GAO Details Regulatory Noncompliance in Private Plan Contraceptive Coverage
A new GAO report reveals recurring regulatory noncompliance among private health insurers and pharmacy benefit managers regarding federal contraceptive coverage mandates. DOL and CMS enforcement efforts highlight persistent cost-sharing violations and improper step-therapy restrictions.
A new Government Accountability Office (GAO) investigation underscores significant compliance vulnerabilities in how private health insurance plans administer federal contraceptive coverage requirements. With roughly two-thirds of Americans relying on private plans for healthcare, federal regulators—including the Department of Labor (DOL) and the Centers for Medicare & Medicaid Services (CMS)—alongside state insurance authorities, share oversight responsibilities. However, recent audit findings indicate that improper cost-sharing mandates and unauthorized step-therapy restrictions persist across employer-sponsored and individual commercial plans.
GAO’s review reveals that regulatory enforcement mechanisms have repeatedly caught insurers and pharmacy benefit managers (PBMs) out of compliance. Over the past six years, DOL enforcement actions uncovered systemic noncompliance, including instances where PBMs unlawfully mandated enrollees to attempt alternative contraceptive methods before granting access to preferred, medically necessary options at zero cost-sharing. Concurrently, CMS identified compliance failures in three out of five market conduct examinations conducted during the same timeframe, primarily involving unauthorized cost-sharing imposed on beneficiaries. In these instances, noncompliant entities were compelled to revise operational policies and reprocess improperly billed claims.
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