I

104TH CONGRESS

2D SESSION H. R. 3436

To protect the health of mothers and newborns against the premature

termination of inpatient care based on denial of health coverage.

IN THE HOUSE OF REPRESENTATIVES

MAY 10, 1996

Mr. DINGELL 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 protect the health of mothers and newborns against the

premature termination of inpatient care based on denial

of health coverage.

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 ‘‘Minimum Obstetrical

5 Medical Security Act of 1996’’ or the ‘‘MOMS Act of

6 1996’’.

7 SEC. 2. FINDINGS.

8 Congress finds that—
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1 (1) health care for mothers and newborn chil2 dren, including the length of post-delivery inpatient

3 care, should be based on the unique characteristics

4 of each mother and her newborn child, taking into

5 consideration the health of the mother, the health

6 and stability of the newborn, the ability and con7 fidence of the mother and father to care for the new8 born, the adequacy of support systems at home, and

9 the access of the mother and newborn to appropriate

10 follow-up health care; and

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

12 her newborn child from the hospital should be made

13 by the attending provider in consultation with the

14 mother.

15 SEC. 3. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

16 STAY FOLLOWING BIRTH.

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

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

19 provides maternity benefits, including benefits for child20 birth, shall ensure that coverage is provided with respect

21 to a mother who is a participant, beneficiary, or policy22 holder under such plan and her newborn child for a mini23 mum of 48 hours of inpatient length of stay following a

24 normal vaginal delivery, and a minimum of 96 hours of

25 inpatient length of stay following a caesarean section,
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1 without requiring the attending provider to obtain author2 ization from the health plan or employee health benefit

3 plan.

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 inpatient

7 length of stay for a mother who is a participant, bene8 ficiary, or policyholder under such plan and her newborn

9 child for 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 following a nor21 mal vaginal delivery or 96 hours following a caesarean sec22 tion, the health plan or employee health benefit plan shall

23 provide coverage for timely post-delivery care. Such health

24 care shall be provided to a mother and her newborn child

25 by a registered nurse, physician, osteopathic physician,
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1 nurse practitioner, nurse midwife, or physician assistant

2 experienced in maternal and child health in—

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

4 birthing center, an intermediate care facility, a fed5 erally qualified health center, a federally qualified

6 rural health clinic, or a State health department ma7 ternity clinic; or

8 (2)another setting determined appropriate by

9 the attending provider and the mother;

10 except that such coverage shall ensure that the mother has

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

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

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

14 is provided—

15 (1) within the 72-hour period immediately fol16 lowing the discharge of a mother and her newborn

17 child from the inpatient setting; and

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

19 needs of the mother and her newborn child and that

20 provides for the appropriate monitoring of the condi21 tions of the mother and child.

22 SEC. 5. PROHIBITIONS.

23 In implementing the requirements of this Act, a

24 health plan or an employee health benefit plan may not—
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1 (1) deny enrollment, renewal, or continued cov2 erage to a mother and her newborn child who are

3 participants, beneficiaries, or policyholders based on

4 compliance with this Act;

5 (2) provide monetary payments or rebates to

6 mothers to encourage such mothers to request less

7 than the minimum coverage required under this Act;

8 (3) penalize or otherwise reduce or limit the re9 imbursement of an attending provider because such

10 provider provided treatment in accordance with this

11 Act; or

12 (4) provide incentives (monetary or otherwise)

13 to an attending provider to induce such provider to

14 provide treatment to an individual policyholder, par15 ticipant, or beneficiary in a manner inconsistent with

16 this Act.

17 SEC. 6. NOTICE.

18 (a) EMPLOYEE HEALTH BENEFIT PLAN.—An em19 ployee health benefit plan shall provide conspicuous notice

20 to each participant regarding coverage required under this

21 Act not later than 120 days after the date of enactment

22 of this Act, and as part of its summary plan description.

23 (b) HEALTH PLAN.—A health plan shall provide no24 tice to each policyholder regarding coverage required
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1 under this Act. Such notice shall be in writing, promi2 nently positioned, and be transmitted—

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

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

5 policyholder; and

6 (2) as part of any annual enrollment packet or

7 brochure sent to the policyholder.

8 SEC. 7. APPLICABILITY.

9 (a) CONSTRUCTION.—

10 (1) IN GENERAL.—A requirement or standard

11 imposed under this Act on a health plan shall be

12 deemed to be a requirement or standard imposed on

13 the health plan issuer. Such requirements or stand14 ards shall be enforced by the State insurance com15 missioner for the State involved or the official or of16 ficials designated by the State to enforce the re17 quirements of this Act. In the case of a health plan

18 offered by a health plan issuer in connection with an

19 employee health benefit plan, the requirements or

20 standards imposed under this Act shall be enforced

21 with respect to the health plan issuer by the State

22 insurance commissioner for the State involved or the

23 official or officials designated by the State to enforce

24 the requirements of this Act.
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1 (2) LIMITATION.—Except as provided in section

2 8(a)(2), the Secretary of Health and Human Serv3 ices shall not enforce the requirements or standards

4 of this Act as they relate to health plan issuers or

5 health plans. In no case shall a State of the Sec6 retary of Health and Human Services enforce the re7 quirements or standards of this Act as they relate

8 to employee health benefit plans.

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

10 shall be construed to affect or modify the provisions of

11 section 514 of the Employee Retirement Income Security

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

13 (c) RULE OF CONSTRUCTION.—Nothing in this Act

14 shall be construed to require that a mother who is a par15 ticipant, beneficiary, or policyholder covered under this

16 Act—

17 (1) give birth in a hospital; or

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

19 time following the birth of her child.

20 SEC. 8. ENFORCEMENT.

21 (a) HEALTH PLAN ISSUERS.—

22 (1) STATE ENFORCEMENT.—Each State shall

23 require that each health plan issued, sold, renewed,

24 offered for sale, or operated in such State by a

25 health plan issuer meet the standards established
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1 under this Act. A State shall submit such informa2 tion as required by the Secretary of Health and

3 Human Services demonstrating effective implemen4 tation of the requirements of this Act.

5 (2) FALLBACK FEDERAL ENFORCEMENT.—In

6 the case of the failure of a State to substantially en7 force the standards and requirements set forth in

8 this Act with respect to health plans, the Secretary

9 of Health and Human Services shall enforce the

10 standards of this Act in such State. In enforcing

11 such standards, the Secretary may apply against a

12 health plan issuer the sanctions similar to the sanc13 tions described in sections 502, 504, 506, and 510

14 of the Employee Retirement Income Security Act of

15 1974 (29 U.S.C. 1132, 1134, 1136, and 1140).

16 (b) EMPLOYEE HEALTH BENEFIT PLANS.—With re17 spect to employee health benefit plans, the standards es18 tablished under this Act shall be enforced in the same

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

20 510 of the Employee Retirement Income Security Act of

21 1974 (29 U.S.C. 1132, 1134, 1136, and 1140). The civil

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

23 502(c) of such Act (29 U.S.C. 1132(c)) shall apply to any

24 information required by the Secretary of Labor to be dis25 closed and reported under this section.
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1 (c) REGULATIONS.—The Secretaries of Health and

2 Human Services and Labor (as the case may be) may pro3 mulgate such regulations as may be necessary or appro4 priate to carry out this Act.

5 SEC. 9. DEFINITIONS.

6 As used in this Act:

7 (1) ATTENDING PROVIDER.—The term ‘‘attend8 ing provider’’ means an obstetrician-gynecologist, pe9 diatrician, family physician, osteopathic physician, or

10 other physician or a nurse practitioner, nurse mid11 wife, or other health care provider primarily respon12 sible for the care of a mother and her newborn child,

13 and includes a group including such a provider.

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

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

16 the Employee Retirement Income Security Act of

17 1974 (29 U.S.C. 1002(8)).

18 (3) EMPLOYEE HEALTH BENEFIT PLAN.—

19 (A) IN GENERAL.—The term ‘‘employee

20 health benefit plan’’ means any employee wel21 fare benefit plan, governmental plan, or church

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

23 and (33) of section 3 of the Employee Retire24 ment Income Security Act of 1974 (29 U.S.C.

25 1002 (1), (32), and (33))) that provides or pays
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1 for health benefits (such as provider and hos2 pital benefits) for participants and beneficiaries

3 whether—

4 (i) directly;

5 (ii) through a health plan offered by

6 a health plan issuer as defined in para7 graph (4); or

8 (iii) otherwise.

9 (B) RULE OF CONSTRUCTION.—An em10 ployee health benefit plan shall not be con11 strued to be a health plan or a health plan is12 suer.

13 (C) ARRANGEMENTS NOT INCLUDED.—

14 Such term does not include the following, or

15 any combination thereof:

16 (i) Coverage only for accident, or dis17 ability income insurance, or any combina18 tion thereof.

19 (ii) Medicare supplemental health in20 surance (as defined under section

21 1882(g)(1) of the Social Security Act).

22 (iii) Coverage issued as a supplement

23 to liability insurance.
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1 (iv) Liability insurance, including gen2 eral liability insurance and automobile li3 ability insurance.

4 (v) Workers compensation or similar

5 insurance.

6 (vi) Automobile medical payment in7 surance.

8 (vii) Coverage for a specified disease

9 or illness.

10 (viii) Hospital or fixed indemnity in11 surance.

12 (ix) Short-term limited duration in13 surance.

14 (x) Credit-only, dental-only, or vision15 only insurance.

16 (xi) A health insurance policy provid17 ing benefits only for long-term care, nurs18 ing home care, home health care, commu19 nity-based care, or any combination there20 of.

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

22 purchaser’’ means any person (as defined under

23 paragraph (9) of section 3 of the Employee Retire24 ment Income Security Act of 1974 (29 U.S.C.

25 1002(9))) or entity that purchases or pays for health
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1 benefits (such as provider or hospital benefits) on

2 behalf of participants or beneficiaries in connection

3 with an employee health benefit plan.

4 (5) HEALTH PLAN.—

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

6 means any group health plan or individual

7 health plan.

8 (B) GROUP HEALTH PLAN.—The term

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

10 certificate, or other arrangement offered by a

11 health plan issuer to a group purchaser that

12 provides or pays for health benefits (such as

13 provider and hospital benefits) in connection

14 with an employee health benefit plan.

15 (C) INDIVIDUAL HEALTH PLAN.—The term

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

17 policy, certificate, or other arrangement offered

18 to individuals by a health plan issuer that pro19 vides or pays for health benefits (such as pro20 vider and hospital benefits) and that is not a

21 group health plan.

22 (D) ARRANGEMENTS NOT INCLUDED.—

23 Such term does not include the following, or

24 any combination thereof:
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1 (i) Coverage only for accident, or dis2 ability income insurance, or any combina3 tion thereof.

4 (ii) Medicare supplemental health in5 surance (as defined under section

6 1882(g)(1) of the Social Security Act).

7 (iii) Coverage issued as a supplement

8 to liability insurance.

9 (iv) Liability insurance, including gen10 eral liability insurance and automobile li11 ability insurance.

12 (v) Workers compensation or similar

13 insurance.

14 (vi) Automobile medical payment in15 surance.

16 (vii) Coverage for a specified disease

17 or illness.

18 (viii) Hospital or fixed indemnity in19 surance.

20 (ix) Short-term limited duration in21 surance.

22 (x) Credit-only, dental-only, or vision23 only insurance.

24 (xi) A health insurance policy provid25 ing benefits only for long-term care, nurs-
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1 ing home care, home health care, commu2 nity-based care, or any combination there3 of.

4 (E) CERTAIN PLANS INCLUDED.—Such

5 term includes any plan or arrangement not de6 scribed in any clause of subparagraph (D)

7 which provides for benefit payments, on a peri8 odic basis, for a period of hospitalization, with9 out regard to the costs incurred or services ren10 dered during the period to which the payments

11 relate.

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

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

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

15 State to offer a health plan.

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

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

18 the Employee Retirement Income Security Act of

19 1974 (29 U.S.C. 1002(7)).

20 SEC. 10. PREEMPTION.

21 (a) IN GENERAL.—The provisions of this Act shall

22 not preempt those provisions of State law—

23 (1) that provide greater protections to patients

24 or policyholders than those required in this Act;
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1 (2) that require health plans to provide cov2 erage for at least 48 hours of inpatient length of

3 stay following a normal vaginal delivery, and at least

4 96 hours of inpatient length of stay following a cae5 sarean section;

6 (3) that require health plans to provide cov7 erage for maternity and pediatric care in accordance

8 with guidelines established by the American College

9 of Obstetricians and Gynecologists, the American

10 Academy of Pediatrics, or other established profes11 sional associations of licensed health care providers

12 specializing in obstetrical, gynecological, or pediatric

13 care; or

14 (4) that leave decisions regarding appropriate

15 length of stay entirely to the attending provider in

16 consultation with the mother.

17 (b) FOLLOW-UP CARE.—The provisions of this Act

18 with respect to follow-up care as described in section 4

19 shall not preempt those provisions of State law that pro20 vide greater protections to patients or policyholders than

21 those required under this Act or that provide mothers and

22 newborns with an option of timely post-discharge follow23 up care in the home.
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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 such plans on the first day of

6 the contract year beginning 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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