Why It Matters
A new U.S. Government Accountability Office (GAO) report on contraceptive coverage compliance found that federal oversight has identified noncompliance across both Department of Labor (DOL) and Centers for Medicare & Medicaid Services (CMS) jurisdictions, even as most private health plans are generally required to cover a range of contraceptive services without out-of-pocket costs.
In documented cases, enrollees faced requirements to try other contraceptives before a pharmacy benefit manager would cover a medically necessary, preferred method without cost-sharing, and at least one health plan failed to provide contraceptive services without cost-sharing. Both the pharmacy benefit manager and health plan revised their practices and reprocessed associated claims after federal officials identified the problems, illustrating how noncompliance can persist until an investigation or examination identifies it.
Two-thirds of Americans receive their health coverage through private health plans. Stakeholders and researchers have raised concerns that health plan enrollees have been denied coverage for certain contraceptive products or services, and those concerns helped prompt the review.
The Big Picture
Most private health plans are generally required under federal law to cover a broad range of contraceptives without cost-sharing, including oral contraceptives, intrauterine devices, and female sterilization services. Oversight of that mandate is divided among three entities: DOL oversees private employer-sponsored group health plans; CMS, an agency within the Department of Health and Human Services (HHS), oversees non-federal governmental plans, qualified health plans offered through federally facilitated exchanges and group and individual plans in states that lack authority to enforce federal requirements or are not otherwise enforcing them; and states oversee individual health plans and some group health plans sold within their borders.
DOL identified noncompliance in three investigations it conducted over the last six years. In one case, a pharmacy benefit manager required enrollees to try other types of contraception before covering the medically necessary, preferred method without cost-sharing. According to DOL officials, the pharmacy benefit manager revised its practices and reprocessed the associated claims after the investigation.
CMS identified noncompliance in three of five market conduct examinations it conducted over the same period. In one example, a health plan failed to provide contraceptive services without cost-sharing, and officials said the health plan revised its practices and reprocessed the associated claims. Across both agencies, GAO identified noncompliance among plans subject to investigations or market conduct examinations.
To conduct the review, GAO analyzed available data from the Agency for Healthcare Research and Quality (AHRQ) on contraceptive prescription purchases, reviewed relevant literature and federal guidance issued by CMS and DOL, and interviewed officials from DOL, CMS, six selected states, selected health plans, and selected stakeholder organizations representing enrollees and providers. GAO selected the six states to capture variation in rurality and state laws, among other criteria.
GAO provided a draft of the report to HHS and DOL. Both agencies provided technical comments, which GAO incorporated as appropriate. The report made no recommendations.
The Bottom Line
With no formal recommendations directed to either agency, oversight of contraceptive coverage compliance remains divided among DOL, CMS, and state regulators, each carrying distinct authorities and responsibilities. The Department of the Treasury also holds oversight authority over certain aspects of federal health coverage compliance for church plans, though that category was explicitly outside the scope of the report.
In states that lack authority to enforce federal requirements or do not enforce them, oversight responsibility for certain plans falls to CMS rather than the state. With noncompliance documented across both DOL and CMS jurisdictions and state-level enforcement varying by authority, the report underscores continuing concerns raised by stakeholders and researchers that some health plan enrollees have been denied federally required coverage for certain contraceptive products or services.
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