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Page Number: 8.0

4 

LITTLE SISTERS OF THE POOR SAINTS PETER 
AND PAUL HOME v. PENNSYLVANIA 
Opinion of the Court 

Fed. Reg. 41728.  The IFR indicated that HRSA planned to
develop its Preventive Care Guidelines (Guidelines) by Au-
gust 2011.  Ibid.  However, it did not mention religious ex-
emptions or accommodations of any kind.

As anticipated, HRSA released its first set of Guidelines 
in August 2011.  The Guidelines were based on recommen-
dations  compiled  by  the  Institute  of  Medicine  (now  called
the  National  Academy  of  Medicine),  “a  nonprofit  group  of 
volunteer advisers.”  Hobby Lobby, 573 U. S., at 697.  The 
Guidelines included the contraceptive mandate, which re-
quired health plans to provide coverage for all contraceptive
methods and sterilization procedures approved by the Food 
and Drug Administration as well as related education and 
counseling.  77 Fed. Reg. 8725 (2012).

The  same  day  the  Guidelines  were  issued,  the  Depart-
ments amended the 2010 IFR.  76 Fed. Reg. 46621 (2011).
When the 2010 IFR was originally published, the Depart-
ments began receiving comments from numerous religious
employers  expressing  concern  that  the  Guidelines  would 
“impinge upon their religious freedom” if they included con-
traception.  Id.,  at  46623.    As  just  stated,  the  Guidelines
ultimately did contain contraceptive coverage, thus making
the potential impact on religious freedom a reality.  In the 
amended IFR, the Departments determined that “it [was] 
appropriate  that  HRSA  . . .  tak[e]  into  account  the  [man-
date’s] effect on certain religious employers” and concluded 
that HRSA had the discretion to do so through the creation
of an exemption.  Ibid.  The Departments then determined
that  the  exemption  should  cover  religious  employers,  and 
they  set  out  a  four-part  test  to  identify  which  employers 
qualified.  The  last  criterion  required  the  entity  to  be  a
church, an integrated auxiliary, a convention or association 
of  churches,  or  “the  exclusively  religious  activities  of  any
religious  order.”  Ibid.  HRSA  created  an  exemption  for
these employers the same day.  78 Fed. Reg. 39871 (2013).