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Internal Revenue Code, § 9811. Standards Relating To Benefits For Mothers And Newborns

I.R.C. § 9811(a) Requirements For Minimum Hospital Stay Following Birth
I.R.C. § 9811(a)(1) In General
A group health plan may not—
I.R.C. § 9811(a)(1)(A)
except as provided in paragraph (2)
I.R.C. § 9811(a)(1)(A)(i)
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 48 hours, or
I.R.C. § 9811(a)(1)(A)(ii)
restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a caesarean section, to less than 96 hours; or
I.R.C. § 9811(a)(1)(B)
require that a provider obtain authorization from the plan or the issuer for prescribing any length of stay required under subparagraph (A) (without regard to paragraph (2)).
I.R.C. § 9811(a)(2) Exception
Paragraph (1)(A) shall not apply in connection with any group health plan 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 paragraph (1)(A) is made by an attending provider in consultation with the mother.
I.R.C. § 9811(b) Prohibitions
A group health plan may not—
I.R.C. § 9811(b)(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;
I.R.C. § 9811(b)(2)
provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum protections available under this section;
I.R.C. § 9811(b)(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;
I.R.C. § 9811(b)(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; or
I.R.C. § 9811(b)(5)
subject to subsection (c)(3), restrict benefits for any portion of a period within a hospital length of stay required under subsection (a) in a manner which is less favorable than the benefits provided for any preceding portion of such stay.
I.R.C. § 9811(c) Rules Of Construction
I.R.C. § 9811(c)(1)
Nothing in this section shall be construed to require a mother who is a participant or beneficiary—
I.R.C. § 9811(c)(1)(A)
to give birth in a hospital; or
I.R.C. § 9811(c)(1)(B)
to stay in the hospital for a fixed period of time following the birth of her child.
I.R.C. § 9811(c)(2)
This section shall not apply with respect to any group health plan which does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn child.
I.R.C. § 9811(c)(3)
Nothing in this section shall be construed as preventing a group health plan 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, except that such coinsurance or other cost-sharing for any portion of a period within a hospital length of stay required under subsection (a) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay.
I.R.C. § 9811(d) Level And Type Of Reimbursements
Nothing in this section shall be construed to prevent a group health plan from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section.
I.R.C. § 9811(e) Preemption; Exception For Health Insurance Coverage In Certain States
The requirements of this section shall not apply with respect to health insurance coverage if there is a State law (including a decision, rule, regulation, or other State action having the effect of law) for a State that regulates such coverage that is described in any of the following paragraphs:
I.R.C. § 9811(e)(1)
Such State law requires such coverage to provide for at least a 48-hour hospital length of stay following a normal vaginal delivery and at least a 96-hour hospital length of stay following a caesarean section.
I.R.C. § 9811(e)(2)
Such State law requires such coverage to provide for maternity and pediatric care in accordance with guidelines established by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, or other established professional medical associations.
I.R.C. § 9811(e)(3)
Such State law requires, in connection with such coverage for maternity care, that the hospital length of stay for such care is left to the decision of (or required to be made by) the attending provider in consultation with the mother.
(Added Pub. L. 105-34, title XVI, Sec. 1531(a)(4), Aug. 5, 1997, 111 Stat 788; amended Pub. L. 105-206, title VI, Sec. 6015(e), July 22, 1998, 112 Stat. 685.)
BACKGROUND NOTES
AMENDMENTS
1998 - Subsec. (f). Pub. L. 105-206, Sec. 6015(e), redesignated subsec. (f) as subsec. (e).
EFFECTIVE DATE
Applicable with respect to group health plans for plan years beginning on or after January 1, 1998.
EFFECTIVE DATE OF 1998 AMENDMENT
Amendment by sec. 6015 of Pub. L. 105-206 effective as if included in the 1997 Tax Payer Relief Act. [Effective date of Pub. L. 105-34, Sec. 1531(a)(4): applicable with respect to group health plans for plan years beginning on or after January 1, 1998.]
COVERAGE OF TESTING FOR COVID–19
Section 6001 of Pub. L. 116-127 provided:
“SEC. 6001. COVERAGE OF TESTING FOR COVID–19.
“(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage (including a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act)) shall provide coverage, and shall not impose any cost sharing (including deductibles, copayments, and coinsurance) requirements or prior authorization or other medical management requirements, for the following items and services furnished during any portion of the emergency period defined in paragraph (1)(B) of section 1135(g) of the Social Security Act (42 U.S.C. 1320b–5(g)) beginning on or after the date of the enactment of this Act:
“(1) In vitro diagnostic products (as defined in section 809.3(a) of title 21, Code of Federal Regulations) for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19 that are approved, cleared, or authorized under section 510(k), 513, 515 or 564 of the Federal Food, Drug, and Cosmetic Act, and the administration of such in vitro diagnostic products.
“(2) Items and services furnished to an individual during health care provider office visits (which term in this paragraph includes in-person visits and telehealth visits), urgent care center visits, and emergency room visits that result in an order for or administration of an in vitro diagnostic product described in paragraph (1), but only to the extent such items and services relate to the furnishing or administration of such product or to the evaluation of such individual for purposes of determining the need of such individual for such product.
“(b) ENFORCEMENT.—The provisions of subsection (a) shall be applied by the Secretary of Health and Human Services, Secretary of Labor, and Secretary of the Treasury to group health plans and health insurance issuers offering group or individual health insurance coverage as if included in the provisions of part A of title XXVII of the Public Health Service Act, part 7 of the Employee Retirement Income Security Act of 1974, and subchapter B of chapter 100 of the Internal Revenue Code of 1986, as applicable.
“(c) IMPLEMENTATION.—The Secretary of Health and Human Services, Secretary of Labor, and Secretary of the Treasury may implement the provisions of this section through sub-regulatory guidance, program instruction or otherwise.
“(d) TERMS.—The terms ‘‘group health plan’’; ‘‘health insurance issuer’’; ‘‘group health insurance coverage’’, and ‘‘individual health insurance coverage’’ have the meanings given such terms in section 2791 of the Public Health Service Act (42 U.S.C. 300gg–91), section 733 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1191b), and section 9832 of the Internal Revenue Code of 1986, as applicable.”