GAO report finds multiple private plan violations of contraceptive coverage rules

The Government Accountability Office's report GAO-26-108446 documents that the Department of Labor (DOL), the Centers for Medicare & Medicaid Services (CMS) and state agencies have each identified instances of noncompliance with federal contraceptive coverage requirements among private health plans over the past six years.

In 2024, about 82 percent of women of reproductive age reported using some form of contraception, and private health plans are generally required to cover the full range of contraceptives without cost-sharing, including oral contraceptives, intrauterine devices and female sterilization services.

DOL's oversight authority covers private employer-sponsored group health plans and includes responding to enrollee complaints, conducting investigations prompted by systemic concerns, and reviewing complaints. CMS oversees non-federal governmental plans, qualified health plans offered through federally-facilitated exchanges, and certain group and individual plans, conducting annual plan reviews, certification, individual complaint investigations and market-conduct examinations. State regulators oversee individual health plans and some group plans sold in their states, conducting pre-market health-plan reviews, collecting individual complaints and carrying out market-conduct examinations.

DOL officials cited three investigations in the last six years in which a pharmacy-benefit manager required enrollees to try other contraceptives before covering a medically necessary, preferred method at no cost-sharing; the manager later revised its practices and reprocessed the associated claims. CMS officials reported that three of five market-conduct examinations uncovered noncompliance, including a health plan that failed to provide contraceptive services without cost-sharing; the plan also revised its practices and reprocessed the claims.

GAO's review drew on Agency for Healthcare Research and Quality data, literature on cost-sharing for contraceptives, federal guidance from CMS and DOL, and interviews with officials from DOL, CMS, six selected states, health plans and stakeholder organizations. The report notes that Treasury oversight of certain church plans falls outside its scope.