Private Health Insurance: Federal and State Oversight of Contraceptive Coverage Requirements
Fast Facts
Most women of reproductive age have reported using some form of contraception. Private health plans must generally cover a range of contraceptives at no cost, including oral contraceptives and intrauterine devices.
The Department of Labor, Centers for Medicare & Medicaid Services, and states oversee plans' compliance with federal coverage requirements.
Since 2020, several federal investigations found noncompliance, such as failing to provide no-cost contraceptives or requiring women to try other contraceptives before covering their preferred method.
Close up of a person's hands with painted red fingernails holding a pack of oral contraceptives
Highlights
What GAO Found
In 2024, about 82 percent of women of reproductive age reported using some form of contraception in the past 12 months, according to research from KFF. Most private health plans are generally required to cover the full range of contraceptives for women. The Department of Labor (DOL), the Centers for Medicare & Medicaid Services (CMS)—an agency within the Department of Health and Human Services—and states each have responsibilities for overseeing private health plans, including plans' coverage of contraception. See table for descriptions of their general oversight responsibilities and activities.
DOL, CMS, and States’ General Responsibilities for Overseeing Private Health Plans
|
|
Oversight authority |
Oversight activities |
|---|---|---|
|
DOL |
Private employer-sponsored group health plans |
Responding to enrollee complaints Conducting investigations in response to systemic concerns identified from various sources, such as complaints |
|
CMS |
Non-federal governmental plans Qualified health plans offered through the federally-facilitated exchanges Group and individual plans in certain states that do not have authority to enforce federal requirements or are not otherwise enforcing requirements |
Conducting annual plan reviews and certification Conducting individual complaint investigations Conducting market conduct examinations of potential systemic compliance issues |
|
States |
Individual health plans and some group health plans sold in their state |
Conducting premarket health plan reviews Collecting individual complaints Carrying out market conduct examinations |
Source: GAO review of information from CMS, DOL, selected state officials and prior GAO work. | GAO-26-108446
Note: The Department of Treasury oversees certain aspects of PPACA compliance for church plans, which were outside the scope of our report.
Of the plans for which they have oversight responsibility, DOL and CMS identified instances of noncompliance within the last 6 years. For example,
- DOL identified noncompliance with federal contraceptive coverage requirements in three investigations DOL conducted in the last 6 years, according to DOL officials. For example, DOL found that a pharmacy benefit manager required enrollees to try other types of contraception before covering the medically necessary, preferred method at no cost-sharing. According to DOL officials, this pharmacy benefit manager revised its practices and reprocessed the associated claims.
- CMS identified instances of health plan noncompliance with federal contraceptive coverage requirements in three out of five market conduct examinations conducted in the last 6 years. For example, CMS found that one health plan failed to provide coverage of contraceptive coverage services without cost-sharing. Officials say this health plan revised its practices and reprocessed the associated claims.
Why GAO Did This Study
Two-thirds of Americans receive their health coverage through private health plans. Private health plans must generally cover a range of contraceptives without cost-sharing including oral contraceptives, intrauterine devices, and female sterilization services, among others. Concerns have been raised by stakeholders and researchers that health plan enrollees have been denied coverage for certain contraceptive products or services.
GAO was asked to review oversight by federal and state agencies of group and individual health plans’ compliance with federal contraceptive coverage requirements. This report provides information on payments enrollees made for contraceptives, including cost-sharing; perspectives from stakeholder organizations and health plans about contraceptive coverage requirements; and federal and state oversight of federal contraceptive coverage requirements.
To conduct this review, GAO analyzed available data from the Agency for Healthcare Research and Quality on contraceptive prescription purchases; reviewed literature to identify information about when enrollees had cost-sharing for contraceptives; reviewed federal guidance issued by CMS and DOL; and interviewed officials from DOL, CMS, six selected states, selected health plans, and selected stakeholder organizations, including those representing enrollees and providers. GAO selected these states to capture variation in rurality and state laws, among other criteria.
GAO provided a draft of this report to the Department of Health and Human Services and DOL. The agencies provided technical comments that we incorporated as appropriate.
For more information, contact John E. Dicken at dickenj@gao.gov.