§ 58-3-169. Required coverage for minimum hospital stay following birth. - North Carolina Statutes

§58‑3‑169.  Required coverage for minimum hospital stay followingbirth.

(a)        Definitions. – Asused in this section:

(1)        "Attendingproviders" includes:

a.         The obstetrician‑gynecologists,pediatricians, family physicians, and other physicians primarily responsiblefor the care of a mother and newborn; and

b.         The nurse midwivesand nurse practitioners primarily responsible for the care of a mother and hernewborn child in accordance with State licensure and certification laws.

(2)        "Health benefitplan" means an accident and health insurance policy or certificate; anonprofit hospital or medical service corporation contract; a healthmaintenance organization subscriber contract; a plan provided by a multipleemployer welfare arrangement; or a plan provided by another benefitarrangement, to the extent permitted by the Employee Retirement Income SecurityAct of 1974, as amended, or by any waiver of or other exception to that Actprovided under federal law or regulation. "Health benefit plan" doesnot mean any of the following kinds of insurance:

a.         Accident,

b.         Credit,

c.         Disability income,

d.         Long‑term ornursing home care,

e.         Medicare supplement,

f.          Specified disease,

g.         Dental or vision,

h.         Coverage issued as asupplement to liability insurance,

i.          Workers' compensation,

j.          Medical paymentsunder automobile or homeowners, and

k.         Insurance underwhich benefits are payable with or without regard to fault and that isstatutorily required to be contained in any liability policy or equivalent self‑insurance.

l.          Hospital income orindemnity.

(3)        "Insurer"means an insurance company subject to this Chapter, a service corporationorganized under Article 65 of this Chapter, a health maintenance organizationorganized under Article 67 of this Chapter, and a multiple employer welfarearrangement subject to Article 49 of this Chapter.

(b)        In General. –Except as provided in subsection (c) of this section, an insurer that providesa health benefit plan that contains maternity benefits, including benefits forchildbirth, shall ensure that coverage is provided with respect to a mother whois a participant, beneficiary, or policyholder under the plan and her newbornchild for a minimum of 48 hours of inpatient length of stay following a normalvaginal delivery, and a minimum of 96 hours of inpatient length of stayfollowing a cesarean section, without requiring the attending provider toobtain authorization from the insurer or its representative.

(c)        Exception. –Notwithstanding subsection (b) of this section, an insurer is not required toprovide coverage for postdelivery inpatient length of stay for a mother who isa participant, beneficiary, or policyholder under the insurer's health benefitplan and her newborn child for the period referred to in subsection (b) of thissection if:

(1)        A decision todischarge the mother and her newborn child before the expiration of the periodis made by the attending provider in consultation with the mother; and

(2)        The health benefitplan provides coverage for postdelivery follow‑up care as described insubsections (d) and (e) of this section.

(d)        Postdelivery Follow‑UpCare. – In the case of a decision to discharge a mother and her newborn childfrom the inpatient setting before the expiration of 48 hours following a normalvaginal delivery or 96 hours following a cesarean section, the health benefitplan shall provide coverage for timely postdelivery care. This health careshall be provided to a mother and her newborn child by a registered nurse,physician, nurse practitioner, nurse midwife, or physician assistantexperienced in maternal and child health in:

(1)        The home, aprovider's office, a hospital, a birthing center, an intermediate carefacility, a federally qualified health center, a federally qualified ruralhealth clinic, or a State health department maternity clinic; or

(2)        Another settingdetermined appropriate under federal regulations promulgated under Title VI ofPublic Law 104‑204.

The attending provider inconsultation with the mother shall decide the most appropriate location forfollow‑up care.

(e)        Timely Care. – Asused in subsection (d) of this section, "timely postdelivery care"means health care that is provided:

(1)        Following thedischarge of a mother and her newborn child from the inpatient setting; and

(2)        In a manner thatmeets the health care needs of the mother and her newborn child, that providesfor the appropriate monitoring of the conditions of the mother and child, andthat occurs not later than the 72‑hour period immediately followingdischarge.

(f)         Prohibitions. – Aninsurer shall not:

(1)        Deny enrollment,renewal, or continued coverage with respect to its health benefit plan to amother and her newborn child who are participants, beneficiaries, orpolicyholders, based on compliance with this section;

(2)        Provide monetarypayments or rebates to mothers to encourage the mothers to request less thanthe minimum coverage required under this section;

(3)        Penalize orotherwise reduce or limit the reimbursement of an attending provider becausethe provider provided treatment to an individual policyholder, participant, orbeneficiary in accordance with this section; or

(4)        Provide monetary orother incentives to an attending provider to induce the provider to providetreatment to an individual policyholder, participant, or beneficiary in amanner inconsistent with this section.

(g)        Effect on Mother. –Nothing in this section requires that a mother who is a participant,beneficiary, or policyholder covered under this section:

(1)        Give birth in ahospital; or

(2)        Stay in the hospitalfor a fixed period of time following the birth of her child.

(h)        Level and Type ofReimbursements. – Nothing in this section prevents an insurer from negotiatingthe level and type of reimbursement with an attending provider for careprovided in accordance with this section. (1997‑259, s. 19.)