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[Billing Codes: 4120-01-P; 4830-01-P; 4510-29-P] - page 62 / 83

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receive if she and prohibited by this violates paragraph

her newborn remained in the hospital, it is

paragraph (b)(2) of

(b)(1). (In this section

addition, the plan because, in effect,

no

copayment or deductible is required for the first portion stay and a double copayment and a deductible are required second portion of the stay.)

of the for the

Example 2.

(i)

A group health plan provides benefits for

at least a delivery.

48-hour hospital length of In the event that a mother

stay following a vaginal and her newborn are

discharged earlier than 48 hours and the discharges consultation with the mother in accordance with the

occur after requirements

of paragraph (a)(5) of this section, follow-up visit by a nurse within 48 to provide certain services that the otherwise receive in the hospital.

the plan provides for a hours after the discharges mother and her newborn would

(ii)

In this Example 2, because the follow-up visit does

not provide any services beyond what the mother would receive in the hospital, coverage for the

and her newborn follow-up visit

is

not prohibited by this

(2)

With

respect

to

paragraph (b)(1). benefit restrictions

(i)

In

general.

Subject to paragraph (c)(3) of this section, a group

health plan, and a health insurance issuer offering group insurance coverage, may not restrict the benefits for any

health portion

of a hospital length of stay required under paragraph (a) of section in a manner that is less favorable than the benefits provided for any preceding portion of the stay.

this

(ii) Example. illustrated by the

The rules of this following example:

paragraph

(b)(2)

are

Example.

requirements

of

(i)

this

A group health plan subject to

section

provides

benefits

for

the hospital

lengths of stay in connection delivery by cesarean section,

with childbirth.

In the case of a

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 an additional 24-hour

a utilization reviewer, who determines if

period

is

medically

necessary.

If

this

approval is not obtained, the plan any succeeding 24-hour period.

will

not

provide

benefits

for

(ii)

In this Example, the requirement to obtain

precertification

for

the

two

24-hour

periods

immediately

62

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