29 U.S.C. § 1185 — Standards relating to benefits for mothers

Page 580 TITLE 29—LABOR § 1185 1 See References in Text note below. rangement may not deny an employer whose employees are covered under such a plan contin- ued access to the same or different coverage under the terms of such a plan, other than— (1) for nonpayment of contributions; (2) for fraud or other intentional misrepre- sentation of material fact by the employer; (3) for noncompliance with material plan provisions; (4) because the plan is ceasing to offer any coverage in a geographic area; (5) in the case of a plan that offers benefits through a network plan, there is no longer any individual enrolled through the employer who lives, resides, or works in the service area of the network plan and the plan applies this paragraph uniformly without regard to the claims experience of employers or any health status-related factor in relation to such indi- viduals or their dependents; and (6) for failure to meet the terms of an appli- cable collective bargaining agreement, to renew a collective bargaining or other agree- ment requiring or authorizing contributions to the plan, or to employ employees covered by such an agreement. (Pub. L. 93–406, title I, § 703, as added Pub. L. 104–191, title I, § 101(a), Aug. 21, 1996, 110 Stat. 1946.) Subpart B—Other Requirements § 1185. Standards relating to benefits for mothers and newborns (a) Requirements for minimum hospital stay fol- lowing birth (1) In general A group health plan, and a health insurance issuer offering group health insurance cov- erage, 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 cesarean 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 or health in- surance issuer in any case in which the deci- sion to discharge the mother or her newborn child prior to the expiration of the minimum length of stay otherwise required under para- graph (1)(A) is made by an attending provider in consultation with the mother. (b) Prohibitions A group health plan, and a health insurance issuer offering group health insurance coverage in connection with 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, or any group health in- surance coverage offered by a health insurance issuer, which does not provide benefits for hos- pital lengths of stay in connection with child- birth 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 con- nection 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) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay. (d) Notice under group health plan The imposition of the requirements of this section shall be treated as a material modifica- tion in the terms of the plan described in section 1022(a)(1) 1 of this title, for purposes of assuring notice of such requirements under the plan; ex- cept that the summary description required to be provided under the last sentence of section 1024(b)(1) of this title with respect to such modi- fication shall be provided by not later than 60 days after the first day of the first plan year in which such requirements apply. (e) Level and type of reimbursements Nothing in this section shall be construed to prevent a group health plan or a health insur- Page 581 TITLE 29—LABOR § 1185a ance issuer offering group health insurance cov- erage from negotiating the level and type of re- imbursement with a provider for care provided in accordance with this section. (f) Preemption; exception for health insurance coverage in certain States (1) In general The requirements of this section shall not apply with respect to health insurance cov- erage if there is a State law (as defined in sec- tion 1191(d)(1) of this title) for a State that regulates such coverage that is described in any of the following subparagraphs: (A) Such State law requires such coverage to provide for at least a 48-hour hospital length of stay following a normal vaginal de- livery and at least a 96-hour hospital length of stay following a cesarean section. (B) 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. (C) 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 consulta- tion with the mother. (2) Construction Section 1191(a)(1) of this title shall not be construed as superseding a State law described in paragraph (1). (Pub. L. 93–406, title I, § 711, as added Pub. L. 104–204, title VI, § 603(a)(5), Sept. 26, 1996, 110 Stat. 2935.) Editorial Notes REFERENCES IN TEXT Section 1022(a)(1) of this title, referred to in subsec. (d), was redesignated section 1022(a) of this title by Pub. L. 105–34, title XV, § 1503(b)(1)(B), Aug. 5, 1997, 111 Stat. 1061. Statutory Notes and Related Subsidiaries EFFECTIVE DATE Section applicable with respect to group health plans for plan years beginning on and after Jan. 1, 1998, see section 603(c) of Pub. L. 104–204, set out as an Effective Date of 1996 Amendment note under section 1003 of this title. § 1185a. Parity in mental health and substance use disorder benefits (a) In general (1) Aggregate lifetime limits In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or sub- stance use disorder benefits— (A) No lifetime limit If the plan or coverage does not include an aggregate lifetime limit on substantially all medical and surgical benefits, the plan or coverage may not impose any aggregate life- time limit on mental health or substance use disorder benefits. (B) Lifetime limit If the plan or coverage includes an aggre- gate lifetime limit on substantially all med- ical and surgical benefits (in this paragraph referred to as the ‘‘applicable lifetime limit’’), the plan or coverage 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 or coverage that is not described in subparagraph (A) or (B) and that includes no or different aggregate life- time limits on different categories of med- ical and surgical benefits, the Secretary shall establish rules under which subpara- graph (B) is applied to such plan or coverage with respect to mental health and substance use disorder benefits by substituting for the applicable lifetime limit an average aggre- gate lifetime limit that is computed taking into account the weighted average of the ag- gregate lifetime limits applicable to such categories. (2) Annual limits In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or sub- stance use disorder benefits— (A) No annual limit If the plan or coverage does not include an annual limit on substantially all medical and surgical benefits, the plan or coverage may not impose any annual limit on mental health or substance use disorder benefits. (B) Annual limit If the plan or coverage includes an annual limit on substantially all medical and sur- gical benefits (in this paragraph referred to as the ‘‘applicable annual limit’’), the plan or coverage shall either— (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.