important information for new parents or expectant parents
If you have health coverage and are pregnant, you and your new child may be entitled to a 48-hour hospital stay after delivery (96 hours for a C-section). If your employer or your spouse’s employer offers a health plan, birth, adoption, and placement for adoption can also trigger a special enrollment opportunity for you, your spouse, and your child, regardless of open enrollment season .
The Affordable Care Act (ACA) adds important protections related to employment-based group health plans that will improve health coverage for you and your family. many of these protections are now available, including extending dependent coverage to age 26, banning pre-existing condition exclusions for children under 19, and banning lifetime limits on coverage for essential health benefits . Additional protections will be available in 2014. This publication does not reflect the provisions of the Affordable Care Act. For more information, visit the Employee Benefits Security Administration’s webpage at dol.gov/ebsa/healthreform.
Your protections under the Maternal and Newborn Health Protection Act (Newborn Act)
If a group health plan, health insurance company, or health maintenance organization (hmo) provides maternity benefits, it cannot restrict benefits for a hospital stay related to childbirth to less than 48 days. hours after a vaginal delivery or 96 hours after a cesarean delivery.
You may not be required to obtain prior authorization from your plan in order for your 48 or 96 hour stay to be covered. (However, certain requirements that you notify the plan of the pregnancy or delivery may apply.)
The law allows you and your baby to be discharged earlier than these time periods only if the treating provider decides, after consultation with you, that you or your baby can be discharged earlier.
In either case, the treating provider cannot be given incentives or disincentives to discharge you or your child earlier than 48 hours (or 96 hours).
If your state has a law that provides similar hospital stay protections, and your plan offers coverage through an insurance policy or hmo, then you may be protected by state law rather than the health protection law. the health of newborns and mothers.
your protections under the health insurance portability and accountability act (hipaa)
If you are eligible but not enrolled in an employer’s health plan, you may enroll yourself, your spouse, and your new child at the time of the birth, adoption, or placement for adoption of a new child. this is known as “special enrollment”.
Special enrollment is available regardless of whether the employer offers open season or when the next open season might be.
To be eligible, you must request special enrollment in the plan within 30 days of the birth, adoption, or placement for adoption. check with your plan administrator or review your plan’s summary plan description (spd) to find out if the plan has special procedures for requesting special enrollment.
Coverage for special members is effective retroactively to the date of birth, adoption, or placement for adoption.
Special Enrollees should be treated the same as people in similar situations who signed up when they were first eligible. cannot be treated as late enrollees (individuals who did not enroll when they were first eligible); therefore, the maximum pre-existing condition exclusion that can be imposed on a special enrollee is 12 months (late enrollees may be subject to an 18-month pre-existing condition exclusion) reduced by prior creditable coverage.
Most health coverage is creditable coverage, including most coverage under a group health plan (including cobra), individual or group health insurance coverage, medicare, medicaid, tricare, Indian health, state risk pools, federal employee health benefit plan, public health plans, Peace Corps plans, and state children’s health insurance programs.
hipaa also prohibits exclusions for pre-existing conditions related to pregnancy and for newborns, adopted children, and children placed for adoption who enroll within 30 days of birth, adoption, or placement for adoption.
For more information on pre-existing condition exclusions, check out your health plan and HIPAA…making the law work for you.
important facts about having a new baby
know your rights. If your plan provides maternity benefits, you should be entitled to a hospital stay of at least 48 hours after a vaginal delivery and 96 hours after a cesarean delivery.
You may not be required to obtain prior authorization from your plan for the minimum hospital stay to be covered.
Your plan must provide you with a notice about your rights related to a hospital stay after giving birth. if your plan is insured, the notice must describe your protections under state law.
Contact your health plan or your spouse’s health plan as soon as possible to find out how to enroll your new baby in group health plan coverage.
As long as you enroll your newborn within 30 days of birth, coverage must be effective as of your baby’s date of birth and your baby cannot be subject to a pre-existing condition exclusion.
Remember, you must enroll your baby within 30 days of the date of birth.
important data when adopting
Contact your health plan or your spouse’s health plan as soon as possible to find out how to enroll your child in group health plan coverage.
As long as you enroll your child within 30 days of adoption or placement for adoption, coverage must be effective as of the date of your child’s adoption or placement and your child cannot be subject to a pre-existing condition exclusion.
Remember, you must register your child within 30 days of the date of adoption or placement for adoption.
I’m pregnant. how does the act of newborns affect my health care benefits?
The newborn law affects the amount of time you and your newborn child are covered for a hospital stay after delivery. Group health plans, insurance companies, and HMOs that provide maternity benefits may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours after a vaginal delivery or 96 hours after a vaginal delivery. cesarean birth. however, your treating provider may decide, after consultation with you, to discharge you or your newborn child sooner. in either case, the treating provider cannot be given incentives or disincentives to discharge you or your child earlier than 48 hours (or 96 hours). The Newborn Act does not require plans, insurance companies, or hmos to provide coverage for hospital stays related to childbirth. Other legal requirements, including Title VII of the Civil Rights Act of 1964, may require this type of coverage.
who is the provider that treats you?
The treating provider is a person licensed under state law who is directly responsible for providing maternity or pediatric care to a mother or newborn. therefore, a plan, hospital, insurance company, or hmo would not be an attending provider.
when does the 48 or 96 hour period start?
If you give birth in the hospital, the 48-hour period (or 96-hour period) begins 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 she gives birth vaginally at 6 a.m. m. on June 12, the 48-hour period begins at 6 a.m. m. June 12.
However, if you give birth outside the hospital and are later admitted to the hospital in connection with the delivery (as determined by your attending provider), the period begins at the time of admission. so, for example, if a woman gives birth at home by vaginal delivery, but begins to bleed excessively in connection with the delivery and is admitted to hospital, the 48-hour period begins at the time of admission.
Is my health plan, insurance company, or hmo allowed to require me to obtain permission for a 48-hour (or 96-hour) stay (sometimes called prior authorization or precertification) based on their determination of whether it is medically necessary?
not. plans, insurance companies, and hmos cannot deny your coverage for a 48-hour (or 96-hour) hospital stay based on a lack of demonstrated medical necessity. however, plans, insurance companies, and hmos may deny coverage for any part of a stay that is longer than 48 hours (or 96 hours) based on their determination of medical necessity.
In addition, a plan may require you to notify the pregnancy prior to admission to the hospital (or notify your admission at the time of admission) in order to obtain more favorable cost sharing. however, a plan may not reduce your benefits because your pregnancy began before the first day of coverage and you did not notify the pregnancy before you were covered by the plan. this type of plan provision works like a pre-existing condition exclusion and these exclusions cannot be applied to pregnancy.
Can group health plans, insurance companies, or hmos impose deductibles or other cost-sharing provisions for hospital stays related to childbirth?
yes, but only if the deductible, coinsurance, or other cost-sharing for the latter part of a 48-hour (or 96-hour) stay is no more than the tax for the earlier part of the stay. for example, with respect to a 48-hour stay, a group health plan is allowed to cover only 80 percent of the cost of the hospital stay. however, a plan that covers 80 percent of the cost for the first 24 hours may not reduce coverage to 50 percent for the second 24 hours.
My provider discharged me in less than 48 hours. is this allowed?
yes. under the newborn law, a treating provider, after consultation with the mother, may discharge the mother or newborn in less than 48 hours. your treating provider, after consulting with you, may decide to discharge you or your newborn sooner. however, your plan or insurance company is not allowed to offer you incentives to induce you to accept less than the minimum protections available to you under the newborn law. In addition, your plan or insurance company is not allowed to provide incentives to induce your health care provider to discharge you or your newborn sooner than 48 hours after delivery (or 96 hours in the case of a newborn). cesarean delivery).
How do I know if the protections of the Newborn Act apply to my coverage?
Even if your plan offers benefits for hospital stays related to childbirth, the newborn law only applies to certain coverages. Specifically, it depends on whether your coverage is “insured” by an insurance company or HMO or “self-insured” by an employment-based plan. (You should refer to your summary plan description (spd), the document that describes your benefits and rights under the plan, or contact your plan administrator to find out if your coverage for childbirth is “insured” or ” self-insured”. ”)
The coverage of the self-insured is subject to the newborn law. however, if your coverage is “insured” by an insurance company or hmo and your state has a similar law regulating coverage for newborns and mothers who meet specific criteria, then your rights will be as provided by state law in place of the rights of newborns. Act. State law may differ slightly from the requirements of the newborn law, so it’s important to know which law applies to your coverage so you know what your rights are. based on a preliminary analysis of state law, most insured coverage is subject to state law requirements rather than federal protections.
How does giving birth to or adopting a baby affect my rights to enroll in my health plan or health insurance coverage?
Under HIPAA, you, your spouse, and your new child have a special right to enroll in your health plan at the time of the birth, adoption, or placement for adoption of your new child, if you, your spouse, and your new child are eligible to enroll in the plan. You must apply to enroll in the plan within 30 days of the birth, adoption, or placement for adoption. Your plan or insurance issuer may not treat you or your spouse as a late enrollee in this circumstance. so, for example, the longest pre-existing condition exclusion that could be imposed on you or your spouse is 12 months. Your family’s coverage under this special enrollment type must be effective as of the date of birth, adoption, or placement for adoption.
Can my health insurance plan or coverage impose pre-existing condition exclusions on my newborn child, adopted child, or child placed for adoption?
Under HIPAA, as long as you enroll your newborn, adopted, or placed child within 30 days of the birth, adoption, or placement for adoption, your insurance plan or coverage cannot impose exclusions for conditions preexisting the child. in addition, any future plan cannot impose a pre-existing condition exclusion, as long as the child does not incur a significant break in coverage (generally, a break in coverage of at least 63 days).
If I enroll in a new health insurance plan or coverage while pregnant, can my insurance plan or coverage impose a pre-existing condition exclusion related to my pregnancy?
not. Under HIPAA, an insurance plan or issuer cannot refuse to pay benefits by imposing a pre-existing condition related to pregnancy.
The newborn law is administered by the us. uu. departments of labor and treasury, state departments of insurance, and the united states department of health and human services.
For more information about your rights and responsibilities under an employer-sponsored group health plan, visit the Employee Benefits Security Administration website at dol.gov/ebsa and go to “Publications and Reports” for a list of ebsa publications, including your health plan and hipaa…making the law work for you.
To request copies of our publications or request assistance from one of our benefits advisors, you can contact ebsa electronically at askebsa.dol.gov or by calling toll-free 1-866-444-3272.
Many states have enacted their own version of the newborn law for insured coverage. in these states, state law may govern instead of federal requirements. For more information, visit the National Association of Insurance Commissioners website at naic.org and go to the “States and Jurisdictions Map” to find your state insurance commissioner’s office. You can also visit the Centers for Medicare and Medicaid Services, U.S. department of health and human services, at cms.gov.
This publication was developed by the us. department of labor, employee benefits security administration. It is available online at dol.gov/ebsa. To order copies or request assistance from a benefits advisor, contact EBSA electronically at askebsa.dol.gov or call toll-free 1-866-444-3272. This material will be made available in an alternate format to persons with disabilities upon request: Voice Phone: (202) 693-8664, TTY: (202) 501-3911. This booklet is a small entity compliance guide for purposes of the Small Business Fairness in Compliance Act of 1996.