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The Newborns' Act was signed into law on September 26,
1996 and includes important protections for mothers and their newborn
children with regard to the length of the hospital stay following
childbirth. The Newborns' Act is subject to concurrent jurisdiction
by the Departments of Labor, the Treasury, and Health and Human Services.
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The Newborns' Act affects the amount of time you and
your newborn child are covered for a hospital stay following childbirth.
Group health plans, insurance companies and health maintenance
organizations (HMOs) that are subject to the Newborns' Act 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. However, the attending provider may
decide, after consulting with you, to discharge you or your newborn child
earlier. In any case, the attending provider cannot receive
incentives or disincentives to discharge you or your child earlier than 48
hours (or 96 hours).
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An attending provider is an individual licensed under
state law who is directly responsible for providing maternity or pediatric
care to a mother or newborn child. Therefore, a plan, hospital,
insurance company or HMO would not be an attending provider.
However, a nurse midwife or a physician assistant may be an attending
provider if licensed in the state to provide maternity or pediatric care
in connection with childbirth. |
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If you deliver in the hospital, the 48-hour period (or
96-hour period) starts at the time of delivery. So, for example, if
a woman goes into labor and is admitted to the hospital at 10 p.m. on June
11, but gives birth by vaginal delivery at 6 a.m. on June 12, the 48-hour
period begins at 6 a.m. on June 12.
However, if you deliver outside the hospital and you
are later admitted to the hospital in connection with childbirth (as
determined by the attending provider), the period begins at the time of
the admission. So, for example, if a woman gives birth at home by
vaginal delivery, but begins bleeding excessively in connection with
childbirth and is admitted to the hospital, the 48-hour period starts at
the time of admission. |
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A plan, insurance company or HMO cannot deny you or
your newborn child coverage for a 48-hour stay (or 96-hour stay) because
the plan claims that you, or your attending provider, have failed to show
that the 48-hour stay (or 96-hour stay) is medically necessary.
However, plans, insurance companies and HMOs generally
can require you to notify the plan of the pregnancy in advance of an
admission if you wish to use certain providers or facilities, or to reduce
your out-of-pocket costs. |
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Yes. But only if the deductible, coinsurance, or
other cost-sharing for the later part of a 48-hour (or 96-hour) stay is
not greater than that imposed for the earlier part of the stay. For
example, with respect to a 48-hour stay, a group health plan is permitted
to cover only 80% of the cost of the hospital stay. However, a plan
covering 80% of the cost of the first 24 hours could not reduce coverage
to 50% for the second 24 hours. |
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No. The Newborns' Act does not require plans,
insurance companies or HMOs to provide coverage for hospital stays in
connection with childbirth. However, other legal requirements may
require this type of coverage, including Title VII of the Civil Rights Act
of 1964. Questions regarding Title VII should be directed to the
Equal Employment Opportunity Commission. |
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It depends. If your plan offers benefits for
hospital stays in connection with childbirth, the Newborns' Act only
applies to certain coverage. Specifically, it depends on whether
your coverage is insured by an insurance company or HMO or self-insured by
the employment-based plan. (You should check your Summary Plan
Description (SPD) or contact your plan administrator to find out if your
coverage in connection with childbirth is insured or self-insured.)
Self-insured coverage is subject to the Newborns' Act.
However, if your coverage is insured by an insurance company or HMO and
your state has a law regulating coverage for newborns and mothers that
meet specific criteria, then your rights depend on state law, rather than
the Newborns' Act. If this is the case, the state law may differ
slightly from the Newborns' Act requirements, so it is important for you
to know which law applies to your coverage in order to know what your
rights are.
If your coverage is insured by an insurance company or
HMO, you should always contact your State Insurance Commissioner's Office
for the most current information. |
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The Newborns' Act requirements apply to group health
plans for plan years beginning on or after January 1, 1998. To find
out when your plan year begins, check your Summary Plan Description (SPD)
or contact your plan administrator. |
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Sample Language for the Newborns' Act Disclosure
Requirement
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The following is the amended sample notice that a group
health plan may use to satisfy the Newborns' Act disclosure requirement:
Group health plans and health insurance issuers
generally may not, under federal law, restrict benefits for any hospital
length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a vaginal delivery, or less than
96 hours following a cesarean section. However, federal law
generally does not prohibit the mother's or newborn's attending
provider, after consulting with the mother, from discharging the mother
or her newborn earlier than 48 hours (or 96 hours as applicable).
In any case, plans and issuers may not, under federal law, require that
a provider obtain authorization from the plan or the issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).
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