Religious groups are battling the state of California over whether employee health insurance plans require them to pay for abortions and some forms of contraception that some find immoral.
So is the state forcing churches to pay for abortions? It depends on who you ask.
The issue gained traction after Michelle Rouillard, director of the California Department of Managed Health Care, sent a letter to Anthem Blue Cross and several other insurance firms in August warning providers that state law requires insurers to not deny woman abortions. "Thus, all health plans must treat maternity services and legal abortion neutrally," she wrote.
Rouillard wrote that state law provides an exemption for religious institutions.
"Although health plans are required to cover legal abortions, no individual health care provider, religiously sponsored health carrier, or health care facility may be required by law or contract in any circumstance to participate in the provision of or payment for a specific service if they object to doing so for reason of conscience or religion," she wrote.
"No person may be discriminated against in employment or professional privileges because of such objection."
However, two legal groups have filed complaints with the U.S. Department of Health and Human Services, alleging the California rule puts faith-based organizations in a position to violate their conscience.
The August letter followed protests by mostly non-Catholic faculty at two Jesuit schools, Loyola Marymount University and Santa Clara University, over the schools' plans to drop abortion coverage from their employee insurance plans.
Earlier this month, California's Catholic bishops filed a federal civil rights complaint over the state requirement, claiming that the DMHC discriminated against those morally opposed to abortion, and requested an investigation.
"It is a flagrant violation of their civil rights and deepest moral convictions, and is government coercion of the worst kind," said a statement from Bishop Robert McElroy, auxiliary bishop of the San Francisco archdiocese and chairman of the Institutional Concerns Committee of the California Catholic Conference.
Seven churches in California received notifications from their insurers that elective surgical abortion coverage would be required as part of their employee health plans, according to Casey Mattox, an attorney with the Arizona-based Alliance Defending Freedom.
On Oct. 9, ADF and the Life Legal Defense Foundation filed a complaint with HHS saying the California abortion-coverage mandate violated the 2004 Weldon Amendment, a measure passed every year, which prohibits funding from the HHS, Labor and Education departments going to states that don't allow conscience exemptions to abortion coverage requirements.
In a statement, the California agency says it only regulates "health plans," not the "purchasers" of health coverage.
The churches' complaint suggests the state receives an estimated $40 billion from Labor Department funding each year. "California accepted those funds with full knowledge of the requirements of the Weldon Amendment, but it has chosen to ignore this law," they wrote in their complaint.
Nonetheless, the insurance plans have the burden to cover abortion, said Maggie Crosby, senior staff attorney of the American Civil Liberties Union of Northern California.
"California has not required churches -- or any other employers -- to cover abortion," Crosby said in a statement. "It has clarified long standing law which regulates commercial insurance plans."
That requirement has been in place since 2002, built on a state law passed in 1975, according to the August letter.
"Because insurers must offer comprehensive care, an employer can't use a subpar health plan to deny a woman the full range of reproductive health care options," Crosby said. "If an employer wants to deny its employees the comprehensive coverage required, it can self-insure."
The question of whether abortion should be covered under health insurance was raised during debates over Obamacare. HHS crafted an accommodation to its contraception mandate for some religious employers that would require third-party administrators to pay for birth control services, but ongoing litigation focuses on whether the accommodation is sufficient.
"The ACLU didn't ask for such an accommodation in California and DMHC didn't create one," Mattox said in a statement. "ACLU asked DMHC to require every health care plan in the state to include elective abortion coverage as 'basic healthcare.' DMHC agreed."
A similar dispute is brewing in the nation's capital.
On Thursday, ADF and six other organizations sent the City Council of the District of Columbia a letter arguing that a proposed bill violates federal law by forcing the groups to provide abortion coverage through their insurance plans.
The group argues that the District's proposed Reproductive Health Non-Discrimination Amendment Act prohibits employers from discriminating against employees for any reproductive health decision, including abortion, which would require employers to provide health insurance for abortions regardless of the employers' beliefs or convictions.
The letter argues that the bill would violate the law since the Hobby Lobby ruling earlier this year, when the Supreme Court ruled that the Hobby Lobby chain and other closely held private businesses with religious objections could opt out of the birth control mandate.
Clashes between the government and religious groups have intensified over health care related to women in recent years. More than 100 for-profit and nonprofit groups have sued over the contraceptive coverage required under the federal Affordable Care Act; the Supreme Court ruling only applied to for-profit businesses.