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WASHINGTON — Although Aug. 1 was a key date in implementation of the Patient Protection and Affordable Care Act, it simply marked the first possible date when health plans could be required to cover eight new preventive services for women -- including all Food and Drug Administration-approved contraceptives.

But most Americans saw no change in their health insurance that day, because their plans renew on another date or are covered by a one-year "temporary enforcement safe harbor" or a "grandfathering" provision that delays changes.

The requirement to provide contraceptives free of charge has prompted an outcry by Catholic leaders and others who object to the mandate on moral grounds and see it as a violation of their religious freedom.

Catholic leaders do not oppose the other mandated preventive services for women, which include well-woman visits, breast-feeding support and counseling, and domestic violence screening and counseling.

Those services "pose little or no medical risk themselves, and they help prevent or ameliorate identifiable conditions that would pose known risks to life and health in the future," Deirdre McQuade, assistant director for policy and communications at the bishops' Secretariat for Pro-Life Activities, pointed out in 2011 to an Institute of Medicine panel charged with making recommendations to HHS.

But the use of prescription contraceptives "actually increases a woman's risk of developing some of the very conditions that the 'preventive services' ... are designed to prevent, such as stroke, heart attacks and blood clots," she added.

The contraceptive mandate does not apply, however, to plans that are "grandfathered" -- those that have remained substantially unchanged since March 23, 2010, in terms of benefits, co-pays, deductibles and employer contributions -- or those covered by what the U.S. bishops and others fee have said is a narrowly drawn religious exemption.

There also is a one-year "temporary enforcement safe harbor" for nonprofit organizations that oppose the contraceptive mandate for religious reasons but do not fit the exemption. After the safe- harbor period ends, these employers will have to cover contraceptive services.

Grandfathered plans can keep that status if they make only routine changes, including cost adjustments to keep pace with medical inflation, adding new benefits, making modest adjustments to existing benefits, voluntarily adopting new consumer protections under the new law, or making changes to comply with state or other federal laws.

The Department of Health and Human Services has estimated that up to 87 percent of the 133 million Americans who get their health insurance through large employers (those with 100 or more workers) and 80 percent of the 43 million who work for small employers remained in grandfathered plans in 2011. The numbers go down to about 66 percent for large employers and 51 percent for small employers in 2013.

Of the roughly 17 million people who get the health insurance through the individual market, HHS estimates that 40 percent to two-thirds will change plans within a year and will therefore not have a grandfathered plan.

Even grandfathered plans have to abide by certain requirements of the Affordable Care Act; they must have no lifetime caps, must not drop insured people if they get sick and must extend parents' coverage to their young adult children up to age 26. Most grandfathered plans also are not permitted to exclude children with pre-existing conditions from coverage or to set annual limits on coverage.

The federal government has exempted from the contraceptive mandate only religious organizations that meet four criteria -- it "has the inculcation of religious values as its purpose; primarily employs persons who share its religious tenets; primarily serves persons who share its religious tenets; and is a nonprofit organization" under specific sections of the Internal Revenue Code.

That definition applies only to a relatively small group of churches and some schools associated with them, but not to the many Catholic hospitals, social service agencies and institutions of higher education that serve and employ people of many faiths or none.

To be eligible for the temporary enforcement safe harbor, an organization must self-certify that it meets three criteria:

-- It "is organized and operates as a nonprofit entity."

-- "Because of the religious beliefs of the organization," it has not provided contraceptive coverage in the health plan or plans to it offers to employees at any time since Feb. 10, 2012.

-- It has notified employees that contraceptive coverage will not be provided under the plan for the first plan year beginning on or after Aug. 1, 2012.

Each organization must document that it meets the criteria by filing a certification with HHS.

But Cardinal Timothy M. Dolan of New York, president of the U.S. Conference of Catholic Bishops, said the yearlong "safe harbor" simply means that the Obama administration "is saying that we have a year to figure out how to violate our consciences."

The exception also leaves out for-profit companies headed by owners who oppose providing contraceptive coverage to employees, as well as individual workers who don't want their health insurance premiums used to provide contraceptives to others. So the court battles in various parts of the country will continue on.

— Nancy Frazier O'Brien, Catholic News Service