Are health plans required to cover male contraception?
There are no federal rules requiring health plans to cover male contraception (vasectomies or male condoms) for male plan enrollees. But some states require state-regulated health plans to cover vasectomies (more details below).
And 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).
The IRS has also issued guidance allowing (but not requiring) HSA-qualified high-deductible health plans (HDHPs) to pay for male condoms pre-deductible, regardless of whether the enrollee is male or female.1
Learn more about preventive care coverage rules, including contraception for women.
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 This includes both internal (female) and external (male) condoms,3 but the prescription cannot be for a cis-male.
Over-the-counter condoms, meaning purchased without a prescription, do not have to be covered by health insurance (although they can now be paid for with pre-tax funds from an HSA, FSA, or HRA4). And condoms prescribed to someone who cannot become pregnant are not required to be covered. However, the Biden administration proposed a rule change in October 2024 that would remove the prescription requirement for coverage of over-the-counter (OTC) contraception.
If finalized, this rule would require non-grandfathered health plans to pay for OTC contraception, without a prescription or cost-sharing, for plan enrollees who could become pregnant. The coverage requirement would include male condoms (for a plan enrollee who can become pregnant), OTC birth control pills (Opill), spermicide, and emergency contraception.5
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,6 but state laws do not apply to self-insured health plans, which account for the majority of employer-sponsored health plans.7
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,8 in response to the fact that some states had implemented vasectomy coverage rules without HDHP exceptions.)
Do health plans have to cover the cost of birth control?
Under rules that have been finalized to implement the ACA's preventive coverage mandate, non-grandfathered health plans are required to cover at least one version of each FDA-approved method of contraception for women without any cost-sharing (free for the enrollee), as long as the contraception has been prescribed by a health care provider. As noted above, a rule change was proposed in 20245 that would eliminate the prescription requirement for contraception that's available over-the-counter, but the coverage would still be limited to health plan enrollees who can become pregnant.
Footnotes
- "Notice 2024-75. Preventive Care for Purposes of Qualifying as a High Deductible Health Plan under Section 223" Internal Revenue Service. Accessed Nov. 20, 2024 ⤶
- 2023 & Free: You May Never Have to Pay for Condoms Again! National Women's Law Center. February 1, 2023. ⤶
- Women’s Preventive Services Guidelines. HRSA. Accessed February 9, 2024. ⤶
- "Notice 2024-71. Expenses Treated as Amounts Paid for Medical Care" Internal Revenue Service. Accessed Nov. 20, 2024 ⤶
- "Enhancing Coverage of Preventive Services Under the Affordable Care Act" U.S. Departments of the Treasury, Labor, and Health & Human Services. Oct. 23, 2024 ⤶ ⤶
- "Insurance Coverage of Contraceptives" Guttmacher Institute. September 20, 2024 ⤶
- Employer Health Benefits, 2024 Annual Survey. KFF. October 9, 2024 ⤶
- Notice 2018-12. Internal Revenue Service. Accessed January 2024. ⤶
