Health Reform Action Center
Women's Health Benefits
The Affordable Care Act (ACA) established a minimum floor of services – called the essential health benefits (EHB) – that all health plans in the individual and small group insurance markets both inside and outside of the new State Exchanges will be required to cover, starting in 2014. These are also mandatory for State Medicaid and State Basic Health Programs.
Essential Health Benefits consist of 10 core benefits that all health plans within the newly established exchanges must cover. Maternity and newborn care is one of the 10 essential benefits requirements. For women, the EHB mandate is critical. Currently, most individual health plans fail to provide coverage for maternity care. Other plans offer coverage only as a rider which has long waiting times and may not kick-in during the time a pregnant woman needs the coverage, or the coverage may be inadequate or prohibitively expensive.
ACOG worked hard during passage of the national health reform law to ensure that women everywhere would be guaranteed meaningful and uniform coverage of maternity care – regardless of where they work or the state they live in. The ACA adopted this approach. However, implementing regulations issued last December by HHS surprised many by giving States flexibility and freedom to design its own EHB package. It is crucial that each State’s EHB package cover comprehensive maternity and newborn services as recommended by ACOG.
States face a September 2012 deadline for establishing their EHB package. States will decide the actual services covered within the 10 categories individually. After EHB packages are set, States will need to monitor health plan compliance. Regulations may be necessary to determine if the new benefits are being delivered.
HHS has not specified the actual services that must be covered in the 10 categories. This will be decided by each State individually. Also, HHS will permit insurers some leeway to deviate from a State’s selected EHB. The final HHS guidance for States to aid in determining the services that make-up the EHB package was a FAQ in February of 2012.
As States' finalize their individual benchmark plans, they should follow ACOG's recommendations on what components are medical necessities for maternity and newborn care.
Find out how far along your State is in determining its EHB package.