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Health Insurance Mandates and Essential Health Benefits

usaA health insurance mandate is a regulation which requires a health insurance company to cover specific conditions and ailments. Mandates vary from state to state, and some require more coverage while others permit less. Common mandates include covering maternity health care costs or conditions like autism.

Sidenote: Health care reform created the individual health insurance mandate which requires an individual to purchase health insurance or pay a fine. This is not to be confused with mandates in states for health insurance coverage of a service.

Health insurance mandates seem to be the wave of the future as states create more mandates for coverage and are given the power to determine “Essential Health Benefits.” Essential benefits are benefits that must be provided a health plan — health care reform also created this provision. Instead of the federal government determining the essential benefits in a plan, they have passed the decision to states.

As always, Massachusetts leads the pack when it comes to insurance reform, and since 2005, this state has mandated insurance for all residents. It also has a lot of mandates regarding infertility treatment, autism and maternity coverage.

Since 2010, the states with the most insurance mandates include:

  • Rhode Island
  • Maryland
  • Minnesota
  • Texas
  • Connecticut

There are several mandates that are common and widely used across the board, including mandates on treatment for mental health, alcoholism, mammograms, breast reconstruction, emergency care, diabetes needs. Currently there are more than 2,100 mandates in the fifty states and there isn’t a nationwide standard.

Q&A on Essential Health Benefits and Mandates

Q: Will health care reform create a nationwide standard?

A: Not really, right now the federal government is allowing states to make the decisions when it comes to coverage with only a baseline to follow.

Q: What happens to my insurance premiums when a new mandate is passed?

A: Health insurance benefits and costs are similar to a balanced scale. When benefits are added to a plan, the health insurance plan cost increases. Lawmakers have to balance the benefits with cost to make sure health insurance is affordable.

Q: What if my state already requires health plans to cover a lot of benefits?

A: If your state already requires health insurance plans to cover a lot of services then there most likely won’t be a lot of changes in the near future to plans.

Q: What if I want my state to cover certain benefits?

A: Contact your state’s insurance department to ask lawmakers to require additional benefits in health plans.

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