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Newborns' and Mothers' Health Protection Act of 1996 (NMHPA)

This topic provides information about the Newborns' and Mothers' Health Protection Act of 1996 (NMHPA, or Newborns' Act), one of the amendments to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

You can read this topic sequentially, or click one of the links below to jump to a specific section:

·               Summary

·               Questions and Answers

·               Interim Rules

·               Statutory Text

Summary

Overview

The Newborns' and Mothers' Health Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth. The law applies both to persons enrolled in group health plans and to persons who have individual health care coverage. In general, plans and health insurance issuers that are subject to NMHPA 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.

If you deliver in the hospital, the 48-hour (or 96-hour) period starts at the time of delivery. If you deliver outside the hospital and you are later admitted to the hospital in connection with childbirth, the period begins at the time of the admission.

Although the NMHPA prohibits group health plans and health insurance issuers from restricting the length of a hospital stay in connection with childbirth, the plan or health insurance issuer does not have to cover the full 48 or 96 hours in all cases. If an attending provider, after speaking with you, determines that either you or your child can be discharged before the 48-hour (or 96-hour) period, the group health plan and health insurance issuers do not have to continue covering the stay for whichever one of you is ready for discharge. An attending provider is an individual, licensed under State law, who is directly responsible for providing maternity or pediatric care to you or your newborn child. In addition to physicians, an individual such as a nurse midwife, physician assistant, or nurse practitioner may be an attending provider. A plan, hospital, insurance company, or HMO would NOT be an attending provider.

Coverage under NMHPA

Two key factors determine whether NMHPA protections apply to your health insurance coverage. First, protection depends on whether the benefits under your group health plan or insurance policy include coverage for hospital stays following childbirth. NMHPA does NOT require group health plans and health insurance issuers to provide that kind of coverage. Second, even if your group health plan or health insurance issuer chooses to cover hospital stays in connection with childbirth, you need to find out how your group health plan provides benefits. Group health plans that provide benefits through insurance are known as insured plans. Group health plans that pay for coverage directly, without purchasing health insurance from an issuer, are called self-insured plans.

Contact your plan administrator to find out if your coverage is insured or self-insured.

If you are in a self-insured group health plan, your health coverage must comply with NMHPA standards. If you are in an insured group plan or if you have individual insurance coverage, the NMHPA might NOT apply if your State has a law with certain protections for hospital stays following childbirth. As of mid-2000, more than 40 states and the District of Columbia had laws that take precedence over NMHPA.

The State in which you reside may have laws that meet the HIPAA minimum standards. In this case, your State department of insurance can assist you with questions and complaints concerning the protections HIPAA provides.

Answers to Commonly Asked Questions

General Questions on the NMHPA

1) Does the 48-hour period (or 96-hour period) apply only to me, or does it also apply to my newborn child?

The 48-hour period (or 96-hour period) applies to your newborn child and is independent of the period that applies to you. This means that the plan or issuer might pay for a different amount of time for you than for your child, depending on the attending provider's decision to discharge one of you before the other. The attending provider will make that decision in consultation with you.

2) May a plan or an issuer require me to get permission (sometimes called prior authorization or precertification based upon medical necessity) for a 48-hour or 96-hour hospital stay?

No. A plan or health insurance issuer cannot require you or your attending provider to show that the 48-hour (or 96-hour) stay is medically necessary. However, a plan or health insurance issuer may require you to get permission - sometimes called prior authorization or precertification based upon medical necessity - for any portion of a stay after the 48 hours (or 96 hours). In addition, a plan or health insurance issuer generally can require you to notify the plan or issuer 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.

3) May plans or health insurance issuers impose deductibles or other cost-sharing arrangements for hospital stays in connection with childbirth?

Yes, but only if the deductible, coinsurance, or other cost-sharing amounts for the later part of the protected 48-hour (or 96-hour) stay are not greater than those imposed for the earlier part of the stay. For example, with respect to a 48-hour stay, a plan is permitted 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 cannot reduce coverage to 50 percent for the second 24 hours.

4) May I be offered incentives to shorten my hospital stay or my newborn's hospital stay? May my doctor be offered incentives to discharge us?

No. Plans and health insurance issuers cannot give you payments (including payments-in-kind such as baby supplies) or rebates in return for your agreeing to an early discharge. Plans and health insurance issuers are prohibited from pressuring you to agree to an early discharge. They may not deny you or your newborn child eligibility or continued eligibility to enroll or renew coverage under your plan or individual policy. Plans and health insurance issuers cannot pressure attending providers to discharge you or your newborn child early by giving them financial or other incentives. Such illegal incentives would include reducing or limiting their compensation or by penalizing them, for example, by taking disciplinary action against them.

5) Is my health plan required to give me notice about my rights under NMHPA?

Yes. Group health plans and health insurance issuers are required to provide you with notice about your rights under this law. If you are in a group health plan, the notice will usually be included in the plan document (sometimes referred to as the 'Summary Plan Description') that provides a description of the benefits covered under your plan. If you have individual health insurance coverage, the notice of your rights under NMHPA will generally be included in your insurance contract.

Interim Rules

The Department of Health and Human Services (DHHS), the Department of Labor, and the Department of the Treasury (the Departments) share authority for implementation and enforcement of the NMHPA. Under this shared authority, the Departments cooperatively developed a Joint Interim Rule that was issued on October 27, 1998. The Joint Interim Rule applies to plans and issuers in the group market for plan years beginning on or after January 1, 1999. The Interim Rule also contains regulations issued exclusively by the DHHS that govern the individual market. The individual market rules apply to health insurance coverage on or after January 1, 1999.

Joint Interim Rule

The Joint Interim Rule provides guidance on how the NMHPA will be implemented and enforced and explains the jurisdiction of each Department. With few exceptions, the rules for each Department are substantively identical.

DHHS Interim Rules

These provisions include the provisions shared with the Department of Labor and the Treasury, as well as those provisions related to the individual market that are within the sole jurisdiction of the DHHS.

Statutory Text

The Newborns' and Mothers' Health Protection Act (P.L. 104-204), enacted September 26, 1996, including the amendments to Title XVII of the Public Health Service Act (PHS Act). The Department of Health and Human Services (DHHS), the Department of Labor, and the Department of the Treasury (the Departments) share authority for implementation and enforcement of the NMHPA.

See Also:

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Overview

Source

Information in this topic was drawn from pages of the Centers for Medicare & Medicaid Services' Health Insurance Portability and Accountability Act of 1996 (HIPAA) website at:
http://www.cms.hhs.gov/HealthInsReformforConsume/05_TheNewborns'andMothers'HealthProtectionAct.asp

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