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Mandated benefits (also known as “mandated health insurance benefits” and “mandates”) are benefits that are required to cover the treatment of specific health conditions, certain types of healthcare providers, and some categories of dependents, such as children placed for adoption.A number of health care benefits are mandated by either state law, federal law — or in some cases — both.
And some other mandates (for example, the requirement—described below—that all plans offered by employers with 15 or more employees cover maternity care) apply to the large group market.
The requirement to include EHBs applies to all individual and small group plans with effective dates of January 1, 2014 or later.
The list of EHBs includes: have to be covered by large group plans ("large group" generally means plans offered by employers with more than 50 employees, although there are four states where "small group" includes employers with up to 100 employees).
Pregnancy Discrimination Act Health plans maintained by employers who have 15 or more employees must provide the same level of coverage for pregnancy as for other conditions.
The states differ greatly in the number and type of mandated benefits, but across all 50 states, there are around 2,000 benefit mandates that have been put in place over the last 30 years.
Between the federal government and the states, there are thousands of health insurance mandates.
Although mandates continue to be added as health insurance requirements, they are controversial.Mental health benefits If a health plan covers mental health services, the annual or lifetime dollar limits must be the same or higher than the limits for regular medical benefits.Minimum hospital stays for newborns and mothers Under The Newborns’ and Mothers’ Health Protection Act of 1996, health plans may not limit benefits for any hospital length of stay related to childbirth for the mother or newborn child.Some examples of additional state-specific benefit mandates are infertility coverage, autism coverage, and limiting out-of-pocket costs for prescriptions.But there are rules that require states—rather than insurers—to cover the cost of benefit mandates that go beyond the ACA's requirements, which means that some states have opted to apply new mandates only to large group plans, which aren't subject to the ACA's essential health benefit requirements (note however, that self-insured plans are regulated under federal rules rather than state oversight, so they are not subject to new requirements that states impose; the majority of very large group plans are self-insured).Patient advocates claim that mandates help to ensure adequate health insurance protection while others (especially health insurance companies) complain that mandates increase the cost of healthcare and health insurance.