Pregnancy
There is no federal entitlement to paid maternity leave. Federal law provides twelve weeks of unpaid, job-protected leave, and only to employees who meet its conditions — which excludes a substantial share of workers. A growing number of states run their own paid family leave programmes. Medicaid covers a large share of all births, and maternal mortality is the highest among comparable countries, with severe racial disparities.
The United States is the only high-income country with no national paid maternity leave. The federal Family and Medical Leave Act gives twelve weeks of unpaid, job-protected leave, and only to employees who meet its service and employer-size conditions — which excludes a large minority of workers. A growing number of states run their own paid family leave insurance schemes, so entitlements depend heavily on where you work.
Key points
| Paid leave | No federal entitlement; a growing number of states run their own programmes |
|---|---|
| Unpaid leave | Twelve weeks of job-protected leave under federal law, subject to conditions |
| Coverage | Medicaid covers a large share of all births; eligibility extends postpartum in most states |
| Cost | Substantial out-of-pocket costs even with insurance |
| Care model | Obstetrician-led; midwifery access varies sharply by state |
| Outcomes | The highest maternal mortality among high-income countries, with wide racial disparities |
| Postpartum coverage | Extended to twelve months after birth in most states |
In practice
- Check your state: paid family leave, Medicaid postpartum coverage and midwifery access all vary enormously.
- Ask for an itemised cost estimate in advance; hospitals must provide good-faith estimates.
- Doula support is covered by Medicaid in a growing number of states and improves outcomes.
- Know the warning signs of postpartum complications: most maternal deaths occur after the birth, not during it.
Cost and coverage
Costs depend entirely on coverage; Medicaid and community health centres exist precisely to close the gap.
Recent changes
More states have introduced paid family and medical leave insurance programmes, and federal law now requires reasonable accommodations for pregnant workers and protected break time and space for nursing employees.
Where to go
- State Medicaid offices and health department maternal programmes.
- Federally qualified health centres for low-cost prenatal care.
- State paid family leave programmes where they exist.
Worth knowing
More than half of pregnancy-related deaths in the United States occur after the birth, and most are judged preventable. Severe headache, heavy bleeding, chest pain or a fever in the weeks after delivery are emergencies.
Frequently asked questions
Is maternity leave paid in the United States?
Not federally. The Family and Medical Leave Act provides twelve weeks of unpaid leave with job protection, for eligible employees only. Around a dozen states and the District of Columbia run paid family leave insurance programmes, and many employers offer paid leave voluntarily.
What does maternity care cost?
With insurance, the out-of-pocket cost of a birth commonly runs into the low thousands of dollars after deductibles and co-insurance; without insurance it is far more. Check your plan's maternity coverage and the network status of the hospital and the anaesthetist early — surprise bills are common.
The general article: Pregnancy · Compare with another country
Periods and period products
The United States has no federal sales tax, so the “tampon tax” is a state matter. Five states have no sales tax at all, and a growing majority of the others have exempted menstrual products since New York, Connecticut and Illinois did so in 2016; by the mid-2020s roughly half the states plus the District of Columbia exempt them, while a dozen or so still tax them. At federal level, the CARES Act of March 2020 made menstrual products eligible expenses for flexible spending accounts and health savings accounts.
Free provision in schools is also state law: California requires products in public schools, community colleges and state universities, New York in schools, and more than twenty states now have similar requirements, usually for grades 6 to 12. Federal law requires products in federal prisons since 2018; the Menstrual Equity for All Act, reintroduced several times, has not passed.
There is no menstrual leave; absence falls under sick leave, which is unpaid at federal level except where state or city laws or employers provide paid sick days. Federal food assistance cannot be used for period products.
Endometriosis care depends on insurance: diagnosis and surgery are covered as medical care subject to deductibles, and specialised excision surgeons are concentrated in large cities, often out of network. The Endometriosis Foundation of America and other groups list specialists.
Key points
| Sales tax | State by state: five states with none, about half exempt period products, a dozen still tax them |
|---|---|
| FSA and HSA | Menstrual products eligible since the CARES Act (2020) |
| Free provision | More than twenty states require products in public schools; federal prisons since 2018 |
| Menstrual leave | None; sick leave rules vary by state and employer |
| Endometriosis | Covered as medical care under insurance; specialists mostly in large cities |
In practice
- Check your state's list of exempt items: the exemption may cover pads, tampons, cups and period underwear or only some of them.
- Use FSA or HSA funds for period products: they qualify since 2020.
- Ask the school whether products are stocked in restrooms; in states with a law, they must be.
- For endometriosis, ask the gynaecologist whether they perform excision surgery or refer to someone who does, and check network status before surgery.
What it costs
A cycle costs roughly $5 to $15 in disposables, plus sales tax in the states that still charge it. Nothing is reimbursed, but FSA and HSA dollars can be used.
What has changed recently
Michigan (2022), Maine (2022) and others have joined the exempt states; school provision laws keep spreading, and federal bills remain stalled.
Where to find help
- Alliance for Period Supplies: state-by-state map of tax and school provision laws.
- State departments of revenue: lists of exempt items.
- Endometriosis Foundation of America: information and specialists.
- Period supply banks and community organisations.
Worth knowing
A federal ban on the tampon tax does not exist despite headlines; the rule is your state's. And an exemption in one state says nothing about the next one over.
Frequently asked questions
Is there a tampon tax in the United States?
In about a dozen states, yes; about half exempt period products and five have no sales tax.
Can I use my FSA or HSA for tampons?
Yes, since the CARES Act of 2020.
Are period products free in schools?
In more than twenty states, public schools must provide them, usually in grades 6 to 12; elsewhere it depends on the district.
Sources
- Alliance for Period Supplies — state-by-state tax and school provision map
- Endometriosis Foundation of America — information and specialists
The general article: Periods and period products · Compare with another country
Sex therapy
No federal title; “sex therapist” is unregulated everywhere except Florida, AASECT certification is the benchmark, and insurance pays only licensed clinicians with a diagnosis.
In the United States, health professions are licensed by each state. Psychologists, marriage and family therapists, clinical social workers, mental health counselors, physicians and nurses all need a state licence to practise; “sex therapist”, by contrast, is not a licensed profession, and in almost every state anyone may use the words. Florida is the exception: licensees under its mental-health chapter may not hold themselves out as sex therapists without a board certification requiring specific training and supervision.
The national benchmark is certification by the American Association of Sexuality Educators, Counselors and Therapists (AASECT). A Certified Sex Therapist must already hold a graduate degree and a state licence in a mental-health or medical field, then complete 90 hours of human sexuality education, 60 hours of sex-therapy training, at least 300 hours of supervised clinical work with sexual concerns and 50 hours of supervision over at least eighteen months. It is a private credential, but a demanding one. Physicians specialising in sexual medicine are found in urology, gynaecology and endocrinology, often through the Sexual Medicine Society of North America or the International Society for the Study of Women's Sexual Health.
Insurance follows the licence, not the specialty. A session with a licensed therapist is billed as mental-health treatment under a diagnosis code; federal parity rules require most plans to cover it like other medical care, but many plans pay only in-network providers, and some exclude codes for sexual dysfunction or relationship counselling. Since January 2024 Medicare also pays marriage and family therapists and mental health counselors. A large share of certified sex therapists work out of network, at roughly $150 to $300 a session, with partial reimbursement depending on the plan.
Medical evaluation of erectile dysfunction, pain or hormonal problems is covered as ordinary medical care, subject to deductibles and copayments.
Key points
| Title | Unregulated in every state but Florida; underlying licence required to practise therapy |
|---|---|
| Licensed professions | Psychologist, marriage and family therapist, clinical social worker, mental health counselor, physician, nurse — state by state |
| Reference credential | AASECT Certified Sex Therapist: licence, 90 h sexuality education, 60 h sex-therapy training, 300 h supervised practice, 50 h supervision |
| Florida | Board certification required to use the title “sex therapist” |
| Insurance | Covers licensed clinicians under a diagnosis; network and exclusions vary; Medicare covers MFTs and counselors since 2024 |
| Typical fee | $150–$300 a session, often out of network |
In practice
- Verify the state licence on the state board's website, then the AASECT certification in the association's directory.
- Ask the practice how sessions are billed and whether the diagnosis used is covered by your plan; request a superbill for out-of-network claims.
- For physical symptoms, start with a physician: the work-up is covered as medical care.
- University training clinics and community mental-health centres offer sliding-scale therapy, sometimes with sex-therapy supervision.
Cost and reimbursement
Licensed therapist in network: your copayment. Out of network: $150–$300 a session with partial reimbursement or none. Medical evaluation: covered as ordinary care.
What has changed recently
Medicare began paying marriage and family therapists and mental health counselors on 1 January 2024, widening access for older patients. AASECT certification requirements were tightened over the last decade, with more supervised hours now required.
Where to go
- AASECT: directory of certified sex therapists, counselors and educators.
- State licensing boards: licence verification and complaints.
- Sexual Medicine Society of North America; International Society for the Study of Women's Sexual Health.
- Community mental-health centres and university clinics: sliding-scale fees.
Worth knowing
A licence matters more than the words “sex therapist”: an unlicensed “sex coach” is not bound by confidentiality rules, cannot bill insurance and answers to no board. Any practitioner proposing physical contact should be reported to the state board.
Frequently asked questions
Is a sex therapist a licensed profession?
No. The therapist must hold a state licence in another field — psychology, counseling, social work, marriage and family therapy, medicine — and then trains in sex therapy. Only Florida restricts the title itself.
Does insurance cover sex therapy?
It covers therapy by licensed clinicians under a diagnosis, subject to network rules and exclusions. Couples counselling as such is rarely covered. Ask before the first session.
What does AASECT certification prove?
Graduate degree, state licence, specific coursework, 300 supervised clinical hours and 50 hours of supervision. It is private, but it is the most rigorous credential available.
Sources
- AASECT — certification requirements and directory of certified sex therapists
- Sexual Medicine Society of North America — sexual-medicine physicians
The general article: Sex therapy · Compare with another country
Mental health
A three-digit crisis line that works everywhere, and coverage that depends entirely on your insurance.
Since 2022 a three-digit number reaches the national suicide and crisis lifeline from any phone, by call or text, at any hour. Beyond crisis, access depends on your insurance: federal parity law requires mental health benefits to match medical ones, but narrow provider networks and a shortage of therapists mean many people pay out of network. Community mental health centres and federally qualified health centres charge on a sliding scale.
Key points
| Crisis line | Three-digit national lifeline, by call or text, at any hour |
|---|---|
| Parity law | Federal law requires mental health benefits to match medical benefits |
| Networks | Narrow provider networks push many patients out of network |
| Sliding scale | Community health centres charge according to income |
| Shortage | Therapist shortages create long waits even with good insurance |
| Involuntary commitment | Rules and duration vary by state |
| Teletherapy | Widespread, and often the fastest route to a first appointment |
In practice
- The three-digit lifeline works from any phone, by call or text, and can dispatch a mobile crisis team in many areas.
- Check whether your plan has an out-of-network benefit: many therapists do not take insurance directly.
- Federally qualified health centres charge on a sliding scale regardless of insurance status.
- Teletherapy platforms are often weeks faster than an in-person appointment.
Cost and coverage
Cost depends on insurance; community health centres charge on a sliding scale, and the crisis lifeline is free.
Recent changes
The three-digit crisis lifeline, launched in 2022, replaced the old ten-digit number and now handles millions of contacts a year.
Where to go
- National suicide and crisis lifeline, three digits, at any hour.
- Community mental health centres and federally qualified health centres.
- Employee assistance programmes, which often fund several free sessions.
Worth knowing
Parity law exists but is unevenly enforced. If your insurer refuses a mental health claim it would have paid for a physical condition, that refusal can be appealed, and the appeal often succeeds.
The general article: Mental health · Compare with another country
Dental care
Dental care sits outside the main health insurance system, and that is the central fact.
Dental coverage is generally separate from medical insurance and is bought as a standalone plan, often through an employer. Typical plans follow a 100-80-50 structure — preventive care fully covered, basic care at 80 %, major work at 50 % — with a waiting period for major work and an annual maximum that has barely moved in decades, commonly $1,000 to $2,000. Medicaid adult dental coverage varies by state; original Medicare does not cover routine dental care, though many Medicare Advantage plans add it.
The annual maximum is the crux: two crowns exhaust a typical plan, and the rest of the year is out of pocket. Splitting major work across two calendar years is standard practice.
Children's dental care is an essential health benefit under the Affordable Care Act, so it is far better covered than adults'.
Dental schools treat patients at roughly half the usual fee, with longer appointments and supervised students.
Cross-border dental travel to Mexico is long established and substantial, with clinics in border towns geared to American patients; Costa Rica and Colombia attract more complex cases.
Whitening is sold widely, including by non-dentists in some states; the rules on who may apply peroxide vary by state and have been litigated.
Key points
| Structure | Standalone dental plans, separate from medical insurance |
|---|---|
| Typical coverage | 100 % preventive, 80 % basic, 50 % major |
| Annual maximum | Commonly $1,000 to $2,000 |
| Medicaid adults | Varies by state, from comprehensive to emergency only |
| Medicare | No routine dental cover in original Medicare |
| Children | Essential health benefit under the ACA |
In practice
- Check your annual maximum and your plan year before agreeing to major work, and ask the practice to sequence it across two years if that helps.
- Ask for a pre-treatment estimate submitted to the insurer: it is not binding but it prevents most surprises.
- Dental schools and community health centres with a sliding fee scale are the two realistic low-cost routes.
Cost and coverage
Examination and cleaning $150–$350. Filling $200–$450. Crown $1,000–$2,500. Implant with crown $3,500–$6,000. Clear aligners $3,000–$8,000.
Recent changes
Medicare Advantage plans have expanded dental benefits as a competitive feature, though caps remain low relative to the cost of prosthetic work.
Where to go
- Dental schools, listed by the American Dental Association.
- Federally qualified health centres with sliding-scale dental clinics.
- State Medicaid programmes, for adult benefit details.
- State dental boards, to verify a licence.
Worth knowing
“Dental savings plans” and “discount plans” are not insurance: they are membership schemes giving access to reduced fees. They can be worth it, but they pay nothing and have no maximum because they cover nothing.
Frequently asked questions
Does Medicare cover the dentist?
Original Medicare does not cover routine dental care. Many Medicare Advantage plans include some dental benefit.
Why did my insurance stop paying halfway through?
Almost certainly the annual maximum, which is commonly $1,000 to $2,000 and is quickly reached by prosthetic work.
The general article: Dental care · Compare with another country
HIV and AIDS
PrEP must be covered without cost sharing, treatment is supported by a dedicated federal programme — but HIV-specific criminal laws remain on the books in many states.
The American system is a patchwork. Preventive services rules require most insurance to cover PrEP, including the associated visits and laboratory tests, without cost sharing. The Ryan White programme funds care for people who are uninsured or underinsured, and state drug assistance programmes cover medication. Separately, more than thirty states retain HIV-specific criminal statutes, several of which predate effective treatment.
Key points
| PrEP coverage | Most insurance must cover PrEP and its monitoring without cost sharing |
|---|---|
| Ryan White programme | Federal funding of care for people uninsured or underinsured |
| Drug assistance | State AIDS Drug Assistance Programs cover medication for those who qualify |
| Testing | Free at health departments and community organisations; self-tests sold over the counter |
| PEP | From emergency departments; cost varies sharply by insurance |
| Criminal law | HIV-specific statutes in more than thirty states, some predating effective treatment |
| Medicaid | Coverage differs by state, which changes access substantially |
In practice
- If your plan charges for PrEP or its monitoring visits, challenge it: preventive coverage rules generally prohibit cost sharing.
- Ask a Ryan White provider about eligibility before assuming you cannot afford care.
- For PEP, go to an emergency department immediately and ask about patient assistance programmes for the cost.
- Check your state's law before making decisions about disclosure.
Cost and coverage
Costs depend entirely on insurance status; Ryan White and drug assistance programmes exist precisely to close the gap.
Where to go
- Ryan White HIV/AIDS Program clinics.
- State and local health department testing services.
- Community organisations and state AIDS Drug Assistance Programs.
Worth knowing
HIV-specific criminal statutes vary enormously between states and several do not take account of undetectable viral load. Take legal advice from a specialist organisation rather than relying on general information.
Sources
Hepatitis B
A birth dose since 1991, and since 2022 a recommendation that every adult under 60 be vaccinated.
The United States introduced universal infant vaccination with a birth dose in 1991, and has one of the longer-running programmes. Two recent changes matter for adults: since 2022 vaccination is recommended for all adults aged 19 to 59 regardless of risk factors, and national guidance now advises that every adult be screened for hepatitis B at least once in their life.
Key points
| Birth dose | Within 24 hours of birth, since 1991 |
|---|---|
| Adult vaccination | Recommended for everyone aged 19 to 59 since 2022, without needing a risk factor |
| Adult screening | Recommended at least once in a lifetime for all adults |
| Antenatal screening | Universal, with repeat testing where risk is ongoing |
| Babies of carriers | Vaccine and immunoglobulin within 12 hours of birth |
| Coverage | Insurance must cover recommended vaccines without cost sharing |
| Higher prevalence groups | People born in Asia, Africa and parts of eastern Europe |
In practice
- Ask for hepatitis B vaccination even without a risk factor: it is recommended for all adults under 60.
- Ask for the triple panel — surface antigen, core antibody and surface antibody — in a single test.
- Insurance generally must cover recommended vaccines without cost sharing.
- After an exposure, seek vaccine and immunoglobulin within 24 hours where possible.
Cost and coverage
Recommended vaccines are covered without cost sharing by most insurance; free programmes exist for uninsured children.
Recent changes
The 2022 move to universal adult vaccination and the recommendation of once-in-a-lifetime adult screening were both intended to reach the large number of undiagnosed carriers.
Where to go
- Primary care and pharmacies for vaccination.
- Federally qualified health centres and health department clinics.
- Hepatitis B Foundation for information and support.
Worth knowing
The universal adult recommendation removed the need to disclose a risk factor in order to be vaccinated. You can simply ask for it.
Sources
HPV
Routine vaccination at 11 or 12, catch-up to 26, and screening that now allows self-collection.
Vaccination is recommended routinely at 11 or 12, with catch-up to 26 and shared decision-making between 27 and 45. Coverage varies widely by state because there is no national school programme. Cervical screening combines cytology and HPV testing depending on age, and self-collection of samples in healthcare settings was authorised in 2024, an important step for people who avoid pelvic examinations.
Key points
| Routine age | 11 or 12, with vaccination possible from 9 |
|---|---|
| Catch-up | Recommended to 26; shared decision-making from 27 to 45 |
| Coverage | Varies widely by state; there is no national school programme |
| Vaccines for Children | Provides free vaccine for eligible uninsured and underinsured children |
| Screening 21-29 | Cytology every three years |
| Screening 30-65 | HPV testing or co-testing every five years, or cytology every three |
| Self-collection | Authorised in 2024 for use in healthcare settings |
In practice
- If your child is uninsured, ask about the Vaccines for Children programme: the vaccine is free.
- Preventive services rules mean most insurance must cover both vaccination and screening without cost sharing.
- Ask about self-collection if a pelvic examination is a barrier for you.
Cost and coverage
Most insurance must cover vaccination and screening without cost sharing; free programmes exist for uninsured children.
Recent changes
Authorisation of self-collection in 2024 opened screening to people who had avoided it because of the examination itself.
Where to go
- Pediatricians, family doctors and pharmacies.
- Federally qualified health centres and Title X clinics.
- State and local health department immunisation programmes.
Worth knowing
Because there is no national school programme, coverage depends heavily on where you live and on your insurance. Do not assume the vaccine will be offered — ask for it.
Sources
General sources
- USA.gov — official guide to government services
- Congress.gov — federal legislation