Jay Nixon (Governor's office photo)

(Bloomberg) — Aetna Inc. is paying a record $4.5 million fine in Missouri in part for something that rarely draws the ire of regulators — paying for procedures it shouldn’t have covered.

See also: States restrict plans from abortion coverage

In this case, those procedures were abortions. Missouri law says health insurers shouldn’t pay to help end a pregnancy unless a woman buys separate coverage.

While Missouri had imposed a similar fine in the past on Aetna, it’s rare for state overseers to ding health plans for paying for too much, said Chris Koller, a former Rhode Island health insurance regulator.

“I have never heard of a company being penalized for covering more than was required,” Koller said in an e-mail. He’s now president of the Milbank Memorial Fund, a nonpartisan group that works with health policy makers. “But it had happened before with them.”

Missouri’s law dates to the early 1980s, but the controversy over insurers’ coverage of abortion gained wider attention in the debate over the 2010 Patient Protection and Affordable Care Act (PPACA), said Elizabeth Nash, who tracks states policies at the Guttmacher Institute. Under a deal worked out by lawmakers on that U.S. bill, states can restrict abortion coverage on their own insurance exchanges, and federal funds can’t be used for the procedure unless the pregnancy endangers the woman’s life or is the result of rape or incest.

See also: GAO: Few exchange plans follow PPACA abortion premium rules

Nine states other than Missouri have limits on abortion coverage by private insurers, according to Guttmacher. Additional states impose restrictions on plans sold on the PPACA exchanges and on Medicaid coverage of abortions.

Autism treatment

In addition to abortion coverage, the fine in Missouri penalized Aetna for not covering some treatments for autism. The insurer admitted to paying for nine abortions and to failing to offer the autism coverage.

Chris Cline, a spokesman for the state’s insurance regulator, said the fine was for the full extent of Aetna’s actions and can’t be broken down to reflect how much the company was penalized for the abortion coverage alone.

The company’s exclusion of some autism coverage could have affected thousands of Missouri families, he said. And the insurer already knew it should have been covering the treatments, and not covering abortions, because of a similar fine imposed by the state in 2012.

That year, Aetna agreed to pay $1.5 million and said it would follow the state’s regulations. Rohan Hutchings, an Aetna spokesman, said the insurer is obeying Missouri law.

“We take our responsibilities to our members and to compliance very seriously,” he said. “When we make mistakes, we take steps to correct our errors.”

Of the new $4.5 million fine, $1.5 million is suspended as long as Aetna follows the agreement.

Strong backer

A statement announcing the settlement from Missouri’s Democratic governor, Jay Nixon, didn’t mention the abortion coverage. That’s because Nixon has been a strong backer of the law that expanded insurance coverage for autism in the state, according to his spokesman, Scott Holste.

“The governor was a real leader on passing that autism bill in 2010,” Holste said. “He has worked closely with the autism community in ensuring that both the diagnosis and treatment are required to be covered.”

See also: Autism mandate has ‘minimal’ effect in Missouri

The Supreme Court legalized abortion in all 50 states in its 1973 Roe vs. Wade decision. Since then, some states have imposed rules designed to curb the procedures. The restrictions on abortion coverage in Missouri are an effort to make the procedure less accessible, said Pamela Sumners, director of NARAL Pro-Choice Missouri.

“To the extent that we put in place mechanical systems and insurance rules that undermine any of that, we are making Roe vs. Wade a right without a remedy,” she said.