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Newborns' and mothers' health insurance rights

The Newborns' and Mothers' Health Protection Act (NMHPA) of 1996 contained numerous provisions guarding a mother and newborn child at the time of delivery.

Under the NMHPA, group health plans, individual health insurance plans, insurance companies and health maintenance organizations (HMOs) offering health coverage for hospital stays in connection with the birth of a child must provide health coverage for a certain period of time. For a vaginal delivery, the minimum stay is 48 hours for both mother and child. For a cesarean delivery, the NMHPA mandates a minimum of 96 hours. According to the rules, the hospital length of stay begins at the time of delivery rather than at the time of admission or onset of labor. In the case of multiple births, the minimum length of time would begin at the time of the last delivery. If the delivery occurs outside a hospital, the hospital length of stay begins at the time the mother and newborn are admitted. If the mother and newborn are doing well, and the doctor agrees, they may choose to leave the hospital early.

If your health plan doesn't cover hospital stays for childbirth, NMHPA doesn't apply to you.

However, if your health plan doesn't cover hospital stays for childbirth, NMHPA doesn't apply to you. NMHPA doesn't require any group health plans to provide hospital stays for childbirth, and insurers may remove such coverage from their plans.

NMHPA allows insurers to charge co-payments for time spent in the hospital after birth, but those co-payments can't be higher than any co-payments the mother may have paid for time spent in the hospital prior to the birth. For example, if a mother paid $50 a day prior to birth, then has a cesarean delivery, NHMPA says she has a minimum stay of 96 hours. For those 96 hours, she can't be charged anything more than $50 per 24-hour period.

Here are frequently asked questions about NMHPA.

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

A: 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 your health plan 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 the decision in consultation with you.

Q: Can a health plan require me to get permission (also known as "prior authorization" or "pre-certification" based upon medical necessity) for a 48-hour or 96-hour hospital stay?

A: No. A health plan cannot require you or your attending provider to show that the 48-hour (or 96-hour) stay is medically necessary. However, a plan may require you to get permission for any portion of a stay after the 48 hours (or 96 hours). In addition, an insurer can require you to notify it of the pregnancy in advance of the hospital admission if you wish to use certain providers or facilities, or to reduce your out-of-pocket costs.

Q: Can I be offered incentives to shorten my hospital stay or my newborn's hospital stay? Can my doctor be offered incentives to discharge us?

A: No. Health plans cannot give you payments (including payments-in-kind such as baby supplies) or rebates in return for your agreeing to an early discharge. Plans are prohibited from pressuring you to agree to an early discharge. They also may not deny you or your newborn child eligibility or continued eligibility to enroll or renew coverage under your plan or individual policy. Plans cannot pressure your 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.

Q: Is my health plan required to give me notice about my rights under NMHPA?

A: Yes. Group health plans 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 generally will be included in your insurance contract.

Source: U.S. Dept. of Labor

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