RS 22:1065

§1065. Standards relating to benefits for mothers and newborns A.(1) A group health plan, and a health insurance issuer offering group health insurance coverage, and Medical Assistance coverage provided under 42 U.S.C. 1396 et seq., may not, except as provided in Paragraph (2) of this Subsection: (a) Restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than forty-eight hours. (b) Restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a cesarean section, to less than ninety-six hours. (c) Require that a provider obtain authorization from the plan or the issuer for prescribing any length of stay required under Paragraph (1) of this Subsection, without regard to Paragraph (2) of this Subsection. (2) The provisions of Paragraph (1) of this Subsection shall not apply in connection with any group health plan or health insurance issuer in any case in which the decision to discharge the mother or her newborn child prior to the expiration of the minimum length of stay otherwise required under such Paragraph (1) is made by an attending provider in consultation with the mother. B. A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, and Medical Assistance coverage provided under 42 U.S.C. 1396 et seq., may not do the following: (1) Deny to the mother or her newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this Section. (2) Provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum protections available under this Section. (3) Penalize or otherwise reduce or limit the reimbursement of an attending provider because such provider provided care to an individual participant or beneficiary in accordance with this Section. (4) Provide incentives, monetary or otherwise, to an attending provider to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this Section. (5) Subject to the provisions of Paragraph (C)(3) of this Section, restrict benefits for any portion of a period within a hospital length of stay required under Subsection A of this Section in a manner which is less favorable than the benefits provided for any preceding portion of such stay. C.(1) Nothing in this Section shall be construed to require a mother who is a participant or beneficiary to do the following: (a) To give birth in a hospital. (b) To stay in the hospital for a fixed period of time following the birth of her child. (2) This Section shall not apply with respect to any group health plan, or any group health insurance coverage offered by a health insurance issuer, which does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn child. (3) Nothing in this Section shall be construed as preventing a group health plan or issuer from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or newborn child under the plan, or under health insurance coverage offered in connection with a group health plan, except that such coinsurance or other cost-sharing for any portion of a period within a hospital length of stay required under Subsection A of this Section may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay. D.(1) A summary plan description of any group health plan shall be furnished to participants and beneficiaries. The summary plan description shall: (a) Include the information described in Paragraph (3) of this Subsection. (b) Be written in a manner calculated to be understood by the average plan participant. (c) Be sufficiently accurate and comprehensive to reasonably apprise such participants and beneficiaries of their rights and obligations under the plan. (2) A summary of any material modification in the terms of the plan and any change in the information required under Paragraph (3) of this Subsection shall be written in a manner calculated to be understood by the average plan participant and shall be furnished within ninety days after he becomes a participant or after he first receives benefits. If later, the information shall be furnished one hundred twenty days after the plan becomes subject to this Subpart. (3) The plan description and summary plan description shall contain the following information: (a) The name and type of administration of the plan. (b) The name and address of the person designated as agent for the service of legal process, if such person is not the administrator. (c) The name and address of the administrator. (d) The names, titles, and addresses of any trustee or trustees if they are persons different from the administrator. (e) A description of the relevant provisions of any applicable collective bargaining agreement. (f) The plan's requirements respecting eligibility for participation and benefits. (g) A description of the provisions providing for nonforfeitable pension benefits. (h) The circumstances which may result in disqualification, ineligibility, or denial or loss of benefits. (i) The source of financing of the plan and the identity of any organization through which benefits are provided. (j) The date of the end of the plan year and whether the records of the plan are kept on a calendar, policy, or fiscal year basis. (k) The procedures to be followed in presenting claims for benefits under the plan and the remedies available under the plan for the redress of claims which are denied in whole or in part. E. Nothing in this Section shall be construed to prevent a group health plan or a health insurance issuer offering group health insurance coverage from negotiating the level and type of reimbursement with a provider for care provided in accordance with this Section. F.(1) Notwithstanding any other provisions to the contrary, a newborn child upon birth shall be enrolled as a dependent under a group health plan, policy, or certificate of coverage issued by a health insurance issuer, effective as of the date of such birth, under which such newborn child may be enrolled. (2) If applicable, the premium for a newborn child added to a policy, plan, or certificate of coverage may be subject to adjustment for the additional coverage provided. Such coverage shall be effective as of the date of birth of such newborn child and pursuant to applicable provisions of the policy, plan, or certificate, shall be subject to the payment of such additional premium, if any, and receipt of any required enrollment information within the time period required by the health insurance issuer. (3) To the extent that such newborn child meets, at birth, the eligibility provisions as set forth in state laws, rules, or regulations implementing the State Plan Medical Assistance under Title XIX of the Social Security Act, such additional coverage shall not be cancelled for nonpayment of any additional premium due, if any, prior to the health insurance issuer giving the secretary of the Louisiana Department of Health ninety days written notice thereof via United States mail, certified, return receipt requested. (4) If the premium remains unpaid after the notice period, the health insurance issuer may cancel the newborn child's coverage effective as of the birth of the newborn child. The health insurance issuer shall mail a copy of the notice provided to the secretary of the Louisiana Department of Health to each health care provider that has submitted a claim for services rendered to the newborn child. The health insurance issuer shall mail the copy of the notice no later than three days after mailing the notice to the secretary of the Louisiana Department of Health. Acts 1997, No. 1138, §1, eff. July 14, 1997; Acts 2004, No. 269, §1, eff. June 15, 2004; Redesignated from R.S. 22:250.4 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009. NOTE: Former R.S. 22:1065 redesignated as R.S. 22:831 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.