities related to prevention and
testing.153 In 2019, President Trump announced the Ending the HIV Epidemic initiative for
FY2020.154 IHS requested funds to continue work on this initiative in FY2023.155 IHS was
included as part of the initiative because, between 2011 and 2016, rates of HIV diagnosis

147 For more information, see HHS, IHS, “Purchased Referred Care, Requirements: Priorities of Care,”
https://www.ihs.gov/prc/eligibility/requirements-priorities-of-care/.
148 HHS, IHS, Fiscal Year 2023 Indian Health Service Justification of Estimates, https://www.ihs.gov/sites/
budgetformulation/themes/responsive2017/display_objects/documents/FY2023BudgetJustificaton.pdf, p. 275.
149 Ibid., p. 272.
150 For more information, see HHS, IHS, “Purchased Referred Care, Requirements: Priorities of Care,”
https://www.ihs.gov/prc/eligibility/requirements-priorities-of-care/.
151 Ibid.
152 HHS, IHS, “HIV/AIDS,” https://www.ihs.gov/hivaids/.
153 Ibid.
154 HHS, Ending the HIV Epidemic: A Plan for America, Washington, DC, February 5, 2019, https://www.hiv.gov/
federal-response/ending-the-hiv-epidemic/overview, and Anthony S. Fauci et al., “Ending the HIV Epidemic: A Plan
for the United States,” JAMA, vol. 321, no. 9 (February 7, 2019), pp. 844-845.
155 HHS, IHS, Fiscal Year 2023 Indian Health Service Justification of Estimates, https://www.ihs.gov/sites/
budgetformulation/themes/responsive2017/display_objects/documents/FY2023BudgetJustificaton.pdf, p. 38.
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increased by 38% among the American Indian/Alaska Native population.156 As part of this
initiative, IHS added PrEP (i.e., Truvada) to its formulary and is focusing on increasing HIV
testing and linkages to care. IHS continues to work with its pharmacies to ensure access to
PrEP.157
Does IHS Provide Gender-Affirming Services?
IHS does not generally provide gender-affirming services. Likewise, PRC will not pay for
gender-affirming surgery. Specifically, IHS lists gender-affirming surgery as an example of
priority level five—excluded services not paid for by PRC. It is not clear whether IHS offers or
will pay for other types of gender-affirming services, either through PRC or within its system.
The U.S. Coast Guard (USCG)
The U.S. Coast Guard (USCG) delivers certain health benefits under Title 14, Chapter 5, and Title
10, Chapter 55, of the U.S. Code to members of the uniformed services, retirees, and their
families.158 USCG delivers a limited range of outpatient medical and dental care in fixed
outpatient health care facilities, ships, and certain deployed environments. Typical health care
services offered include primary care; occupational health; flight medicine; optometry; mental
health; physical therapy; dentistry; and basic laboratory, radiology, and pharmacy services.
Patients with medical needs exceeding a USCG clinic’s capabilities may be referred or medically
evacuated to a DOD MTF or civilian medical facility participating in TRICARE.159 USCG clinics
typically offer limited outpatient medical and dental care only.
Does USCG Provide Reproductive Health Services?
USCG clinics offer limited reproductive health services, often provided by primary care
providers.160 USCG clinics may refer beneficiaries to DOD MTFs (preferable option) or to a
TRICARE provider (secondary option) for comprehensive reproductive health services.161
Does USCG Provide Contraceptive Services?
USCG clinics offer limited contraceptive services, including family planning counseling and
contraception prescriptions.162 Contraceptive services not available in USCG clinics may be

156 NCHHSTP, CDC, HIV and American Indians and Alaska Natives, Atlanta, GA, March 2018, https://www.cdc.gov/
hiv/pdf/group/racialethnic/aian/cdc-hiv-natives.pdf, and IHS, “HIV in Indian Country,” https://www.ihs.gov/
newsroom/factsheets/hiv-in-indian-country/.
157 HHS, IHS, Fiscal Year 2023 Indian Health Service Justification of Estimates, https://www.ihs.gov/sites/
budgetformulation/themes/responsive2017/display_objects/documents/FY2023BudgetJustificaton.pdf, p. 45.
158 The term uniformed services includes the Armed Forces (Army, Navy, Air Force, Marine Corps, Space Force, and
Coast Guard), the commissioned corps of the Public Health Service, and the commissioned corps of the National
Oceanic and Atmospheric Administration.
159 For additional information about the TRICARE program, see the “Department of Defense (DOD)” section of this
report.
160 Email communication with U.S. Coast Guard (USCG) officials, April 2019.
161 Commandant Instruction M6000.1F, Coast Guard Medical Manual, June 2018, p. 110, https://media.defense.gov/
2018/Jul/05/2001939216/-1/-1/0/CIM_6000_1F.PDF. For more information on DOD reproductive health services, see
the “Does DOD Provide Reproductive Health Services?” section of this report.
162 Email communication with USCG officials, April 2019.
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accessed through the TRICARE program. Services available through USCG or through
TRICARE include the following:
 Short-Acting Reversible Contraceptives (SARCs): oral contraceptive, patch,
vaginal ring, injection.
 Long-Acting Reversible Contraceptives (LARCs): IUD, implantable rod.
 Barriers: diaphragm, cervical cap, sponge, male/female condom.
 Sterilization: male/female surgical sterilization, permanent implant.
 Emergency Contraceptives (ECs): Plan B One Step/ Next Choice One Dose,
Ella.163
Section 718 of the FY2016 NDAA (P.L. 114-92) requires the Secretary of Defense to make
annual (as well as pre- and intra-deployment) contraceptive counseling available to female
members of the Armed Forces (including USCG) through the TRICARE program. DOD policy
also requires USCG to offer contraceptive counseling during the annual periodic health
assessment and during accession training (i.e., boot camp or officer candidate school).164
Deployed servicemembers may also receive prescribed contraceptives (up to 180-day supply)
prior to their departure and while in-theater (90-day supply increments) when subscribed to the
DPP.165 In-theater military health care providers are authorized to issue new or renewal
prescriptions that would be filled through the DPP.
Does USCG Provide Abortions or Abortion Counseling?
USCG policy prohibits the use of government funds to provide or pay for abortion services,
except where the life of the mother would be endangered if the pregnancy were carried to term, or
in a case in which the pregnancy is the result of an act of rape or incest.166 USCG clinics are
authorized to provide counseling related to covered abortions.167
Similarly, Title 10, Section 1093, of the U.S. Code prohibits TRICARE from directly providing or
paying for abortion services, except where the life of the mother would be endangered if the
pregnancy were carried to term, or in a case in which the pregnancy is the result of an act of rape
or incest. TRICARE may offer or pay only for health care services related to a covered abortion.
Abortion counseling, referral, preparation, or follow-up care for noncovered abortions is not
available in MTFs or paid for by TRICARE.168

163 DOD offers counseling and contraception methods in accordance with Section 718 of NDAA for FY2016 (P.L. 114-
92) and CDC’s medical eligibility criteria and selected practice recommendations for contraceptive use. For more on
DOD’s contraception benefit, see DHA Procedural Instruction 6200.02, Comprehensive Contraceptive Counseling and
Access to the Full Range of Methods of Contraception
, May 13, 2019.
164 Ibid., p. 1. According to DOD policy, this requirement is applicable to USCG “by agreement” with DHS. The
periodic health assessment is an annual evaluation of a servicemember’s physical and mental health used to determine
deployability and military readiness status.
165 The DPP delivers prescription medications to deployed servicemembers via the military mail system (i.e., Army
Post Office, Fleet Post Office). DOD civil service employees and DOD contractors without other health insurance are
also eligible for DPP. For more information on the DPP, see https://tricare.mil/dpp.
166 USCG, Commandant Instruction 1000.9, “Pregnancy in the Coast Guard,” September 29, 2011,
https://media.defense.gov/2017/Mar/06/2001707433/-1/-1/0/CI_1000_9.PDF; and email communication with USCG
officials, April 2019.
167 Email communication with USCG officials, April 2019.
168 See Chapter 4, Section 18.3 of the TRICARE Policy Manual 6010.60-M, April 1, 2015.
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Does USCG Provide Infertility Services?
Certain USCG clinics offer initial infertility evaluations only.169 Other infertility services, such as
ART for certain servicemembers, are available at DOD MTFs or from civilian health care
providers participating in TRICARE.170
Does USCG Provide Maternity Services?
Certain USCG clinics offer outpatient maternity services, including prenatal care and maternal-
fetal medicine.171 Other maternity services are available at DOD MTFs or from civilian health
care providers participating in TRICARE.172
Does USCG Provide Reproductive Health Screening, Prevention, and
Treatment Services?

USCG clinics offer limited reproductive health screening and preventive services, including well-
woman exams, as well as counseling and testing for STIs and cancer of the breast, cervix,
testicles, or prostate.173 Comprehensive reproductive health services and related treatment are
available at DOD MTFs or from civilian health care providers participating in TRICARE.174
Does USCG Provide Gender-Affirming Services?
Certain USCG clinics offer medically necessary nonsurgical treatment (i.e., hormone therapy,
pubertal suppression, or psychotherapy) for gender dysphoria.175 USCG servicemembers
diagnosed with gender dysphoria may access surgical treatment based on DOD policies and
processes for considering and approving SRS.
Department of Veterans Affairs (VA)
The VA provides health care services through the Veterans Health Administration (VHA) for
approximately 9.3 million enrolled veterans176 at 1,456 VA sites of care.177 The VHA is primarily

169 Ibid.
170 For more information on DOD infertility services, see the “Does DOD Provide Infertility Services?” section of this
report.
171 Ibid. Maternal-fetal medicine refers to the obstetric subspecialty focusing on high-risk pregnancy and related
medical complications.
172 For more on DOD maternity services, see the “Does DOD Provide Maternity Services?” section of this report.
173 Commandant Instruction M6000.1F, Coast Guard Medical Manual, June 2018, pp. 110 and 145; and email
communication with USCG officials, April 2019.
174 For more on DOD reproductive health services, see the “Does DOD Provide Reproductive Health Screening,
Prevention, and Treatment Services?”
section of this report.
175 Email communication with USCG officials, April 2019.
176 Department of Veterans Affairs (VA), FY2021 Congressional Submission, Medical Programs and Information
Technology Programs
, vol. 2 of 4, February 2020, p. VHA-19.
177 VA, FY2021 Congressional Submission, Budget in Brief, February 2020, p. BiB-11. Sites of care used in this
calculation are VA hospitals, community living centers, health care centers, community-based outpatient clinics
(CBOCs), other outpatient service sites, and dialysis centers.
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a direct provider of care; it owns the facilities and employs the clinicians. However, under certain
circumstances, the VA will pay for a veteran to receive care in the community.178
Not all veterans qualify for enrollment in the VA health care system. Enrollment is based
primarily on veteran status (i.e., previous military service), service-connected disability, and
income.179 All enrolled veterans are eligible for a standard medical package, which includes a full
range of health care, gender-specific medical services, prescription drugs, long-term care, and
social support services.180
Does the VA Provide Reproductive Health Services?
The VA standard medical benefits package includes reproductive health services, such as routine
physical exams, cervical and prostate cancer screening, evaluation and treatment of vaginal
infections, pelvic pain and abnormal uterine bleeding, treatment of erectile dysfunction,
reproductive mental health, and STI screening, among other services, to eligible veterans who are
enrolled in the VA’s health care system.181
Does the VA Provide Contraceptive Services?
The VA provides both contraception counseling and contraceptives as part of the standard medical
benefits package. The VA uses a national formulary for medications.182 The formulary includes
oral contraceptives, IUDs, and implants.183 VA health care maintains a tiered structure for
copayments for medication, which is dependent on each veteran’s enrollment status. Some
veterans are subject to copayments for medication, whereas some receive medication free of
charge.184
The VA provides EC (e.g., Plan B One Step [Levonorgestrel]). VA policy requires that EC be
made available to patients on the same day as their appointment, even in cases where the provider
requested to opt out from providing EC due to right-of-conscience claims.185
The VA provides sterilization services (e.g., salpingectomy, tubal occlusion procedures, and
vasectomy) as part of the medical benefits package. All surgeons performing sterilization
procedures must ensure that the patient is aware of the risks and benefits of the procedure,
including the potential for regret, the chances of failure, the permanence of the sterilization

178 Under certain circumstances, the VA is authorized to pay for primary and specialty care under the Veterans
Community Care Program (38 U.S.C. §1703 and 38 C.F.R. §17.4000), for emergent care (38 U.S.C. §1725 and §1728),
for urgent care (38 U.S.C. §1725A), and health care abroad (38 U.S.C. §1724), among others.
179 For more information on veterans health care eligibility and enrollment, see CRS Report R42747, Health Care for
Veterans: Answers to Frequently Asked Questions
.
180 38 C.F.R. §17.38.
181 VA, Veterans Health Administration (VHA), Women’s Health Services, State of Reproductive Health In Women
Veterans-VA Reproductive Health Diagnoses and Organization of Care
, February 2014, p. 30.
182 VA, VHA, VHA Formulary Management Process, VHA Directive 1108.08(1), November 2016.
183 VA, “Pharmacy Benefits Management Services, VA Formulary Search,” https://www.pbm.va.gov/apps/
VANationalFormulary/.
184 For more information on copayments for medication, see CRS Report R42747, Health Care for Veterans: Answers
to Frequently Asked Questions
.
185 VA, VHA, Healthcare Services for Women Veterans, VHA Handbook 1330.01(3), February 2017.
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procedure, and the availability of reversible, highly effective contraceptives (e.g., IUD and
subcutaneous contraceptive implants).186
Does the VA Provide Abortions or Abortion Counseling?
Under current regulations, the VA does not provide abortions, abortion counseling, or medication
to induce an abortion (e.g., mifepristone, also known as RU-486).187
Does the VA Provide Infertility Services?
The VA does provide certain infertility services to veterans. Covered infertility services for both
female and male veterans are listed in Table 3. These covered services are provided to all
enrolled veterans without exception. The VA is not authorized to provide or cover the cost of IVF
or other ART. A narrow exception to this policy allows the VA to provide IVF services to veterans
and their spouses if a service-connected disability results in the inability of the veteran to
procreate without the treatment.188 This exception is authorized on an annual basis through
appropriations acts.189 Such services and benefits may be provided in a manner similar to those
described in a memorandum issued by the Assistant Secretary of Defense for Health Affairs,190
along with guidance issued by DOD. The VA is exempt from DOD requirements applicable to the
duration of embryo cryopreservation and storage.191 Namely, the VA may provide
cryopreservation and storage for an unlimited amount of time.192 The VA is not authorized to
cover gestational surrogacy treatment or costs associated with sperm or oocyte donation.193
Table 3. Infertility Services Offered by the VA
Diagnosis and Treatment for Female Veterans
Diagnosis and Treatment for Male Veterans
Diagnostic Tests:
Diagnostic Tests:

186 VA, VHA, Infertility Evaluation and Treatment, VHA Directive 1332, June 2017.
187 38 C.F.R. §17.38; and VA, VHA, Health Care Services for Women Veterans, VHA Directive 1330.01(2), February
15, 2017. Medically necessary procedures for the management of a miscarriage are provided under the medical benefits
package.
188 38 C.F.R. §17.380.
189 This policy has been authorized in appropriations acts since FY2017. Section 260 of the Continuing Appropriations
and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and the Zika Response
and Preparedness Act (P.L. 114-223) permitted the VA to use funds from the Medical Services account for this purpose
for FY2017. Section 236 of Division J of the Military Construction, Veterans Affairs, and Related Agencies
Appropriations Act, 2018 (P.L. 115-141) continued this policy for FY2018 and FY2019. Section 235 of the Energy and
Water, Legislative Branch, and Military Construction and Veterans Affairs Appropriations Act, 2019 (P.L. 115-244)
continued this policy for FY2019 and FY2020. Section 235 of the Military Construction, Veterans Affairs, and Related
Agencies Appropriations Act, 2020 (Division F of the Further Consolidated Appropriations Act, 2020; P.L. 116-94)
allows the VHA to use FY2020 appropriations and FY2021 advance appropriations to continue providing IVF services
to certain veterans and their spouses; Section 234 of Division J of the Consolidated Appropriations Act, 2021 (P.L.
116-260) continued allowing the use of FY2021 appropriations and FY2022 advance appropriations for this purpose.
Section 234 of Division J of the Consolidated Appropriations Act, 2022 (P.L. 117-103), continued allowing the use of
FY2022 appropriations and FY2023 advance appropriations for this purpose.
190 DOD, Office of the Assistant Secretary of Defense for Health Affairs, “Policy for Assisted Reproductive Services
for the Benefit of Seriously or Severely Ill/Injured (Category II or III) Active Duty Service Members,” dated April 3,
2012.
191 VA, “Final Rule-Fertility Counseling and Treatment for Certain Veterans and Spouses,” 84 Federal Register 8254-
8257, March 7, 2019.
192 38 C.F.R. §17.380(b).
193 VA, VHA, Infertility Evaluation and Treatment, VHA Directive 1332(2), June 2017.
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Diagnosis and Treatment for Female Veterans
Diagnosis and Treatment for Male Veterans

Laboratory blood testing: fol icle stimulating

Laboratory blood testing: serum testosterone, FSH,
hormone (FSH); thyroid stimulating hormone (TSH)
luteinizing hormone (LH), estradiol

Genetic counseling and testing

Semen analysis

Pelvic and/or transvaginal ultrasound

Genetic counseling and testing

Hysterosalpingogram

Transrectal and/or scrotal ultrasonography

Saline-infused sonohysterogram

Postejaculatory urinalysis
Treatments:
Treatments:

Surgical correction of structural pathology

Evaluation and treatment of erectile dysfunction

Reversal of tubal ligation

Surgical correction of structural pathology

Intrauterine insemination (IUI)

Vasectomy reversal

Medication for ovulation induction (e.g., clomiphene) 
Hormonal therapies (e.g., clomiphene citrate, human

Injectable gonadotropin medications
chorionic gonadotropin, phosphodiesterase type 5

medications, testosterone)

Hormonal therapies (e.g., control ed ovarian
hyperstimulation)

Sperm retrieval techniques

Additional hormonal therapies as approved by VA

Sperm cryopreservation for medically indicated
Pharmacy Benefits Management
conditions

Oocyte cryopreservation for medically indicated

Ejaculation techniques (e.g., electroejaculation,
conditions
vibratory stimulation)
Source: Prepared by CRS based on U.S. Department of Veterans Affairs, Veterans Health Administration,
Infertility Evaluation and Treatment
, VHA Directive 1332(2), June 2017.
Notes: This table, including terminology, is adapted directly from VHA Directive 1332(2). The use of gender-
specific terminology to refer to available infertility services corresponds to how the services are represented in
the directive.
Does the VA Provide Maternity Services?
The VA currently provides and pays for a limited number of maternity and newborn health care
services to eligible veterans and their family members.194 Veterans can access maternity care as
soon as their pregnancies are confirmed. However, VA medical facilities do not operate full-
service birthing centers with medical units such as maternity wards, newborn nurseries, and
neonatal intensive care units. The VA does not have specialized health care providers or
functioning birth-related medical units in VA medical facilities to deliver babies on a continual
basis.195 Veterans must therefore deliver babies at non-VA medical facilities, such as DOD
medical facilities and community hospitals. The VA may perform emergency childbirth
deliveries.
The VA is authorized to provide certain health care services to a newborn child of a veteran
receiving maternity care furnished by the VA. Health care for the newborn is authorized for a
maximum of seven days after the birth of the child if the veteran delivered the child in a VA
facility or in another facility pursuant to a VA contract for maternity services.196

194 VA, VHA, Maternity Health Care and Coordination, VHA Handbook 1330.03, November 2020.
195 VA, VHA, Women’s Health Services, State of Reproductive Health In Women Veterans-VA Reproductive Health
Diagnoses and Organization of Care
, February 2014, p. 39.
196 38 U.S.C. §1786.
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Does the VA Provide Reproductive Health Screening, Prevention, and
Treatment Services?

The VA provides reproductive health screening and preventive services as part of the standard
medical benefits package. Preventive screenings, such as mammography, are offered as part of
routine health care. The VA also operates a national HIV program with policies for screening,
prevention, and treatment.197 It is VA policy that all veterans receiving care through the VA are
tested for HIV at least once as part of their routine care. More frequent testing is available for
veterans who are at higher risk of contracting HIV. The VA follows CDC guidance regarding the
use of PrEP, and it is a covered benefit for veterans enrolled in the VA health care system. All
FDA-approved medications for PrEP must be readily available at all VA medical facilities, and
such medications must be offered routinely as part of a comprehensive risk-reduction program for
veterans who are considered to be at an increased risk for HIV infection.
In addition, the VA provides medically necessary reproductive health treatment services as part of
the standard medical benefits package. With limited exceptions (e.g., abortions and certain IVF
discussed in previous sections), the VA will provide care to individuals if the appropriate health
care professionals determine that the care is needed to promote, preserve, or restore the health of
the individual and is in accord with generally accepted standards of medical practice.198
Does the VA Provide Gender-Affirming Services?
Under current regulations, the VA is prohibited from providing gender-confirming/affirming
surgeries.199 The VA provides other gender-affirming services as part of the standard medical
benefits package, such as hormonal therapy, mental health care, and preoperative evaluation. In
addition, the VA provides medically necessary postoperative and long-term care following
gender-confirming surgeries if an appropriate health care professional determines that the care is
needed to promote, preserve, or restore the health of the individual and is in accord with generally
accepted standards of medical practice.200
Federal Health Insurance Programs
The Social Security Act (SSA) defines a federal health care program as any plan or program that
provides health benefits—whether directly, through insurance, or otherwise—and is funded
directly, in whole, or in part by the U.S. government (with the exception of the Federal
Employees Health Benefits Program) or one of four specified state health care programs.201
Medicaid, the federal-state program for certain low-income individuals, and Medicare, the
national health insurance program that pays for covered services furnished to beneficiaries
(generally the elderly and disabled) are among the key federal health programs. The questions

197 VA, VHA, National Human Immunodeficiency Virus Program, VHA Directive 1304, August 2019.
198 38 C.F.R. §17.38(b).
199 38 C.F.R. §17.38(c)(4). On May 9, 2016, the VA received a petition for rulemaking to remove the exclusion for
gender alterations. The VA sought comments regarding such removal in 2018. No action has been taken since. VA,
“Exclusion of Gender Alterations From the Medical Benefits Package,” 83 Federal Register 31711, July 9, 2018.
200 VA, VHA, Providing Health Care for Transgender and Intersex Veterans, VHA Directive 1341(2), February 2018.
201 Social Security Act (SSA) §1128B(f) [42 U.S.C. §1320a–7b]. The four state health care programs are Medicaid
(SSA title XIX), Maternal and Child Health Services Block Grand (SSA title V), Block Grants and Programs for Social
Services (SSA title XX).
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below discuss how these federal health care programs provide, establish coverage, and pay for
reproductive health services for their beneficiaries.
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 low-
income population, including eligible children, pregnant women, adults, individuals with
disabilities, and people aged 65 and older.202 Participation in Medicaid is voluntary for states; all
states, the District of Columbia, and 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
FY2019, Medicaid provided health care services to an estimated 75 million individuals203 at a
total cost of $627 billion (including federal and state expenditures).204
Medicaid provides a health care safety net for low-income populations, playing a more significant
role for certain subpopulations.205 For example, in 2019 approximately 20% of the U.S.
population received Medicaid coverage.206 In that same year, Medicaid provided health coverage
for 58% of all nonelderly individuals with incomes below 100% of the federal poverty level
(FPL).207
For some types of services (including reproductive health services), Medicaid is a significant
payer. For instance, Medicaid paid for 42% of all births in the United States in 2019208 and
provided 75% of all public expenditures on family planning services in FY2015.209

202 For more information about the Medicaid program, see CRS Report R43357, Medicaid: An Overview.
203 This enrollment figure is measured according to person-year equivalents, which represent the average program
enrollment over the course of a year and differ from ever-enrolled counts, which measure the number of people covered
by Medicaid for any period of time during the year. (Christopher J. Truffer, Kathryn E. Rennie, Lindsey Wilson, et al.,
2018 Actuarial Report on the Financial Outlook for Medicaid, Office of the Actuary, Centers for Medicare & Medicaid
Services [CMS], HHS, 2020, at https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/
ActuarialStudies/MedicaidReport.)
204 CMS, Form CMS-64 data as of September 15, 2020, at https://www.medicaid.gov/medicaid/financial-management/
state-expenditure-reporting-for-medicaid-chip/expenditure-reports-mbescbes/index.html.
205 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.
206 U.S. Census Bureau, American Community Survey Tables for Health Insurance Coverage, Table HI-05, Health
Insurance Coverage Status and Type of Coverage by State and Age for All People: 2019
, at https://www.census.gov/
data/tables/time-series/demo/health-insurance/acs-hi.html.
207 Henry J. Kaiser Family Foundation, Health Insurance Coverage of the Nonelderly (0-64) with Incomes below 100%
Federal Poverty Level (FPL), as of 2019
, State Health Facts, accessed November 4, 2020, at
https://www.officeforado.org/other/state-indicator/nonelderly-up-to-100-fpl/.
208 Joyce A. Martin, Brady E. Hamilton, Michelle Osterman, et al., Births: Final Data for 2019, National Center for
Health Statistics (NCHS), National Vital Statistics Reports, vol. 70, no. 2, Hyattsville, MD, March 23, 2021, at
https://dx.doi.org/10.15620/cdc:100472.
209 Guttmacher Institute, Publicly Supported Family Planning Services in the United States, October 2019, at
https://www.guttmacher.org/sites/default/files/factsheet/publicly-supported-fp-services-us.pdf.
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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).210 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 woman who are entitled to limited pregnancy-related services, and
women needing treatment for breast or cervical cancer). In addition, states can use waiver
authority211 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 services212 for
all categorically needy individuals.213 In addition, states may provide optional services—that is,
services that states can choose whether to provide under their state plans.214 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.

210 SSA §1937 [42 U.S.C. §1396u-7].
211 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).
212 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.
213 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.
214 SSA §1905(a)(6)-(16), (18)-(20), (22)-(27) [42 U.S.C. §§1396d(a)(6)-(16), (18)-(20), (22)-(27)]; 42 C.F.R.
§440.225.
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Within the general Medicaid service categories listed in statute, states define the specific features
of each covered benefit within four broad federal guidelines.215 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,
 breast feeding 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,216 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.217

215 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.
216 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.
217 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://brightfutures.aap.org/materials-
and-tools/guidelines-and-pocket-guide/Pages/default.aspx.
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Alternative Benefit Plans (ABPs)
As an alternative to providing the mandatory and selected optional benefits under traditional
Medicaid, states can enroll specified groups in ABPs. However, states that choose to implement
the Patient Protection and Affordable Care Act (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).218
Under ABPs, states must provide comprehensive benefit coverage that is based on one of three
commercial insurance products: (1) the standard Blue Cross/Blue Shield preferred provider
option service plan offered through the Federal Employees Health Benefit Program-equivalent
health insurance coverage; (2) the commercial health maintenance organization with the largest
insured commercial, non-Medicaid enrollment in the state; (3) the health benefits plan offered to
state employees). A fourth, “Secretary-approved,” coverage option is available instead of a list of
discrete items and services, as required under traditional Medicaid.219
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 benefit220
and family planning services and supplies for individuals of childbearing age.221 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).222 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.223 (Information on Medicaid coverage of
specific types of reproductive health services appears below.)

218 For more information, see CRS In Focus IF10399, Overview of the ACA Medicaid Expansion.
219 For more information, see CRS Report R45412, Medicaid Alternative Benefit Plan Coverage: Frequently Asked
Questions
.
220 SSA §1937(a)(1)(A)(ii) [42 U.S.C. §1396u-7(a)(1)(A)(ii)].
221 SSA §1937(b)(7) [42 U.S.C. §1396u-7(b)(7)]; 42 C.F.R. §440.345(b).
222 Federal requirements related to the EHBs generally apply to certain private health insurance plans. The 10
categories of EHB are (1) ambulatory patient services, (2) emergency services, (3) hospitalization, (4) maternity and
newborn care, (5) mental health and substance use disorder services (including behavioral health treatment), (6)
prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and
wellness services and chronic disease management, and (10) pediatric services, including oral and vision care. For
more information about private health insurance EHB requirements, see the “Does Federal Law Require Private Health
Insurance Coverage of Reproductive Health Services?”
section of this report. For Medicaid ABP requirements
regarding the EHBs, see SSA §1937(b)(5) [42 U.S.C. §1396u-7(b)(5)]; 42 C.F.R. §440.347.
223 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,
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Under ABPs, states are permitted to waive the statewideness and comparability requirements that
apply to traditional Medicaid benefits. This flexibility allows states to define the populations
served and the specific benefit packages that apply. 224 States can even 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 text box in “What Are Contraceptive Services?”), as
prescribed, to meet the EHB preventive services requirement.225 (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 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, for example, Minnesota covers
doulas under Medicaid’s traditional mandatory pregnancy-related services category, while
Oregon covers them under Medicaid’s traditional optional preventive services category.226
Nebraska, by contrast, covers doula services for certain enrollees as a value-added service (i.e.,
services that are not a plan benefit but are included as a part of a benefit package as an incentive

Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and
Enrollment; Final Rule,” Federal Register 901, 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/
preventive-care-benefits/.
224 SSA §1937(a)(1) [42 U.S.C. §1396u-7(a)(1)].
225 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.
226 A doula is a trained nonmedical professional whose job it is to provide physical, emotional and informational
support to a mother before, during and after childbirth. See DONA International, “What is a Doula,”
https://www.dona.org/what-is-a-doula/.
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for enrollment in the managed-care plan)227 under one of the state’s managed-care contracts.228 In
each of these 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.229 Medicaid beneficiaries access
reproductive health services in various types of facilities, including freestanding birth centers,
federally qualified health centers, family planning clinics, health departments, certain school-
based health centers, and other clinics.230
In general, under Medicaid’s “freedom of choice of provider” requirement, states must permit
enrollees to receive services from any willing Medicaid-participating provider,231 and states
cannot exclude providers solely on the basis of the range of services they provide.232 However,
this federal requirement is currently being challenged in the courts.233 Medicaid managed-care
enrollees may be restricted to providers in a given managed-care plan network,234 except in the
case of family planning services.235 Medicaid enrollees (regardless of whether they receive
services through the managed care delivery system or not) may obtain family planning services

227 Taylor Platt and Neva Kaye, Four State Strategies to Employ Doulas to Improve Maternal Health and Birth
Outcomes in Medicaid
, National Academy for State Health Policy (NASHP), July 30, 2020, at https://www.nashp.org/
four-state-strategies-to-employ-doulas-to-improve-maternal-health-and-birth-outcomes-in-medicaid/#toggle-id-1.
228 Under managed care, Medicaid enrollees get most or all of their services through a managed-care organization under
contract with the state.
229 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.
230 A 2013 survey found that, among Medicaid-enrolled women aged 15-44 who had their most recent gynecological
exam in the past three years, 57% received the service in a private physician’s office or health maintenance
organization setting; 13%, in a community health center or public clinic; 5%, in a family planning or Planned
Parenthood clinic; and 5%, in a school or college-based or urgent care/walk-in facility. The rest received the
gynecological exam in other places or did not answer the question. See Alina Salganicoff, Usha Ranji, Adara
Beamesderfer, et al., Women and Health Care in the Early Years of the ACA: Key Findings from the 2013 Kaiser
Women’s Health Survey
, Kaiser Family Foundation, Washington, DC, May 2014, at https://www.kff.org/wp-content/
uploads/2014/05/8590-women-and-health-care-in-the-early-years-of-the-affordable-care-act.pdf. See also Kaiser
Family Foundation, Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s
Health Survey
, March 2018, at https://www.kff.org/womens-health-policy/issue-brief/womens-sexual-and-
reproductive-health-services-key-findings-from-the-2017-kaiser-womens-health-survey/.
231 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.
232 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.
233 SCOTUSblog, Pending Petition in Kerr v. Planned Parenthood South Atlantic, at https://www.scotusblog.com/case-
files/cases/kerr-v-planned-parenthood-south-atlantic.
234 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.
235 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.
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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.236
Does Medicaid Cover Contraceptive Services?
States are required237 to provide family planning services and supplies to prevent or delay
pregnancy under both traditional and ABP benefit coverage for most individuals238 of
childbearing age (including minors) who desire such services and supplies.239 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.240 Family planning services
and supplies must be available to Medicaid enrollees without undue burden, coercion, or mental
pressure.241 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.242 States may pay for sterilization
services only if certain specified conditions are met.243 In addition, Medicaid beneficiaries must
be free to choose the provider of their choice and the method of family planning to be used.244
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.245 Specifically, states may receive a 90% FMAP rate for

236 42 C.F.R. §431.51.
237 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.)
238 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.
239 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.
240 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).
241 SSA §1905(a)(4)(C) [42 U.S.C. §1396d(a)(4)(C)]; 42 C.F.R. §441.20.
242 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.
243 42 C.F.R. §§441.253-441.256.
244 SSA §1902(a)(23) [42 U.S.C. §1396a(a)(23)]; 42 C.F.R. §441.20, and 42 C.F.R. §431.51.
245 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
, The Henry J. Kaiser Family Foundation, February 17, 2022, at https://www.kff.org/womens-health-
policy/report/medicaid-coverage-of-family-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-policy-guidance/downloads/sho16008.pdf.
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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
conception, and infertility services, including sterilizations and sterilization reversals),246 and for
related administrative costs.247 By contrast, family planning-related services are reimbursable at
the state’s regular FMAP rate.248 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.249 (Family planning-related services are discussed in more detail in the “Does Medicaid
Cover Reproductive Health Screening and Preventive Services?”
section of this report.)
The specific benefits that states offer under the family planning service category vary. For
Medicaid enrollees who receive traditional state plan coverage, states may identify the specific
services and supplies they cover (including EC),250 as long as the services meet basic federal
requirements (e.g., they are determined by CMS to be sufficient in amount, duration, and scope to
reasonably achieve their purpose,251 and beneficiaries are permitted to choose which family
planning method to use). States generally cover a broad range of medically approved methods,
procedures (e.g., sterilization), and devices to prevent conception under traditional Medicaid,
including over-the-counter contraceptive methods (e.g., male/female condoms, spermicide, the
sponge, EC) and prescription contraceptives (e.g., oral contraceptives, LARCs, patch, diaphragm,
injectable, IUDs).252
Prescription drugs are considered an optional Medicaid service, but all states cover them. State
coverage of various FDA-approved prescription contraceptives under traditional Medicaid is
generally established through national drug rebate agreements between drug manufacturers and
the HHS Secretary under the Medicaid Drug Rebate program.253 States are permitted to rely on

246 SSA §1903(a)(5) [42 U.S.C. §1396b(a)(5)]; CMS, State Medicaid Manual §4270.B.1 at https://www.cms.gov/
regulations-and-guidance/guidance/manuals/paper-based-manuals-items/cms021927.
247 42 C.F.R. §433.15(b)(2).
248 For FY2022, states’ regular FMAP rates range from 50.00% to 78.31%, depending on the state’s per capita income.
FMAPs may also vary by population (e.g., services to some persons newly eligible under the ACA Medicaid expansion
are reimbursed at a 90% FMAP rate for 2020 and subsequent years). See CRS Report R43847, Medicaid’s Federal
Medical Assistance Percentage (FMAP)
.
249 CMS, “Re: Family Planning Services Option and New Benefit Rules for Benchmark Plans,” SHO Letter,
SMDL#10-013 ACA# 4, July 2, 2010, at http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/
SMD10013.pdf, and HHS, CMS “Re: Family Planning and Family Planning Related Services Clarification,” SHO
Letter, SMDL#14-003 ACA# 31, April 16, 2014, at https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/
SMD-14-003.pdf.
250 For more information on state coverage of emergency contraception (EC) as of July 1, 2021, see Usha Ranji, Ivette
Gomez, Alina Salganicoff, et al., Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State Survey,
The Henry J. Kaiser Family Foundation, February 17, 2022, at https://www.kff.org/womens-health-policy/report/
medicaid-coverage-of-family-planning-benefits-findings-from-a-2021-state-survey/.
251 CMS, State Medicaid Manual §4270.B.1, at https://www.cms.gov/regulations-and-guidance/guidance/manuals/
paper-based-manuals-items/cms021927.
252 For more on the range of family planning benefits covered by states under traditional Medicaid, see Usha Ranji,
Ivette Gomez, Alina Salganicoff, et al., Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State
Survey
, The Henry J. Kaiser Family Foundation, February 17, 2022, at https://www.kff.org/womens-health-policy/
report/medicaid-coverage-of-family-planning-benefits-findings-from-a-2021-state-survey/.
253 Drug manufacturers enter into national rebate agreements with the HHS Secretary under the Medicaid Drug Rebate
Program. The program requires a drug manufacturer to enter into, and have in effect, a national rebate agreement with
the HHS Secretary to rebate a portion of the Medicaid payment for the drug to the states based on a statutory formula.
States then share the rebate they receive from pharmaceutical manufacturers with the federal government as a way to
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utilization controls, such as preferred drug lists and prior authorization, to encourage providers to
prescribe certain drugs over others. However, in general, Medicaid covers most FDA-approved
drugs produced by manufacturers that enter into rebate agreements with HHS, which results in
enrollee access to a wide range of prescription drugs.254
For Medicaid enrollees who receive ABP coverage, states must cover family planning services
and supplies that meet EHB preventive services requirements, including coverage of at least one
form of contraception within each of the contraceptive methods, as prescribed, approved by FDA
(see text box in “What Are Contraceptive Services?”),255 and all of the services recommended by
the USPSTF (e.g., counseling on STIs and HIV and screening for breast and cervical cancers).
(See the USPSTF text box in the “What Are Reproductive Health Prevention and Treatment
Services?”
section)256 In addition, states may provide targeted family planning services under
Medicaid for populations who are not otherwise eligible for traditional Medicaid (e.g.,
nonpregnant, nondisabled childless adults) through special waivers of federal law (i.e., Section
1115 family planning waivers).257 States have discretion to determine the populations and benefits
covered under Section 1115 family planning waivers. However, such coverage is time-limited and
must be budget-neutral to the federal government, whereby the estimated federal spending under
the waiver cannot exceed the estimated federal cost of the state’s Medicaid program without the
waiver.
The ACA established an optional Medicaid eligibility group for family planning services so that
states no longer have to rely on time-limited waiver authority to extend limited benefit coverage
for family planning services and supplies to targeted eligibility groups (including groups who
were not traditionally eligible for Medicaid).258 The ACA family planning eligibility group
includes individuals (men and women) (1) who are not pregnant and (2) whose income does not
exceed the highest income eligibility level established by the state for pregnant women.259

offset the costs of prescription drugs under the Medicaid program in exchange for state Medicaid coverage of most of
the manufacturer’s drugs. For more information, see CRS Report R43778, Medicaid Prescription Drug Pricing and
Policy
.
254 Rachel Dolan, Understanding the Medicaid Prescription Drug Rebate Program, Kaiser Family Foundation, Issue
Brief, November 2019, at http://files.kff.org/attachment/Issue-Brief-Understanding-the-Medicaid-Prescription-Drug-
Rebate-Program.
255 For more information, see CMS, “RE: Family Planning and Family Planning Related Services Clarification,” State
Medicaid Directors Letter (SMDL), SMDL#14-003 ACA# 31, April 16, 2014, at https://www.medicaid.gov/Federal-
Policy-Guidance/Downloads/SMD-14-003.pdf. See also CMS, “Re: Medicaid Family Planning Services and Supplies,”
SHO letter, SHO # 16-008, June 14, 2016, at https://www.medicaid.gov/federal-policy-guidance/downloads/
sho16008.pdf.
256 For more on the range of family planning benefits covered by states under Medicaid ABPs, see Usha Ranji, Ivette
Gomez, Alina Salganicoff, et al., Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State Survey,
The Henry J. Kaiser Family Foundation, February 17, 2022, at https://www.kff.org/womens-health-policy/report/
medicaid-coverage-of-family-planning-benefits-findings-from-a-2021-state-survey/.
257 Section 1115 targeted family planning waivers may offer a limited set of services (i.e., family planning services and
supplies and related services) to a specific population identified in the waiver special terms and conditions. These
individuals may not be eligible for full Medicaid state plan services. As of September 1, 2020, nine states have CMS
approval for Medicaid Section 1115 family planning waivers. For more information, see, Kaiser Family Foundation,
State Health Facts, “States That Have Expanded Eligibility for Coverage of Family Planning Services Under
Medicaid,” at https://www.kff.org/medicaid/state-indicator/family-planning-services-waivers/.
258 As of September 1, 2021, 17 states have CMS approval for Medicaid family planning state plan amendments. For
more information, see Kaiser Family Foundation, State Health Facts, “States That Have Expanded Eligibility for
Coverage of Family Planning Services Under Medicaid,” at https://www.kff.org/medicaid/state-indicator/family-
planning-services-waivers/.
259 SSA §1902(a)(10) in subdivision (XVI) after (G) [42 U.S.C. §1396a(a)(10) in subdivision (XVI) after (G)].
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Benefits for this eligibility group are limited to family planning services and supplies and related
medical diagnosis and treatment services.260 Unlike Section 1115 family planning demonstration
waivers, family planning coverage under the state plan authority is not time-limited or subject to
budget neutrality.
Comparing family planning coverage across the various types of Medicaid benefit coverage (i.e.,
traditional Medicaid, ABP coverage, Section 1115 family planning waivers, or the optional ACA
family planning eligibility group) reveals a key difference: under ABPs, states must comply with
the EHB preventive service requirements that establish a federal coverage floor of FDA-approved
contraceptives (see (see text box in “What Are Contraceptive Services?”) and the USPSTF
services.261 Under the other coverage types, states have more discretion when defining covered
benefits. The multiple eligibility pathways and related service coverage options make it difficult
to assess the relative richness of the benefit coverage within and across states. However, findings
from a 2021 50-state survey of Medicaid fee-for-service (FFS) coverage of select family planning
services highlight the mandatory nature of various types of contraceptive coverage under ABPs,
as well as state choices in offering different types of contraception under the other coverage
types. The survey also captures differences across coverage types in terms of utilization controls
(e.g., whether prescription required, brand/type restrictions, quantity or frequency limits, medical
necessity requirements), which states use to control costs or otherwise influence how
beneficiaries use the benefit.262
Does Medicaid Cover Abortions or Abortion Counseling?
Like other HHS programs, Medicaid is subject to the Hyde Amendment, which prohibits the use
of federal funds for abortions, except in the cases of rape, incest, or endangerment of a woman’s
life (for more information on the Hyde Amendment, see the “Can Federal Funds Be Used to Pay
for Abortions or Abortion Counseling?”
section of this report.)263 The Hyde Amendment does not

260 “Family planning related services are medical, diagnostic, and treatment services provided pursuant to a family
planning visit that address an individual’s medical condition and may be provided for a variety of reasons including,
but not limited to: treatment of medical conditions routinely diagnosed during a family planning visit, such as treatment
for urinary tract infections or sexually transmitted infection; preventive services routinely provided during a family
planning visit, such as the HPV vaccine; or treatment of a major medical complication resulting from a family planning
visit.” See CMS, “Re: Medicaid Family Planning Services and Supplies,” SHO letter, SHO # 16-008, June 14, 2016, at
https://www.medicaid.gov/federal-policy-guidance/downloads/sho16008.pdf.
261 For a summary of federal coverage requirements for Medicaid family planning services, by coverage type, see Usha
Ranji, Yali Bair, and Alina Salganicoff, Medicaid and Family Planning: Background and Implications of the ACA,
Kaiser Family Foundation, February 2016, p. 18, at http://files.kff.org/attachment/issue-brief-medicaid-and-family-
planning-background-and-implications-of-the-aca.
262 For more information, see Usha Ranji, Ivette Gomez, Alina Salganicoff, et al., Medicaid Coverage of Family
Planning Benefits: Findings from a 2021 State Survey
, The Henry J. Kaiser Family Foundation, February 17, 2022, at
https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-family-planning-benefits-findings-from-a-
2021-state-survey/.
263 In FY2016, states claimed federal financial participation (FFP) for 69 abortions: 34 were due to endangerment to the
life of the mother, 33 were due to rape, and 2 were due to incest. HHS, Office of the Assistant Secretary for Financial
Resources, FY 2018 Moyer Material, June 21, 2017, Addendum: Abortion-Related Reporting. GAO has since noted
problems with the accuracy of the above-mentioned HHS report (i.e., FY 2018 Moyer Material). According to GAO,
some states reported their Medicaid abortions inaccurately and the HHS report lacked data on abortions paid through
managed care organizations. GAO conducted its own survey of state Medicaid officials and identified nearly 5,000
abortions for which states claimed federal funding from FY2013 through FY2016. GAO noted that its own count was
also incomplete because some states were unable to provide complete, or any, information on Medicaid abortions
eligible for federal funding. For more state-reported information on Medicaid coverage of abortions, see GAO,
Medicaid: CMS Action Needed to Ensure Compliance with Abortion Coverage Requirement, GAO-19-159, January
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restrict federal funding for the cost of treating a physical disorder, injury, or illness, including a
physician-certified, life-endangering condition that is caused by or arises from pregnancy.
Moreover, Medicaid program regulations permit federal reimbursement for the termination of
ectopic pregnancies, which are nonviable and endanger the life of the mother.264 As of June 1,
2022, 16 state Medicaid programs fund all or most “medically necessary” abortions. Seven states
do so voluntarily, and nine states do so pursuant to a court order.265 It remains to be seen what
effects the U.S. Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization266 will
have on coverage of abortions under the Medicaid program, especially in jurisdictions where state
laws are in effect that may prohibit Medicaid beneficiaries from obtaining an abortion in cases
that would otherwise be permissible for Medicaid to cover.
In addition, the Hyde Amendment does not prohibit a “state, locality, entity, or private person”
from paying for abortion services, or managed care providers from offering abortion coverage,
nor does it affect a state’s or locality’s ability to contract with a managed care provider for such
coverage with state-only funds (as long as such funds are not the state share of Medicaid
matching funds).267 Some states rely on state-only funds to pay for abortions that do not meet the
Hyde amendment exceptions.268
Through program regulations,269 and later revised through program guidance, Medicaid enrollees
and providers may be required to comply with reasonable documentation requirements to ensure
that the abortion meets the Hyde amendment criteria and is eligible for Medicaid federal
reimbursement. However, such documentation requirements may not prevent or impede coverage
for abortions and may be waived if the treating physician certifies that the patient was unable to
comply.270
Does Medicaid Cover Infertility Services?
States are permitted to cover fertility diagnosis services (e.g., lab tests, semen analysis, and
imaging studies) and infertility treatment services (e.g., medications, surgeries, ARTs such as IUI
or IVF) at state option under all coverage types (i.e., traditional Medicaid, ABPs, Section 1115
Medicaid family planning waivers, and the optional ACA family planning eligibility group).271

2019, at https://www.gao.gov/assets/700/696338.pdf.
264 42 C.F.R. §441.207.
265 For more information, see Guttmacher Institute, State Laws and Policies, State Funding of Abortion Under
Medicaid, at https://www.guttmacher.org/state-policy/explore/state-funding-abortion-under-medicaid.
266 For more information, see CRS Legal Sidebar LSB10768, Supreme Court Rules No Constitutional Right to Abortion
in Dobbs v. Jackson Women’s Health Organization
.
267 Department of Labor, Health and Human Services, and Education and Related Agencies Appropriations Act, 1998,
(P.L. 105-78) Section 509 and 510. These restrictions have been continued in the HHS Appropriations Acts, most
recently through the enactment of the Further Consolidated Appropriations Act, 2022 (P.L. 117-103). See also HHS,
Health Care Financing Administration (HCFA), Center for Medicaid and State Operations (CMSO), SMDL, February
12, 1998, at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd021298.pdf.
268 Although FFP is forbidden for most abortions, 16 state Medicaid programs fund all or most “medically necessary”
abortions. Seven states do so voluntarily, and nine states do so pursuant to a court order. For more information, see
Guttmacher Institute, State Laws and Policies, State Funding of Abortion Under Medicaid, as of December 1, 2020, at
https://www.guttmacher.org/state-policy/explore/state-funding-abortion-under-medicaid.
269 42 C.F.R. §§441.203, 441.206 and 441.208.
270 HHS, HCFA, CMSO, SMDL, February 12, 1998, at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/
smd021298.pdf.
271 For more information of state coverage of fertility services by program type, see Usha Ranji, Ivette Gomez, Alina
Salganicoff, et al., Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State Survey, The Henry J.
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Although state Medicaid programs are required to cover most manufacturers’ prescription drugs
to receive rebates under the Medicaid Drug Rebate Program, states are permitted to exclude or
otherwise restrict coverage of outpatient fertility drugs.272
Some states cover treatments for conditions that may affect fertility (e.g., treatment of
gynecological abnormalities, thyroid medications); five states (California, Illinois, Maryland,
New York, and Wisconsin) cover fertility medications for women (e.g., human menopausal
gonadotropin); two states (Illinois and Maryland) cover IUI and IVF; and one state (Illinois)
covers egg freezing, as of July 1, 2021.273
Does Medicaid Cover Maternity Services?
Medicaid is a significant payer of maternal health services and births in the United States.
According to CDC, Medicaid paid for 42% of all births in the United States in 2020.274 In
general, Medicaid benefits for pregnant women can differ by eligibility pathway across and
within states.275
Medicaid Eligibility Pathways
Medicaid’s mandatory poverty-related pregnant women pathway provides access to pregnancy
coverage under traditional Medicaid for pregnant women with incomes less than 133% of FPL,276
and up to 185% of FPL at state option.277As of July 2021, 278 the Medicaid upper-income
eligibility threshold for pregnant women ranged from 133% of FPL in four states (Idaho,
Louisiana, Oklahoma, and South Dakota) to 375% of FPL (in Iowa).279 Coverage for these

Kaiser Family Foundation, February 17, 2022, at https://www.kff.org/womens-health-policy/report/medicaid-coverage-
of-family-planning-benefits-findings-from-a-2021-state-survey/.
272 SSA §1927(d)(2)(B) [42 U.S.C. §1396r-8(d)(2)(B)].
273 For more on the range of benefits covered by states, see Usha Ranji, Ivette Gomez, Alina Salganicoff, et al.,
Medicaid Coverage of Pregnancy-Related Services: Findings from a 2021 State Survey, The Henry J. Kaiser Family
Foundation, May 2022, at https://files.kff.org/attachment/Report-Medicaid-Coverage-of-Pregnancy-Related-Services-
Findings-from-a-2021-State-Survey.pdf.
274 Michelle J.K. Osterman, Brady E. Hamilton, Joyce A. Martin, et al., Births: Final Data for 2020, National Center
for Health Statistics (NCHS), National Vital Statistics Report, vol. 70, no. 17, Hyattsville, MD, February 7, 2022, at
https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-17.pdf.
275 For more information on Medicaid’s pregnancy coverage, see Medicaid and CHIP Payment and Access
Commission (MACPAC), MACPAC Report to the Congress, Chapter 3: Issues in Pregnancy Coverage under Medicaid
and Exchange Plans, March 2014, at https://www.macpac.gov/wp-content/uploads/2014/03/Issues-in-Pregnancy-
Coverage-under-Medicaid-and-Exchange-Plans.pdf. See also Maggie Clark, Medicaid and CHIP Coverage for
Pregnant Women: Federal Requirements, State Options
, Georgetown University Health Policy Institute, Center for
Children and Families, November 5, 2020, at https://ccf.georgetown.edu/2020/11/05/medicaid-and-chip-coverage-for-
pregnant-women-federal-requirements-state-options/.
276 SSA §§1902(a)(10)(A)(i)(III) [42 U.S.C. §1396a(a)(10)(A)(i)(III)]; 1902(a)(10)(A)(i)(IV) [42 U.S.C.
§1396a(a)(10)(A)(i)(IV)]; 1902(l)(2)(A) [42 U.S.C. §1396a(l)(2)(A)]; and 1905(n) [42 U.S.C. §1396d(n)].
277 SSA §§1902(a)(10)(A)(ii)(I) [42 U.S.C. §1396a(a)(10)(A)(ii)(I)]; 1902(a)(10)(A)(ii)(IV) [42 U.S.C.
§1396a(a)(10)(A)(ii)(IV)]; 1902(a)(10)(A)(ii)(IX) [42 U.S.C. §1396a(a)(10)(A)(ii)(IX)]; and 1902(l)(2)(A)(ii)(I) 42
U.S.C. §1396a(l)(2)(A)(ii)(I).
278 MACPAC, MACStats, EXHIBIT 35. Medicaid and CHIP Income Eligibility Levels as a Percentage of the FPL for
Children and Pregnant Women by State, July 2021, at https://www.macpac.gov/wp-content/uploads/2015/01/
EXHIBIT-35.-Medicaid-and-CHIP-Income-Eligibility-Levels-as-a-Percentage-of-the-FPL-for-Children-and-Pregnant-
Women-by-State-July-2021.pdf.
279 Prior to the enactment of the ACA, states had the flexibility to determine what types of income to include or
disregard when determining Medicaid income eligibility for most nondisabled Medicaid eligibility groups, and income
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women may include full Medicaid benefit coverage, or states may limit services to those related
to pregnancy.280 According to the Medicaid and CHIP Payment and Access Commission
(MACPAC), as of January 2019, five states (Arkansas, Idaho, New Mexico, North Carolina, and
South Dakota) provided only pregnancy-related services.281 In either case, coverage generally
begins at the time of application and ends after 60 days postpartum. While states may impose cost
sharing in the form of program participation fees (e.g., premiums) for pregnant women with
incomes above 150% FPL, pregnant women are exempt from point-of-service cost sharing (e.g.,
copays, coinsurance) for pregnancy-related services, including tobacco cessation counseling.282
Women who are otherwise eligible for Medicaid (e.g., who meet the financial eligibility criteria
of a state’s former Aid to Families with Dependent Children [AFDC] program, or who are
eligible through a family coverage pathway) and become pregnant are generally permitted to
retain their existing full Medicaid state plan coverage (whether provided under traditional
Medicaid or ABP coverage) until that individual’s next eligibility redetermination (up to 12
months).283
States have the option, when certain conditions are met, to extend full Medicaid benefit coverage
during pregnancy and throughout the 12-month postpartum period to women who received
Medicaid coverage while pregnant. In addition to any available pregnancy-related services and
60-day postpartum care that a woman might be entitled to under the Medicaid state plan (or
waiver), pregnancy and postpartum coverage under this state plan option includes the full
Medicaid benefit coverage that is available to other mandatory eligibility groups (or substantially
equivalent benefit coverage as determined by the HHS Secretary). Such coverage is available
during the pregnancy through the last day of the month of the 12-month period beginning on the
last day of the individual’s pregnancy. This state plan option is in effect for a five-year period that
begins April 1, 2022.284

counting rules varied greatly across Medicaid eligibility categories and across states. Under the ACA, states are
required to transition to a new Medicaid eligibility income-counting rule based on Modified Adjusted Gross Income
(MAGI) to establish uniform standards for what income to include or disregard in determining Medicaid eligibility for
most Medicaid eligibility categories. In transitioning to MAGI, states converted their old income-counting rules to
MAGI-based income standards set by each state in coordination with CMS. As a result, the upper-income eligibility
thresholds for pregnant women is effectively higher than 185% of FPL statutory maximum in a number of states. For
more information, see CRS Report R43861, The Use of Modified Adjusted Gross Income (MAGI) in Federal Health
Programs
.
280 SSA §§1902(a)(10) in subdivisions (V), (VII) after (G) [42 U.S.C. §1396a(a)(10) in subdivisions (V), (VII) after
(G)], see also MACPAC, Pregnant Women, at https://www.macpac.gov/subtopic/pregnant-women/.
281 MACPAC, MACPAC Report to the Congress, Chapter 5: Medicaid’s Role in Maternal Health June 2020, at
https://www.macpac.gov/wp-content/uploads/2020/06/June-2020-Report-to-Congress-on-Medicaid-and-CHIP.pdf.
282 SSA §1902(e)(5) [42 U.S.C. §1396a(e)(5)].
283 Women who are otherwise eligible for Medicaid (under the ACA Medicaid expansion pathway, for example) and
who become pregnant are generally permitted to retain their existing Medicaid benefit coverage unless the woman self-
identifies as pregnant and requests a change in her Medicaid coverage category. In this example, the individual would
be entitled to ABP coverage, and such coverage would continue until her next eligibility redetermination (i.e., coverage
may extend after the 60-day postpartum period). Source: CMS, “Medicaid Program; Eligibility Changes,” 77 Federal
Register
17149, March 23, 2012.
284 As of May 25, 2022, 11 states (California, Florida, Illinois, Kentucky, Louisiana, Michigan, New Jersey, Oregon,
South Carolina, Tennessee, and Virginia) have CMS approval to extend Medicaid and CHIP coverage from 60 days to
12 months postpartum under this temporary state plan option. For more information, see CMS Pres Release, HHS
Applauds 12-Month Postpartum Expansion in California, Florida, Kentucky, and Oregon
, May 25, 2022, at
https://www.hhs.gov/about/news/2022/05/25/hhs-applauds-12-month-postpartum-expansion-in-california-florida-
kentucky-and-oregon.html#:~:text=
California%2C%20Florida%2C%20Kentucky%2C%20and%20Oregon%20join%20South%20Carolina%2C,days%20t
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Many qualified aliens, such as Legal Permanent Residents who entered the United States after
August 22, 1996,285 are prohibited from receiving Medicaid for five years (often referred to as the
five-year bar).286 States are permitted to provide Medicaid coverage to certain lawfully residing
pregnant women within the five-year waiting period when certain conditions are met (e.g., the
state offers coverage to all such individuals who meet the definition of lawfully residing, or
applicants meet state residency requirements).
For nonpregnant women who would be eligible for Medicaid but for their citizenship status,
states are required to pay for services to treat an emergency medical condition under emergency
Medicaid.287 For pregnant women, emergency Medicaid includes services covered under the state
plan, including routine prenatal care, labor and delivery, and routine postpartum care. States may
provide additional services to treat conditions that may complicate the pregnancy or the
delivery.288
Benefit Coverage
Medicaid’s pregnancy-related benefit under traditional Medicaid covers services that are
“necessary for the health of a pregnant woman and fetus, or have become necessary as a result of
the woman having been pregnant.”289 Coverage varies by state. States use the targeted pregnancy
benefit coverage that is available through Medicaid’s poverty-related pregnant women pathways
to provide enhanced pregnancy-related benefits (e.g., prenatal vitamins, genetic counseling,
smoking cessation services, nutrition counseling, dental care, child birth education classes, doula
services, depression screening, breast feeding support and supplies, case management, postpartum
home visits).290 States also rely on various Medicaid waiver authorities to undertake
demonstration projects that in the HHS Secretary’s judgement further the goals of the Medicaid
program by providing targeted benefits to pregnant women (e.g., Substance Use Disorder Section
1115 demonstrations that target pregnant and postpartum women, among other populations).291
Finally, states rely on a number of Medicaid care delivery models (e.g., pregnancy medical home)
and payment initiatives (e.g., value-based payment) to promote positive health outcomes for
pregnant women and newborns.292

o%2012%20months%20postpartum.
285 Qualified aliens in statute (8 U.S.C. §1641(b)) are Legal Permanent Residents, refugees, aliens paroled into the
United States for at least one year, aliens granted asylum or related relief, certain abused spouses and children, and
Cuban-Haitian entrants. For more information, see CRS Report RL34500, Unauthorized Aliens’ Access to Federal
Benefits: Policy and Issues
.
286 8 U.S.C. §1613.
287 SSA §1903(v)(3) [42 U.S.C. §1396b(v)(3)].
288 42 C.F.R. §440.255(b)(2).
289 42 C.F.R. §440.210(a)(2)(i).
290 For more information on the kinds of pregnancy benefits that states offer under their Medicaid programs, Usha
Ranji, Ivette Gomez, Alina Salganicoff, et al., Medicaid Coverage of Pregnancy-Related Services: Findings from a
2021 State Survey, The Henry J. Kaiser Family Foundation, May 2022, at https://files.kff.org/attachment/Report-
Medicaid-Coverage-of-Pregnancy-Related-Services-Findings-from-a-2021-State-Survey.pdf. See also Becky Normile,
Karen VanLandeghem, and Alex King, Medicaid Financing of Home Visiting Services for Women, Children and Their
Families
, NASHP, August 2017, at https://nashp.org/wp-content/uploads/2017/09/Home-Visiting-Brief.pdf.
291 For more information, see CMS, 1115 Substance Use Disorder Demonstrations, at https://www.medicaid.gov/
resources-for-states/innovation-accelerator-program/program-areas/substance-use-disorders/1115-substance-use-
disorder-demonstrations/index.html.
292 For examples of state efforts to improve maternal and child health outcomes, see MACPAC, MACPAC Report to the
Congress
, Chapter 5: Medicaid’s Role in Maternal Health June 2020, at https://www.macpac.gov/wp-content/uploads/
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Pregnant women are among the groups who are exempt from mandatory enrollment in ABPs;
however, special federal rules apply to those who are eligible for and choose to participate in such
coverage. Specifically, ABPs must cover at least the 10 categories of health care services—known
as the EHBs—as defined in Section 1302(b) of the ACA (for more information, see the “Does
Federal Law Require Private Health Insurance Coverage of Reproductive Health Services?”
section of this report.)293 Under the maternity and newborn care and preventive services EHB
coverage categories, Medicaid ABPs must cover several services related to maternity care at no
cost to the enrollee, including but not limited to prenatal visits, folic acid supplements, and
breastfeeding support services.
Comparing Medicaid Maternity Coverage Across Coverage Types
Coverage of Medicaid maternity services can and does vary within and across states based on
enrollees’ eligibility pathways. According to a 2015 survey of Medicaid FFS pregnancy and
perinatal benefits by coverage type (i.e., traditional Medicaid, ABP coverage, and pregnancy-only
Medicaid), most states cover basic prenatal services such as ultrasounds, prenatal vitamins,
prenatal genetic testing, and postpartum visits. However, coverage of maternity-related services
after delivery (e.g., parenting classes, breastfeeding and lactation support services) is less
common. The survey also found that while coverage requirements differ across eligibility
pathways, in general, states aligned their pregnancy and perinatal benefit coverage across the
coverage types captured in the survey (i.e., traditional Medicaid, ABP coverage, and pregnancy-
only Medicaid).294
Does Medicaid Cover Reproductive Health Screening and Preventive Services?
In general, Medicaid covers a wide array of reproductive health screenings, preventive services,
and treatment of conditions identified during screenings. Coverage varies within and across
states.
Traditional Benefits
An enrollee’s eligibility pathway determines the reproductive health screenings, preventive
services, and treatments for conditions identified during these screenings that are available.
Different federal rules may apply, depending on the eligibility pathway and/or service category
under which the benefit is offered. States are permitted to rely on different statutory authorities to
direct federal Medicaid funds to pay for similar services.

2020/06/June-2020-Report-to-Congress-on-Medicaid-and-CHIP.pdf.
293 Federal requirements related to the EHBs generally apply to certain private health insurance plans. The 10
categories of EHB are (1) ambulatory patient services, (2) emergency services, (3) hospitalization, (4) maternity and
newborn care, (5) mental health and substance use disorder services (including behavioral health treatment), (6)
prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and
wellness services and chronic disease management, and (10) pediatric services, including oral and vision care. For
more information about private health insurance EHB requirements, see the “Does Federal Law Require Private Health
Insurers to Cover Reproductive Health Services?” section of this report. For Medicaid ABP requirements regarding the
EHBs, see SSA §1937(b)(5) [42 U.S.C. §1396u-7(b)(5)]; 42 C.F.R. §440.347.
294 For more information on Medicaid state coverage of routine prenatal services, counseling and support services,
delivery and postpartum care, and breastfeeding supports by coverage type, see Kathy Gifford, Jenna Walls, Usha
Ranji, et al., Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a State Survey, Kaiser Family
Foundation, April 27, 2017, at https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-pregnancy-and-
perinatal-benefits-results-from-a-state-survey/.
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For example, states must cover certain screening services (e.g., mammograms, cervical cancer
screenings and diagnostic services) as a mandatory family planning benefit without enrollee cost
sharing for individuals eligible under Medicaid’s pregnancy-related eligibility pathways and
traditional Medicaid, or under EPSDT for children through age 21. These screenings may be
offered at state option as a targeted benefit under a Section 1115 family planning waiver, or under
the optional ACA family planning eligibility group.
In each case, states define the specific features of each covered benefit within the broad federal
rules that apply for each eligibility pathway and covered benefit. The breadth of coverage for a
given benefit can, and does, vary from state to state, even for mandatory services. Examples of
Medicaid services that states offer as a part of reproductive health screenings, preventive services,
and treatment of conditions identified during screenings under traditional Medicaid include
physicians visits; well-care visits; breast and pelvic exams; laboratory tests; medical diagnosis,
screening, and treatment services for conditions including breast and cervical cancer, HIV/AIDS,
and STI; domestic violence screening and related treatment; EPSDT services; and preventive
services routinely provided during a family planning visit, such as the HPV vaccine.295
ABPs
For program enrollees who receive care through ABPs, the “preventive and wellness services and
chronic disease management” EHB category requires states to cover all preventive services under
Public Health Service Act (PHSA) Section 2713 without beneficiary cost sharing. (The EHB
categories are described in the following sections of this report: “Coverage of the Essential Health
Benefits (EHB),
” and “Coverage of Certain Preventive Services Without Cost Sharing.”) These
EHB coverage requirements represent a floor for all ABP benefit coverage. Examples of ABP
reproductive health screening, preventive services, and treatment for conditions identified under
these screenings under this EHB coverage category include screening, counseling and treatment
for STIs, universal HIV screening and treatment, breast and cervical cancer screenings and
follow-up treatment, gynecological exams and Pap smears, well-woman visits, vaccines (e.g.,
HPV), and domestic and interpersonal violence screenings and related treatment.
Comparing Medicaid Reproductive Health Screenings and Preventive Services
Across Coverage Types
Comparing reproductive health screenings and preventive services coverage across the various
types of Medicaid benefit coverage (i.e., traditional Medicaid, ABP coverage, Section 1115
family planning waivers, or the optional ACA family planning eligibility group) reveals a key
difference: under ABPs, states must comply with the EHB requirement for states to cover all
required services without beneficiary cost sharing. Under the other coverage types, states have
more discretion when defining covered benefits. As with many of the other reproductive health
benefits addressed in this report, Medicaid’s multiple eligibility pathways and service coverage
options make it difficult to assess the differences in coverage of these benefits within and across
states.296

295 For examples of the types of Medicaid services that states offer as a part of reproductive health screenings,
preventive services, and treatment of conditions identified during screenings, see Kaiser Family Foundation, Issue
Brief, Woman’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Woman’s Health
Survey
, March 13, 2018, at https://www.kff.org/womens-health-policy/issue-brief/womens-sexual-and-reproductive-
health-services-key-findings-from-the-2017-kaiser-womens-health-survey/.
296 Key findings from a 2015 50-state survey of Medicaid FFS coverage of cervical and breast cancer screening and
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Does Medicaid Cover Gender-Affirming Services?
Medicaid covers a broad range of medically necessary physical and mental health care services
for transgender, nonbinary, and gender-nonconforming individuals. Like other Medicaid benefits,
coverage of such services may vary state by state and within states across eligibility pathways,
benefit categories, and by coverage type.297 Examples of Medicaid-covered services for such
individuals include surgical interventions, speech and language interventions, behavioral health
services, hormone therapy, and hair removal. According to a recent study, 19 states and the
District of Columbia require Medicaid coverage of gender-affirming care, and 2 states (Iowa and
Wisconsin) have been directed by court order to cover medically necessary gender-affirming care
under their Medicaid programs. The study also identified nine states as having policies in place
that explicitly exclude Medicaid coverage of certain gender-affirming services.298 Another recent
study identified 18 states and the District of Columbia as including (or in the process of extending
coverage) gender-affirming care.299
Medicare
Medicare is a federal program that pays for covered health care services for qualified
beneficiaries, namely individuals 65 and older and permanently disabled individuals under the
age of 65. It consists of four parts (A through D), which cover hospitalizations, physician
services, prescription drugs, skilled nursing facility care, home health visits, and hospice care,
among other services and supplies.300
The majority of Medicare beneficiaries are 65 years old or older. However, in 2021,
approximately 8.3 million beneficiaries under age 65 were enrolled in Medicare Part A and/or B
as a result of disability, including an unspecified number of women of childbearing age.301

preventive services offer a limited view of state coverage under this broad coverage category; however, the survey does
highlight the mandatory nature of breast and cervical screenings under ABPs, and state choices in offering this type of
benefit coverage under the other coverage types. For more information, see Jenna Walls, Kathy Gifford, Usha Ranji, et
al., Medicaid Coverage of Family Planning Benefits: Results from a State Survey, Kaiser Family Foundation,
September 2016, at http://files.kff.org/attachment/Report-Medicaid-Coverage-of-Family-Planning-Benefits-Results-
from-a-State-Survey.
297 For more information, see Movement Advancement Project, Health Care Laws and Policies: Medicaid Coverage
for Transition-Related Care
, at https://www.lgbtmap.org/img/maps/citations-medicaid.pdf.
298 For more information on the types of gender-affirming care that are covered under Medicaid and a list of states that
cover these services under their Medicaid programs, see Candace Gibson and Priscilla Huang, Protected: Medicaid as
an LGBTQ Reproductive Justice Issue: A Primer
, National Health Law Program, June 21, 2019, at
https://healthlaw.org/resource/medicaid-as-an-lgbtq-reproductive-justice-issue-a-primer/. The above-cited Movement
Advancement Project, a nonprofit advocacy and research organization, also tracks Medicaid Coverage of Transgender-
Related Care at https://www.lgbtmap.org/img/maps/citations-medicaid.pdf and https://www.lgbtmap.org/equality-
maps/healthcare_laws_and_policies/medicaid.
299 Christy Mallory and William Tentindo, UCLA School of Law; Williams Institute, “Medicaid Coverage for Gender-
Affirming Care,” October 2019.
300 CRS Report R40425, Medicare Primer.
301 Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2022
Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical
Insurance Trust Funds
, June 1, 2022, at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-
and-Reports/ReportsTrustFunds/index.html.
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Does Medicare Cover Reproductive Health Services?
Medicare covers some types of reproductive health services. Cost sharing—a deductible and co-
insurance—applies to some, such as many physician services, and is waived for others, such as
most preventive services. Covered services, described further below, include prenatal and
maternity care, and preventive services. Other services, such as contraception, abortion, infertility
services, and gender-affirming services, may be covered in specified circumstances.
Many reproductive health services are recommended for Medicare beneficiaries who are older
than childbearing age, including breast and gynecological exams for women, and STI screening
and treatment for men and women. As a result, any type of reproductive health service may be
sought or advised for at least some Medicare beneficiaries.
Does Medicare Cover Contraceptive Services?
There is no explicit statutory requirement for Medicare to cover contraceptive services or supplies
for its enrollees. Women Medicare beneficiaries may get oral contraceptives covered through
Medicare Part D prescription drug coverage. These and other forms of contraception may be
covered to varying extents under Medicare Advantage (MA) plans, which are health plans offered
by private companies that contract with Medicare to provide benefits.
Male or female sterilization (e.g., vasectomy, tubal ligation) is covered only where it is a
necessary part of the treatment of an illness or injury. For example, removal of reproductive
organs may be required to treat cancers of those organs. Sterilization is not covered as an elective
procedure or for the sole purpose of preventing any effects of a future pregnancy.302
For individuals who are dually eligible for Medicare and Medicaid, Medicare is the primary
payer. Medicaid pays for any additional services that it covers, and Medicare does not, after
Medicare denies payment. For example, many contraceptive products and services for those
dually eligible may be paid through the more generous Medicaid benefits.303
Does Medicare Cover Abortions or Abortion Counseling?
Abortions are not covered Medicare procedures except (1) if the pregnancy is the result of an act
of rape or incest or (2) in the case where a woman suffers from a physical disorder, physical
injury, or physical illness, including a life-endangering physical condition caused by or arising
from the pregnancy itself, that would, as certified by a physician, place the woman in danger of
death unless an abortion is performed.304 Consistent with typical Medicare-covered physician
services, a Medicare-covered abortion could include care activities such as taking a patient’s
medical and situational history, determining how the coverage criteria may apply, and discussing
what specific procedures are under consideration, the potential complications, and follow-up.

302 CMS, Medicare National Coverage Determination for Sterilization (230.3), http://www.cms.gov/medicare-
coverage-database/.
303 Henry J. Kaiser Family Foundation, “Private and Public Coverage of Contraceptive Services and Supplies in the
United States,” July 10, 2015, http://kff.org/womens-health-policy/fact-sheet/private-and-public-coverage-of-
contraceptive-services-and-supplies-in-the-united-states/.
304 CMS, Medicare National Coverage Determination for Abortion (140.1), June 19, 2006, http://www.cms.gov/
medicare-coverage-database/.
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Does Medicare Cover Infertility Services?
The Medicare Benefit Policy Manual states that “[r]easonable and necessary services associated
with treatment for infertility are covered under Medicare. Infertility is a condition sufficiently at
variance with the usual state of health to make it appropriate for a person who normally is
expected to be fertile to seek medical consultation and treatment.”305
Does Medicare Cover Maternity Services?
The Medicare Benefit Policy Manual states that Medicare covers the “events of pregnancy” from
diagnosis through prenatal care, delivery, and necessary postnatal care of the mother.306 Coverage
applies whether the pregnancy ends in live birth, miscarriage, or therapeutic abortion (i.e., where
the life of the mother would be endangered if the fetus were brought to term). Of note, covered
services do not apply to care for a child; rather, they are limited to care of the mother, who is the
Medicare beneficiary.
Does Medicare Cover Reproductive Health Screening, Prevention, and
Treatment Services?

Medicare Part B covers a number of preventive services that involve reproductive health. These
include, among others, annual wellness visits, breast cancer screening, screening pelvic exams,
Pap smears, screening for HIV and other STIs, and prostate cancer screening.307 Cost sharing is
waived for most, but not all, of these preventive services.
In addition, Medicare Parts A or B typically cover diagnostic and treatment services furnished by
a certified provider; cost sharing typically applies. Such reproductive health services include
diagnosis and treatment of STIs and urinary tract infections, and management of precancerous
and cancerous gynecological abnormalities.
Does Medicare Cover Gender-Affirming Services?
Medicare coverage of gender-affirming surgery is generally determined by Medicare
Administrative Contractors (MACs) or MA plans, as is common for many Medicare-covered
services. Prior to 2014, Medicare excluded coverage of affirmation-related medical care as
“experimental.”308 The Medicare Appeals Council lifted that exclusion in 2016.309 In 2016, CMS
announced that it would not issue a national coverage determination (NCD) for gender-affirming
surgery, instead allowing MACs and MA plans to determine whether surgery is medically
necessary on a case-by-case basis.310

305 CMS, Medicare Benefit Policy Manual, Ch. 15 – Covered Medical and Other Health Services, May 2022, pp. 12,
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.
306 Ibid., p. 11.
307 CMS, “Preventive Services,” interactive chart, May 2022, https://www.cms.gov/Medicare/Prevention/
PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html.
308 Eleesha Lockett, “Gender Affirmation: Does Medicare Cover It?” healthline, July 7, 2020,
https://www.healthline.com/health/medicare/does-medicare-cover-gender-affirmation.
309 HHS, Departmental Appeals Board, Decision of Medicare Appeals Council Docket Number: M-15-1069, January
21, 2016, https://www.hhs.gov/sites/default/files/static/dab/decisions/council-decisions/m-15-1069.pdf.
310 CMS, Medicare Coverage Database, “Decision Memo for Gender Dysphoria and Gender Reassignment Surgery
(CAG-00446N),” August 30, 2016, https://www.cms.gov/medicare-coverage-database/details/nca-decision-
memo.aspx?NCAId=282.
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Federal Regulation of Private Health Insurance
Private health insurance is the predominant source of health insurance coverage in the United
States.311 The federal government has the authority to regulate private health insurance plans,
including by requiring plans to cover certain benefits.
Private health insurance includes both the group market (largely made up of employer-sponsored
insurance) and the nongroup market (commonly referred to as the individual market, which
includes plans directly purchased from an insurer). The group market is divided into small- and
large-group market segments; a small group is typically defined as a group of up to 50 individuals
(e.g., employees), and a large group is typically defined as one with 51 or more individuals.312
Employers and other group health plan sponsors may purchase coverage from an insurer in the
small- and large-group markets (i.e., they may fully insure). Sponsors may instead finance
coverage themselves (i.e., they may self-insure).313 The individual and small-group markets
include plans sold on and off the health insurance exchanges—the individual exchanges and
Small Business Health Options Program (SHOP) exchanges, respectively.314
Covered benefits, consumer costs, and other plan features often vary by plan, subject to
applicable federal and state requirements. The federal government has authority to regulate all the
coverage types noted above (i.e., individual coverage, fully insured small- and large-group
coverage, and self-insured group plans).315 In general, states are permitted to regulate all but self-
insured group plans.316 Federal and state requirements may vary by coverage type. For the federal
reproductive health coverage requirements discussed in this section, applicability to each
coverage type is noted.317

311 See CRS In Focus IF10830, U.S. Health Care Coverage and Spending.
312 In general, for purposes of health insurance requirements, small groups are those with 50 or fewer individuals (e.g.,
employees). However, states can define small groups as having 100 or fewer individuals. The definition of large group
is 51 or more individuals, or 101 or more individuals, depending on the definition of small group.
313 Employers or other plan sponsors that self-insure set aside funds to pay for health benefits directly, and they bear the
risk of covering medical expenses generated by the individuals covered under the self-insured plan.
314 The individual exchanges and small business health options program (SHOP) exchanges are virtual marketplaces in
which consumers and small businesses, respectively, can shop for and purchase private health insurance coverage.
Plans sold in the individual and SHOP exchanges have to meet all the requirements applicable to the individual and
small-group markets, respectively. Additional requirements apply only to exchange plans. For more information, see
CRS Report R44065, Overview of Health Insurance Exchanges.
315 Federal requirements applicable to the coverage types outlined in this section (individual coverage, fully insured
small- and large-group coverage, and self-insured group plans) are technically applicable to “group health plans and
health insurers offering individual and group health insurance coverage.” In this section on private health insurance,
references to requirements on “plans” and “coverage types” may include requirements on plans, sponsors, and/or
insurers. For more information about types of plans and federal regulation of them, see CRS Report R45146, Federal
Requirements on Private Health Insurance Plans
.
316 States are the primary regulators of private health insurance, and they may enact their own benefit coverage
requirements on nongroup and/or fully insured group plans. Discussion of state-level requirements is out of scope of
this report, but lists of mandated benefits by state are available at CMS, Center for Consumer Information and
Insurance Oversight (CCIIO), “Information on Essential Health Benefits (EHB) Benchmark Plans,” not dated, at
https://www.cms.gov/cciio/resources/data-resources/ehb.
317 In terms of group coverage, this section on private health insurance requirements focuses on plans sponsored by
private-sector employers and other sponsors. Although governmental employers may also offer health insurance
coverage to their employees, including coverage provided through private health insurers, the applicability of the
requirements discussed in this section may vary with regard to federal, state, local, and other governmental employers.
For example, self-insured nonfederal governmental plans are able to opt out of certain federal requirements; see CRS
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Some plans within a market segment may be exempt from requirements that otherwise apply to
plans in that market segment. For example, grandfathered plans are individual or group plans in
which at least one individual was enrolled as of enactment of the ACA, and which continue to
meet certain criteria.318 Plans that maintain their grandfathered status are exempt from some, but
not all, federal requirements. For the reproductive health coverage requirements discussed in this
section, applicability to grandfathered plans is noted.
Certain types of private health coverage arrangements are not subject to, or otherwise do not
comply with, some or all federal requirements on private health insurance. This includes, for
example, short-term, limited duration insurance (STLDI) and health care-sharing ministries
(HCSMs). These are out of scope of this report but are discussed in CRS Report R46003,
Applicability of Federal Requirements to Selected Health Coverage Arrangements.
Plans may voluntarily cover benefits, subject to applicable federal and state laws. This includes
providing coverage that exceeds federal or state requirements, or providing coverage where there
is no applicable requirement to do so, as long as there is no applicable prohibition on such
coverage.
Does Federal Law Require Private Health Insurance Coverage of Reproductive
Health Services?

Various federal laws address private health insurance coverage of different types of reproductive
health services. (For background on this term and the types of services it encompasses, see the
“What Are Reproductive Health Services?” section of this report.)
Two federal requirements—coverage of EHBs and coverage of certain preventive services
without cost sharing—are applicable to multiple types of reproductive health services.319 These
provisions, along with other federal requirements applicable to specific types of reproductive
health services, are discussed below.
Where there is a benefit coverage requirement, one or more details may be specified. For
example, coverage requirements may or may not specify any cost-sharing requirements. In
general, private health insurance cost sharing includes deductibles, coinsurance, and
copayments.320 Coverage requirements may depend on how or where the service or item is
furnished (e.g., by an in-network versus out-of-network provider).321 Coverage requirements may

Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements.
318 The ACA was enacted on March 23, 2010. For more information about grandfathered plans, and for another type of
plan exempt from some requirements otherwise applicable to its market segment (transitional or grandmothered
plans
), see CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements.
319 The provisions described here have some direct relevance to coverage of reproductive health services, among other
services. Other federal requirements on private health insurance may also be more generally related to coverage of
reproductive health services. For example, the requirement to cover pre-existing health conditions could be relevant to
an enrollee who has pre-existing reproductive health conditions. For more information about provisions not discussed
in this report, see CRS Report R45146, Federal Requirements on Private Health Insurance Plans.
320 A deductible is the amount an insured consumer pays for covered health care services before coverage begins (with
exceptions). Coinsurance is the share of costs, figured in percentage form, an insured consumer pays for a covered
health service. A copayment is the fixed dollar amount an insured consumer pays for a covered health service.
321 Under private insurance, benefit coverage and consumer cost sharing is often contingent upon whether the service or
item is furnished by a provider that the insurer has contracted with (i.e., whether that provider is in network for a given
plan). In instances where a contract between an insurer and provider does not exist, the provider is considered out of
network. For more information, see the overview section of CRS Report R46856, Surprise Billing in Private Health
Insurance: Overview of Federal Consumer Protections and Payment for Out-of-Network Services
.
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also specify whether plans are allowed to impose medical management requirements. For
example, as a condition for covering the care, some insurers require an enrollee to obtain prior
authorization from the insurer for routine hospital inpatient care, or require that primary care
physicians provide approval or referrals for specialty care.322 To the extent that information is
available and relevant, these issues are addressed with regard to federal requirements on private
health insurance coverage of reproductive health services (see Table 4).
Coverage of the Essential Health Benefits (EHB)
The ACA requires certain plans to offer a core package of 10 categories of health care services,
known as the essential health benefits (EHB).323 However, states, rather than the federal
government, generally specify the benefit coverage requirements within those categories. Current
regulation allows each state to select an EHB “benchmark plan.” The benchmark plan serves as a
reference plan on which plans subject to EHB requirements must substantially base their benefits
packages. Because states select their own EHB-benchmark plans, EHB coverage varies
considerably from state to state.324
EHB categories particularly relevant to reproductive health services include “maternity and
newborn care” (further discussed in the maternity services question in this section) and
“preventive and wellness services and chronic disease management” (which incorporates the
preventive services provision discussed below). Other EHB categories may also include benefits
relevant to reproductive health.325
Cost-sharing and medical management requirements are possible for most categories of EHB,
subject to applicable federal and state requirements. Federal requirements limit cost sharing on
the EHB.326 Coverage and cost sharing for EHB services furnished by out-of-network providers
may vary.
All (nongrandfathered) individual and fully insured small-group plans are required to cover the
EHB.
Coverage of Certain Preventive Services Without Cost Sharing
The ACA, via Section 2713 of the PHSA, also requires most plans to cover specified preventive
services without cost sharing, “such as a copayment, coinsurance, or a deductible.”327 This
includes, at a minimum, four categories of statutorily required coverage: (1) any preventive
service recommended with an A or B rating by the USPSTF; (2) any immunization with a

322 For more information, see the appendix of CRS Report RL32237, Health Insurance: A Primer.
323 42 U.S.C. §300gg-6 and 42 U.S.C. §18022.
324 For more information on the process for defining the essential health benefits (EHB) in each state, as well as each
state’s benchmark plan, see CMS, CCIIO, “Information on Essential Health Benefits (EHB) Benchmark Plans,” not
dated, at https://www.cms.gov/cciio/resources/data-resources/ehb.
325 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.
326 See CRS Report R45146, Federal Requirements on Private Health Insurance Plans, regarding several federal
requirements relevant to consumer cost sharing on the EHB (e.g., annual out-of-pocket limits, minimum actuarial value
requirements, and prohibition on lifetime limits and annual limits).
327 42 U.S.C. §300gg-13; 45 C.F.R. §147.130.
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recommendation by the Advisory Committee on Immunization Practices (ACIP), adopted by
CDC, for routine use for a given individual; (3) additional preventive care and screenings for
infants, children, and adolescents as recommended by the Health Resources and Services
Administration (HRSA); and (4) additional preventive care and screenings for women as
recommended by HRSA.328
Examples of reproductive health preventive services in these four categories include (1) screening
and counseling for STIs; (2) universal HIV screening; (3) breast cancer screening, genetic testing,
and preventive medications such as Tamoxifen (to lower the risk of developing breast cancer
among women with specified risk factors); (4) gynecological exams and Pap smears; (5) well-
woman visits; (6) a variety of prenatal care services; and (7) contraception.329 These services are
further discussed under the relevant questions in this section.
Although cost sharing is generally prohibited for specified services and items, cost sharing for
office visits associated with a furnished preventive service may or may not be allowed, as
specified in regulation.330 By regulation, plans are generally not required to cover preventive
services furnished out of network.331 Plans are allowed to use “reasonable medical management”
techniques, within provided guidelines, which may permit use of a formulary, among other
things.332
The requirement to cover specified preventive services without cost sharing is incorporated into
the EHB category “preventive and wellness services and chronic disease management.”333 These
incorporated benefits are the only EHB that must be covered without cost sharing.
The requirement to cover preventive services does not apply only to plans subject to the EHB
requirements; rather, it broadly applies to nongrandfathered private health insurance plans offered
in the individual, small-group, and large-group markets, as well as self-insured plans.334

328 For these United States Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization
Practices (ACIP) recommendations, see https://uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-
a-and-b-recommendations and https://www.cdc.gov/vaccines/acip/recommendations.html, respectively. The Health
Resources and Services Administration (HRSA) adopts the Bright Futures guidelines, developed in partnership with the
AAP, for coverage of additional pediatric preventive services; see https://mchb.hrsa.gov/programs-impact/bright-
futures. The HRSA guidelines on coverage of additional services for women are at https://www.hrsa.gov/womens-
guidelines/index.html.
329 The preventive services that must be covered are listed in their entirety at Healthcare.gov, “Preventive health
services,” https://www.healthcare.gov/preventive-care-benefits/.
330 In general, whether cost sharing for office visits is allowed or prohibited depends on whether the preventive service
or item was the primary purpose of the visit, and whether the service or item was billed or tracked separately from the
office visit. See 45 C.F.R. §147.130(a)(2).
331 45 C.F.R. §147.130(a)(3).
332 As specified, plans are able to use “reasonable medical management techniques to determine the frequency, method,
treatment, or setting for an item or service.” 45 C.F.R. §147.130(a)(4).
333 45 C.F.R. §156.115(a)(4), referencing 45 C.F.R. §147.130.
334 42 U.S.C. §300gg-13; 45 C.F.R. §147.130. While many legal challenges to PHSA Section 2713 have centered on
the contraceptive coverage requirement (discussed in the next section), a case pending in federal district court includes
broader challenges to the statute’s delegations of authority to HRSA, USPSTF, and ACIP, brought by individuals and
entities who object to paying for other forms of preventive-care coverage on religious or other grounds. Order at 3,
Kelley v. Azar, No. 20-cv-00283 (N.D. Tex. Feb. 25, 2021).
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Does Federal Law Require Private Health Insurance Coverage of
Contraceptive Services?

The preventive services coverage provision discussed above requires applicable plans to cover,
without cost sharing, HRSA-recommended women’s preventive healthcare services.335 Since
2011, the HRSA recommendations on such services have included contraception.336 Specifically,
HRSA guidelines, updated December 2021, currently recommend “that all adolescent and adult
women have access to the full range of contraceptives and all contraceptive care to prevent
unintended pregnancies and improve birth outcomes,” including screening, education, counseling,
provision of contraceptives, and follow-up care, including management and removal.337
Through rulemaking and guidance, the Departments of HHS, the Treasury, and Labor confirmed
that applicable plans (except those exempted, as discussed in the next question) must provide
contraceptive coverage as recommended by HRSA.338 This includes coverage of at least one form
of contraception in each of the methods (i.e., categories of contraception, such as the copper IUD
or the patch) in the FDA Birth Control Guide (see text box in “What Are Contraceptive
Services?”
).339 Although the FDA Birth Control Guide includes male contraceptive methods
(male sterilization and male condoms), they are excluded from the contraceptive coverage
requirement because the statutory coverage requirement is specific to women’s preventive health
services.340
Plans are allowed to impose “reasonable medical management” coverage limitations under the
preventive services provision. This means, with regard to contraception, that a plan is allowed to
cover certain brands of contraception but not others within a method, as long as it does not restrict
access to a method altogether.341
Nongrandfathered private health insurance plans offered in the individual, small-group, and large-
group markets, as well as self-insured plans, are subject to these federal contraceptive coverage

335 42 U.S.C. §300gg-13(a)(4). Also see the “Coverage of Certain Preventive Services Without Cost Sharing” section of
this report.
336 HRSA, “Women’s Preventive Services Guidelines,” initially released August 1, 2011, at https://www.hrsa.gov/
womens-guidelines-historical-files.
337 HRSA, “Women’s Preventive Services Guidelines” updated December 2021, at https://www.hrsa.gov/womens-
guidelines/index.html.
338 See, for example, Departments of Labor (DOL), HHS, and the Treasury, “Coverage of Certain Preventive Services
Under the Affordable Care Act, Final Rule,” 78 Federal Register 39869, July 2, 2013, at
https://www.federalregister.gov/documents/2013/07/02/2013-15866/coverage-of-certain-preventive-services-under-the-
affordable-care-act (hereinafter referred to as “Preventive Services Final Rule, July 2013”). Also see DOL, HHS, and
the Treasury, “FAQs about Affordable Care Act Implementation, Part XXVI,” May 11, 2015, http://www.cms.gov/
CCIIO/Resources/Fact-Sheets-and-FAQs/index.html#Affordable%20Care%20Act (hereinafter referred to as “ACA
Implementation FAQ XXVI”). ”). A January 10, 2022, FAQ (Part 51) by DOL, HHS, and the Treasury also includes
updates regarding contraceptive coverage: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/
FAQs-Part-51.pdf.
339 See the “What Are Contraceptive Services?” section of this report. See also https://www.fda.gov/consumers/free-
publications-women/birth-control-chart.
340 See, for example, Preventive Services Final Rule, July 2013; ACA Implementation FAQ XXVI.
341 ACA Implementation FAQ XXVI. However, the guidance requires coverage accommodations for “any individual
for whom a particular drug (generic or brand name) would be medically inappropriate, as determined by the
individual’s health care provider, by having a mechanism for waiving the otherwise applicable cost-sharing for the
brand or non-preferred brand version.”
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requirements, unless exempted. States are the primary regulators of private health insurance, and
they may implement their own contraceptive coverage requirements on the plans they regulate.342
Are There Exemptions for the Contraceptive Coverage Requirement?
The ACA’s implementing regulations initially exempted only houses of worship and similar
religious orders from the contraceptive coverage requirement (i.e., with regard to the health plans
they offer to their employees).343 An exemption is now available to most types of nonprofit and
for-profit entities with sincerely held religious or moral beliefs against contraception.344
The initial exemption has been revised several times. In 2013, the Departments of HHS, the
Treasury, and Labor established an accommodation process for nonprofit, religious organizations
with religious objections to some or all forms of contraception that did not qualify for the
automatic exemption for houses of worship.345 Under that accommodation process, an eligible
employer could execute a self-certification form provided by HHS documenting its objection and
eligibility for the accommodation.346 The rule required the employer’s insurer or third-party
administrator (TPA), upon receiving a copy of the form, to exclude the objected-to benefits from
the entity’s group health plan and separately pay for (or arrange payment for) contraceptive
coverage required by the ACA.347
Due to litigation over the contraceptive coverage requirement and the accommodation process the
Departments expanded accommodations to include closely held, for-profit companies with
religious objections, and allowed objecting entities to notify HHS of their objections (along with
their insurers’ or TPAs’ contact information), instead of executing a self-certification form.348
In two rules finalized in November 2018, the Departments further revised the regulations to
exempt a broader range of entities with sincerely held religious or moral beliefs against
contraception, including for-profit and nonprofit nongovernmental employers and health
insurance issuers.349 The rules essentially allow objecting employers to choose between two

342 In general, states may regulate individual market plans and fully insured group plans but not self-insured group
plans. See the introduction to this section of this report.
343 DOL, HHS, and the Treasury, “Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive
Services Under the Patient Protection and Affordable Care Act,” 76 Federal Register 46621, August 3, 2011, at
https://www.federalregister.gov/documents/2011/08/03/2011-19684/group-health-plans-and-health-insurance-issuers-
relating-to-coverage-of-preventive-services-under.
344 For more detail on the issues discussed in this section, see CRS Report R45928, The Federal Contraceptive
Coverage Requirement: Past and Pending Legal Challenges
. Questions from congressional clients regarding legal
issues addressed in this section may be directed to Victoria L. Killion, CRS Legislative Attorney, who contributed to
this section.
345 Preventive Services Final Rule, July 2013. The accommodation also applies to religious nonprofit colleges and
universities with student plans; see page 39897 of the July 2013 rule.
346 Preventive Services Final Rule, July 2013 at 39894–97.
347 Group plan sponsors that self-insure their coverage may hire a third-party administrator (TPA) to handle certain
administrative duties of offering a health plan, such as member services, premium collection, and utilization review.
TPAs do not bear risk for paying claims. (See the introduction to this section of this report for additional information
about self-insured versus fully-insured group plans.) Requirements and options regarding eligible employers and their
issuers or TPAs are at 29 C.F.R. §2590.715-2713A.
348 DOL, HHS, and the Treasury, “Coverage of Certain Preventive Services Under the Affordable Care Act,” 80
Federal Register 41317, July 14, 2015, at https://www.federalregister.gov/documents/2015/07/14/2015-17076/
coverage-of-certain-preventive-services-under-the-affordable-care-act. Also see Burwell v. Hobby Lobby Stores, Inc.,
573 U.S. 682 (2014); Wheaton Coll. v. Burwell, 573 U.S. 958 (2014).
349 DOL, HHS, and the Treasury, “Religious Exemptions and Accommodations for Coverage of Certain Preventive
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options. They may decline to cover the forms of contraception to which they object, in which case
their employees would not receive coverage for such services through the employer’s plan.
Alternatively, objecting employers can utilize the previously established accommodation process,
thereby shifting the responsibility to provide contraceptive coverage to the insurer or TPA, so
long as that entity does not also qualify for and invoke the exemption.
A number of states challenged the 2018 rules on various legal grounds. In 2020, the Supreme
Court upheld the rules, holding that the ACA authorized HHS to adopt them.350 While some
claims challenging the rules on other legal grounds are still pending in the lower courts,351 those
cases are stayed as of the date of this report’s publication.352 HHS has indicated that it is working
on potential amendments to the 2018 rules.353
Does Federal Law Require Private Health Insurance Coverage of Abortions or
Abortion Counseling?

Federal law does not generally require or prohibit private health insurance coverage of abortion
services. However, employers that provide health coverage to their employees must ensure
coverage for such services if a mother’s life would be endangered if the pregnancy were carried
to term.354
There are federal provisions addressing abortion coverage by private health insurance plans,
including qualified health plans (QHPs), which are private health insurance plans certified to
meet relevant requirements to be sold in the health insurance exchanges.355 For example, the ACA
specifies that none of its provisions “shall be construed” to require a QHP to cover abortion.356 In
addition, while federal EHB provisions generally require plans in the individual and small-group
markets (including QHPs) to provide coverage substantially similar to a state’s selected EHB

Services Under the Affordable Care Act,” 83 Federal Register 57536, November 15, 2018, at
https://www.federalregister.gov/documents/2018/11/15/2018-24512/religious-exemptions-and-accommodations-for-
coverage-of-certain-preventive-services-under-the. DOL, HHS, and the Treasury, “Moral Exemptions and
Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act,” 83 Federal Register
57592, November 15, 2018, at https://www.federalregister.gov/documents/2018/11/15/2018-24514/moral-exemptions-
and-accommodations-for-coverage-of-certain-preventive-services-under-the-affordable. See also Henry J. Kaiser
Family Foundation, “New Regulations Broadening Employer Exemptions to Contraceptive Coverage: Impact on
Women,” November 19, 2018, https://www.kff.org/health-reform/issue-brief/new-regulations-broadening-employer-
exemptions-to-contraceptive-coverage-impact-on-women/.
350 Little Sisters of the Poor Saints Peter & Paul Home v. Pennsylvania, 140 S. Ct. 2367, 2382 (2020).
351 See, for example, Memorandum of Law in Support of Plaintiffs’ Motion for Summary Judgment 1–2, Pennsylvania
v. Trump, No. 2:17-cv-04540 (E.D. Pa. Sept. 29, 2020) (arguing, inter alia, that the rules are “arbitrary and capricious”
under the Administrative Procedure Act and violate the First Amendment’s Establishment Clause).
352 See Order, Massachusetts v. HHS, No. 21-1076 (1st Cir. June 9, 2022) (holding appeal in abeyance for an additional
90 days); Order, Pennsylvania v. Biden, No. 2:17-cv-04540 (E.D. Pa. Jan. 3, 2022) (staying the case and directing the
federal government to file status reports every 90 days); California v. Becerra, No. 4:17-cv-05783 (N.D. Cal. Aug. 17,
2021) (staying the case and directing the parties to file a joint status report every three months).
353 Status Report at 3, California, No. 4:17-cv-05783 (N.D. Cal. May 2, 2022).
354 See 42 U.S.C. §2000e(k). Regulations promulgated by the Equal Employment Opportunity Commission (EEOC)
further provide: “Health insurance benefits for abortion, except where the life of the mother would be endangered if the
fetus were carried to term ... are not required to be paid by an employer; nothing herein, however, precludes an
employer from providing abortion benefits or otherwise affects bargaining agreements in regard to abortion.” 29 C.F.R.
§1604.10(b).
355 For more information on the exchanges and qualified health plans (QHPs), see CRS Report R44065, Overview of
Health Insurance Exchanges
.
356 42 U.S.C. §18023(b).
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benchmark plan, there is an exception for abortion. In other words, even if a state selects an EHB
benchmark plan that covers abortion services, applicable plans are not federally required to cover
abortion, in order to meet EHB standards.357
States are the primary regulators of private health insurance, and they may implement their own
abortion coverage requirements on the plans they regulate.358 The ACA specifies that states are
allowed to prohibit abortion coverage by QHPs offered in their exchange.359 Furthermore, federal
provisions regarding abortion coverage do not preempt any state laws “regarding the prohibition
of (or requirement of) coverage, funding, or procedural requirements on abortions.”360 This means
that beyond the issues discussed above, states are able to prohibit, or require, abortion coverage
by any or all of the plans they regulate. Regarding the EHB example above, even though plans
may not be federally required to cover abortion services, there may be applicable state
requirements.
Can Federal Funds Be Used to Pay for Abortion in Private Health
Insurance Plans?
There are restrictions related to the use of federal funds that reduce the cost of coverage in the
individual health insurance exchanges.361
Certain consumers purchasing QHP coverage in the individual exchanges are eligible to receive
premium tax credits (PTCs) from the federal government that effectively reduce the cost of
specified plans.362 As discussed above, there are limitations on the use of federal funds for certain
abortion services.363
Under the ACA, individuals who receive a PTC are permitted to select a QHP that includes
coverage for nontherapeutic or elective abortions. However, the issuer of such a plan cannot use
any funds attributable to the tax credit to pay for such services.364 The issuer is required to collect
two separate payments from each enrollee in the plan: one payment that reflects an amount equal
to the portion of the premium for coverage of health services other than elective abortions, and
another payment that reflects an amount equal to the actuarial value of the coverage for elective
abortions.365 The issuer is required to deposit the separate payments into separate allocation

357 45 C.F.R. §156.115(c). Also see the “Coverage of the Essential Health Benefits (EHB)” section of this report.
358 In general, states may regulate individual market plans and fully insured group plans but not self-insured group
plans. (See the introduction to this section of this report.)
359 42 U.S.C. §18023(a).
360 42 U.S.C. §18023(c).
361 For more detail on the issues discussed in this section, see the “Health Reform” section of CRS Report RL33467,
Abortion: Judicial History and Legislative Response.
362 Certain consumers who receive premium tax credits (PTCs) may also be eligible for cost-sharing reductions (CSRs)
that effectively reduce out of pocket costs associated with selected QHPs. The requirements described in this section
technically apply to both PTCs and CSRs (see 45 C.F.R. §156.280(e)). For background about CSRs and federal
payments, see Bipartisan Policy Center, “Stabilizing the Individual Insurance Market: What Happened and What
Next?,” March 2018, at https://bipartisanpolicy.org/wp-content/uploads/2019/03/BPC-Health-Stabilizing-The-
Individual-Health-Insurance-Market.pdf. Federal CSR payments are currently being litigated; see Katie Keith, “CSR
Litigation, New Non-ACA Plan Decision,” Health Affairs Blog, October 5, 2020, at https://www.healthaffairs.org/do/
10.1377/hblog20201005.420115/full/.
363 See the “Can Federal Funds Be Used to Pay for Abortions or Abortion Counseling?” section of this report. For more
information on PTCs, see CRS Report R44425, Health Insurance Premium Tax Credit and Cost-Sharing Reductions.
364 42 U.S.C. §18023(b)(2)(A).
365 Ibid. §18023(b)(2)(B)(i). Through rulemaking, different Administrations have taken varied approaches to
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accounts that consist solely of each type of payment and that are used exclusively to pay for the
specified services.366 State health insurance commissioners ensure compliance with the
segregation requirements in accordance with applicable provisions of generally accepted
accounting requirements, Office of Management and Budget (OMB) circulars on funds
management, and Government Accountability Office (GAO) guidance on accounting.367
Does Federal Law Require Private Health Insurance Coverage of
Infertility Services?

No federal law specifically addresses private health insurance coverage of infertility services.
However, the requirement that certain plans cover 10 categories of EHB may be relevant,
depending on state implementation.368 If a state selects a benchmark plan that includes infertility
services in one or more EHB categories, then applicable plans in that state must provide coverage
substantially similar to the benchmark plan’s coverage. EHB requirements apply to
nongrandfathered plans in the individual and small-group markets.
States are the primary regulators of private health insurance, and they may implement their own
infertility services coverage requirements on the plans they regulate.369
Does Federal Law Require Private Health Insurance Coverage of
Maternity Services?

There are federal requirements for private health insurance coverage of certain maternity services.
As stated above, one of the EHB categories of coverage is “maternity and newborn care.”370 This
means that nongrandfathered plans in the individual and small-group markets must provide
coverage of maternity and newborn care services substantially similar to such coverage provided
by the state’s EHB benchmark plan. The same is true of other EHB categories, some of which
may also include services relevant to maternity and newborn care.
In addition, the preventive services provision described above includes the requirement for
applicable plans to cover certain prenatal and postnatal services without cost sharing. This
includes, for example, well-woman visits that cover recommended preconception, prenatal, and
interconception care services, and breastfeeding services and supplies.371 Nongrandfathered
private health insurance plans offered in the individual, small-group, and large-group markets, as
well as self-insured plans, are subject to this coverage provision.
The Pregnancy Discrimination Act of 1978 (PDA, P.L. 95-555, as amended) requires applicable
employers offering health insurance to cover “expenses for pregnancy-related conditions on the

implementing this requirement. The most recent such rule, which also discusses prior rulemaking, is HHS, “Patient
Protection and Affordable Care Act; Updating Payment Parameters, Section 1332 Waiver Implementing Regulations,
and Improving Health Insurance Markets for 2022 and Beyond,” 86 Federal Register 53412, September 27, 2021,
starting at page 53447, regarding 45 C.F.R. §156.280.
366 Ibid. §18023(b)(2)(B)(ii).
367 Ibid. §18023(b)(2)(E)(i).
368 See the “Coverage of the Essential Health Benefits (EHB)” section of this report.
369 In general, states may regulate individual market plans and fully insured group plans but not self-insured group
plans. See the introduction to this section of this report.
370 See the “Coverage of the Essential Health Benefits (EHB)” section of this report.
371 See the “Coverage of Certain Preventive Services Without Cost Sharing” section of this report.
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same basis as expenses for other medical conditions” for employees enrolled in the group plan.372
If the group plan offers coverage to employees’ spouses and dependents, the requirement to cover
pregnancy-related services also applies to employees’ spouses, but not necessarily to other
dependents, enrolled in the plan.373
There do not appear to be specific requirements related to cost sharing, out-of-network coverage,
or medical management, other than the requirement that features of the plan related to coverage
of pregnancy-related conditions must not be substantially different than they are for other medical
conditions. For example, if a plan has an overall deductible, it cannot have a higher deductible for
pregnancy-related services. The PDA applies to employers with 15 or more employees, whether
the coverage is fully insured or self-insured.374
Finally, the Newborns’ and Mothers’ Health Protection Act of 1996 (P.L. 104-204, as amended)
prohibits plans from restricting the length of a hospital stay for childbirth for either the mother or
newborn child to less than 48 hours following vaginal deliveries and to less than 96 hours
following caesarian deliveries.375 In addition, prior authorization requirements for these stays are
prohibited. There is an exception to the length-of-coverage requirement when providers make
earlier discharge decisions in consultation with mothers. Plans are prohibited from offering
incentives or penalties to providers or mothers to encourage shorter stays.
Cost sharing is allowed, as long as the cost sharing for the portions of hospital stays addressed by
this law (those following deliveries) is not greater than cost sharing for preceding portions of such
stays. The law does not specify whether its requirements apply out-of-network.
The law generally applies to individual, small-group, large-group, and self-insured plans that
cover maternity-related hospital stays, regardless of grandfathered status. The law’s hospital stay
requirements do not apply when a state has its own law (meeting specified requirements) about
such hospital stays.
States are the primary regulators of private health insurance, and they may implement their own
maternity services coverage requirements on the plans they regulate.376

372 See 42 U.S.C. §2000e; 29 C.F.R. §1604.10, and, including for the language quoted above, 29 C.F.R. §1604,
Appendix to Part 1604—Questions and Answers on the Pregnancy Discrimination Act, P.L. 95-555, 92 Stat. 2076
(1978) (hereinafter referred to as “29 C.F.R. §1604 Appendix”). Also see EEOC, “Enforcement Guidance on
Pregnancy Discrimination and Related Issues” (particularly the “Health Insurance” section), June 25, 2015, at
https://www.eeoc.gov/laws/guidance/enforcement-guidance-pregnancy-discrimination-and-related-issues; and EEOC,
“Questions and Answers about the EEOC’s Enforcement Guidance on Pregnancy Discrimination and Related Issues”
U.S. EEOC, June 25, 2015, at https://www.eeoc.gov/laws/guidance/pregnancy_qa.cfm (hereinafter, “EEOC
Enforcement Guidance” and “EEOC Q&A,” respectively).
373 See 29 C.F.R. §1604 Appendix, questions 21-23 regarding coverage of pregnancy-related conditions for spouses
and dependents. Also note that other federal requirements are relevant to employers’ offer of coverage for dependents.
For example, most plans that offer dependent coverage are required to make that coverage available for both married
and unmarried adult children under the age of 26 (42 U.S.C. §300gg-14). In addition, the employer shared-
responsibility provisions generally incentivize large employers to offer adequate and affordable health insurance
coverage to their full-time employees and full-time employees’ children under the age of 26 (26 U.S.C.
§4980H). Separately, note that the requirements to cover EHB, and to cover certain preventive services without cost
sharing apply to all enrollees in a plan, including spouses and dependents. See 45 C.F.R. §156.115(a)(2) and ACA
Implementation FAQ XXVI.
374 EEOC Q&A. See this source for other entities subject to the PDA that are out of scope of this report.
375 42 U.S.C. §300gg-25; 45 C.F.R. §146.130.
376 In general, states may regulate individual market plans and fully insured group plans but not self-insured group
plans. (See the introduction to this section of this report.)
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Does Federal Law Require Private Health Insurance Coverage of Reproductive
Health Screening, Prevention, and Treatment Services?

The preventive services provision described above includes the requirement for applicable plans
to cover certain reproductive health screening and preventive services without cost sharing. This
includes, for example, screening and counseling for STIs/STDs; universal HIV screening; well-
woman visits; breast cancer screening, genetic testing, and preventive medications such as
Tamoxifen (to lower the risk of developing breast cancer among women with specified risk
factors); gynecological exams, Pap smears, and cervical cancer screenings; colorectal cancer
screenings; and the HPV vaccine.377
In June 2019, the USPSTF recommended the use of PrEP with effective antiretroviral therapy to
persons who are at high risk of HIV acquisition.378 By regulation, the requirement to cover this
service without cost sharing (subject to limitations already discussed) applied for plan years
beginning one year later.379 Per federal guidance, plans are also required to cover ancillary
services such as blood testing recommended to monitor one’s health status while on PrEP.380
If a screening results in a diagnosis of a condition such as an STI or reproductive cancer, no
federal laws specifically mandate coverage of treatment services. However, treatments for various
conditions may be covered under different EHB categories in the benchmark plans that states
select, which would require applicable plans to cover such treatments.381
In addition, the Women’s Health and Cancer Rights Act of 1998 (P.L. 105-277, as amended)
states that if plans provide coverage for mastectomies, they must also cover breast reconstruction
services and prostheses. Despite the name of the law, this requirement is applicable for female
and male enrollees, and the mastectomy does not need to have been connected to a cancer
diagnosis. The requirement applies to individual, small-group, large-group, and self-insured
plans, regardless of grandfathered status.382
States are the primary regulators of private health insurance, and they may implement their own
reproductive health screening and prevention (and treatment) services coverage requirements on
the plans they regulate.383

377 See the “Coverage of Certain Preventive Services Without Cost Sharing” section of this report.
378 USPSTF, “Final Recommendation Statement Prevention of Human Immunodeficiency Virus (HIV) Infection:
Preexposure Prophylaxis,” June 11, 2019, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/
prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis.
379 45 C.F.R. §147.130(b). Group plan years do not necessarily align with the calendar year, and this requirement was
in effect for any group plans beginning in the second half of 2020. For plans in the individual market, this generally
became effective as of plan year (calendar year) 2021.
380 DOL, HHS, and the Treasury, “FAQS ABOUT AFFORDABLE CARE ACT IMPLEMENTATION PART 47,”
July 19, 2021, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-Part-47.pdf.
381 See the “Coverage of the Essential Health Benefits (EHB)” section of this report.
382 29 U.S.C. §1185b, 42 U.S.C. §300gg-27, and 42 U.S.C. §300gg-52. Also see Employee Benefits Security
Administration, “Compliance Assistance Guide: Health Benefits Coverage Under Federal Law….” September 2014, at
https://www.dol.gov/general/topic/health-plans/womens. See DOL, HHS, and the Treasury, “Faqs About Affordable
Care Act Implementation Part 31, Mental Health Parity Implementation, And Women’s Health And Cancer Rights Act
Implementation,” April 20, 2016, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-
31_Final-4-20-16.pdf, for additional details.
383 In general, states may regulate individual market plans and fully insured group plans but not self-insured group
plans. (See the introduction to this section of this report.)
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Does Federal Law Require Private Health Insurance Coverage of Gender-
Affirming Services?

No federal law specifically requires private health insurance coverage of gender-affirming
services.
However, the requirement that certain plans cover 10 categories of EHB may be relevant,
depending on state implementation. If a state selects a benchmark plan that includes coverage of
gender-affirming services in one or more EHB categories, then applicable plans in that state
would be required to offer substantially similar coverage.384
One federal requirement, Section 1557 of the ACA, has been implemented differently by
presidential administrations with respect to private health insurance coverage of gender-affirming
services. This provision “prohibits discrimination on the basis of race, color, national origin, sex,
age, or disability in certain health programs or activities.”385 Regulations issued in May 2016
interpreted the prohibition on discrimination “on the basis of sex” to include, among other things,
a prohibition on applicable plans from “hav[ing] or implement[ing] a categorical coverage
exclusion or limitation for all health services related to gender transition.”386 Regulations issued
in June 2020 repealed this prohibition.387 Following the Supreme Court’s decision in Bostock v.
Clayton County
, HHS announced that it will issue a proposed rule addressing prohibited sex
discrimination on the basis of sexual orientation and gender identity under ACA Section 1557.388
States are the primary regulators of private health insurance, and they may implement their own
gender-affirming services coverage requirements on the plans they regulate.389

384 See the “Coverage of the Essential Health Benefits (EHB)” section of this report.
385 Section 1557 of the ACA is codified at 42 U.S.C. §18116.
386 HHS, “Nondiscrimination in Health Programs and Activities,” 81 Federal Register 31375, May 18, 2016. See
discussion and language adopted for 45 C.F.R. §92.207, which included the gender affirming services provision quoted
above, among other coverage-related provisions. Discussion of applicability of this requirement to types of plans and
other “covered entities” starts at page 31428 of the rule.
387 HHS, “Nondiscrimination in Health and Health Education Programs or Activities, Delegation of Authority,” 85
Federal Register 37160, June 19, 2020. See pages 37196, 37200-01.
388 See Bostock v. Clayton Cnty., 140 S. Ct. 1731, 1737 (2020); HHS, Office for Civil Rights (OCR), “Section 1557 of
the Patient Protection and Affordable Care Act,” updated May 25, 2022, at https://www.hhs.gov/civil-rights/for-
individuals/section-1557/index.html. For other discussion of prior and potential rulemaking, see Katie Keith, “Final
2023 Payment Rule, Part 1: Essential Health Benefits And Other Market Reforms,” April 29, 2022, at
https://www.healthaffairs.org/do/10.1377/forefront.20220429.865892/ and CRS Report R46832, Potential Application
of Bostock v. Clayton County to Other Civil Rights Statutes
.
389 In general, states may regulate individual market plans and fully insured group plans but not self-insured group
plans. (See the introduction to this section of this report).
Congressional Research Service

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Table 4. Federal Requirements on Private Health Insurance Coverage of Reproductive Health Services
Group Marketc











Fully Insurede


Authority
Provision
Coverage and Cost-Sharing
Medical Management
Applies
Large
Small
Self-
Individual
Requirements
Approaches
Out-of-
Groupg Groupg Insuredf Marketd
Allowed?a
Network?b
Requirements applicable to coverage of various reproductive health services
42 U.S.C. §300gg-6, Coverage of
Applicable plans are required to cover 10
Allowed; may vary by
No
N.A.

N.A.

42 U.S.C. §18022
Essential Health
categories of health care services.h EHB
plan

Benefits (EHB)
requirements apply to coverage of certain
45 C.F.R. §156.100-
reproductive health services, in some cases
155,
subject to state and plan variation.
45 C.F.R. §147.150

Cost sharing is possible and may vary by plan.
There are provisions limiting cost sharing on
the EHB.i
42 U.S.C. §300gg-13 Coverage of
Specified items and services (including various Allowed; may vary by
No





Preventive Services reproductive health services) must be covered plan
45 C.F.R. §147.130- Without Cost
without cost sharing if recommended by the
133
Sharing
ACIP or USPSTF, or if listed in HRSA guidelines
for women’s or pediatric preventive services.j
Contraceptive services
42 U.S.C. §300gg-13 Applicability of
Applicable plans are required to cover HRSA-
Allowed; may vary by
No





preventive services
recommended women’s preventive services
plan
45 C.F.R. §147.130- requirement
without cost sharing, which includes specified
133
contraceptive items and services.k

An exemption is available to most types of
nonprofit and for-profit entities with sincerely
held religious or moral beliefs against
contraception.
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Group Marketc











Fully Insurede


Authority
Provision
Coverage and Cost-Sharing
Medical Management
Applies
Large
Small
Self-
Individual
Requirements
Approaches
Out-of-
Groupg Groupg Insuredf Marketd
Allowed?a
Network?b
Abortion services and counselingl
42 U.S.C. §18023
Applicability of EHB Even if a state selects an EHB benchmark plan N.A.
N.A.
N.A.

N.A.


requirement
that provides abortion coverage, plans in the
45 C.F.R.
state that are otherwise subject to EHB
§156.115(c) and 45
requirements are not federally required to
C.F.R. §156.122(b),
provide abortion coverage.
each referencing
45 C.F.R. §156.280
42 U.S.C. §18023
Provisions affecting
A state is allowed to prohibit abortion coverage N.A.
N.A.
N.A.
QHPs in N.A.
QHPs in

QHPs sold in
by QHPs offered in its exchange.
SHOPs
exchanges
45 C.F.R. §156.280m exchanges

Insurers offering QHPs that cover
nontherapeutic abortions may not use federal
funds (attributable to eligible individuals’ PTCs)
to pay for such services. There are related rules
about segregation of plan payments for
nontherapeutic abortion services versus other
covered services.
42 U.S.C. §18023
Federal non-
Federal provisions do not preempt state
N.A.
N.A.


N.A.


preemption of state abortion laws. States may prohibit, require, and
45 C.F.R. §156.280 laws
otherwise regulate abortion coverage by the
plans they regulate.
42 U.S.C. §2000e
Applicability of
This provision does not require coverage of
See “Coverage of Pregnancy-Related



N.A.

pregnancy-related
abortion, “except where the life of the mother Conditions on the Same Basis as Other
(groups
conditions
would be endangered if the fetus were carried Medical Conditions” in this table.
29 C.F.R.
over 15)
requirement
to term or where medical complications have
§1604.10(b)
arisen from an abortion,” while “nothing herein,
however, precludes an employer from providing
abortion benefits or otherwise affects bargaining
agreements in regard to abortion.”
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Group Marketc











Fully Insurede


Authority
Provision
Coverage and Cost-Sharing
Medical Management
Applies
Large
Small
Self-
Individual
Requirements
Approaches
Out-of-
Groupg Groupg Insuredf Marketd
Allowed?a
Network?b
Infertility servicesl
42 U.S.C. §300gg-6, Applicability of EHB If a state selects a benchmark plan that includes Allowed; may vary by
No
N.A.

N.A.

42 U.S.C. §18022
requirement
infertility treatments in one or more EHB
plan
categories, applicable plans in that state would

be required to offer substantially similar
45 C.F.R. §156.115
coverage.
Maternity services
42 U.S.C. §300gg-6, Applicability of EHB One of the 10 EHB categories is “maternity and Allowed; may vary by
No
N.A.

N.A.

42 U.S.C. §18022
requirement
newborn care.” Applicable plans must cover this plan

category, and services in any other category
45 C.F.R. §156.110,
that may be relevant, in a substantially similar
45 C.F.R. §156.115
manner as the state’s EHB benchmark plan.
42 U.S.C. §300gg-13 Applicability of
This provision includes the requirement for
Allowed; may vary by
No





preventive services
applicable plans to cover certain prenatal and
plan
45 C.F.R. §147.130 requirement
post-natal services without cost sharing.j
42 U.S.C. §2000e
Coverage of
Applicable employers offering health insurance must cover “expenses for pregnancy-



N.A.

Pregnancy-Related related conditions on the same basis as expenses for other medical conditions” for
(groups
29 C.F.R. §1604.10, Conditions on the employees enrol ed in the group plan. Plan features (e.g., cost-sharing requirements,
over 15)
29 C.F.R. §1604
Same Basis as
medical management requirements, out-of-network coverage) as related to pregnancy-
Appendixn
Other Medical
related conditions must not be substantially different than they are for other covered
Conditionso
medical conditions.

If the plan offers coverage to employees’ spouses and dependents, this also applies to
employees’ spouses, but not necessarily to other dependents, enrol ed in the plan.
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Group Marketc











Fully Insurede


Authority
Provision
Coverage and Cost-Sharing
Medical Management
Applies
Large
Small
Self-
Individual
Requirements
Approaches
Out-of-
Groupg Groupg Insuredf Marketd
Allowed?a
Network?b
42 U.S.C. §300gg-25 Minimum Hospital Plans that cover maternity hospital stays are
Prior authorization
Not specified ✓ (GF)r ✓ (GF)r ✓ (GF)r ✓ (GF)r

Stay After
prohibited from restricting the length of a
requirements for these
45 C.F.R. §146.130, Childbirthp
hospital stay for childbirth for either the mother stays, and incentives
45 C.F.R. §148.170
or newborn child to less than 48 hours
offered for shorter stays,
fol owing vaginal deliveries and to less than 96 are prohibited.q
hours fol owing caesarian deliveries. Cost
sharing is allowed, as specified.q
Reproductive health screening, prevention, and treatment services
42 U.S.C. §300gg-13 Applicability of
This provision includes the requirement that
Allowed; may vary by
No





preventive services
specified reproductive health screening and
plan
45 C.F.R. §147.130 requirement
preventive services must be covered without
cost sharing.j
42 U.S.C. §300gg-27 Reconstruction
Plans that provide coverage for mastectomies
Not specified
Not specified ✓ (GF)r ✓ (GF)r ✓ (GF)r ✓ (GF)r
After Mastectomys must also cover breast reconstruction services
and prostheses. This applies for women and
men, and it need not be connected to a cancer
diagnosis. Cost sharing is allowed, if consistent
with cost sharing for other covered
medical/surgical benefits.t
Gender-affirming servicesl
42 U.S.C. §300gg-6, Applicability of EHB If a state selects a benchmark plan that includes Allowed; may vary by
No
N.A.

N.A.

42 U.S.C. §18022
requirement
gender-affirming services in one or more EHB plan
categories, applicable plans in that state would

be required to offer substantially similar
45 C.F.R. §156.115
coverage.
Source: CRS analysis of relevant legislation, statute, regulation, and guidance.
Notes: Checkmark () indicates that the requirement is applicable to that type of health plan. The variation (+GF) indicates that the requirement is also applicable to
grandfathered plans; see table note “r”. N.A. indicates that the requirement is not applicable to that type of health plan.
CRS-68


EHB = essential health benefits. USPSTF = United States Preventive Services Task Force. ACIP = Advisory Committee on Immunization Practices. HRSA = U.S. Health
Resources and Services Administration. FDA = U.S. Food and Drug Administration. QHP = qualified health plan. SHOP = Small Business Health Options Program.
The requirements listed in the table are not a comprehensive list of all federal requirements and standards that apply to all health plans that may be related to
reproductive health. Listed requirements are provisions of the Patient Protection and Affordable Care Act (ACA, P.L. 111-148 as amended), unless otherwise specified.
a. An example of a medical management technique that insurers may use, as allowed, is requiring that an enrol ee obtain prior authorization from the insurer for
coverage of certain services before using them. For more information, see the appendix of CRS Report RL32237, Health Insurance: A Primer.
b. All requirements apply to services or items furnished in-network. Under private insurance, benefit coverage and consumer cost sharing are often contingent upon
whether a service or item is furnished by a provider that the insurer has contracted with (i.e., whether that provider is in network for a given plan). In instances
where a contract between an insurer and provider does not exist, the provider is considered out of network. For more information, see the background section of
CRS Report R46116, Surprise Billing in Private Health Insurance: Overview and Federal Policy Considerations.
c. Health insurance may be provided to a group of people who are drawn together by an employer or other organization, such as a trade union. Such groups generally
are formed for purposes other than obtaining insurance, such as employment. When insurance is provided to a group, it is referred to as group coverage or group
insurance
. In the group market, the entity that purchases health insurance on behalf of a group is referred to as the plan sponsor.
d. Consumers who are not associated with a group can obtain health coverage by purchasing it directly from an insurer in the individual (or nongroup) health
insurance market.
e. A fully insured health plan is one in which the plan sponsor purchases health coverage from a state-licensed insurer; the insurer assumes the risk of paying the
medical claims for benefits covered under the health plan of the sponsor’s enrol ed members.
f.
Self-insured plans refer to health coverage that is provided directly by the organization sponsoring coverage for its members (e.g., a firm providing health benefits to
its employees). Such organizations set aside funds and pay for health benefits directly. Under self-insurance, the organization bears the risk for covering medical
claims. In general, the size of a self-insured employer does not affect the applicability of federal requirements.
g. In general, for purposes of health insurance requirements, small groups are those with 50 or fewer individuals (e.g., employees). States can also define small groups as
having 100 or fewer individuals. The definition of large group is 51 or more individuals, or 101 or more individuals, depending on the definition of small group.
h. The 10 categories of essential health benefits (EHB) are ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health
and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services;
preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
i.
See CRS Report R45146, Federal Requirements on Private Health Insurance Plans, regarding several federal requirements relevant to consumer cost sharing on the EHB
(e.g., annual out-of-pocket limits, minimum actuarial value requirements, and prohibition on lifetime limits and annual limits). Certain types of plans—self-insured
plans and plans offered in the large-group market—must comply with these requirements even though they are not required to cover the EHB. HHS has indicated
that such plans must use a permissible definition of EHB (including any state-selected EHB benchmark plans) to determine whether they comply with the
requirement.
j.
The preventive services that must be covered are listed in their entirety at Healthcare.gov, “Preventive health services,” https://www.healthcare.gov/preventive-care-
benefits/. Cost sharing for office visits associated with applicable vaccinations and other preventive services may or may not be allowed. In general, this depends on
whether the preventive service or item was the primary purpose of the visit, and whether the service or item was bil ed or tracked separately from the office visit.
See 45 C.F.R. §147.130(a)(2).
k. See HRSA, “Women’s Preventive Services Guidelines,” initially released August 1, 2011, updated December 2021, at https://www.hrsa.gov/womens-guidelines/
index.html. Also see FDA, “Birth Control Guide,” updated June 2021, at https://www.fda.gov/consumers/free-publications-women/birth-control.
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link to page 70 link to page 67
l.
No federal law specifically requires or prohibits private health insurance coverage of abortion services and counseling, infertility services, or gender-affirming
services. (See the “Does Federal Law Require Private Health Insurance Coverage of Gender-Affirming Services?” section of this report for discussion of the different
interpretations of the applicability of ACA Section 1557 to coverage of gender-affirming services.)
m. The individual exchanges and smal -business health options program (SHOP) exchanges are virtual marketplaces in which consumers and small businesses,
respectively, can shop for and purchase private health insurance coverage. Qualified health plans (QHPs) are private health insurance plans certified to be sold in the
individual and SHOP exchanges, and they must meet all requirements applicable to the individual and small-group markets, respectively, plus certain additional
requirements. For more information, see CRS Report R44065, Overview of Health Insurance Exchanges.
n. Title 29 of the Code of Federal Regulations, Appendix to Part 1604—Questions and Answers on the Pregnancy Discrimination Act, P.L. 95-555, 92 Stat. 2076
(1978).
o. This provision is from the Pregnancy Discrimination Act of 1978 (PDA, P.L. 95-555, as amended).
p. This provision is from the Newborns’ and Mothers’ Health Protection Act of 1996 (P.L. 104-204, as amended).
q. See the “Does Federal Law Require Private Health Insurance Coverage of Maternity Services?” section of this report for additional details.
r. Grandfathered plans are individual or group plans in which at least one individual was enrol ed as of enactment of the Patient Protection and Affordable Care Act
(ACA; P.L. 111-148, as amended), and which continue to meet certain criteria. Plans that maintain their grandfathered status are exempt from some federal
requirements.
s. This provision is from the Women’s Health and Cancer Rights Act of 1998 (P.L. 105-277, as amended).
t.
See Employee Benefits Security Administration, “Compliance Assistance Guide: Health Benefits Coverage Under Federal Law…”, September 2014, at
https://www.dol.gov/general/topic/health-plans/womens. See Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury, “FAQs About
Affordable Care Act Implementation Part 31, Mental Health Parity Implementation, and Women’s Health and Cancer Rights Act Implementation,” April 20, 2016, at
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-31_Final-4-20-16.pdf, for additional detail.

CRS-70

Federal Support for Reproductive Health Services: Frequently Asked Questions

Grant Programs Focused on Reproductive Health
The following sections discuss federal programs that focus on one or more specific reproductive
health topics. The first two programs—family planning and teen pregnancy prevention
programs—discuss each of the six reproductive health service categories included in this report.
The final three questions focus on programs that provide specific reproductive health services;
these questions discuss information about program missions and the specific services provided.
The Title X Family Planning Program
The Title X Family Planning Program (Title X) was enacted in 1970 as Title X of the PHSA.390
Title X provides grants to public and nonprofit agencies for family planning services, research,
and training. The Office of Population Affairs (OPA) within HHS administers Title X, which is
the only domestic federal program devoted solely to family planning and related preventive
health services.391
In 2019, HHS promulgated a rule that, among other things, prohibited Title X projects from
referring clients for abortion as a method of family planning. It also required physical separation
between Title X projects and certain abortion-related activities. The 2019 rule took effect in all
states except Maryland, where it was enjoined.392
In 2021, HHS promulgated a new rule that, among other things, revokes the 2019 rule in its
entirety. For example, it requires Title X projects to provide an abortion referral if requested by
the client and removes the physical separation requirement. The 2021 rule has been in effect since
November 8, 2021.393 This report describes the Title X program under the 2021 rule that is
currently in effect.
Title X grantees can provide family planning services directly or they can subaward Title X
monies to other entities to provide services. In 2020, the most recent year for which client data
are available, Title X projects served 1.5 million clients through 3,031 clinics operated by 75
grantees or their 867 subrecipients (also known as subgrantees or subawardees).394
In 2022, HHS told CRS:

390 Title X was enacted by P.L. 91-572, Family Planning Services and Population Research Act of 1970. It is codified
as amended at 42 U.S.C. §§300 through 300a-6.
391 CRS In Focus IF10051, Title X Family Planning Program.
392 Office of the Assistant Secretary for Health (OASH), Office of the Secretary, HHS, “Compliance With Statutory
Program Integrity Requirements,” 84 Federal Register 7714, March 4, 2019, https://www.federalregister.gov/d/2019-
03461; CRS In Focus IF11142, Title X Family Planning Program: 2019 Final Rule.
393 Office of the Assistant Secretary for Health, Office of the Secretary, Department of Health and Human Services
(HHS), “Ensuring Access to Equitable, Affordable, Client-Centered, Quality Family Planning Services,” 86 Federal
Register
56144-56180, October 7, 2021, https://www.federalregister.gov/d/2021-21542; CRS In Focus IF11986, Title X
Family Planning Program: 2021 Final Rule.

394 Christina Fowler, Julia Gable, and Beth Lasater, Family Planning Annual Report: 2020 National Summary, HHS,
OPA, September 2021, https://opa.hhs.gov/sites/default/files/2021-09/title-x-fpar-2020-national-summary-sep-
2021.pdf. More grantees are participating in the program for FY2022; the May 2022 Family Planning Directory lists 96
grantees that operate Title X family planning services projects. HHS, OPA, Title X Family Planning Directory, May
2022, https://opa.hhs.gov/sites/default/files/2022-06/Title%20X%20Directory%20-%20May_2022_508.pdf. Current
and past directories of Title X grantees, subawardees, and service sites are at HHS, OPA, Current Title X Service
Grantees
, https://opa.hhs.gov/grant-programs/title-x-service-grants/current-title-x-service-grantees.
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HHS’s Title X grantees provide contraceptive education and counseling; breast and
cervical cancer screening; testing for sexually transmitted infections and HIV, referral, and
prevention education; and pregnancy diagnosis and counseling, using a combination of
funding sources to cover the costs for eligible clients. Under the 2021 Title X final rule,
Title X funds are awarded to provide high-quality, affordable, and confidential voluntary
family planning and related preventive health services to either help achieve or prevent
pregnancy. HHS’s Office of Population Affairs requires all family planning services to be
delivered consistent with nationally recognized standards of care, including nondirective
pregnancy options counseling and referral. Moreover, Title X-funded sites not offering a
broad range of methods on-site must provide a prescription to the client for their method
of choice or referrals, as requested.395
Title X projects are required to provide services free of charge for individuals under 100% of the
federal poverty level and to provide sliding scale fees for individuals between 100% and 250% of
the federal poverty level. For unemancipated minors who request confidential services, eligibility
for discounts is based on the minor’s own income.396
Do Title X Projects Provide Reproductive Health Services?
Title X regulations define family planning services to include certain reproductive health services,
such as
a broad range of medically approved services, which includes Food and Drug
Administration (FDA)-approved contraceptive products and natural family planning
methods, for clients who want to prevent pregnancy and space births, pregnancy testing
and counseling, assistance to achieve pregnancy, basic infertility services, sexually
transmitted infection (STI) services, and other preconception health services.397
The program’s clinical guidelines include reproductive health services, such as breast and
cervical cancer screening and prevention; STD and HIV prevention education, counseling,
testing, and referral; preconception health services; basic infertility services; and counseling on
establishing a reproductive life plan.398
Do Title X Projects Provide Contraceptive Services?
As noted above, program regulations define family planning services to include FDA-approved
contraceptive products.399 Program regulations require that each Title X project must provide “a
broad range of acceptable and effective medically approved family planning methods (including
natural family planning methods).... If an organization offers only a single method of family
planning, it may participate as part of a project as long as the entire project offers a broad range of
acceptable and effective medically approved family planning methods and services. Title X
service sites that are unable to provide clients with access to a broad range of acceptable and

395 Email from the HHS Office of the Assistant Secretary for Legislation, July 1, 2022.
396 42 C.F.R. §59.2, definition for “Low-income family”; 42 C.F.R. §59.5(a)(7)-(8).
397 42 C.F.R. §59.2, definition for “Family planning services.”
398 Loretta Gavin, Susan Moskosky, 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; and HHS, OPA, Quality Family Planning,
https://opa.hhs.gov/grant-programs/title-x-service-grants/about-title-x-service-grants/quality-family-planning. See also
HHS, OPA, Key Issues for Title X Grantees, https://opa.hhs.gov/grant-programs/title-x-service-grants/about-title-x-
service-grants/key-issues-title-x-grantees.
399 42 C.F.R. §59.2; see text box in “What Are Contraceptive Services?”.
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effective medically approved family planning methods and services, must be able to provide a
prescription to the client for their method of choice or referrals to another provider, as
requested.”400 Program regulations also require projects to “provide for medical services related
to family planning (including consultation by a clinical services provider, examination,
prescription and continuing supervision, laboratory examination, contraceptive supplies), in
person or via telehealth, and necessary referral to other medical facilities when medically
indicated, and provide for the effective usage of contraceptive devices and practices.” The
regulations permit the HHS Secretary to omit this requirement, with an established good cause.401
Title X clinical guidelines published in 2014 advise providers that “contraceptive services should
include consideration of a full range of FDA-approved contraceptive methods, a brief
assessment to identify the contraceptive methods that are safe for the client, contraceptive
counseling to help a client choose a method of contraception and use it correctly and
consistently, and provision of one or more selected contraceptive method(s), preferably on site,
but by referral if necessary” (see text box in “What Are Contraceptive Services?”).402
The Family Planning Annual Report presents the following 2020 data on female Title X clients’
primary contraceptive methods:403
 19% relied on the “most effective” methods (including vasectomy, female
sterilization, implants, and IUDs);
 38% relied on “moderately effective” methods (including injectable
contraception, vaginal ring, contraceptive patch, pills, diaphragm with
spermicidal cream/jelly, and the cervical cap);
 16% relied on “less effective” methods (including male condoms, female
condoms, the vaginal sponge, withdrawal, fertility awareness-based methods
(FAM) and lactational amenorrhea methods (LAM), and spermicides);
 5% relied on abstinence;
 14% used no contraceptive methods, for example because they were pregnant or
seeking to become pregnant; and
 for 7%, the primary contraceptive method was unknown.

400 42 C.F.R. §59.5(a)(1).
401 42 C.F.R. §59.5(b)(1).
402 Title X clinical guidelines are laid out in HHS, OPA, Quality Family Planning, https://opa.hhs.gov/grant-programs/
title-x-service-grants/about-title-x-service-grants/quality-family-planning. See also HHS, OPA, Key Issues for Title X
Grantees
, https://opa.hhs.gov/grant-programs/title-x-service-grants/about-title-x-service-grants/quality-family-
planning. FDA-approved contraceptive methods are listed in Loretta Gavin, Susan Moskosky, Marion Carter, et al.,
“Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs,”
Figure 3, “The typical effectiveness of Food and Drug Administration–approved contraceptive methods,” p. 10; and
FDA, Birth Control Chart, https://www.fda.gov/consumers/free-publications-women/birth-control-chart.
403 Christina Fowler, Julia Gable, and Beth Lasater, Family Planning Annual Report: 2020 National Summary, pp. 34-
35. Percentages may not sum to 100% due to rounding. Illustrations of contraceptive methods and their effectiveness
are in Kathryn M. Curtis, Naomi K. Tepper, Tara C. Jatlaoui, et al., “U.S. Medical Eligibility Criteria for Contraceptive
Use, 2016,” Morbidity and Mortality Weekly Report, Recommendations and Reports, July 29, 2016, “Figure:
Effectiveness of Family Planning Methods,” https://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm#F-1-1_down.
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Do Title X Projects Provide Abortions or Abortion Counseling?
By law, Title X funds may not be used for abortions.404 Under program guidance, the prohibition
on abortion does not apply to all the activities of a Title X grantee; it applies only to activities that
are within the Title X project. The grantee’s abortion activities have to be “separate and distinct”
from the Title X project activities.405 The guidance notes that “a Title X project may not provide
services that directly facilitate the use of abortion as a method of family planning, such as
providing transportation for an abortion, explaining and obtaining signed abortion consent forms
from clients interested in abortions, negotiating a reduction in fees for an abortion, and scheduling
or arranging for the performance of an abortion, promoting or advocating abortion within Title X
program activities, or failing to preserve sufficient separation between Title X program activities
and abortion-related activities.”406
Program regulations require Title X projects to offer pregnant clients information and counseling
on each of the following options: prenatal care and delivery; infant care, foster care, or adoption;
and pregnancy termination.407 If the client requests such information and counseling, the project
has to give “neutral, factual information and nondirective counseling on each of the options, and
referral upon request, except with respect to any option(s) about which the pregnant client
indicates they do not wish to receive such information and counseling.”408
Do Title X Projects Provide Infertility Services?
Title X regulations require projects to provide “basic infertility services”409 and clinical guidelines
state that “infertility visits to a family planning provider are focused on determining potential
causes of the inability to achieve pregnancy and making any needed referrals to specialist
care.”410
A 2015 survey of publicly funded family planning clinics found that 60% of Title X clinics
provided infertility counseling onsite, while 37% referred clients to another clinic or provider.

404 42 U.S.C. §300a-6. In addition, language in annual Departments of Labor, Health and Human Services, and
Education, and Related Agencies appropriations bills have also stated that Title X funds “shall not be expended for
abortions.” (In FY2022, this provision appeared in Consolidated Appropriations Act, 2022 [P.L. 117-103], Division H,
Title II).
405 HHS, OPA, “Provision of Abortion-Related Services in Family Planning Services Projects,” 65 Federal Register
41281-41282, July 3, 2000, https://federalregister.gov/a/00-16759. Program guidance states that a grantee’s abortion-
related activities and its Title X project activities can share the same facility, staff, waiting room, and records system,
“so long as it is possible to distinguish between the Title X supported activities and non-Title X abortion-related
activities,” for example, through allocating and prorating costs. Specifically, a Title X project’s non-Title X abortion-
related activities have to be distinguishable from the project’s Title X activities. The above 2000 guidance is cited in
the 2021 rule’s preamble at 86 Federal Register 56150: “In readopting the 2000 rule, the program is also reinstating
interpretations and policies under section 1008 of the statute that were in place for much of the program’s history and
published in the Federal Register in 2000. 65 FR 41281 (July 3, 2000).”
406 65 Federal Register 41281.
407 42 C.F.R. §59.5(a)(5)(i).
408 42 C.F.R. §59.5(a)(5)(ii). The Title X program funds the Reproductive Health National Training Center (RHNTC),
which offers training to Title X providers; RHNTC training resources on nondirective counseling include Exploring All
Options: Pregnancy Counseling Without Bias Video
, https://rhntc.org/resources/exploring-all-options-pregnancy-
counseling-without-bias-video.
409 42 C.F.R. §59.5(a)(1). Program regulations also define family planning services as including “basic infertility
services” (42 C.F.R. §59.2).
410 Loretta Gavin, Susan Moskosky, Marion Carter, et al., “Providing Quality Family Planning Services:
Recommendations of CDC and the U.S. Office of Population Affairs.”
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Fifty-four percent of Title X clinics provided basic infertility testing (such as pelvic exams or
hormone levels) onsite, while 37% referred clients to another clinic or provider. 411
Do Title X Projects Provide Maternity Services?
HHS told CRS in 2020:
Title X grantees provide a broad range of family planning and preventive services related
to achieving pregnancy, preventing pregnancy, and assisting women, men, and couples
with achieving their desired number and spacing of children. Services centered around
preconception health and achieving pregnancy, include:
 Basic infertility services;
 Sexually transmitted infection (STI) prevention education, screening, and treatment;
 HIV testing and referral for treatment when appropriate; and
 Screening for substance use disorders and referral when appropriate to help reduce
adverse pregnancy-related outcomes and improve individuals’ reproductive health
generally.
Services to manage pregnancy (e.g., prenatal and delivery care) are out of the scope of Title
X funding.412
Program regulations require Title X projects to provide a broad range of family planning services,
including “pregnancy testing and counseling.”413 With respect to pregnancy counseling,
regulations require Title X projects to offer pregnant clients information and counseling on each
of the following options: prenatal care and delivery; infant care, foster care, or adoption; and
pregnancy termination.414 If the client requests such information and counseling, the project has
to give “neutral, factual information and nondirective counseling on each of the options, and
referral upon request, except with respect to any option(s) about which the pregnant client
indicates they do not wish to receive such information and counseling.”415
With respect to referrals, regulations generally require Title X projects to provide for
“coordination and use of referrals and linkages with primary healthcare providers, other providers
of healthcare services, local health and welfare departments, hospitals, voluntary agencies, and
health services projects supported by other federal programs, who are in close physical proximity

411 Mia R. Zolna and Jennifer J. Frost, Publicly Funded Family Planning Clinics in 2015: Patterns and Trends in
Service Delivery Practices and Protocols
, pp. 36, 52. An earlier 2013-2014 survey, conducted before Title X’s current
clinical guidelines were published, asked a sample of Title X clinics about infertility services; see Ana Carolina Loyola
Briceno, Katherine A.Ahrens, Marie E.Thoma, et al., “Availability of Services Related to Achieving Pregnancy in U.S.
Publicly Funded Family Planning Clinics,” Women’s Health Issues, vol. 29, no. 6 (November-December 2019), pp.
447-454. It states: “Our study characterizes the delivery of these services in publicly funded clinics before the
publication of the 2014 QFP [Quality Family Planning] recommendations.” QFP contains Title X clinical guidelines.
412 Email from the HHS Office of the Assistant Secretary for Legislation, July 1, 2022.
413 42 C.F.R. §59.5(a)(1). Program regulations also define family planning services as including “pregnancy testing and
counseling” (42 C.F.R. §59.2).
414 42 C.F.R. §59.5(a)(5)(i).
415 42 C.F.R. §59.5(a)(5)(ii). Title X funds the Reproductive Health National Training Center (RHNTC), which offers
training to Title X service providers; RHNTC training resources on nondirective counseling include Exploring All
Options: Pregnancy Counseling Without Bias Video
, https://rhntc.org/resources/exploring-all-options-pregnancy-
counseling-without-bias-video.
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to the Title X site, when feasible, in order to promote access to services and provide a seamless
continuum of care.”416
Do Title X Projects Provide Reproductive Health Screening, Prevention, and
Treatment Services?

Title X clinical guidelines recommend that providers offer STI services in accordance with the
CDC’s STI treatment and HIV testing guidelines, and cervical and breast cancer screening in
accordance with professional recommendations such as USPSTF recommendations.417 Title X
clinical guidelines also recommend certain other “related preventive health services”, such as
taking a medical history.418 A 2015 survey of publicly funded family planning clinics found the
following percentages of Title X clinics that provided certain services onsite:
 94% provided HIV testing,
 26% provided PrEP for HIV,
 99% provided chlamydia/gonorrhea screening/testing, 94% offered syphilis
screening/testing, 97% provided Pap tests,
 69% provided combined Pap and DNA testing,
 36% provided colposcopy (examination of the cervix and vagina),
 98% provided clinical breast exams, and
 14% provided mammography. 419
In March 2019, an HHS blog post stated that “currently, nearly 90 percent of Title X sites provide
HIV testing and approximately one-third of sites offer PrEP.”420
In general, Title X services focus on family planning and related preventive health services, but
treatment services are more limited. Title X clinical guidelines do recommend that providers offer
STI services in accordance with the CDC’s STI treatment guidelines.421 A 2015 survey of publicly
funded family planning clinics found that 99% provided or prescribed STI treatment onsite.422
With regard to HIV/AIDS and cancers of reproductive organs, Title X clinical guidelines
recommend various services related to prevention and screening, but the guidelines do not

416 42 C.F.R. §59.5(a\b)(8).
417 Loretta Gavin, Susan Moskosky, Marion Carter, et al., “Providing Quality Family Planning Services:
Recommendations of CDC and the U.S. Office of Population Affairs.”
418 Loretta Gavin, Susan Moskosky, Marion Carter, et al., “Providing Quality Family Planning Services:
Recommendations of CDC and the U.S. Office of Population Affairs.” See for example “Related preventive health
services” (p. 20), Table 2, Checklist of family planning and related preventive health services for women (p. 22), and
Table 3, Checklist of family planning and related preventive health services for men (p. 23).
419 Mia R. Zolna and Jennifer J. Frost, Publicly Funded Family Planning Clinics in 2015: Patterns and Trends in
Service Delivery Practices and Protocols
, pp. 36, 50.
420 Diane Foley, Deputy Assistant Secretary, OPA, HHS, Increasing the Availability of PrEP Services in Title-X
Funded Family Planning Service Sites: Development of a Decision Tool
, March 8, 2019, https://www.hiv.gov/blog/
increasing-availability-prep-services-title-x-funded-family-planning-services-sites-development.
421 Loretta Gavin, Susan Moskosky, Marion Carter, et al., “Providing Quality Family Planning Services:
Recommendations of CDC and the U.S. Office of Population Affairs.”
422 Mia R. Zolna and Jennifer J. Frost, Publicly Funded Family Planning Clinics in 2015: Patterns and Trends in
Service Delivery Practices and Protocols
, Guttmacher Institute, November 2016, pp. 36, 49, 50, 51, 53,
https://www.guttmacher.org/sites/default/files/report_pdf/publicly-funded-family-planning-clinic-survey-2015_1.pdf.
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explicitly address treatment.423 Title X regulations require projects more generally to provide for
coordination and use of referrals and linkages with primary healthcare providers, other providers
of health care services, local health and welfare departments, hospitals, voluntary agencies, and
health services projects supported by other federal programs, who are in close physical proximity
to the Title X site, when feasible, in order to promote access to services and provide a seamless
continuum of care.”424 In 2022, HHS told CRS:
Regarding HIV/AIDS treatment services, Title X projects provide screening and
prevention, through the distribution of PrEP, for instance, however Title X funds are not
used for treatment. Title X program funding is limited to services necessary to help
individuals prevent or achieve pregnancy, and to help individuals determine the number
and spacing of children. Thus, Title X funds are not used for treatment.
Similarly, screening for cancers of reproductive organs (e.g., breast cancer, cervical cancer)
is eligible for Title X funding, but treatment is not eligible.425
Do Title X Projects Provide Gender-Affirming Services?
In 2022, HHS told CRS:
Gender affirming procedures and/or medication are not eligible for Title X funding,
however gender affirming approach to all clients is expected to be incorporated into quality
family planning services. As mentioned previously, because Title X program funding is
limited to services necessary to prevent or achieve pregnancy, and to help individuals
determine the number and spacing of children, gender affirming procedures and/or
medications would be outside the scope of the Title X program.426
Title X clinical guidelines “encourage taking a client-centered approach” by, among other things,
delivering services in “a culturally competent manner so as to meet the needs of all clients,
including … those who are lesbian, gay, bisexual, transgender, or questioning their sexual identity
(LGBTQ).” 427 The guidelines state: “In addition, professional recommendations for how to
address the needs of diverse clients, such as LGBTQ persons or persons with disabilities, should
be consulted and integrated into procedures, as appropriate. For example, as noted before,
providers should avoid making assumptions about a client’s gender identity, sexual orientation,
race, or ethnicity; all requests for services should be treated without regard to these
characteristics.”428
The Title X program funds the Reproductive Health National Training Center, which offers
training to Title X providers.429 The center’s website lists resources related to gender-affirming

423 Loretta Gavin, Susan Moskosky, Marion Carter, et al., “Providing Quality Family Planning Services:
Recommendations of CDC and the U.S. Office of Population Affairs.”
424 42 C.F.R. §59.5(b)(8).
425 Emails from the HHS Office of the Assistant Secretary for Legislation, February 3, 2020, December 1, 2020, and
July 1, 2022.
426 Emails from the HHS Office of the Assistant Secretary for Legislation, February 3, 2020, December 1, 2020,
February 9, 2021, and July 1, 2022.
427 Loretta Gavin, Susan Moskosky, Marion Carter, et al., “Providing Quality Family Planning Services:
Recommendations of CDC and the U.S. Office of Population Affairs.”
428 Ibid.
429 Title X training grants are authorized under Title X of the PHSA, Section 1003, codified in the U.S. Code at 42
U.S.C. §300a-1. The Family Planning National Training Center’s LGBTQ Services Resources are listed at
https://www.fpntc.org/training-packages/lgbtq-services.
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services, including The Need for Accepting and Affirming Care in Title X Settings Video,430
Support LGBTQ+ Clients with Affirming Language Job Aid,431 and Innovative Models for PrEP
Programs in Family Planning Sites Webinar
, which discusses “services integrating PrEP and
gender-affirming care.”432
What Are Teen Pregnancy Prevention Programs?
Given the consequences associated with teen births for both adolescents and their children,
federal law authorizes programs designed to delay sexual activity and prevent pregnancies among
teenagers.433 Four HHS programs focus exclusively on providing teen pregnancy prevention
education: the (1) Teen Pregnancy Prevention (TPP) program, (2) the Personal Responsibility
Education Program (PREP), (3) the Title V Sexual Risk Avoidance Education program, and (4)
the General Departmental Management (GDM) Sexual Risk Avoidance Education program.434 All
of the programs serve children and teenagers, with a focus on those with risk factors for teenage
pregnancy. HHS competitively awards program funding to grantees that include states,
community-based organizations, and selected other entities. The programs provide education and
social supports in schools, afterschool programs, community centers, and other settings. The
activities carried out under these programs vary, but they generally seek to support youth in
making healthy choices about engaging (or not) in sex and reducing sexual risk behaviors.
Do Teen Pregnancy Prevention Programs Provide Reproductive
Health Services?

Teen pregnancy prevention programs are intended to prevent pregnancy, STIs, and associated
sexual risk behaviors for children and teens. The programs vary in their approaches to prevention
education.435 The Title V Sexual Risk Avoidance Education and the GDM Sexual Risk Avoidance
Education programs focus exclusively on abstaining from premarital sex. The PREP program
requires most grantees to place “substantial emphasis on both abstinence and contraception for
the prevention of pregnancy among youth and sexually transmitted infections.”436 Under the TPP
program, either or both approaches may be used.
Grantees that receive funding under the four programs use education models that have been
developed by research organizations and other entities, with curriculum that is generally carried

430 Reproductive Health National Training Center, The Need for Accepting and Affirming Care in Title X Settings
Video
, https://rhntc.org/resources/need-accepting-and-affirming-care-title-x-settings-video.
431 Reproductive Health National Training Center, Support LGBTQ+ Clients with Affirming Language Job Aid,
https://rhntc.org/resources/support-lgbtq-clients-affirming-language-job-aid.
432 Family Planning National Training Center, Innovative Models for PrEP Programs in Family Planning Sites
Webinar
, https://www.fpntc.org/resources/innovative-models-prep-programs-family-planning-sites-webinar. PrEP
refers to preexposure prophylaxis for HIV prevention.
433 For further information about teen birth rates and consequences of teen pregnancy, see CRS Report R45184, Teen
Birth Trends: In Brief
.
434 Despite their similar names and purposes, the latter two programs have different authorizing laws and funding
mechanisms. For FY2022, the Teen Pregnancy Prevention (TPP) program was funded at $101 million; the Personal
Responsibility Education Program (PREP) and Title V Sexual Risk Avoidance Education programs were each funded
at $75 million (prior to sequestration); and the General Departmental Management (GDM) Sexual Risk Avoidance
Education program was funded at $35 million. For further information, see CRS Report R45183, Teen Pregnancy:
Federal Prevention Programs
.
435 CRS Report R45183, Teen Pregnancy: Federal Prevention Programs.
436 Section 513(b)(2)(A)(i) of the SSA.
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out by trained facilitators. Some of these programs were identified in HHS’s Teen Pregnancy
Prevention Evidence Review as being effective in improving behaviors related to (1) sexual
activity, (2) the number of sexual partners, (3) contraceptive use, (4) STIs or HIV, and/or (5)
pregnancies.437 Grantees that use a sexual risk avoidance approach prioritize sexual risk
avoidance education
, or not engaging in consensual sexual activity. They may also address sexual
risk cessation
, or discontinuing consensual sexual activity after having engaged in it.438 Both
approaches may provide information about preventing STDs and HIV, the benefits of practicing
sexual abstinence, the risks that can be associated with sexual activity outside of marriage, and
strategies and tactics to practice abstaining from sex and building relationships without having
sex.439 Grantees that use broader sexual health education programs may focus on teaching
education that focuses on increasing participants’ knowledge about STDs and HIV and reducing
risk behaviors, while building skills in problem solving and negotiation related to relationships
and sexual activity. Some programs may additionally encourage abstinence, negotiating skills
around abstaining from sex, improving contraceptive use, and using condoms correctly, among
other topics.440
Do Teen Pregnancy Prevention Programs Provide Contraceptive Services?
As noted, grantees that use a broader approach to providing sexual health education can use
program models that provide information about contraceptives, including proper use of
contraceptives. Given the focus on contraceptive education among some programs, and no
identified prohibition on distributing them in statute or guidance, grantees may potentially
provide contraceptives such as condoms.
Do Teen Pregnancy Prevention Programs Provide Abortions or
Abortion Counseling?

As discussed above, the Hyde Amendment has routinely been added to the annual appropriations
measure for HHS to restrict federal funds to pay for abortions, except in cases of rape, incest, or
endangerment of a mother’s life.441 Two of the teen pregnancy prevention programs, the GDM

437 The Teen Pregnancy Prevention Evidence Review was managed by the Assistant Secretary for Planning and
Evaluation (ASPE) in collaboration with the Administration for Children and Families’ (ACF) Family and Youth
Services Bureau (FYSB), and the former Office of Adolescent Health (OAH) within OASH. HHS contracted with
Mathematica Policy Research, Inc., a social policy research organization, to review studies of teen pregnancy
prevention programs. The review was active from 2010 to 2019, and funding was set aside to reestablish it as part of
FY2022 appropriations. See Juliet Lugo-Gil et al., Updated Findings from the HHS Teen Pregnancy Prevention
Evidence Review: August 2015 through October 2016
, Mathematica Policy Research for HHS, ASPE, April 2018. The
website for these models and studies are now at Youth.gov, HHS Teen Pregnancy Prevention Evidence Review,
https://tppevidencereview.youth.gov/EvidencePrograms.aspx.
438 Mathematica, Conceptual Models to Depict the Factors that Influence the Avoidance and Cessation of Sexual Risk
Behaviors Among Youth
for HHS, OASH and ACF, Office of Planning, Research, and Evaluation (OPRE), February
2020.
439 See for example, Youth.gov, HHS Teen Pregnancy Prevention Review, “Making a Difference! Program Overview”
and “Heritage Keepers Abstinence Education Program Overview.” These are examples of abstinence education
approaches and are included for illustrative purposes only.
440 See for example, Youth.gov, HHS Teen Pregnancy Prevention Review, “¡Cuídate! Program Overview” and “Be
Proud! Be Responsible Program Overview.” These are examples of sexual health education approaches and are
included for illustrative purposes only.
441 For more information about the Hyde Amendment, see “Can Federal Funds Be Used to Pay for Abortions or
Abortion Counseling?”
in this report.
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Sexual Risk Avoidance Education program and the TPP program, are funded via annual
appropriations measures for HHS; therefore, the Hyde Amendment applies to these programs.
The other two programs, Title V Sexual Risk Avoidance Education program and PREP, are
funded via mandatory appropriations through their authorizing statutes under SSA Title V. These
authorizing provisions do not address abortion. However, in 2020 funding announcements for the
Title V Sexual Risk Avoidance Education program, HHS has specified that “HHS does not allow
federal programs to make referrals for abortions or to facilities where abortion is a method of
family planning.” HHS further specified that “referral resources should include, but not be limited
to, substance use and abuse and mental health services. Referrals cannot be made to family
planning organizations that provide abortions.”442 PREP grant announcements do not appear to
address abortion. 443 In the absence of program guidance on the topic, general HHS guidance on
prohibiting funding for abortions applies.444
Do Teen Pregnancy Prevention Programs Provide Infertility Services?

The teen pregnancy prevention programs do not provide infertility services.
Do Teen Pregnancy Prevention Programs Provide Maternity Services?
The teen pregnancy prevention programs do not provide maternity services.
Do Teen Pregnancy Prevention Programs Provide Reproductive Health
Screening, Prevention, and Treatment Services?

The teen pregnancy prevention programs do not provide reproductive health screening or
treatment services. The programs do address preventive services to prevent pregnancy, STDs, and
related sexual risk outcomes.
Do Teen Pregnancy Prevention Programs Provide Gender-Affirming Services?
The teen pregnancy prevention programs do not provide gender-affirming services.
What Federal Grant Programs Address Sexually Transmitted
Infections (STIs)?
Both CDC and HRSA provide funding to address STIs. CDC’s program focuses on multiple
STIs, while HRSA’s targets HIV/AIDS specifically.

442 See, for example, HHS, ACF, Administration on Children, Youth, and Families (ACYF), FYSB, Standing
Announcement for Title V State Sexual Risk Avoidance Education
, HHS-2020-ACF-ACYF-SRAE-1848, 2020.
443 See, for example, HHS, ACF, FYSB, State Personal Responsibility Education Program (PREP), HHS-2016-ACF-
ACYF-PREP-1138, 2016.
444 HHS, Office of the Assistant Secretary for Resources and Technology, Office of Grants, HHS Grants Policy
Statement
, January 1, 2007.
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What Centers for Disease Control and Prevention (CDC) Programs
Address STIs?

A number of federal programs administered by CDC address STIs. Chief among them are several
cooperative agreements (a type of grant program) administered by the CDC National Center for
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).445 For example:
HIV Prevention and Control: CDC provides technical and funding assistance to
community-based organizations and state/local health departments on many
aspects of planning, implementing, and evaluation of HIV prevention
programs.446
STD Prevention and Control: CDC funds cooperative agreements for STD
prevention and control programs to health departments in the 50 U.S. states; the
District of Columbia; Puerto Rico; the U.S. Virgin Islands; Baltimore, MD;
Chicago, IL; Los Angeles, CA; Philadelphia, PA; New York City, NY; and San
Francisco, CA. The current program targets three major STDs: chlamydia,
gonorrhea, and syphilis.447
These are long-standing assistance programs, although award structures, goals, and amounts often
change from one year to the next. Current programs support a number of activities, for example,
referrals for screening and treatment, contact tracing and partner notification, and provider
education and training. Additional CDC assistance programs may address HIV and STD
prevention in part. These include programs for adolescent and school health and for state
epidemiology and laboratory capacity, among others.
What Is the Ryan White HIV/AIDS Program?
The main federal program that targets HIV/AIDS prevention and treatment is the Ryan White
HIV/AIDS program (“Ryan White”), administered by HRSA. The program provides grants to
metropolitan areas and states to provide HIV-related services, including testing and treatment, to a
safety net population.448 States also receive funding for the AIDS Drug Assistance Program
(ADAP), which is used to pay for HIV/AIDS drugs for individuals who do not have another
source of payment. The Ryan White program is considered to be a residual payer; its funds are
not used to provide services to individuals with another source of coverage (e.g., private health
insurance).449 Ryan White Part C provides grants to health centers, family planning clinics, and

445 CDC, NCHHSTP, https://www.cdc.gov/nchhstp/partners-programs.htm. A cooperative agreement is a type of grant
for which there is substantial involvement of both the federal awarding agency and the nonfederal recipient entity in
carrying out the purposes of the federal award. See Grants.gov, “What is a cooperative agreement?,”
https://grantsgovprod.wordpress.com/2016/07/19/what-is-a-cooperative-agreement/.
446 CDC, HIV Program Resources, https://www.cdc.gov/hiv/programresources/index.html; and CDC, HIV Funding and
Budget, https://www.cdc.gov/hiv/funding/index.html.
447 CDC, Strengthening STD Prevention and Control for Health Departments (STD PCHD), https://www.cdc.gov/std/
funding/pchd/default.htm.
448 For more information about the Ryan White Program, see CRS Report R44282, The Ryan White HIV/AIDS
Program: Overview and Impact of the Affordable Care Act
, and HRSA, “HIV/AIDS Programs,” http://hab.hrsa.gov/.
Ryan White has six parts each with multiple components; for further information, see the Appendix in CRS Report
R44282, The Ryan White HIV/AIDS Program: Overview and Impact of the Affordable Care Act.
449 According to the Ryan White statute (PHSA §2605(a)(6), 2617(b)(7)(F), 2664(f)(1) and 2671(i)), the program is the
payer of last resort. Program guidance clarifies that this includes Medicaid among other federal programs. See HHS,
HRSA, HIV/AIDS Bureau, “Ryan White HIV/AIDS Program: Part A Manual,” revised 2013, https://hab.hrsa.gov/sites/
default/files/hab/Global/happartamanual2013.pdf.
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community-based organizations, among others, to support outpatient HIV early intervention
services to the safety net population. The program is required to serve people with HIV/AIDS
and, as such, does not provide PrEP; it does, however, through the Part C-Early Intervention
Service program, provide testing and counseling for individuals at risk of acquiring HIV.450 Ryan
White Part F authorizes demonstration and training efforts, including provider training, special
projects of regional and national significance, and the Minority AIDS Initiative (MAI). MAI
provides additional funds to Ryan White-funded entities to support education and outreach to
increase minority access to Ryan White services. The program has also received funding through
the Ending the HIV Epidemic in the United States initiative. In 2022, the program received
additional funding for states and metropolitan areas to reduce new HIV infections, for workforce
development, and for technical assistance to support health care and social systems
coordination.451 Additional funding was also provided in 2021 and 2020 for this initiative.452
What Is the National Breast and Cervical Cancer Early Detection Program?
In 1990, Congress established the National Breast and Cervical Cancer Early Detection Program
(NBCCEDP) within CDC. This program provides low-income, uninsured, and underserved
women access to screening and diagnostic services to detect breast and cervical cancer at an early
stage.453 Currently, the program funds 70 grantees: all 50 states, the District of Columbia, six U.S.
territories, and 13 American Indian/Alaska Native tribes or tribal organizations.
Despite various coverage requirements for these services (as described in this report; see the
sections on Medicare and Medicaid programs and certain private health insurance coverage),
CDC reports that many women remain eligible for the NBCCEDP services due to lack of an
alternate payment source. The NBCCEDP is funded through annual discretionary
appropriations,454 which historically have not been sufficient to meet the needs of all eligible
women. According to CDC:
During 2015-2017, about 5.7% of U.S. women were eligible for NBCCEDP cervical
cancer screening services, and the program served 6.8% of eligible women. During 2016-
2017, about 5.3% of U.S. women were eligible for NBCCEDP breast cancer screening
services, and the program served 15.0% of eligible women.455
CDC states that cervical cancer screenings provided under this program are targeted toward
women who have never or rarely been screened for cervical cancer, with a focus on reducing
disparities and reaching women who may have delayed screening or services during the COVID-

450 Ibid.
451 HHS Press Office, “HHS Awards $115 Million to Support Ending the HIV Epidemic in the United States,” press
release, June 16, 2022, https://www.hhs.gov/about/news/2022/06/16/hhs-awards-115-million-to-support-ending-hiv-
epidemic-in-united-states.html.
452 HHS, HRSA, “HRSA Awards $99 Million to End the HIV Epidemic in the United States,” March 4, 2021,
https://www.hrsa.gov/about/news/press-releases/hrsa-awards-99-million-to-end-hiv-epidemic, and HHS Press Office,
“HHS Awards $117 Million to End the HIV Epidemic in the United States,” February 26, 2020,
https://public3.pagefreezer.com/content/HHS.gov/31-12-2020T08:51/https://www.hhs.gov/about/news/2020/02/26/
hhs-awards-117-million-to-end-hiv-epidemic-in-the-united-states.html.
453 CDC, National Breast and Cervical Cancer Early Detection Program, https://www.cdc.gov/cancer/nbccedp/.
454 CDC, Justification of Estimates for Appropriation Committees, FY2023, p. 167, https://www.cdc.gov/budget/
documents/fy2023/FY-2023-CDC-congressional-justification.pdf.
455 CDC, National Breast and Cervical Cancer Early Detection Program, https://www.cdc.gov/cancer/nbccedp/
about.htm. See also Florence Tangka et al., “The Eligibility and Reach of the National Breast and Cervical Cancer
Early Detection Program after Implementation of the Affordable Care Act,” Cancer Causes & Control, vol. 26, pp.
649-650, March 21, 2015, https://link.springer.com/content/pdf/10.1007%2Fs10552-015-0561-0.pdf.
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19 pandemic.456 Individuals who screen positive in CDC’s discretionary-funded Breast and
Cervical Cancer Early Detection Program are given presumptive Medicaid eligibility for services
including, but not limited to, treatment of the cancer.
Grant Programs That May Be Used to Support
Reproductive Health Services
The following questions discuss federal programs that have broad purposes but may provide
some types of reproductive health services. General descriptions of these programs, and brief
explanations of the extent of their focus on reproductive health, appear below.
How Does the Federal Health Center Program Support Reproductive
Health Services?

The Federal Health Center Program, administered by HHS’s HRSA,457 awards grants to
nonprofit, tribal, or state and local government facilities to provide outpatient health services to
populations located in underserved areas. These facilities are required to be Medicaid providers
and to provide services to all individuals regardless of their ability to pay.458 Health centers focus
on providing primary care services and are required to provide voluntary family planning
services. Health center data from 2020 reports that more than 2.5 million visits were for
contraceptive management, provided to nearly 1.5 million patients.459 While specific health
services may vary by facility, health centers generally provide preventive health services,
including reproductive health screenings. In 2020, health centers provided more than 900,000
mammograms, according to health center data. Health centers also provide STI testing and
treatments. In particular, from 2020 to 2022, health centers received supplemental funding as part
of the Ending the HIV Epidemic: A Plan for America initiative to identify individuals who may be
at risk for contracting the virus, provide preventive services, test for HIV, and prescribe PrEP
when appropriate.460 Health centers must provide access to pharmaceutical services either onsite
or through contracts. Health centers may receive Title X grants and must comply with program
requirements if they do. Health centers are prohibited from using federal funds to provide
abortions.461 No information is available about whether health centers provide infertility services.

456 CDC, Justification of Estimates for Appropriation Committees, FY2023, p. 167, https://www.cdc.gov/budget/
documents/fy2023/FY-2023-CDC-congressional-justification.pdf. Individuals who screen positive in CDC’s
discretionary-funded Breast and Cervical Cancer Early Detection Program are given presumptive Medicaid eligibility
for services including, but not limited to, treatment of the cancer.
457 These facilities are also called federally qualified health centers (FQHCs) or community health centers.
458 CRS Report R43937, Federal Health Centers: An Overview. See 42 C.F.R. 51c.102(h).
459 HHS, HRSA, “Uniform Data System National Report 2020, Table 6A: Selected Diagnoses and Services Rendered,”
https://data.hrsa.gov/tools/data-reporting/program-data/national/table?tableName=6A&year=2020.
460 HHS, HRSA, “HHS Awards $117 Million to End the HIV Epidemic in the United States,” February 26, 2020,
https://www.hhs.gov/about/news/2020/02/26/hhs-awards-117-million-to-end-hiv-epidemic-in-the-united-states.html,
HHS, HRSA, “HHS Awards Over $48 Million to Health Centers for Ending the HIV Epidemic in the U.S. Initiative,”
https://www.hhs.gov/about/news/2021/09/16/hhs-awards-48-million-to-health-centers-to-end-the-hiv-epidemic.html.
As of the date of this report’s publication, HRSA has not awarded the FY2022 funds for this initiative; however, P.L.
117-103 included $122.5 million for health centers for the Ending the HIV Epidemic Initiative.
461 Health centers receive funding both under discretionary appropriations, which are subject to the Hyde Amendment,
and from the Community Health Center Fund (see CRS Report R43911, The Community Health Center Fund: In
Brief
). Recent appropriations for the Community Health Center Fund has applied Hyde language in appropriations to
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How Does the Title V Maternal Child Health Services Block Grant Support
Reproductive Health Services?

HRSA’s Maternal Child Health Bureau administers the Maternal Child Health (MCH) Services
Block Grant, which is authorized in Title V of the SSA.462 The block grant provides flexible
funding to states and territories to operate programs that seek to improve the health and well-
being of low-income pregnant women, mothers, and children. This includes support for direct
health services, including family planning. Each state is required to submit a state action plan that
details how funding will be used. Most of these plans aim to increase access to family planning
services and preventive screenings for the women served by the program. In some cases, state
MCH programs may use funding to provide services directly; however, they may also refer and
connect patients to services through other providers (e.g., health centers). In addition, state MCH
programs are required to coordinate with other federal programs, including Medicaid and the Title
X program.463 State MCH programs are not required to provide specific services directly; flexible
funds are provided to states that determine how to best meet a state’s needs. Because of this, the
degree to which the MCH Service Block grant includes or excludes specific services is unclear.
The grant receives its funding from discretionary appropriations provided in the annual
appropriations measure for the Departments of Labor, HHS, and Education, and Related Agencies
(LHHS). As such, these funds are subject to the LHHS bill’s abortion restrictions (commonly
referred to as the Hyde Amendment).464
How Does the Social Services Block Grant Program Support Reproductive
Health Services?

The Social Services Block Grant Program (SSBG), administered by the HHS Administration for
Children and Families (ACF), provides flexible funding to states and territories to support a wide
range of social services.465 Federal regulations issued in 1993 established uniform definitions for
28 main SSBG service categories, including family planning services, pregnancy and parenting,
and health related and home health services.466 States are not required to spend SSBG funds in
any particular service category and may support other services as well. In FY2020, the most
recent year for which complete data are available, roughly 0.3% of all SSBG expenditures were
spent on family planning services, 0.3% were spent on pregnancy and parenting, and roughly
0.9% were spent on health related and home health services.467 The SSBG is an annually
appropriated capped entitlement. Mandatory appropriations for the SSBG are provided each year

these funds. See Section 301(d) of Title III, Subtitle A, of P.L. 116-260.
462 CRS Report R44929, Maternal and Child Health Services Block Grant: Background and Funding.
463 Section 501 of the SSA.
464 For more information, see the “Restrictions Related to Certain Controversial Issues” section in CRS Report R46492,
Labor, Health and Human Services, and Education: FY2020 Appropriations. For more information about the Hyde
Amendment, see “Can Federal Funds Be Used to Pay for Abortions or Abortion Counseling?” in this report. Also see
CRS Report RL33467, Abortion: Judicial History and Legislative Response.
465 CRS In Focus IF10115, Social Services Block Grant, and CRS Report 94-953, Social Services Block Grant:
Background and Funding
.
466 These regulations were codified at 45 C.F.R. §96, Appendix A.
467 For more information, see HHS, ACF, Office of Community Services, Social Services Block Grant Program Annual
Report 2020,
https://www.acf.hhs.gov/sites/default/files/documents/ocs/RPT_SSBG_Annual%20Report_FY2020.pdf.
These percentages were calculated based on spending from state Social Services Block Grant (SSBG) allotments as
well as, where applicable, state transfers to SSBG from the Temporary Assistance for Needy Families (TANF) block
grant.
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in the LHHS Appropriations Act and, as such, are subject to the LHHS bill’s abortion-related
restrictions (commonly referred to as the Hyde amendment).468
How Does the Maternal, Infant, and Early Childhood Home Visiting
(MIECHV) Program Support Reproductive Health Services?

The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program supports
home visiting services for pregnant women and families with young children who reside in
communities that have concentrations of poor child health and other indicators of risk.469 Home
visiting services involve assessing family needs, educating and supporting parents, and providing
referrals and coordinating services. While the focus of the MIECHV program is not on
reproductive health services, the program provides information and resources about related topics
such as health during pregnancy, postpartum care, and birth spacing. At the federal level, the
program is jointly administered by HRSA and ACF at HHS. The ACA, and amendments to the
act, have directly appropriated mandatory funding for the program. Most recently, the Bipartisan
Budget Act of 2018 (BBA 2018, P.L. 115-123) provided $400 million annually through FY2022.
In recent years, HHS has distributed MIECHV funding to states based primarily on a formula that
accounts for poverty and selected other factors. Territories and tribes also receive funding.470
Generally, a jurisdiction’s public health or social services department is the lead agency that
administers MIECHV program funds.471 The agency determines which home visiting model(s) to
implement in the state, though 75% of each jurisdiction’s funds must be expended for using
models that HHS has determined to be evidence-based at improving certain outcomes, including
maternal and newborn health.472 Depending on the model, home visits may be conducted by
nurses, mental health clinicians, social workers, or paraprofessionals with specialized training.
Generally, they visit the homes of eligible families on a regular basis (e.g., weekly or monthly)
over an extended period (e.g., six months or longer) to provide support to caregivers and children,
such as providing information about birth spacing, breastfeeding, and nutrition.473

468 For more information, see the “Restrictions Related to Certain Controversial Issues” section in CRS Report R47029,
Labor, Health and Human Services, and Education: FY2022 Appropriations. For more information about the Hyde
Amendment, see “Can Federal Funds Be Used to Pay for Abortions or Abortion Counseling?” in this report. Also see
CRS Report RL33467, Abortion: Judicial History and Legislative Response.
469 CRS Report R43930, Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program: Background and
Funding
.
470 CRS Report R43930, Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program: Background and
Funding
. The statute is silent about how funds are to be distributed under the program, except to require that HHS
reserve 3% of the annual appropriation for Indian tribal entities and another 3% for training, technical assistance, and
evaluations. In addition, HHS must use the most accurate data available for eligible jurisdictions if funding is awarded
on the basis of relative population or poverty considerations. Section 511(j) of the SSA.
471 For further information, see CRS Report R43930, Maternal, Infant, and Early Childhood Home Visiting (MIECHV)
Program: Background and Funding
. Under the law, HHS may make grants to nonprofit organizations to carry out a
home visiting program in a state that did not apply, or receive approval, for a grant as of FY2012. Nonprofit
organizations operate Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV)-funded home visiting
programs in three states (Florida, North Dakota, and Wyoming).
472 Section 511(d)(3)(iii). HHS, HRSA and ACF, “Maternal, Infant, and Early Childhood Home Visiting Program,” 75
Federal Register, July 23, 2010.
473 See Appendix B of CRS Report R43930, Maternal, Infant, and Early Childhood Home Visiting (MIECHV)
Program: Background and Funding
. See also Charles Michalopoulos et al., Impacts on Family Outcomes of Evidence-
Based Early Childhood Home Visiting: Results from the Mother and Infant Home Visiting Program Evaluation, HHS,
ACF, OPRE, OPRE Report 2019-07.
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The MIECHV law requires states to demonstrate improvements in certain outcome areas,
including maternal and newborn health. The maternal and newborn health outcome includes
performance metrics for (1) preterm birth, (2) breastfeeding, (3) depression screening, (4) well-
child visit, (5) postpartum care, and (6) tobacco cessation referrals. Most states and territories
(81%) demonstrated improvements in maternal and newborn health during the first three years of
the program.474 MIECHV law also required an evaluation of the program, and found mixed
outcomes regarding maternal and child health across four home visiting models.475 Regarding
maternal health, the study found that program participation generally did not affect whether
mothers had a subsequent pregnancy by the time their children were 15 months old, but found
that participation did result in increased health care coverage for mothers. In addition, mothers
receiving services were also significantly less likely to report that their health was fair or poor and
to report fewer depressive symptoms.
The MIECHV statute is silent about abortion, and past grant announcements do not appear to
address the topic.476 In the absence of guidance specific to the program, the general HHS
guidance on prohibiting funding for abortions applies.477
How Does the Pregnancy Assistance Fund (PAF) Program Support
Reproductive Health Services?

The Pregnancy Assistance Fund (PAF) sought to improve the educational, health, and social
outcomes for vulnerable individuals during pregnancy and the postnatal period.478 This group
included expectant and parenting teens, women, men, and their families, as well as women of any
age who were survivors of domestic violence, sexual violence, sexual assault, and stalking. PAF
was administered by OPA in HHS’s Office of the Assistant Secretary for Health (OASH). The
ACA established the program and authorized funding of $25 million annually from FY2010
through FY2019.479 (No new grants were issued after FY2019, effectively terminating the
program; the ACA provisions that apply to the program have not been repealed.)
HHS distributed PAF funding on a competitive basis to states, the District of Columbia, U.S.
territories, and tribal entities. These grantees could decide how to use funding under four purpose
areas. Three of the purpose areas focused on providing services to the eligible expectant and
parenting population through subgrants and partnerships.480 In general, grantees provided

474 HHS, ACF, and HRSA, Demonstrating Improvement in the Maternal, Infant, and Early Childhood Home Visiting
Program: A Report to Congress
, March 2016. Most tribal grantees also demonstrated improvement in maternal and
newborn health. Kate Lyon et al., Tribal Maternal, Infant, and Early Childhood Home Visiting: A Report to Congress,
HHS, ACF, OPRE, OPRE Report 2015-88, November 2015. In addition to the initial reporting on outcomes,
jurisdictions must report to HHS about the benchmarks at least 30 days after the end of FY2020 and every three years
thereafter. The metrics cited here were implemented in FY2017. Prior to that time, the maternal and newborn health
metrics included additional items such as inter-birth intervals, breastfeeding, and maternal and child health insurance
status.
475 Charles Michalopoulos et al., Impacts on Family Outcomes of Evidence-Based Early Childhood Home Visiting:
Results from the Mother and Infant Home Visiting Program Evaluation
, HHS, ACF, OPRE, OPRE Report 2019-07.
476 See, for example, HHS, HRSA, Maternal, Infant, and Early Childhood Home Visiting Program Formula Awards,
FY 2020 Non-Competing Continuation Update, 2020.
477 HHS, Office of the Assistant Secretary for Resources and Technology, Office of Grants, HHS Grants Policy
Statement
, January 1, 2007.
478 For further information, see CRS Report R45426, The Pregnancy Assistance Fund: An Overview.
479 42 U.S.C. §18201-18204.
480 The fourth category focuses on public awareness about such services; however, HHS advises that grantees may not
use funding solely for public awareness activities.
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subgrants to school districts, community service organizations, and institutions of higher
education (IHE) that directly served the expectant and parenting population.481 For the most
recent year of available data (2017-2018), the most common services provided to expectant and
recent parents were parenting supports, concrete supports (e.g., transportation), and health care
services.482 Health care services included health insurance supports and enrollment assistance,
reproductive health care, primary health care, and breastfeeding skills and resources. (These
health-related terms are not further defined.)
The PAF authorizing statute addresses reproductive health care in selected contexts. Subgrantees
that are IHEs must annually assess how well they are meeting the needs of pregnant and parenting
college students, including whether the IHE offers maternity coverage and availability of riders
for additional family members in student health coverage.483 Separately, grantees that provide
training and technical assistance—related to domestic violence, sexual violence, sexual assault,
and stalking against pregnant women or women who were pregnant within the past year—must
address certain issues, including evaluating the impact of the violence or stalking on the pregnant
woman’s health.484
HHS advised in past PAF funding announcements that public awareness and education activities
should not include abortion services. Further, the announcements stated that “abortion referrals
are not within the scope of permissible referral services under this grant and, therefore, grant
funds may not be used for this purpose.”485

481 CRS Report R45426, The Pregnancy Assistance Fund: An Overview.
482 HHS, OASH, OAH (now known as the Office of Population Affairs [OPA]), Performance Measures Snapshot The
Pregnancy Assistance Fund (PAF) Program: 2017-2018
, May 2019. See also Amy Margolis et al., “Meeting the
Multifaceted Needs of Expectant and Parenting Young Families Through the Pregnancy Assistance Fund,” Maternal
and Child Health Journal
, vol. 24 (May 8, 2020).
483 42 U.S.C. §18203(b)(4).
484 42 U.S.C. §18203(d)(3).
485 See, for example, HHS, OASH, OAH, Announcement of Anticipated Availability of Funds for Support for Expectant
and Parenting Teens, Women, Fathers, and Their Families
, AH-SP1-18-001, 2018.
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Appendix A. Acronyms Used in This Report
Table A-1. Acronyms Used in This Report
Acronym
Definition
AAP
American Academy of Pediatrics
ABP
Alternative Benefit Plan
ACA
Patient Protection and Affordable Care Act (P.L. 111-148, as amended)
ACF
Administration for Children and Families
ACIP
Advisory Committee on Immunization Practices
ACYF
Administration for Children, Youth, and Families
ADAP
AIDS Drug Assistance Program
AFDC
Aid to Families with Dependent Children
AIDS
Acquired Immunodeficiency Syndrome
ART
Assisted Reproductive Technology
ASPE
Assistant Secretary for Planning and Evaluation
BBA 2018
Bipartisan Budget Act of 2018 (P.L. 115-72)
BOP
Bureau of Prisons
CBOC
Community-Based Outpatient Clinic
CCIIO
Center for Consumer Information and Insurance Oversight
CDC
Centers for Disease Control and Prevention
CFR
Code of Federal Regulations
CHIP
Children’s Health Insurance Program
CMCS
Center for Medicaid, CHIP and Survey & Certification
CMS
Centers for Medicare & Medicaid Services
CMSO
Center for Medicaid and State Operations
CRS
Congressional Research Service
CSR
Cost-Sharing Reduction
DHA
Defense Health Agency
DHS
Department of Homeland Security
DOD
Department of Defense
DOJ
Department of Justice
DOL
Department of Labor
DPP
Deployed Prescription Program
EC
Emergency Contraceptive
EEOC
Equal Employment Opportunity Commission
EHB
Essential Health Benefits
EPSDT
Early and Periodic Screening, Diagnosis, and Treatment
ERO
Enforcement and Removal Operations
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Acronym
Definition
FAM
Fertility Awareness-Based Method
FDA
Food and Drug Administration
FFP
Federal Financial Participation
FFS
Fee-for-Service
FMAP
Federal Medical Assistance Percentage
FPL
Federal Poverty Level
FQHC
Federally Qualified Health Center
FSH
Fol icle Stimulating Hormone
FY
Fiscal Year
FYSB
Family and Youth Services Bureau
GAO
U.S. Government Accountability Office
GDM
General Departmental Management (Sexual Risk Avoidance Education Program)
GID
Gender Identity Disorder
GRS
Gender Reassignment Surgery
HCFA
Health Care Financing Administration
HCSM
Health Care Sharing Ministry
HHS
Department of Health and Human Services
HIV
Human Immunodeficiency Virus
HPV
Human Papil omavirus
HRSA
Health Resources and Services Administration
ICE
U.S. Immigration and Customs Enforcement
IHE
Institute of Higher Education
IHS
Indian Health Service
IUD
Intrauterine Device
IUI
Intrauterine Insemination
IVF
In Vitro Fertilization
LAM
Lactational Amenorrhea Method
LARC
Long-Acting Reversible Contraceptive
LGBTQ
Lesbian, Gay, Bisexual, Transgender, or Questioning Their Sexual Identity
LH
Luteinizing Hormone
LHHS
Appropriation bil that provides funding for the Departments of Labor, HHS, and Education, and
Related Agencies
LTSS
Long-Term Services and Supports
MA
Medicare Advantage
MAC
Medicare Administrative Contractor
MACPAC
Medicaid and CHIP Payment and Access Commission
MAGI
Modified Adjusted Gross Income
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Acronym
Definition
MAI
Minority AIDS Initiative
MCH
Maternal Child Health
MHS
Military Health System
MIECHV
Maternal, Infant, and Early Childhood Home Visiting Program
MINT
Mothers and Infants Nurturing Together Program
MTF
Military Treatment Facility
NBCCEDP
National Breast and Cervical Cancer Early Detection Program
NCD
National Coverage Determination
NCHHSTP
CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
NCHS
National Center for Health Statistics
NDAA
National Defense Authorization Act
NDS
National Detention Standards
OAH
Office of Adolescent Health
OASH
Office of the Assistant Secretary for Health
OB/GYN
Obstetrician/Gynecologist
OCR
Office for Civil Rights (HHS)
OIG
Office of Inspector General
OMB
Office of Management and Budget
OPA
Office of Population Affairs
OPRE
Office of Planning, Research, and Evaluation
PAF
Pregnancy Assistance Fund
PBNDS
Performance-Based National Detention Standards
PDA
Pregnancy Discrimination Act of 1978 (P.L. 95-555)
PEP
Post-Exposure Prophylaxis
PHSA
Public Health Service Act
PRC
Purchased Referred Care Program
PrEP
Pre-exposure Prophylaxis
PREP
Personal Responsibility Education Program
PTC
Premium Tax Credit
QFP
Quality Family Planning
QHP
Qualified Health Plan
RRC
Residential Reentry Center
SARC
Short-Acting Reversible Contraceptive
SHO
State Health Official
SHOP
Small Business Health Options Program
SMDL
State Medicaid Directors Letter
SRS
Sex Reassignment Surgery
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Acronym
Definition
SSA
Social Security Act
SSBG
Social Services Block Grant Program
STD
Sexually Transmitted Disease
STI
Sexually Transmitted Infection
STLDI
Short-Term, Limited Duration Insurance
TANF
Temporary Assistance for Needy Families
TPA
Third-Party Administrator
TPP
Teen Pregnancy Prevention Program
TSH
Thyroid Stimulating Hormone
UIO
Urban Indian Organization
USC
U.S. Code
USCG
U.S. Coast Guard
USPSTF
United States Preventive Services Task Force
VA
Department of Veterans Affairs
VHA
Veterans Health Administration
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Appendix B. Policy Experts Table

Topic
Contact
Reproductive Health Services (General)
Elayne J, Heisler
Abortion (Services)
Elayne J, Heisler
Abortion (Legal issues)
Jon Shimabukuro
Regulation of Contraceptives
Amanda K. Sarata, Hassan Z. Sheikh
Maternal Mortality
Kavya Sekar
Bureau of Prisons (BOP)
Nathan James
Department of Defense (DOD)
Bryce H.P. Mendez
U.S. Immigration and Customs Enforcement
Abigail F. Kolker; Audrey Singer
(ICE)
Indian Health Service
Elayne J. Heisler
The U.S. Coast Guard
Bryce H.P. Mendez
Department of Veterans Affairs
Jared S. Sussman
Medicaid
Evelyne P. Baumrucker
Medicare
Paulette C. Morgan
Private Health Insurance
Vanessa C. Forsberg
Private Health Insurance (Legal Issues)
Jennifer A. Staman
Federal Contraceptive Coverage Requirement (Legal
Victoria L. Kil ion
Issues)
Title X Program
Angela Napili; Taylor R. Wyatt
Teen Pregnancy Prevention Program
Jessica Tol estrup
Sexually Transmitted Infections (STI)
Kavya Sekar
Prevention Grants
The Ryan White HIV/AIDS Program
Elayne J. Heisler
National Breast and Cervical Cancer Early
Kavya Sekar
Detection Program
Federal Health Center Program
Elayne J. Heisler
Title V Maternal and Child Health Services
Elayne J, Heisler
Block Grant
Social Services Block Grant Program (SSBG)
Karen E. Lynch
Maternal, Infant, and Early Childhood Home
Patrick A. Landers
Visiting (MIECHV) Program
Pregnancy Assistance Fund (PAF)
Jessica Tol estrup; Taylor R. Wyatt

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Author Information

Elayne J. Heisler, Coordinator
Bryce H. P. Mendez
Specialist in Health Services
Analyst in Defense Health Care Policy


Evelyne P. Baumrucker
Angela Napili
Specialist in Health Care Financing
Senior Research Librarian


Vanessa C. Forsberg
Hassan Z. Sheikh
Analyst in Health Care Financing
Analyst in Public Health Emergency Management


Nathan James
Audrey Singer
Analyst in Crime Policy
Specialist in Immigration Policy


Abigail F. Kolker
Jared S. Sussman
Analyst in Immigration Policy
Analyst in Health Policy


Patrick A. Landers
Jessica Tollestrup
Analyst in Social Policy
Specialist in Social Policy



Acknowledgments
Simi V. Siddalingaiah, former CRS Analyst in Health Economics, also coordinated this report. CRS
employees (current and former) Adrienne L. Fernandes-Alcantara, Sarah A. Lister, and Isaac A. Nicchitta,
and Taylor R. Wyatt, all contributed to earlier versions of this report.

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
material from a third party, you may need to obtain the permission of the copyright holder if you wish to
copy or otherwise use copyrighted material.

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