26 U.S.C. § 9811 — Standards relating to benefits for mothers

Page 4180 TITLE 26—INTERNAL REVENUE CODE [§ 9804 1 No section 9814 has been enacted. 2 No section 9821 has been enacted. Editorial Notes REFERENCES IN TEXT Section 3(40) of the Employee Retirement Income Se- curity Act of 1974, referred to in subsec. (b), is classified to section 1002(40) of Title 29, Labor. The date of the enactment of this section, referred to in subsec. (b), is the date of enactment of Pub. L. 104–191, which was approved Aug. 21, 1996. Statutory Notes and Related Subsidiaries EFFECTIVE DATE Section applicable to plan years beginning after June 30, 1997, see section 401(c) of Pub. L. 104–191, set out as a note under section 9801 of this title. [§ 9804. Renumbered § 9831] [§ 9805. Renumbered § 9832] [§ 9806. Renumbered § 9833] Subchapter B—Other Requirements Sec. 9811. Standards relating to benefits for mothers and newborns. 9812. Parity in mental health and substance use disorder benefits. 9813. Coverage of dependent students on medically necessary leave of absence. 9815. Additional market reforms.1 9816. Preventing surprise medical bills. 9817. Ending surprise air ambulance bills. 9818. Continuity of care. 9819. Maintenance of price comparison tool. 9820. Protecting patients and improving the accu- racy of provider directory information. 9822. Other patient protections.2 9823. Air ambulance report requirements. 9824. Increasing transparency by removing gag clauses on price and quality information. 9825. Reporting on pharmacy benefits and drug costs. Editorial Notes AMENDMENTS 2020—Pub. L. 116–260, div. BB, title I, §§ 102(c)(3), 105(a)(3)(B), 106(b)(3)(B), 113(b)(2), 114(b)(2), 116(d)(2), title II, §§ 201(d)(2), 204(d)(2), Dec. 27, 2020, 134 Stat. 2796, 2851, 2855, 2871, 2874, 2887, 2894, 2922, added items 9815 to 9820 and 9822 to 9825. 2008—Pub. L. 110–381, § 2(c)(2), Oct. 9, 2008, 122 Stat. 4086, added item 9813. Pub. L. 110–343, div. C, title V, § 512(g)(3)(B), Oct. 3, 2008, 122 Stat. 3892, added item 9812 and struck out former item 9812 ‘‘Parity in the application of certain limits to mental health benefits’’. 1997—Pub. L. 105–34, title XV, § 1531(a)(4), Aug. 5, 1997, 111 Stat. 1081, added subchapter heading and analysis. § 9811. Standards relating to benefits for mothers and newborns (a) Requirements for minimum hospital stay fol- lowing birth (1) In general A group health plan may not— (A) except as provided in paragraph (2)— (i) restrict benefits for any hospital length of stay in connection with child- birth for the mother or newborn child, fol- lowing a normal vaginal delivery, to less than 48 hours, or (ii) restrict benefits for any hospital length of stay in connection with child- birth for the mother or newborn child, fol- lowing a caesarean section, to less than 96 hours; or (B) require that a provider obtain author- ization from the plan or the issuer for pre- scribing any length of stay required under subparagraph (A) (without regard to para- graph (2)). (2) Exception Paragraph (1)(A) shall not apply in connec- tion 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 re- quired under paragraph (1)(A) is made by an attending provider in consultation with the mother. (b) Prohibitions A group health plan may not— (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 re- quirements 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 be- cause such provider provided care to an indi- vidual participant or beneficiary in accord- ance with this section; (4) provide incentives (monetary or other- wise) to an attending provider to induce such provider to provide care to an individual par- ticipant or beneficiary in a manner incon- sistent with this section; or (5) subject to subsection (c)(3), restrict bene- fits for any portion of a period within a hos- pital length of stay required under subsection (a) in a manner which is less favorable than the benefits provided for any preceding por- tion of such stay. (c) Rules of construction (1) Nothing in this section shall be construed to require a mother who is a participant or ben- eficiary— (A) to give birth in a hospital; or (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 which does not provide benefits for hospital lengths of stay in connec- tion with childbirth for a mother or her newborn child. (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 Page 4181 TITLE 26—INTERNAL REVENUE CODE § 9812 stay required under subsection (a) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay. (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 pro- vider for care provided in accordance with this section. (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 fol- lowing paragraphs: (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. (2) Such State law requires such coverage to provide for maternity and pediatric care in ac- cordance with guidelines established by the American College of Obstetricians and Gyne- cologists, the American Academy of Pediat- rics, or other established professional medical associations. (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 XV, § 1531(a)(4), Aug. 5, 1997, 111 Stat. 1081; amended Pub. L. 105–206, title VI, § 6015(e), July 22, 1998, 112 Stat. 821.) Editorial Notes AMENDMENTS 1998—Subsecs. (e), (f). Pub. L. 105–206 redesignated subsec. (f) as (e). Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 1998 AMENDMENT Amendment by Pub. L. 105–206 effective, except as otherwise provided, as if included in the provisions of the Taxpayer Relief Act of 1997, Pub. L. 105–34, to which such amendment relates, see section 6024 of Pub. L. 105–206, set out as a note under section 1 of this title. EFFECTIVE DATE Section applicable with respect to group health plans for plan years beginning on or after Jan. 1, 1998, see sec- tion 1531(c) of Pub. L. 105–34, set out as an Effective Date of 1997 Amendment note under section 4980D of this title. § 9812. Parity in mental health and substance use disorder benefits (a) In general (1) Aggregate lifetime limits In the case of a group health plan that pro- vides both medical and surgical benefits and mental health or substance use disorder bene- fits— (A) No lifetime limit If the plan does not include an aggregate lifetime limit on substantially all medical and surgical benefits, the plan may not im- pose any aggregate lifetime limit on mental health or substance use disorder benefits. (B) Lifetime limit If the plan includes an aggregate lifetime limit on substantially all medical and sur- gical benefits (in this paragraph referred to as the ‘‘applicable lifetime limit’’), the plan shall either— (i) apply the applicable lifetime limit both to the medical and surgical benefits to which it otherwise would apply and to mental health and substance use disorder benefits and not distinguish in the applica- tion of such limit between such medical and surgical benefits and mental health and substance use disorder benefits; or (ii) not include any aggregate lifetime limit on mental health or substance use disorder benefits that is less than the ap- plicable lifetime limit. (C) Rule in case of different limits In the case of a plan that is not described in subparagraph (A) or (B) and that includes no or different aggregate lifetime limits on different categories of medical and surgical benefits, the Secretary shall establish rules under which subparagraph (B) is applied to such plan with respect to mental health and substance use disorder benefits by sub- stituting for the applicable lifetime limit an average aggregate lifetime limit that is computed taking into account the weighted average of the aggregate lifetime limits ap- plicable to such categories. (2) Annual limits In the case of a group health plan that pro- vides both medical and surgical benefits and mental health or substance use disorder bene- fits— (A) No annual limit If the plan does not include an annual limit on substantially all medical and sur- gical benefits, the plan may not impose any annual limit on mental health or substance use disorder benefits. (B) Annual limit If the plan includes an annual limit on substantially all medical and surgical bene- fits (in this paragraph referred to as the ‘‘ap- plicable annual limit’’), the plan shall ei- ther— (i) apply the applicable annual limit both to medical and surgical benefits to which it otherwise would apply and to mental health and substance use disorder benefits and not distinguish in the applica- tion of such limit between such medical and surgical benefits and mental health and substance use disorder benefits; or (ii) not include any annual limit on men- tal health or substance use disorder bene- fits that is less than the applicable annual limit.