26 U.S.C. § 9811 — Standards relating to benefits for mothers and newborns
submitted 29 years ago by Pub. L. 105-34 to r/title-26-INTERNAL-REVENUE-CODE · 712 words · no verdicts yet
Group health plans generally must cover at least 48 hours after a vaginal birth and 96 hours after a cesarean birth, subject to an attending provider’s decision with the mother. Plans may not pressure people or providers to accept less protection, and specified state laws can replace these requirements.
(a)(1) A group health plan* may not, except under paragraph (2), (A)(i) limit childbirth hospital-stay benefits for mother or newborn after a normal vaginal delivery to less than 48 hours or (ii) after a cesarean section to less than 96 hours, or (B) require a provider to obtain plan or issuer authorization for any stay required by (A). (2) The limits in paragraph (1)(A) do not apply when an attending provider, consulting with the mother, decides to discharge her or the newborn before the minimum period ends. (b) A plan may not: (1) deny or end enrollment or renewal for mother or newborn just to avoid this section; (2) pay or rebate money to encourage a mother to accept less protection; (3) penalize or reduce an attending provider’s reimbursement for care complying with this section; (4) give an attending provider monetary or other incentives to provide inconsistent care; or (5) subject to (c)(3), make benefits for a part of the required stay less favorable than benefits for an earlier part. (c)(1) This section does not require a participant or beneficiary mother to (A) give birth in a hospital or (B) stay a fixed time. (2) It does not apply to a plan offering no childbirth hospital-stay benefits. (3) It does not prevent deductibles, coinsurance, or other cost sharing, but cost sharing for any part of the required stay cannot exceed cost sharing for an earlier part. (d) It does not prevent a plan from negotiating reimbursement level and type with a complying provider. (e) It does not apply to health coverage regulated by a state law that (1) requires at least 48 hours after vaginal birth and 96 after cesarean, (2) requires maternity and pediatric care under guidelines of the named professional associations or other established medical associations, or (3) leaves the maternity stay to the attending provider’s decision, or requires that decision, in consultation with the mother.
A group health plan* may not—
except as provided in paragraph (2)—
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
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
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)).
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.
A group health plan may not—
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;
provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum protections available under this section;
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;
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
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.
Nothing in this section shall be construed to require a mother who is a participant or beneficiary—
to give birth in a hospital; or
to stay in the hospital for a fixed period of time following the birth of her child.
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.
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.
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.
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:
Such State law requires such coverage to provide for at least a 48-hour hospital length of stay following a normal vaginal delivery and at least a 96-hour hospital length of stay following a caesarean section.
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.
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.
Source credit: (Added Pub. L. 105–34, title XV, § 1531(a)(4), Aug. 5, 1997, 111 Stat. 1081; amended Pub. L. 105–206, title VI, § 6015(e), July 22, 1998, 112 Stat. 821.)
- 1997Enacted · Pub. L. 105-34 · 111 Stat. 1081
- 1998Amended · Pub. L. 105-206 · 112 Stat. 821
A history note hasn’t been published yet. The record shows enactment by Pub. L. 105-34 on 1997-08-05.
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