§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 (
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§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.
NOTE: Former R.S. 22:1065 redesignated as R.S. 22:831 by Acts 2008, No.
415, §1, eff. Jan. 1, 2009.