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- Health Benefits Advisor for Employers

Determining Compliance with the Newborns' Act Provisions in Part 7 of ERISA

Newborns' Act Substantive Provisions - General 48/96-Hour Rule

Does the plan comply with the general 48/96 hour rule?

Plans generally may not restrict benefits for a hospital length of stay in connection with childbirth to less than 48 hours in the case of a vaginal delivery (See ERISA section 711(a)(1)(A)(i)), or less than 96 hours in the case of a cesarean section (See ERISA section 711(a)(1)(A)(ii)).

Therefore, a plan cannot deny a mother or her newborn benefits within a 48/96-hour stay based on medical necessity. (A plan may require a mother to notify the plan of a pregnancy to obtain more favorable cost-sharing for the hospital stay. This second type of plan provision is permissible under the Newborns' Act if the cost-sharing is consistent throughout the 48/96-hour stay.)

An attending provider may, however, decide, in consultation with the mother, to discharge the mother or newborn earlier.