ACA Maternity and Newborn Coverage Requirements

The Affordable Care Act mandates maternity and newborn care as one of ten Essential Health Benefits that most health plans sold in the individual and small-group markets must cover. This requirement closed a significant gap in pre-ACA coverage, where individual market plans routinely excluded maternity services entirely. Understanding how these mandates are structured, which plans must comply, and where gaps can still exist is essential for employers, plan sponsors, and individuals evaluating coverage options.

Definition and scope

Under Section 1302(b) of the ACA (42 U.S.C. § 18022), maternity and newborn care is one of 10 categories of Essential Health Benefits under the ACA that non-grandfathered plans in the individual and small-group markets must include. The mandate covers the full continuum of pregnancy-related services: prenatal care, labor and delivery (both vaginal and cesarean), postpartum care for the mother, and hospital care for the newborn.

The scope of the requirement draws on the benchmark plan standards established by the Department of Health and Human Services (HHS). Each state's Essential Health Benefit benchmark, based on a reference plan selected under 45 C.F.R. Part 156, defines the specific services that must be included. States can update their benchmarks, which means the precise service list can differ between states, but all benchmarks must include the maternity and newborn category.

The mandate applies to:

Large-group and self-funded employer plans are not required to cover the EHB maternity category under federal law, though they face separate federal protections under the Pregnancy Discrimination Act and the Newborns' and Mothers' Health Protection Act (NMHPA) (29 U.S.C. § 1185).

How it works

Prenatal and antepartum care. Plans must cover office visits, ultrasounds, laboratory tests, and screenings associated with routine prenatal care. Under ACA preventive care rules (42 U.S.C. § 300gg-13), preventive prenatal services rated A or B by the U.S. Preventive Services Task Force (USPSTF) — including gestational diabetes screening, Rh incompatibility testing, and anemia screening — must be covered without cost-sharing.

Labor, delivery, and inpatient stay. Plans must cover hospital admission for delivery. Under the NMHPA, enforced jointly by the Department of Labor (DOL) and HHS, plans and issuers that cover maternity hospital stays cannot restrict the length of stay to fewer than 48 hours following a vaginal delivery or 96 hours following a cesarean section (29 U.S.C. § 1185). These minimum stay protections apply to all group health plans, not just individual market plans.

Postpartum care. Coverage must extend to follow-up visits after delivery. The benchmark plan definition determines how many postpartum visits are covered and at what intervals.

Newborn care. Plans covering maternity services must also cover newborn care beginning at birth. This includes well-baby care, circumcision where included in the benchmark, and newborn screenings. Notably, the newborn must be enrolled in coverage for benefits to apply; a newborn is not automatically covered on a parent's plan indefinitely. Special enrollment rights triggered by birth allow enrollment within 30 days under HIPAA/ACA rules, and coverage typically applies retroactively to the date of birth.

Cost-sharing. While the services must be covered, plans may apply in-network deductibles, copayments, and coinsurance, subject to the ACA's annual out-of-pocket maximum limits. For plan year 2024, HHS set the out-of-pocket maximum at $9,450 for self-only coverage (HHS Notice of Benefit and Payment Parameters for 2024).

Common scenarios

Scenario 1 — Individual market plan, first pregnancy. An enrollee in a non-grandfathered individual market plan discovers she is pregnant mid-plan-year. The plan must cover all prenatal visits, the hospital delivery, and postpartum follow-up as in-network benefits. Preventive screenings must be covered at no cost-sharing; therapeutic services (e.g., treatment for gestational hypertension) are subject to normal cost-sharing up to the out-of-pocket maximum.

Scenario 2 — Small employer, self-funded plan. A company with 40 employees operates a self-funded health plan. Because self-funded employer plans are exempt from the EHB mandate, the employer is not required by the ACA to cover maternity services. However, the plan remains subject to NMHPA minimum stay requirements and the Pregnancy Discrimination Act prohibition against treating pregnancy differently from other medical conditions. If the plan does cover maternity, the NMHPA length-of-stay floors apply.

Scenario 3 — Grandfathered plan. A plan that maintained grandfathered status under ACA rules is also exempt from the EHB maternity coverage mandate. The broader regulatory context for the ACA explains how grandfathered plan status is preserved and what protections such plans still must provide.

Scenario 4 — Newborn enrollment timing. An enrollee delivers a child but delays submitting enrollment paperwork for 45 days. The plan is not required to cover newborn services beyond the 30-day special enrollment window; if enrollment is not completed within 30 days of birth, the newborn may be left without coverage (or enrolled only prospectively), leaving a gap in newborn care costs.

Decision boundaries

The following structured comparison identifies where the ACA maternity mandate applies versus where other legal frameworks govern:

  1. Non-grandfathered individual/small-group plans → Full EHB maternity coverage required; NMHPA minimum stay floors apply; preventive prenatal services at zero cost-sharing required.

  2. Non-grandfathered large-group fully insured plans → EHB maternity mandate does not apply; NMHPA applies if maternity is covered; Pregnancy Discrimination Act applies to all employer plans.

  3. Self-funded employer plans of any size → EHB mandate does not apply; NMHPA applies if maternity is covered; Pregnancy Discrimination Act applies.

  4. Grandfathered plans → EHB mandate does not apply; NMHPA applies; Pregnancy Discrimination Act applies.

  5. Qualified Health Plans on the ACA Marketplace → Full EHB maternity and newborn coverage required; HHS benchmark standards govern service specifics.

The key regulatory boundary is the EHB applicability line: only non-grandfathered individual and small-group market coverage, including Marketplace plans, is legally compelled to treat maternity and newborn care as a covered benefit category. For all other plan types, maternity coverage depends on plan design choices, subject only to non-discrimination and minimum-stay floors.

Benefit administrators and HR professionals evaluating ACA coverage obligations should consult the full framework available at the ACA Authority home resource, which maps how all coverage mandates intersect across plan types and employer sizes.

References

The law belongs to the people. Georgia v. Public.Resource.Org, 590 U.S. (2020)