§ 9811. Standards relating to benefits for mothers and newborns

Legislative history

Reconstructed from this section’s Code source credit and amendment notes, resolved against the local Statutes at Large. Editorial notes are evidence, not the law that made the change.

1. 1997

   Pub. L. 105–34 title XV § 1531(a)(4) · 111 Stat. 788

   Enacted · 26 U.S.C. § 9811

   Added Pub. L. 105–34, title XV, § 1531(a)(4), Aug. 5, 1997, 111 Stat. 1081

   Source evidence

   Code source credit
   Added Pub. L. 105–34, title XV, § 1531(a)(4), Aug. 5, 1997, 111 Stat. 1081

   Enacted provision · exact public law section
   (4) by inserting after section 9803 the following: “Subchapter B— Other Requirements “Sec. 9811. Standards relating to benefits for mothers and newborns. “Sec. 9812. Parity in the application of certain limits to mental health benefits. “SEC. 9811. STANDARDS RELATING TO BENEFITS FOR MOTHERS AND NEWBORNS. “(a) Requirements for Minimum Hospital Stay Following Birth.— “(1) In general.— A group health plan may not— “(A) except as provided in paragraph (2)— “(i) restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than 48 hours, or “(ii) restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a caesarean section, to less than 96 hours; or “(B) require that a provider obtain authorization from the plan or the issuer for prescribing any length of stay required under subparagraph (A) (without regard to paragraph (2)). “(2) Exception.— Paragraph (1)(A) shall not apply in connection with any group health plan in any case in which the decision to discharge the mother or her newborn child prior to the expiration of the minimum length of stay otherwise required under paragraph (1)(A) is made by an attending provider in consultation with the mother. “(b) Prohibitions.— A group health plan may not— “(1) deny to the mother or her newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section; “(2) provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum protections available under this section; “(3) penalize or otherwise reduce or limit the reimbursement of an attending provider because such provider provided care to an individual participant or beneficiary in accordance with this section; “(4) provide incentives (monetary or otherwise) to an attending provider to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section; or “(5) subject to subsection (c)(3), restrict benefits for any portion of a period within a hospital length of stay required under subsection (a) in a manner which is less favorable than the benefits provided for any preceding portion of such stay. “(c) Rules of Construction.— “(1) Nothing in this section shall be construed to require a mother who is a participant or beneficiary— “(A) to give birth in a hospital; or “(B) to stay in the hospital for a fixed period of time following the birth of her child. “(2) This section shall not apply with respect to any group health plan which does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn child. “(3) Nothing in this section shall be construed as preventing 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 newborn child under the plan, except that such coinsurance or other cost-sharing for any portion of a period within a hospital length of stay required under subsection (a) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay. “(d) Level and Type of Reimbursements.— Nothing in this section shall be construed to prevent a group health plan from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section. “(f) Preemption; Exception for Health Insurance Coverage in Certain States.— The requirements of this section shall not apply with respect to health insurance coverage if there is a State law (including a decision, rule, regulation, or other State action having the effect of law) for a State that regulates such coverage that is described in any of the following paragraphs: “(1) Such State law requires such coverage to provide for at least a 48-hour hospital length of stay following a normal vaginal delivery and at least a 96-hour hospital length of stay following a caesarean section. “(2) Such State law requires such coverage to provide for maternity and pediatric care in accordance with guidelines established by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, or other established professional medical associations. “(3) Such State law requires, in connection with such coverage for maternity care, that the hospital length of stay for such care is left to the decision of (or required to be made by) the attending provider in consultation with the mother. “SEC. 9812. PARITY IN THE APPLICATION OF CERTAIN LIMITS TO MENTAL HEALTH BENEFITS. “(a) In General.— “(1) Aggregate lifetime limits.— In the case of a group health plan that provides both medical and surgical benefits and mental health benefits— “(A) No lifetime limit.— If the plan does not include an aggregate lifetime limit on substantially all medical and surgical benefits, the plan may not impose any aggregate lifetime limit on mental health benefits. “(B) Lifetime limit.— If the plan includes an aggregate lifetime limit on substantially all medical and surgical benefits (in this paragraph referred to as the ‘applicable lifetime limit’), the plan shall either— “(i) apply the applicable lifetime limit both to the medical and surgical benefits to which it otherwise would apply and to mental health benefits and not distinguish in the application of such limit between such medical and surgical benefits and mental health benefits; or “(ii) not include any aggregate lifetime limit on mental health benefits that is less than the applicable lifetime limit. “(C) Rule in case of different limits.— In the case of a plan that is not described in subparagraph (A) or (B) and that includes no or different aggregate lifetime limits on different categories of medical and surgical benefits, the Secretary shall establish rules under which subparagraph (B) is applied to such plan with respect to mental health benefits by substituting for the applicable lifetime limit an average aggregate lifetime limit that is computed taking into account the weighted average of the aggregate lifetime limits applicable to such categories. “(2) Annual limits.— In the case of a group health plan that provides both medical and surgical benefits and mental health benefits— “(A) No annual limit.— If the plan does not include an annual limit on substantially all medical and surgical benefits, the plan may not impose any annual limit on mental health benefits. “(B) Annual limit.— If the plan includes an annual limit on substantially all medical and surgical benefits (in this paragraph referred to as the ‘applicable annual limit’), the plan shall either— “(i) apply the applicable annual limit both to medical and surgical benefits to which it otherwise would apply and to mental health benefits and not distinguish in the application of such limit between such medical and surgical benefits and mental health benefits; or “(ii) not include any annual limit on mental health benefits that is less than the applicable annual limit. “(C) Rule in case of different limits.—In the case of a plan that is not described in subparagraph (A) or (B) and that includes no or different annual limits on different categories of medical and surgical benefits, the Secretary shall establish rules under which subparagraph (B) is applied to such plan with respect to mental health benefits by substituting for the applicable annual limit an average annual limit that is computed taking into account the weighted average of the annual limits applicable to such categories. “(b) Construction.— Nothing in this section shall be construed— “(1) as requiring a group health plan to provide any mental health benefits; or “(2) in the case of a group health plan that provides mental health benefits, as affecting the terms and conditions (including cost sharing, limits on numbers of visits or days of coverage, and requirements relating to medical necessity) relating to the amount, duration, or scope of mental health benefits under the plan, except as specifically provided in subsection (a) (in regard to parity in the imposition of aggregate lifetime limits and annual limits for mental health benefits). “(c) Exemptions.— “(1) Small employer exemption.— This section shall not apply to any group health plan for any plan year of a small employer (as defined in section 4980D(d)(2)). “(2) Increased cost exemption.— This section shall not apply with respect to a group health plan if the application of this section to such plan results in an increase in the cost under the plan of at least 1 percent. “(d) Separate Application to Each Option Offered.— In the case of a group health plan that offers a participant or beneficiary two or more benefit package options under the plan, the requirements of this section shall be applied separately with respect to each such option. “(e) Definitions.— For purposes of this section: “(1) Aggregate lifetime limit.—The term ‘aggregate lifetime limit’ means, with respect to benefits under a group health plan, a dollar limitation on the total amount that may be paid with respect to such benefits under the plan with respect to an individual or other coverage unit. “(2) Annual limit.— The term ‘annual limit’ means, with respect to benefits under a group health plan, a dollar limitation on the total amount of benefits that may be paid with respect to such benefits in a 12-month period under the plan with respect to an individual or other coverage unit. “(3) Medical or surgical benefits.— The term ‘medical or surgical benefits’ means benefits with respect to medical or surgical services, as defined under the terms of the plan, but does not include mental health benefits. “(4) Mental health benefits.— The term ‘mental health benefits’ means benefits with respect to mental health services, as defined under the terms of the plan, but does not include benefits with respect to treatment of substance abuse or chemical dependency. “(f) Sunset.— This section shall not apply to benefits for services furnished on or after September 30, 2001.”.

   Effective date note
   Amendment by Pub. L. 105–206 effective, except as otherwise provided, as if included in the provisions of the Taxpayer Relief Act of 1997, Pub. L. 105–34, to which such amendment relates, see section 6024 of Pub. L. 105–206, set out as a note under section 1 of this title.

2. 1998

   Internal Revenue Service Restructuring and Reform Act of 1998

   Pub. L. 105–206 title VI § 6015(e) · 112 Stat. 685

   Redesignated · 26 U.S.C. § 9811(e); 26 U.S.C. § 9811(f)

   Pub. L. 105–206 redesignated subsec. (f) as (e)

   Source evidence

   Code amendment note
   Subsecs. (e), (f). Pub. L. 105–206 redesignated subsec. (f) as (e).

   Enacted provision · exact public law section
   (e) Amendment Related to Section 1531 of 1997 Act.— Subsection (f) of section 9811 of the 1986 Code (as added by section 1531 of the 1997 Act) is redesignated as subsection (e).

   Effective date note
   Amendment by Pub. L. 105–206 effective, except as otherwise provided, as if included in the provisions of the Taxpayer Relief Act of 1997, Pub. L. 105–34, to which such amendment relates, see section 6024 of Pub. L. 105–206, set out as a note under section 1 of this title.

2 of 2 references resolved to an enrolled provision