Private Health Insurance: Federal and State Oversight of Contraceptive Coverage Requirements

The GAO report examines federal and state oversight of private health plan compliance with contraceptive coverage requirements under the Patient Protection and Affordable Care Act (PPACA/ACA). Private health plans are generally required to cover the full range of FDA-approved contraceptives for women without cost-sharing, including oral contraceptives, intrauterine devices, and female sterilization services. Oversight responsibility is divided among DOL (private employer-sponsored group health plans), CMS (non-federal governmental plans, qualified health plans on federally-facilitated exchanges, and plans in states lacking enforcement capacity), and state regulators (individual and certain group health plans sold in-state). DOL identified noncompliance with federal contraceptive coverage requirements in three investigations conducted within the last six years. In one documented instance, a pharmacy benefit manager required enrollees to attempt other contraceptive methods before covering the medically necessary, preferred method at no cost-sharing, a step-therapy practice the DOL found to violate coverage requirements. Following DOL action, the PBM revised its practices and reprocessed the associated claims. CMS identified noncompliance in three of five market conduct examinations it conducted over the same six-year period. In one instance, a health plan failed to provide contraceptive services without cost-sharing as required. CMS directed that plan to revise its practices and reprocess claims. CMS oversight activities include annual plan reviews and certification, individual complaint investigations, and market conduct examinations targeting systemic compliance issues. GAO's methodology included analysis of contraceptive prescription purchase data from the Agency for Healthcare Research and Quality, review of federal guidance issued by CMS and DOL, and interviews with officials from DOL, CMS, six states, selected health plans, and stakeholder organizations representing enrollees and providers. State regulators perform premarket plan reviews, complaint collection, and market conduct examinations for plans within their jurisdiction.