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 healthcare benefits are mandated by either state law, federal law—or in some cases—both. Between the federal government and the states, there are thousands of health insurance mandates.

This article will explain how mandated benefits are created and enforced, and what types of health coverage are subject to various mandated benefit requirements.

Although mandates continue to be added as health insurance requirements, they are controversial. Patient advocates claim that mandates help to ensure adequate health insurance protection, while others complain that mandates increase the cost of health care and health insurance.

Mandated Health Insurance Benefit Laws

Laws regarding mandated health insurance benefits—enacted at either the federal or state level— usually fall into one of three categories:

  • A requirement that health plans cover various healthcare services or treatments, such as substance abuse treatment, contraception, in vitro fertilization, maternity services, prescription drugs, or smoking cessation.A requirement that health plans include coverage for treatment by providers other than physicians, such as acupuncturists, chiropractors, nurse midwives, occupational therapists, and social workers.A requirement that health plans cover dependents and other related individuals, such as adopted children, dependent students, grandchildren, and domestic partners.

The mandated benefit laws most often apply to health insurance coverage offered by employers and private health insurance purchased by individuals, either through the health insurance exchanges or off-exchange. But there are also mandates that apply to Medicare and Medicaid/CHIP coverage.

State mandates don’t apply to self-insured group health plans in that state, since self-insured plans are regulated under federal law (ERISA) rather than state law.

So for example, if a state requires health plans to cover vasectomies (a few have), in addition to the female contraceptive coverage that’s required under federal law, that mandate would apply to individual market plans and employer-sponsored plans in which the employer buys coverage from an insurance company. But it would not apply to employer-sponsored plans in which the employer self-insures, which is what most very large employers do.

(Note that self-insured employers typically contract with an insurance company to administer the benefits, so the employees will have ID cards that have an insurance company name on them. But medical needs are funded by the employer, rather than by the insurer, which makes a big difference in terms of how the plan is regulated.)

Among workers with employer-sponsored health coverage, 65% were covered by self-insured plans in 2022. So state-mandated benefits actually don’t apply to the majority of people who get their insurance from an employer-sponsored plan.

Mandated Insurance Benefits and the Cost of Health Insurance

Most people—whether for or against mandates—agree that mandated health benefits increase health insurance premiums. Depending on the mandated benefit and how that benefit is defined, the increased cost of a monthly premium can increase from less than 1% to more than 5%.

Trying to figure out how a mandated benefit will impact an insurance premium is very complicated. The mandate laws differ from state to state and even for the same mandate, the rules and regulations may vary.

For example, most states mandate coverage for chiropractors, but the number of allowed visits may vary from state to state. One state may limit the number of chiropractor visits to four each year while another state may require insurers to cover up to 12 chiropractor visits each year. Since chiropractor services can be expensive, the impact on health insurance premiums may be greater in the state with a more generous benefit.

Another example is infertility coverage, which is not required under federal law but is required by several states. Across those states, there’s wide variation in terms of what has to be covered in terms of infertility treatment, which means that the impact on premiums differs significantly from state to state.

Additionally, the lack of mandates could also increase the cost of health care and health insurance premiums. If someone who has a medical problem goes without necessary health care because it is not covered by her insurance, she may become sicker and need more expensive services in the future.

An example of this is the fact that adult dental care is not one of the essential health benefits mandated under the ACA, nor is adult dental care required to be covered under Medicaid (some states do include dental coverage in their adult Medicaid programs, while others don’t). The resulting lack of access to affordable dental care can result in serious long-term complications.

Federal Mandated Health Benefits

Federal law includes a number of insurance-related mandates:

ACA essential health benefits (EHBs)The Affordable Care Act was a landmark change in terms of mandated health benefits, creating a universal floor in terms of the essential health benefits that must be included on every new individual/family and small group health plan in every state.

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:

  • Ambulatory services (outpatient care)
  • Emergency services
  • Hospitalization (inpatient care)
  • Maternity and newborn care
  • Mental health and substance use disorder services
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive care and chronic disease management (certain specific preventive care is free on all new plans, regardless of whether the plan member has met the deductible).
  • Pediatric services, including oral and vision care (adult dental and vision coverage aren’t required to be covered, and there’s some flexibility in terms of the mandates for pediatric dental).

Within the parameters of those general EHB categories, each state defines its own benchmark plan, with insurers then modeling their individual and small group plans on the state’s EHB benchmark plan. So even though all new individual and small group plans have to cover all of the EHBs, the specifics of the coverage will vary from one state to another, and will depend on various coverage mandates that each state imposes.

With the exception of preventive care, inpatient care, and physician services, EHBs do not have to be covered by large group plans, or by self-insured plans of any size. (To clarify, “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.)

Large group plans (many of which are self-insured) do tend to be fairly robust, however. 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.

COBRA continuation coverageCOBRA is a federal law that provides certain former employees and their dependents the right to continue coverage for a maximum of 18 to 36 months. COBRA only applies to employers with 20 or more employees, but many states have state continuation laws that allow employees to continue their coverage after losing access to a smaller employer’s plan.

Coverage of adoptive childrenCertain health plans must provide coverage to children placed with families for adoption under the same conditions that apply to biological or already-adopted children, whether the adoption has become final or not.

Mental health benefitsIf 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. This is known as mental health parity, and stems from a federal law that was enacted in 1996. The Affordable Care Act extended mental health parity rules to individual/family and small group plans, as the original mental health parity law only applied to large employer-sponsored health coverage.

Minimum hospital stays for newborns and mothersUnder 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.

Reconstructive surgery after mastectomyA health plan must provide someone who is receiving benefits related to a mastectomy with coverage for reconstruction of the breast on which a mastectomy has been performed.

Americans with Disabilities Act (ADA)Disabled and nondisabled individuals must be provided the same benefits with regard to premiums, deductibles, limits on coverage, and pre-existing condition waiting periods.

Family and Medical Leave Act (FMLA)Requires an employer to maintain health coverage for the duration of an FMLA leave.

Uniformed Services Employment and Reemployment Rights Act (USERRA)Gives an employee the right to continuation of health coverage under the employer’s health plans while absent from work due to service in the uniformed services.

Pregnancy Discrimination ActHealth plans maintained by employers with 15 or more employees must provide the same level of coverage for pregnancy as for other conditions. This has been federal law since the late 1970s.

But for people buying health insurance in the individual market, the majority of plans available for purchase did not include maternity benefits at all until 2014. Some states had mandated maternity coverage for their individual markets prior to 2014, but there was no federal requirement until the ACA included maternity coverage as an essential health benefit.

State Mandated Health Benefits

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. 

You can find information about individual state mandates from several sources:

  • Your state’s insurance department, which you can access from the website of the National Association of Insurance Commissioners
  • The National Conference of State Legislatures (NCSL)
  • The Kaiser Family Foundation’s compilation of State Health Facts

Under the ACA, all new (effective since 2014) individual and small group plans in all states must include coverage for the EHBs, must have adequate provider networks, and must cover pre-existing conditions and be issued without regard for medical history.

(Note that for essential health benefits, the specific services that must be covered by individual and small group plans do vary from one state to another. Each state sets its own benchmark plan that’s used to determine what services must be covered. So although all new individual and small group health plans must cover the essential health benefits, the exact services that they cover do differ from one state to another.)

The ACA sets the minimum standard to which the plans must adhere, but states can go beyond the ACA’s requirements. Some examples of additional state-specific benefit mandates are infertility coverage, autism coverage, male sterilization coverage, and limiting out-of-pocket costs for prescriptions.

But there are rules that require states—rather than insurers—to cover the cost of new benefit mandates that go beyond the ACA’s requirements. Because of this, 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.

As described above, however, self-insured group plans are regulated under federal rules rather than state oversight. So they are not subject to new requirements that states impose, and the majority of very large group plans are self-insured. 

Summary

Mandated health insurance benefits refer to state and federal rules that require health plans to cover certain services, providers, and enrollees. Mandated benefit rules can be set at the state or federal level. Benefit mandates set by a state do not apply to self-insured group plans, since those are regulated at the federal level instead (the majority of workers with employer-sponsored health insurance are covered by self-insured plans). Federal benefit mandates can apply to some plans but not others (for example, the individual and small group market but not the large group market, or only groups with 15+ or 20+ employees, for example.

A Word From Verywell

Benefit mandates help to ensure that consumers have adequate coverage. But it’s important to understand which health plans are subject to any particular benefit mandate requirements. If your state requires certain services to be covered, you’ll need to understand whether your health plan is subject to state rules. In general, you’ll always need to read the specific details for the plan you have (or any plan you’re considering) in order to understand what’s covered and what’s not.