The Newborns' and Mothers' Health Protection Act of 1996


The Newborns' and Mothers' Health Protection Act of 1996 (NMHPA) was enacted on September 26, 1996 to provide protections for mothers and their newborns with regard to hospital lengths of stay following childbirth.

NMHPA applies to group health plans, to health insurance coverage sold to group health plans (the "group market"), and to health insurance sold in the individual market (not related to group health plans).

The Departments of Health and Human Services (HHS), Labor, and the Treasury published interim final rules regarding NMHPA in the Federal Register on Tuesday, October 27, 1998. These rules and the statutory provisions of NMHPA are described below.

General Rule

NMHPA imposes a requirement on group health plans and health insurance issuers in the group and individual markets if they provide benefits for hospital stays following childbirth. These plans and issuers may not restrict benefits for a mother or her newborn to less than 48 hours following a vaginal delivery or less than 96 hours following a delivery by cesarean section. Earlier discharges are permitted only if the attending provider decides, in consultation with the mother, to discharge the mother or newborn earlier.

  • NMHPA does not require plans or issuers to provide benefits for a hospital stay in connection with childbirth.
  • In addition, NMHPA does not require that a mother give birth in a hospital or stay in the hospital for a fixed period of time.

The interim final rules clarify that an attending provider is an individual who is licensed under applicable State law to provide maternity or pediatric care and who is directly responsible for providing maternity or pediatric care to a mother or newborn. A plan, hospital, managed care organization, or other issuer is not an attending provider. However, an individual such as a nurse midwife, physician assistant, or nurse practitioner may be an attending provider if licensed in the State to provide maternity or pediatric care in connection with childbirth.

The interim final rules also clarify that when delivery occurs in a hospital, the stay begins at the time of delivery (at the time of the last delivery for multiple births). When delivery occurs outside the hospital, the stay begins at the time the mother or newborn is admitted. The interim final rules clarify that the determination of whether an admission is in connection with childbirth is a medical decision to be made by the attending provider.

Prohibitions

Plans and issuers cannot pressure either the mother or the attending provider to agree to an early discharge through any of the following methods:

  • denying a mother or her newborn eligibility or continued eligibility;
  • providing payments (including payments-in-kind) or rebates to encourage the mother to accept a shorter hospital length of stay;
  • restricting benefits for any portion of a protected 48-hour (or 96-hour) hospital stay in a manner less favorable than the benefits provided for any preceding portion of the stay;
  • penalizing (for example, taking disciplinary action against or retaliating against) the attending provider, or reducing or limiting compensation, because a shorter hospital length of stay was not recommended; and
  • providing financial or other incentives to induce, or which could induce, the attending provider to discharge early.

In addition, plans and issuers may not require an attending provider to obtain authorization from the plan or issuer to prescribe a hospital length of stay of up to 48 (or 96) hours after delivery.

NMHPA does not prevent plans or issuers from imposing deductibles, coinsurance, or other cost-sharing measures as long as the cost-sharing for any portion of a 48-hour (96-hour) hospital stay is not less favorable than that imposed on any preceding portion of the stay.

In addition, NMHPA does not prevent plans or issuers from negotiating with an attending provider the level and type of compensation for maternity care.

Applicability in Certain States

State law, rather than the requirements of the Federal statute, will apply to health insurance coverage in a state that has a law that meets any of the following criteria:

  • requires health insurance coverage to provide at least a 48-hour (or 96-hour) hospital length of stay in connection with childbirth;
  • requires health insurance coverage to provide care in accordance with guidelines established by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, or any other established professional medical association; or
  • requires that decisions regarding the appropriate hospital length of stay in connection with childbirth be left to the attending provider in consultation with the mother.

The interim final rules clarify that State laws that require the decision to be made by the attending provider with the consent of the mother satisfy the last criterion.

The interim final rules clarify that if a plan purchases insurance in a state in which state law applies instead of NMHPA, the plan is considered to be in compliance with NMHPA if it purchases health insurance coverage that complies with that state law.

Notice Requirements

Plans and issuers subject to NMHPA's requirements must provide participants and beneficiaries or covered individuals with a statement describing those requirements.

The statement must be included in the plan document that provides a description of plan benefits or a rider or equivalent document.

The Department of Labor's interim final rules for notice requirements for plans subject to ERISA are not included as part of the interim final rules published for NMHPA. Instead, they were published separately with other ERISA Summary Plan Description guidance in the Federal Register on September 9, 1998.

HHS's interim final rules for notice requirements for nonfederal governmental plans and issuers in the individual market are found in the interim final rules published for NMHPA. The interim final rules set forth the mandatory language that must be used.

For nonfederal governmental plans, notice must be given in accordance with the regulatory requirements not later than 60 days after the first day of the first plan year beginning on or after January 1, 1999.

For issuers of individual health insurance coverage, notice must be given in accordance with the regulatory requirements not later than 60 days after January 1, 1999.

Effective Dates

The statutory provisions of NMHPA apply to plans and issuers in the group market for plan years beginning on or after January 1, 1998. The interim final rules of NMHPA apply for plans years beginning on or after January 1, 1999.

In the individual market, the statutory provisions of NMHPA apply to health insurance coverage on or after January 1, 1998. The interim final rules of NMHPA apply on or after January 1, 1999.

Keep in mind, the rules may differ based upon changes in U.S. health care laws and policies and the Affordable Care Act (ACA).