With respect to benefit restrictions
Subject to paragraph (c)(3) of this section, an issuer
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. illustrated by the
The rules of this following example:
An issuer subject to the requirements of this
section provides benefits for hospital lengths of stay in
connection with childbirth. cesarean section, the issuer
In the case of a delivery by automatically pays for the first
hours. With respect to each succeeding 24-hour period, the covered individual must call the issuer 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 issuer will not provide benefits for any succeeding 24-hour period.
In this Example, the requirement to obtain
the initial 48-hour stay is (b)(2) because benefits for
restricted in a manner a preceding portion of
that is less favorable than benefits
precertification addition, if the
for any issuer’s
utilization reviewer denied any mother or within the 96-hour stay, the issuer would (a) of this section.
her newborn benefits also violate paragraph
With respect or indirectly
An issuer may not
(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 covered individual in accordance with this section; or