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The Newborns' and Mothers' Health Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth. The law may apply to three different types of coverage: 1) Self-funded group health plans (CMS has jurisdiction over self-funded public sector (non federal governmental) plans while the Department of Labor 866-444-3272 has jurisdiction over private sector self-funded group health plans.); 2) Fully insured group health plans; and 3) Individual (non-employment based) health insurance policies. Contact your state's insurance department to find out about whether additional protections apply to your coverage if you are in a fully insured group health plan or have individual market (non-employment based) health coverage. Important: In order to have your newborn added to a policy, you must enroll the newborn within the timeframe specified by the plan. Medicare and Medicaid are not issuers of health insurance. They are public health plans through which individuals obtain health coverage. Contact your specific Medicare or Medicaid contractor to discuss your level of benefits. Employment related group health plans that provide benefits through insurance are known as fully insured group health plans. Employment related group health plans that pay for coverage directly, without purchasing health insurance from an issuer, are called self-funded group health plans. Contact your plan administrator to find out if your group coverage is fully insured or self-funded. Non-employment related individual health insurance policies are sold to individual policy holders. NMHPA does not apply to State high risk pools since the pool is not an issuer of health insurance. The pool is a means by which individuals obtain health coverage. In general, group health plans and health insurance issuers that are subject to NMHPA may NOT restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by Cesarean section. If you deliver in the hospital, the 48-hour (or 96-hour) period starts at the time of delivery. If you deliver outside the hospital and you are later admitted to the hospital in connection with childbirth, the period begins at the time of the admission. Although the NMHPA prohibits group health plans and health insurance issuers from restricting the length of a hospital stay in connection with childbirth, the plan or health insurance issuer does not have to cover the full 48-hours (or 96-hours) in all cases. If the attending provider, in consultation with the mother, determines that either the mother or the newborn child can be discharged before the 48-hour (or 96-hour) period, the group health plan and health insurance issuers do not have to continue covering the stay for whichever one of them is ready for discharge. An attending provider is an individual, licensed under State law, who is directly responsible for providing maternity or pediatric care to the mother or the newborn child. In addition to physicians, an individual such as a nurse midwife, physician assistant, or nurse practitioner may be an attending provider. A plan, hospital, insurance company, or HMO would NOT be an attending provider. Two key factors determine whether NMHPA protections apply to your health insurance coverage. • First, protection depends on whether the benefits under your group health plan or insurance policy include coverage for hospital stays following childbirth. NMHPA does NOT require group health plans and health insurance issuers to provide that kind of coverage. • Second, even if your group health plan or health insurance issuer chooses to cover hospital stays in connection with childbirth, you need to find out how your group health plan provides benefits. If you are in a self-funded group health plan, your health coverage must comply with NMHPA standards. If you are in a fully insured group health plan or if you have individual (non-employment based) insurance coverage, the NMHPA might NOT apply if your State has a law with certain protections for hospital stays following childbirth. Most states have laws that take precedence over NMHPA. For additional information, you may e-mail us at phig@cms.hhs.gov. Note: A non federal government employer that provides self-funded group health plan coverage to its employees (coverage that is not provided through an insurer) may elect to exempt its plan (opt-out) from most requirements of title XXVII of the Public Health Service (PHS) Act, with the exception of requirements pertaining to the certification and disclosure of an individual's creditable coverage under the plan.
Page Last Modified: 07/24/2008 12:36:31 PM
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