Do student health policies have to cover birth control without co-pays?

Q. Do student health policies have to cover birth control without co-pays?

A. Yes, although schools with religious or moral objections to contraception are not required to include contraceptive coverage in their student health plans (as discussed below, the Biden administration has proposed a rule change to ensure access to zero-cost contraception for women enrolled in plans with an exemption).

Under ACA implementation rules, policies that began on or after August 1, 2012, are required to provide all FDA-approved contraceptive methods for women, including sterilization, with no cost-sharing. That doesn’t mean that every birth control option for women is provided at no cost. Rather, it means at least one version of every type of contraceptive is covered at no cost to the patient. So for example, a health plan only has to offer one combined pill, one patch, one mini-pill, etc. at no charge. Other versions of those same types of contraception can have cost-sharing, although a plan must have a non-burdensome exemption process for scenarios in which the zero-cost option is not medically appropriate for the enrollee (as determined by their medical provider), to ensure access to medically necessary zero-cost contraception.¹.

The contraception coverage mandate does include over-the-counter (OTC) contraception for plan enrollees who can become pregnant, as long as the OTC contraception is prescribed by a medical provider. But the Biden administration has proposed a rule change that would eliminate the need for a prescription to have coverage for OTC contraception. If these rules are finalized, non-grandfathered health plans would have to pay for OTC contraception — including condoms (for plan enrollees who can become pregnant), OTC daily oral contraception, spermicide, and emergency contraception — without the need for a prescription and without any cost-sharing for enrollees who could become pregnant.¹

Learn more about the ACA’s preventive care requirements, including contraception coverage.

Religious employers were exempt from the mandate to cover contraceptives for their employees from the start. But religiously affiliated employers such as universities and hospitals were not considered religious employers under the ACA. However, that position was challenged by Hobby Lobby in a highly publicized case that ended up before the Supreme Court in 2015.

The Court ruled that Hobby Lobby (and other “closely held” corporations with religious objections to some or all contraceptives) did not have to cover certain types of contraceptives under its health insurance plan. HHS quickly issued an accommodation that essentially created a separate plan under which the women could obtain contraceptives as needed, without the religiously affiliated organization having to fund the contraception.

But the Trump administration expanded access to full exemptions from the contraceptive coverage mandate (rather than accommodations) for employers and schools with religious or moral objections. The mandate itself isn’t part of the ACA. The ACA just requires health plans to cover the ten essential health benefits, one of which is preventive care at no charge to the patient. The task of defining what should be included under the preventive care umbrella was left to HHS, and the agency created guidelines after the ACA had been implemented. So the Trump Administration HHS had the flexibility to change those guidelines, as regulatory changes can be made without the need to pass legislation.

In 2020, the Supreme Court upheld the Trump administration’s regulations that allow organizations with religious or moral objections to contraception to avoid covering it in their employer or student health plan. So students attending religiously affiliated schools should carefully consider the student health plan to see what preventive services are covered. If contraception is a service that’s important to a student, it might also be worth considering the other health coverage options that are available.

However, the Biden administration proposed a rule change in 2023 that would expand access to zero-cost contraception. If finalized, the proposed rule would remove the moral objection as a way for an entity to obtain an exemption, so there would only be a religious exemption. It would also create an “independent pathway” that would allow women to obtain zero-cost contraception, even if they’re enrolled in a plan with an exemption and the plan issuer is not using the optional accommodation process.

The proposed rule had not yet been finalized as of late 2024. The Department of Labor indicated in the fall of 2023 that they do intend to finalize the proposed rule.² But an October 2024 multi-department proposed rule related to expanded contraception coverage mentioned the proposed 2023 rule but did not provide any additional detail about when or whether the departments intend to finalize it.¹.

One other note: It’s also important to understand that if a school’s health plan is self-insured, it’s not subject to ACA rules, nor is it subject to the ERISA rules that apply to self-insured employer-sponsored plans. Depending on the state, there may be state rules for these plans. But if your school offers a self-insured student health plan, you’ll want to read the fine print to see what is and isn’t included.

Read more FAQs about health reform, and student health insurance.

1. ”Enhancing Coverage of Preventive Services Under the Affordable Care Act” U.S. Departments of the Treasury, Labor, and Health & Human Services. Oct. 23, 2024 ⤶ ⤶ ⤶
2. Fall 2023 Statement of Regulatory Priorities. U.S. Department of Labor. Accessed January 2024. ⤶