I

104TH CONGRESS

2D SESSION H. R. 3226

To require that health plans provide coverage for a minimum hospital stay

for a mother and child following the birth of the child, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

MARCH 29, 1996

Mr. SOLOMON (for himself and Mr. MILLER of California) introduced the following bill; which was referred to the Committee on Commerce, and in

addition to the Committee on Economic and Educational Opportunities,

for a period to be subsequently determined by the Speaker, in each case

for consideration of such provisions as fall within the jurisdiction of the

committee concerned

A BILL

To require that health plans provide coverage for a minimum

hospital stay for a mother and child following the birth

of the child, and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Newborns’ and Moth5 ers’ Health Protection Act of 1996’’.

6 SEC. 2. FINDING.

7 Congress finds that—
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1 (1) the length of post-delivery inpatient care

2 should be based on the unique characteristics of

3 each mother and her newborn child, taking into con4 sideration the health of the mother, the health and

5 stability of the infant, the ability and confidence of

6 the mother to care for her infant, the adequacy of

7 support systems at home, and the access of the

8 mother and infant to appropriate follow-up health

9 care; and

10 (2) the timing of the discharge of a mother and

11 her newborn child from the hospital should be made

12 by the attending provider in consultation with the

13 mother.

14 SEC. 3. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

15 STAY FOLLOWING BIRTH.

16 (a) IN GENERAL.—Except as provided in subsection

17 (b), a health plan or an employee health benefit plan that

18 provides maternity benefits, including benefits for child19 birth, shall ensure that coverage is provided with respect

20 to a mother who is a participant, beneficiary, or policy21 holder under such plan and her newborn child for a mini22 mum of 48 hours of in-patient care following a normal

23 vaginal delivery, and a minimum of 96 hours of in-patient

24 care following a caesarean section, without requiring the

25 attending provider to obtain authorization from the health
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1 plan or employee health benefit plan in order to keep a

2 mother and her newborn child in the inpatient setting for

3 such period of time.

4 (b) EXCEPTION.—Notwithstanding subsection (a), a

5 health plan or an employee health benefit plan shall not

6 be required to provide coverage for post-delivery in-patient

7 care for a mother who is a participant, beneficiary, or pol8 icyholder under such plan and her newborn child during

9 the period referred to in subsection (a) if—

10 (1) a decision to discharge the mother and her

11 newborn child prior to the expiration of such period

12 is made by the attending provider in consultation

13 with the mother; and

14 (2) the health plan or employee health benefit

15 plan provides coverage for post-delivery follow-up

16 care as described in section 4.

17 SEC. 4. POST-DELIVERY FOLLOW-UP CARE.

18 (a) IN GENERAL.—In the case of a decision to dis19 charge a mother and her newborn child from the inpatient

20 setting prior to the expiration of 48 hours in the case of

21 a normal vaginal delivery or 96 hours in the case of a

22 caesarean section, the health plan or employee health ben23 efit plan shall provide coverage for timely post-delivery

24 care. Such health care shall be provided to a mother and

25 her newborn child by a registered nurse, physician, nurse
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1 practitioner, nurse midwife or physician assistant experi2 enced in maternal and child health in—

3 (1) the home, a provider’s office, a hospital, a

4 federally qualified health center, a federally qualified

5 rural health clinic, or a State health department ma6 ternity clinic; or

7 (2) another setting determined appropriate

8 under regulations promulgated by the Secretary, in

9 consultation with the Secretary of Health and

10 Human Services, (including a birthing center or an

11 intermediate care facility);

12 except that such coverage shall ensure that the mother has

13 the option to be provided with such care in the home.

14 (b) TIMELY CARE.—As used in subsection (a), the

15 term ‘‘timely post-delivery care’’ means health care that

16 is provided—

17 (1) following the discharge of a mother and her

18 newborn child from the inpatient setting; and

19 (2) in a manner that meets the health care

20 needs of the mother and her newborn child, that

21 provides for the appropriate monitoring of the condi22 tions of the mother and child, and that occurs within

23 the 24- to 72-hour period immediately following dis24 charge.
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1 (c) CONSISTENCY WITH STATE LAW.—The Secretary

2 shall, with respect to regulations promulgated under sub3 section (a) concerning appropriate post-delivery care set4 tings, ensure that, to the extent practicable, such regula5 tions are consistent with State licensing and practice laws.

6 SEC. 5. PROHIBITIONS.

7 (a) TERMS AND CONDITIONS.—In implementing the

8 requirements of this Act, a health plan or an employee

9 health benefit plan may not—

10 (1) deny enrollment, renewal, or continued cov11 erage to a mother and her newborn child who are

12 participants, beneficiaries or policyholders based on

13 compliance with this Act;

14 (2) provide monetary incentives to mothers to

15 encourage such mothers to request less than the

16 minimum coverage required under this Act; or

17 (3) provide incentives (monetary or otherwise)

18 to an attending provider to induce such provider to

19 provide treatment in a manner inconsistent with this

20 Act.

21 (b) PROVIDERS.—In implementing the requirements

22 of this section, a health plan or an employee health benefit

23 plan may not penalize or otherwise reduce or limit the re24 imbursement of an attending provider because such pro25 vider provided treatment in accordance with this Act.
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1 (c) RULE OF CONSTRUCTION.—Nothing in this Act

2 shall be construed to require that a mother who is a par3 ticipant, beneficiary, or policyholder covered under this

4 Act—

5 (1) give birth in a hospital; or

6 (2) stay in the hospital for a fixed period of

7 time following the birth of her child.

8 SEC. 6. NOTICE.

9 (a) EMPLOYEE HEALTH BENEFIT PLAN.—An em10 ployee health benefit plan shall provide notice to each par11 ticipant regarding coverage required under this Act in ac12 cordance with regulations promulgated by the Secretary.

13 (b) HEALTH PLAN.—A health plan shall provide no14 tice to each policyholder regarding coverage required

15 under this Act.

16 (c) REQUIREMENTS.—Notice required under this sec17 tion shall be in writing, prominently positioned in, and be

18 transmitted—

19 (1) in a mailing made within 120 days of the

20 date of enactment of this Act by such plan to the

21 participant or policyholder; and

22 (2) as part of the annual informational packet

23 sent to the participant or policyholder.

24 SEC. 7. APPLICABILITY.

25 (a) CONSTRUCTION.—
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1 (1) IN GENERAL.—A requirement or standard

2 imposed under this Act on a health plan shall be

3 deemed to be a requirement or standard imposed on

4 the health plan issuer. Such requirements or stand5 ards shall be enforced by the State insurance com6 missioner for the State involved or the official or of7 ficials designated by the State to enforce the re8 quirements of this Act. In the case of a health plan

9 offered by a health plan issuer in connection with an

10 employee health benefit plan, the requirements or

11 standards imposed under this Act shall be enforced

12 with respect to the health plan issuer by the State

13 insurance commissioner for the State involved or the

14 official or officials designated by the State to enforce

15 the requirements of this Act.

16 (2) LIMITATION.—Except as provided in section

17 8(c), the Secretary shall not enforce the require18 ments or standards of this Act as they relate to

19 health plan issuers or health plans. In no case shall

20 a State enforce the requirements or standards of

21 this Act as they relate to employee health benefit

22 plans.

23 (b) RULE OF CONSTRUCTION.—Nothing in this Act

24 shall be construed to affect or modify the provisions of
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1 section 514 of the Employee Retirement Income Security

2 Act of 1974 (29 U.S.C. 1144).

3 SEC. 8. ENFORCEMENT.

4 (a) HEALTH PLAN ISSUERS.—Each State shall re5 quire that each health plan issued, sold, renewed, offered

6 for sale or operated in such State by a health plan issuer

7 meet the standards established under this Act. A State

8 shall submit such information as required by the Secretary

9 demonstrating effective implementation of the require10 ments of this Act.

11 (b) EMPLOYEE HEALTH BENEFIT PLANS.—With re12 spect to employee health benefit plans, the standards es13 tablished under this Act shall be enforced in the same

14 manner as provided for under sections 502, 504, 506, and

15 510 of the Employee Retirement Income Security Act of

16 1974 (29 U.S.C. 1132, 1134, 1136, and 1140). The civil

17 penalties contained in paragraphs (1) and (2) of section

18 502(c) of such Act (29 U.S.C. 1132(c) (1) and (2)) shall

19 apply to any information required by the Secretary to be

20 disclosed and reported under this section.

21 (c) FAILURE TO ENFORCE.—In the case of the fail22 ure of a State to substantially enforce the standards and

23 requirements set forth in this Act with respect to health

24 plans, the Secretary, in consultation with the Secretary

25 of Health and Human Services, shall enforce the stand-
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1 ards of this Act in such State. In the case of a State that

2 fails to substantially enforce the standards set forth in this

3 Act, each health plan issuer operating in such State shall

4 be subject to civil enforcement as provided for under sec5 tions 502, 504, 506, and 510 of the Employee Retirement

6 Income Security Act of 1974 (29 U.S.C. 1132, 1134,

7 1136, and 1140). The civil penalties contained in para8 graphs (1) and (2) of section 502(c) of such Act (29

9 U.S.C. 1132(c) (1) and (2)) shall apply to any information

10 required by the Secretary to be disclosed and reported

11 under this section.

12 (d) REGULATIONS.—The Secretary, in consultation

13 with the Secretary of Health and Human Services, may

14 promulgate such regulations as may be necessary or ap15 propriate to carry out this Act.

16 SEC. 9. DEFINITIONS.

17 As used in this Act:

18 (1) ATTENDING PROVIDER.—The term ‘‘attend19 ing provider’’ shall include the obstetrician-gyne20 cologists, pediatrician, family physician, or other

21 physician attending the mother or newly born child.

22 Such term shall also include any other health care

23 provider who, in accordance with applicable State

24 law, may be primarily responsible for the care of a
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1 mother and her newborn child (including nurse mid2 wives and nurse practitioners).

3 (2) BENEFICIARY.—The term ‘‘beneficiary’’ has

4 the meaning given such term under section 3(8) of

5 the Employee Retirement Income Security Act of

6 1974 (29 U.S.C. 1002(8)).

7 (3) EMPLOYEE HEALTH BENEFIT PLAN.—

8 (A) IN GENERAL.—The term ‘‘employee

9 health benefit plan’’ means any employee wel10 fare benefit plan, governmental plan, or church

11 plan (as defined under paragraphs (1), (32),

12 and (33) of section 3 of the Employee Retire13 ment Income Security Act of 1974 (29 U.S.C.

14 1002 (1), (32), and (33))) that provides or pays

15 for health benefits (such as provider and hos16 pital benefits) for participants and beneficiaries

17 whether—

18 (i) directly;

19 (ii) through a health plan offered by

20 a health plan issuer as defined in para21 graph (4); or

22 (iii) otherwise.

23 (B) RULE OF CONSTRUCTION.—An em24 ployee health benefit plan shall not be con-
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1 strued to be a health plan or a health plan is2 suer.

3 (C) ARRANGEMENTS NOT INCLUDED.—

4 Such term does not include the following, or

5 any combination thereof:

6 (i) Coverage only for accident, or dis7 ability income insurance, or any combina8 tion thereof.

9 (ii) Medicare supplemental health in10 surance (as defined under section

11 1882(g)(1) of the Social Security Act).

12 (iii) Coverage issued as a supplement

13 to liability insurance.

14 (iv) Liability insurance, including gen15 eral liability insurance and automobile li16 ability insurance.

17 (v) Workers compensation or similar

18 insurance.

19 (vi) Automobile medical payment in20 surance.

21 (vii) Coverage for a specified disease

22 or illness.

23 (viii) Hospital or fixed indemnity in24 surance.
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1 (ix) Short-term limited duration in2 surance.

3 (x) Credit-only, dental-only, or vision4 only insurance.

5 (xi) A health insurance policy provid6 ing benefits only for long-term care, nurs7 ing home care, home health care, commu8 nity-based care, or any combination there9 of.

10 (4) GROUP PURCHASER.—The term ‘‘group

11 purchaser’’ means any person (as defined under

12 paragraph (9) of section 3 of the Employee Retire13 ment Income Security Act of 1974 (29 U.S.C.

14 1002(9)) or entity that purchases or pays for health

15 benefits (such as provider or hospital benefits) on

16 behalf of participants or beneficiaries in connection

17 with an employee health benefit plan.

18 (5) HEALTH PLAN.—

19 (A) IN GENERAL.—The term ‘‘health plan’’

20 means any group health plan or individual

21 health plan.

22 (B) GROUP HEALTH PLAN.—The term

23 ‘‘group health plan’’ means any contract, policy,

24 certificate or other arrangement offered by a

25 health plan issuer to a group purchaser that
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1 provides or pays for health benefits (such as

2 provider and hospital benefits) in connection

3 with an employee health benefit plan.

4 (C) INDIVIDUAL HEALTH PLAN.—The term

5 ‘‘individual health plan’’ means any contract,

6 policy, certificate or other arrangement offered

7 to individuals by a health plan issuer that pro8 vides or pays for health benefits (such as pro9 vider and hospital benefits) and that is not a

10 group health plan.

11 (D) ARRANGEMENTS NOT INCLUDED.—

12 Such term does not include the following, or

13 any combination thereof:

14 (i) Coverage only for accident, or dis15 ability income insurance, or any combina16 tion thereof.

17 (ii) Medicare supplemental health in18 surance (as defined under section

19 1882(g)(1) of the Social Security Act).

20 (iii) Coverage issued as a supplement

21 to liability insurance.

22 (iv) Liability insurance, including gen23 eral liability insurance and automobile li24 ability insurance.
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1 (v) Workers compensation or similar

2 insurance.

3 (vi) Automobile medical payment in4 surance.

5 (vii) Coverage for a specified disease

6 or illness.

7 (viii) Hospital or fixed indemnity in8 surance.

9 (ix) Short-term limited duration in10 surance.

11 (x) Credit-only, dental-only, or vision12 only insurance.

13 (xi) A health insurance policy provid14 ing benefits only for long-term care, nurs15 ing home care, home health care, commu16 nity-based care, or any combination there17 of.

18 (E) CERTAIN PLANS INCLUDED.—Such

19 term includes any plan or arrangement not de20 scribed in any clause of subparagraph (D)

21 which provides for benefit payments, on a peri22 odic basis, for—

23 (i) a specified disease or illness, or

24 (ii) a period of hospitalization,
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1 without regard to the costs incurred or services

2 rendered during the period to which the pay3 ments relate.

4 (6) HEALTH PLAN ISSUER.—The term ‘‘health

5 plan issuer’’ means any entity that is licensed (prior

6 to or after the date of enactment of this Act) by a

7 State to offer a health plan.

8 (7) PARTICIPANT.—The term ‘‘participant’’ has

9 the meaning given such term under section 3(7) of

10 the Employee Retirement Income Security Act of

11 1974 (29 U.S.C. 1002(7)).

12 (8) SECRETARY.—The term ‘‘Secretary’’ unless

13 otherwise specified means the Secretary of Labor.

14 SEC. 10. PREEMPTION.

15 The provisions of this Act shall not preempt those

16 provisions of State law that require health plans to provide

17 a minimum of 48 hours of in-patient care in the case of

18 a normal vaginal delivery, and 96 hours of in-patient care

19 in the case of a caesarean section, or that require health

20 plans to provide for maternity and pediatric care that is

21 in accordance with guidelines established by the American

22 College of Obstetricians and Gynecologists and the Amer23 ican Academy of Pediatrics, and to provide follow-up care

24 consistent with this Act.
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1 SEC. 11. EFFECTIVE DATE.

2 Except as otherwise provided for in this Act, the pro3 visions of this Act shall apply as follows:

4 (1) With respect to health plans, such provi5 sions shall apply to plans offered, sold, issued, re6 newed, in effect, or operated on or after January 1,

7 1997.

8 (2) With respect to employee health benefit

9 plans, such provisions shall apply to such plans on

10 the first day of the first plan year beginning on or

11 after January 1, 1997.

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