Interim Guidelines Issued for the Newborns’ and Mothers' Health Protection Act of 1996 (NMHPA)

The government recently issued guidelines on implementing the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) with respect to the length of maternity stays. The new guidelines are effective on November 9, 1998. Plans must comply by the date on which the first summary of material modification (or SPD) is required to be furnished to participants and beneficiaries following November 9, 1998.

The NMHPA requires group health insurance plans and health insurance carriers that offer maternity benefits to allow 48-hour hospital stays after vaginal deliveries (with or without complications) or 96-hour hospital stays following cesarean deliveries. The plans may not require that providers to obtain pre-authorization for stays up to this amount of time. The minimum stay rules can be waived, but only by way of consultation between the provider and the mother.

The implementation instructions provide guidance regarding when coverage starts. In particular, according to the new rules, a delivery does not have to occur inside a hospital in order for the admission to be in connection with childbirth. The determination of whether an admission is in connection with childbirth is a medical decision that can be made only by an attending provider.

The regulations do make a distinction between deliveries made inside a hospital and those made elsewhere. When a delivery occurs in a hospital, the stay begins at the time of delivery. In the case of multiple births, the stay begins from the time of the last delivery. When a delivery occurs outside of a hospital, the stay begins at the time the mother or newborn is admitted. Also, plans and carriers cannot reduce or limit reimbursements to health care providers who comply with the minimum stay provisions of the Act.

It is also stipulated in the new rules that monetary payments or rebates cannot be made to a mother or provider as an incentive not to use the minimum stay provisions of the NMHPA. However, a plan may provide after-discharge follow-up services to a mother and newborn discharged earlier than the minimums provided by law, so long as those services are not more than the mother and newborn would have received if they had stayed in the hospital for the full 48 or 96 hours.

The new rules also provide that a plan or insurer may not offer less generous benefits for any portion of an extended hospital stay than those benefits provided during the preceding portion of the stay. Although participants and beneficiaries remain responsible for paying deductibles, coinsurance, or other cost-sharing expenses, these expenses cannot be greater than those for any preceding portion of the hospital stay.

The interim rule provided the following NMHPA language to be inserted in SPDs for ERISA-covered group health plans:

(u) In the case of a group health plan, as defined in section 733(a)(1) of the Act, that provides maternity or newborn infant coverage, a statement indicating the following: 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).

Employers should be aware of these requirements applicable to group health plans and group health insurance policies and ensure that providers are in compliance.

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