A small examination program found repeated violations
The Centers for Medicare & Medicaid Services found contraceptive-coverage noncompliance in three of five market-conduct examinations initiated in Texas in 2021, GAO reported. That is 60%, although five examinations are far too few to estimate a national insurer violation rate.
GAO described a case in which a plan required step therapy before covering a preferred medically necessary contraceptive. The affected plans revised practices or reprocessed claims after federal review.
| Oversight measure | Result | What it means |
|---|---|---|
| CMS market examinations | 5 | Limited Texas sample begun in 2021 |
| CMS exams finding noncompliance | 3 | 60% of examined plans |
| Labor Department investigations finding noncompliance | 3 | Across the prior six years |
| Privately insured women with an out-of-pocket contraceptive purchase | Estimated 16.5% | 2020–23; payment may or may not be improper |
Out-of-pocket data show exposure, not automatic violations
GAO estimated that 16.5% of privately insured reproductive-age women who purchased a prescription contraceptive from 2020 through 2023 had some out-of-pocket payment. The underlying data could not show whether each payment reflected a lawful exception, a noncovered service or an improper charge.
That limitation matters: the survey estimate should not be multiplied into a national count of violations. It does show that cost exposure persisted while targeted examinations and investigations documented specific coverage failures.
The accountability gap is the scale of enforcement evidence
The public-interest finding is that a very small federal examination set found noncompliance frequently, while the available national payment data cannot distinguish correct from incorrect charges. Consumers and regulators therefore lack a national compliance rate.
The Labor Department reported three investigations with contraceptive-coverage noncompliance in the last six years. GAO made no recommendations and said the responsible agencies supplied technical comments that were incorporated.
Method and limitations
The newsroom reviewed GAO’s September 24 report and calculated 3 divided by 5. We kept the CMS examination result, Labor investigations and survey estimate separate because they measure different populations and enforcement channels.
The market exams were selected and geographically limited, not a representative sample. The report does not support ranking insurers or concluding that 60% of all health plans violated the law.