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[Billing Codes: 4120-01-P; 4830-01-P; 4510-29-P] - page 49 / 83





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what the mother and her newborn would receive in the hospital, coverage for the follow-up visit is not prohibited by this paragraph (b)(1).

(2) With respect to benefit restrictions — (i) In general. Subject to paragraph (c)(3) of

this section, a group health plan, and a health insurance issuer offering group health insurance

coverage, may not restrict the benefits for any portion of a hospital length of stay required under

paragraph (a) of this section in a manner that is less favorable than the benefits provided for any

preceding portion of the stay.

(ii) Example. The rules of this paragraph (b)(2) are illustrated by the following example:

Example. (i) A group health plan subject to the requirements of this section provides benefits for hospital lengths of stay in connection with childbirth. In the case of a delivery by cesarean section, the plan automatically pays for the first 48 hours. With respect to each succeeding 24-hour period, the participant or beneficiary must call the plan to obtain precertification from a utilization reviewer, who determines if an additional 24-hour period is medically necessary. If this approval is not obtained, the plan will not provide benefits for any succeeding 24-hour period.

(ii) In this Example, the requirement to obtain precertification for the two 24-hour periods immediately following the initial 48-hour stay is prohibited by this paragraph (b)(2) because benefits for the latter part of the stay are restricted in a manner that is less favorable than benefits for a preceding portion of the stay. (However, this section does not prohibit a plan from requiring precertification for any period after the first 96 hours.) In addition, if the plan’s utilization reviewer denied any mother or her newborn benefits within the 96-hour stay, the plan would also violate paragraph (a) of this section.

(3) With respect to attending providers. A group health plan, and a health insurance

issuer offering group health insurance coverage, may not directly or indirectly —

(i) Penalize (for example, take disciplinary action against or retaliate against), or otherwise

reduce or limit the compensation of, an attending provider because the provider furnished care to

a participant or beneficiary in accordance with this section; or

(ii) Provide monetary or other incentives to an attending provider to induce the provider


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