Newborn’s and Mothers’ Health Protection Act

Scope

The type of coverage provided by the plan (insured or self-insured) and state law will determine whether the Newborns’ Act applies to a mother’s or newborn’s coverage. The Newborns’ Act provisions always apply to coverage that is self-insured. For coverage that is insured, if the state has a law that meets certain criteria, state law applies to the coverage rather than the Newborns’ Act.

Regulatory citations

• None

Key definitions

• None

Summary of requirements

Minimum protections. The Newborns’ Act, and its regulations, prohibit incentives (either positive or negative) that could encourage less than the minimum protections under the Act.

The Newborns’ Act and its regulations provide that health plans and insurance issuers may not restrict a mother’s or newborn’s benefits for a hospital length of stay that is connected to childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section. However, the attending provider (who may be a physician or nurse midwife) may decide, after consulting with the mother, to discharge the mother or newborn child earlier.

A mother cannot be encouraged to accept less than the minimum protections available to her under the Newborns’ Act and an attending provider cannot be induced to discharge a mother or newborn earlier than 48 or 96 hours after delivery. If delivery occurs in the hospital, the 48-hour period (or 96-hour period) starts at the time of delivery. If delivery occurs outside the hospital and the woman is later admitted to the hospital in connection with childbirth (as determined by the attending provider), the period begins at the time of the admission.

Group health plans. All group health plans that provide maternity or newborn infant coverage must include a statement in their summary plan description (SPD) advising individuals of the Newborns’ Act requirements.

Under the Newborns’ Act, group health plans, insurance companies, or Health Maintenance Organizations (HMOs) may impose deductibles or other cost-sharing provisions for hospital stays in connection with childbirth. This is true 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 percent of the cost of the hospital stay. However, a plan covering 80 percent of the cost of the first 24 hours could not reduce coverage to 50 percent for the second 24 hours.

Summary Plan Description (SPD) statements. If the health plan provides maternity or newborn infant coverage, the SPD must include a statement describing any requirements under federal or state law and any health insurance coverage offered under the plan, relating to hospital length of stay in connection with childbirth for the mother or newborn.

The following sample language may be used for plans subject to the Newborns’ Act in their SPDs to describe the federal requirements:

“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 form the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).”

Plans subject to state law requirements will need to prepare SPD statements describing any applicable state law.