Essential health benefits are ten categories of care, including hospitalization, prescription drugs, maternity, and mental health, that ACA-compliant individual and small-group plans must cover. The exact services follow each state’s benchmark plan.
The Women’s Health and Cancer Rights Act requires group and individual plans that cover mastectomies to also cover breast reconstruction, prostheses, and treatment of related complications such as lymphedema. Plans must notify members of these rights yearly.
It depends on your state and plan. As of late 2025, 25 states plus Washington, D.C. require some fertility coverage, and 15 of those include in vitro fertilization (IVF). Coverage is not an ACA essential health benefit, so plans not subject to a mandate may exclude it.
Yes. Maternity and newborn care are essential health benefits, so all ACA-compliant individual and small-group plans must cover them. Birth is a qualifying life event that opens a special enrollment period to add the baby.