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[Billing Codes: 4120-01-P; 4830-01-P; 4510-29-P] - page 39 / 83

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  • (1)

    Hospital stays not mandatory. This section does not require a mother to —

    • (i)

      Give birth in a hospital; or

    • (ii)

      Stay in the hospital for a fixed period of time following the birth of her child.

  • (2)

    Hospital stay benefits not mandated. This section does not apply to any group health

plan that does not provide benefits for hospital lengths of stay in connection with childbirth for a

mother or her newborn child.

(3) Cost-sharing rules — (i) In general. This section does not prevent 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 a newborn under the plan or

coverage, except that the coinsurance or other cost-sharing for any portion of the hospital length

of stay required under paragraph (a) of this section may not be greater than that for any preceding

portion of the stay.

(ii) Examples. The rules of this paragraph (c)(3) are illustrated by the following

examples. In each example, the group health plan is subject to the requirements of this section, as

follows:

Example 1. (i) A group health plan provides benefits for at least a 48-hour hospital length of stay in connection with vaginal deliveries. The plan covers 80 percent of the cost of the stay for the first 24-hour period and 50 percent of the cost of the stay for the second 24-hour period. Thus, the coinsurance paid by the patient increases from 20 percent to 50 percent after 24 hours.

(ii) In this Example 1, the plan violates the rules of this paragraph (c)(3) because coinsurance for the second 24-hour period of the 48-hour stay is greater than that for the preceding portion of the stay. (In addition, the plan also violates the similar rule in paragraph (b)(2) of this section.)

Example 2. (i) A group health plan generally covers 70 percent of the cost of a hospital length of stay in connection with childbirth. However, the plan will cover 80 percent of the cost of the stay if the participant or beneficiary notifies the plan of the pregnancy in advance of

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