What Happened?
A federal watchdog review found that some Americans enrolled in private health plans were denied contraceptive coverage they are legally entitled to receive at no cost. The U.S. Government Accountability Office (GAO) reviewed contraceptive coverage compliance across federal and state regulators and documented violations in both of the two main federal oversight agencies.
Federal law generally requires most private health plans to cover a broad range of contraceptives, including oral contraceptives, intrauterine devices, and female sterilization services, without any out-of-pocket costs to the enrollee. That requirement has been in place for years, but the GAO review found it is not always being followed.
Why Does it Matter to Me?
About two-thirds of Americans get their health coverage through private health plans, meaning the compliance gaps the GAO identified could affect a large share of the country. In practical terms, that means some people may have paid out of pocket for birth control they were legally owed at no charge.
In one documented case, a pharmacy benefit manager required patients to try other contraceptive methods before it would cover their medically necessary, preferred option without cost-sharing. In another, a health plan simply failed to cover contraceptive services at no cost as required. They are cases federal investigators actually found and documented.
Both the pharmacy benefit manager and the health plan revised their practices and reprocessed affected claims only after federal investigators identified the problems. That means patients who were overcharged may not have known they were owed a refund until regulators stepped in.
Both Sides, Now
Oversight of the contraceptive coverage mandate is split among three types of regulators: the Department of Labor (DOL) oversees private employer-sponsored group health plans; the Centers for Medicare and Medicaid Services (CMS), part of the Department of Health and Human Services, oversees non-federal governmental plans and plans in states that do not enforce federal requirements; and states oversee individual and some group health plans sold within their borders.
DOL found noncompliance in three investigations over the past six years, and CMS found noncompliance in three of five market conduct examinations over the same period. Those who pushed for the review argue the divided oversight structure leaves gaps that allow violations to go undetected until a formal investigation begins.
The GAO report made no formal recommendations to either agency. Without directed recommendations, neither DOL nor CMS is formally required to change how it monitors compliance. Some observers argue that limits the review's practical effect.
What Happens Next?
Because the GAO report issued no formal recommendations, oversight of contraceptive coverage compliance remains divided among the Department of Labor (DOL), the Centers for Medicare & Medicaid Services (CMS), and state regulators, each carrying distinct authorities and responsibilities.
In states that lack authority to enforce federal requirements or choose not to enforce them, CMS carries the oversight burden for certain plans. That means the level of protection a person has can depend on where they live. Congress could act to consolidate oversight or direct the agencies to strengthen enforcement, but no legislation addressing the issue is currently scheduled for a vote.
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