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[Billing Codes: 4120-01-P; 4830-01-P; 4510-29-P] - page 79 / 83

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illustrated by the following examples.

In each example, the

issuer is follows:

subject

to

the

requirements

of

this

section,

as

Example 1. 48-hour hospital

deliveries.

The

(i)

An issuer provides benefits for at least a

length issuer

of stay in connection with vaginal covers 80 percent of the cost of the

stay

for the first 24-hour period and 50 percent of stay for the second 24-hour period. Thus, the by the patient increases from 20 percent to 50

the cost of the coinsurance paid percent after 24

hours. (ii)

In this Example 1, the issuer 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

portion similar

of the stay.

(In

rule

in

paragraph

addition, (b)(2) of

the issuer also this section.)

the preceding violates the

Example 2.

(i)

An issuer generally covers 70 percent of

the cost of childbirth.

a hospital length of However, the issuer

stay will

in connection with cover 80 percent of

the

cost of the stay if the covered individual notifies the the pregnancy in advance of admission and uses whatever the issuer may designate.

issuer of hospital

(ii)

In this Example 2, the issuer does not violate the

rules of this paragraph (c)(3) because the level of benefits provided (70 percent or 80 percent) is consistent throughout 48-hour (or 96-hour) hospital length of stay required under

the

paragraph (a) of this section. violate the rules in paragraph section.)

(In addition, the issuer does not (a)(4) or paragraph (b)(2) of this

(4) Compensation of attending provider. This section does not prevent an issuer from negotiating with an attending provider the level and type of compensation for care furnished in accordance with this section (including paragraph (b) of this section).

(5) Applicability.

This section applies to all health

insurance

coverage

issued

in

the

individual

market,

and

is

not

limited in its application to coverage that is provided to eligible individuals as defined in section 2741(b) of the PHS

79

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