PRIA, Government Policy, Made Personal

Summary

Group health plans must cover at least 48 hours in the hospital after a normal vaginal birth and at least 96 hours after a cesarean. Plans cannot force a doctor or hospital to get prior approval for those stays. If the mother and her doctor or midwife agree the mother or baby can leave earlier, the shorter stay is allowed. Plans may not cancel or refuse coverage just to dodge these rules. They cannot pay mothers to leave early or punish or pay doctors to send mothers home sooner. Plans can still charge deductibles, copays, or other cost-sharing, but those costs for the later part of a required stay cannot be higher than for the earlier part. Plans can negotiate how much to pay providers. These federal rules do not apply when a State law already requires the same minimum stays, follows professional maternity guidelines, or leaves the length of stay up to the mother and her doctor.

Title 26, §9811

Internal Revenue Code, Source: USLM XML via OLRC

(a)Requirements for minimum hospital stay following birth

(1)In general

A group health plan may not—

(A)except as provided in paragraph (2)—

(i)restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than 48 hours, or

(ii)restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a caesarean section, to less than 96 hours; or

(B)require that a provider obtain authorization from the plan or the issuer for prescribing any length of stay required under subparagraph (A) (without regard to paragraph (2)).

(2)Exception

Paragraph (1)(A) shall not apply in connection with any group health plan in any case in which the decision to discharge the mother or her newborn child prior to the expiration of the minimum length of stay otherwise required under paragraph (1)(A) is made by an attending provider in consultation with the mother.

(b)Prohibitions

A group health plan may not—

(1)deny to the mother or her newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section;

(2)provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum protections available under this section;

(3)penalize or otherwise reduce or limit the reimbursement of an attending provider because such provider provided care to an individual participant or beneficiary in accordance with this section;

(4)provide incentives (monetary or otherwise) to an attending provider to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section; or

(5)subject to subsection (c)(3), restrict benefits for any portion of a period within a hospital length of stay required under subsection (a) in a manner which is less favorable than the benefits provided for any preceding portion of such stay.

(c)Rules of construction

(1)Nothing in this section shall be construed to require a mother who is a participant or beneficiary—

(A)to give birth in a hospital; or

(B)to stay in the hospital for a fixed period of time following the birth of her child.

(2)This section shall not apply with respect to any group health plan which does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn child.

(3)Nothing in this section shall be construed as preventing a group health plan from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or newborn child under the plan, except that such coinsurance or other cost-sharing for any portion of a period within a hospital length of stay required under subsection (a) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay.

(d)Level and type of reimbursements

Nothing in this section shall be construed to prevent a group health plan from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section.

(e)Preemption; exception for health insurance coverage in certain States

The requirements of this section shall not apply with respect to health insurance coverage if there is a State law (including a decision, rule, regulation, or other State action having the effect of law) for a State that regulates such coverage that is described in any of the following paragraphs: (1)

(2)Such State law requires such coverage to provide for maternity and pediatric care in accordance with guidelines established by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, or other established professional medical associations.

(3)Such State law requires, in connection with such coverage for maternity care, that the hospital length of stay for such care is left to the decision of (or required to be made by) the attending provider in consultation with the mother.

Notes & Related Subsidiaries

Editorial Notes

Amendments

1998—Subsecs. (e), (f). Pub. L. 105–206 redesignated subsec. (f) as (e).

Statutory Notes and Related Subsidiaries

Effective Date

of 1998 AmendmentAmendment by Pub. L. 105–206 effective, except as otherwise provided, as if included in the provisions of the Taxpayer Relief Act of 1997, Pub. L. 105–34, to which such amendment relates, see section 6024 of Pub. L. 105–206, set out as a note under section 1 of this title.

Effective Date

Section applicable with respect to group health plans for plan years beginning on or after Jan. 1, 1998, see section 1531(c) of Pub. L. 105–34, set out as an

Effective Date

of 1997 Amendment note under section 4980D of this title.

§9811 Standards Relating to Benefits for Mothers and Newborns

Summary

Title 26, §9811

Notes & Related Subsidiaries

Editorial Notes

Amendments

Statutory Notes and Related Subsidiaries

Effective Date

Effective Date

Effective Date

Citations & Metadata