Childbirth is taxing on a new mom’s body. The first few days after having a baby are an important time for rest and recovery, both physically and emotionally. New moms can be incontinent, be constipated, have sore breasts, continue to have contractions, have hot and cold flashes, hemorrhoids, and have more serious problems including cesarean wound, uterus, or breast infections, blood clots, and heavy bleeding that may require longer hospital stays.
The Newborn's and Mother's Health Protection Act of 1996 requires health plans that offer maternity coverage to pay for at least a 48-hour hospital stay following vaginal delivery or 96-hour stay for a cesarean delivery. The 48 or 96-hour period doesn’t start until delivery, not admittance, unless the baby was born outside the hospital.
Pregnant women can’t be required to obtain pre-authorization for the 48 to 96-hour hospital stay. However, this Act don’t prevent the health care provider from discharging the mother or newborn child from the hospital earlier, if they’re healthy and the doctor consulted with mother first.
The Act doesn’t apply to all health plans.
Whether or not the Newborns' and Mothers’ Health Protection Act applies to a health plan is determined by the type of coverage the plan provides. If your plan doesn’t offer benefits for hospitals stays in connection with childbirth, then the Act likely doesn’t apply. You can check your Summary Plan Description to see if childbirth is covered.
The Act generally applies to two types of health insurance:
Group health plans can either be “insured” plans, i.e. health insurance is purchased from a health insurance provider, or “self-funded” plans, i.e. where the health plan pays for coverage directly. Private employer group health plans are regulated by the Department of Labor. State and local government plans are regulated by the Centers for Medicare & Medicaid Services (CMS). When a group health plan buys insurance, the insurance itself is regulated by the State’s insurance department.
In a private, self-funded group health plan, the health coverage must comply with the Newborns' and Mothers' Health Protection Act. Your plan administrator can you tell you whether your plan is insured or self-funded and what entities regulate your benefits. If you’re in an insured group health plan or have individual, non-employment based coverage, the federal Newborns' and Mothers' Health Protection Act standards may not apply directly if your state has a law with similar protections. You can contact your state insurance department to find out what law applies and if there are additional protections for new moms & babies in your state.
Employers can be checked for their health plan's compliance with this Act.
The Employee Benefits Security Administration (EBSA), through the Health Benefits Security Project (HBSP) conducts Health Plan Audits. During an audit, the employer group health plan will be reviewed for compliance with Part 7 of ERISA, which includes the Newborns' and Mother’s Health Protection Act, among other women’s health, cancer, mental health, and genetic nondiscrimination acts. When a health plan doesn’t comply with this Act, there can be civil or criminal penalties, including fines of up to $100,000, if the non-compliance isn’t corrected within the allotted time. Read more about ERISA (Employee Retirement Income Security Act) in FindLaw's ERISA section.
If your company needs to prepare for a health plan audit, the Department of Labor has useful health benefits laws checklists.
Who do I contact if I think my health plan has denied me this benefit?
If you have concerns about your plan’s compliance with the Newborns' and Mothers' Protection Act, contact the Center for Consumer Information & Insurance Oversight at 1-877-267-2323 ext. 6-1565 or at [email protected].
You may also wish to consult with a qualified health law attorney.