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Are vasectomies and condoms covered under ACA’s preventive health services coverage mandate?

Are vasectomies and condoms covered under ACA’s preventive health services coverage mandate?

Are health plans required to cover male contraception?

Vasectomies do not have to be covered unless it’s a state-regulated health plan in a state that requires coverage for vasectomies. But condoms are covered by non-grandfathered health plans as long as they’re prescribed by a health care provider to someone who can become pregnant (a woman, trans man, or nonbinary person who could become pregnant).

This includes both internal (female) and external (male) condoms,1 but the prescription cannot be for a cis-male. The condom coverage requirement is a recent change to the ACA’s preventive coverage guidelines, applicable to health plans issued or renewed after December 30, 2022.2

Are condoms covered under the ACA's preventive health services coverage mandate?

Yes, condoms are covered by non-grandfathered health plans as long as they’re prescribed by a health care provider to someone who can become pregnant.

The Women’s Preventive Services Guidelines include all FDA-approved methods of contraception for women, which means that insurers have to cover at least one type of each method at no cost to the member. The women’s health guidelines used to specify that condom coverage only included internal condoms, but the coverage requirement was changed to simply “condoms” (including both internal and external) for health plans issued or renewed on or after December 30, 2022.2

Over-the-counter condoms, meaning purchased without a prescription, do not have to be covered. And condoms prescribed to someone who cannot become pregnant are not required to be covered.

Are health plans required to cover vasectomies under the ACA's preventive health services coverage mandate?

Some health plans do cover all or part of the cost of a vasectomy, but they are not required to do so under federal rules. Although female sterilization (which costs much more than a vasectomy) has to be covered in full by non-grandfathered health plans, the same is not true for male sterilization.

Some states require state-regulated health plans to cover vasectomies,3 but state laws do not apply to self-insured health plans, which account for the majority of employer-sponsored health plans.4

States that require pre-deductible vasectomy coverage must have an exception for HSA-qualified high-deductible health plans (HDHPs) if they want HDHPs to continue to be available, as these plans would cease to be HSA-eligible if they provided pre-deductible vasectomy coverage. (Until the beginning of 2020, the IRS waived that rule,5 in response to the fact that some states had implemented vasectomy coverage rules without HDHP exceptions.)

Footnotes

  1. Women’s Preventive Services Guidelines. HRSA. Accessed February 9, 2024. 
  2. 2023 & Free: You May Never Have to Pay for Condoms Again! National Women’s Law Center. February 1, 2023.  
  3. Insurance Coverage of Contraceptives” Guttmacher Institute. September 1, 2023. 
  4. Employer Health Benefits, 2023 Annual Survey. KFF. October 2023. 
  5. Notice 2018-12. Internal Revenue Service. Accessed January 2024. 

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