Newborns’ Act 48 and 96 Hour Hospital Stay Rules
A plan that covers childbirth hospital stays cannot cut benefits below 48 hours after a vaginal delivery or 96 hours after a cesarean section. This page walks through the minimums, the early-discharge exception and what a plan may and may not do.
The Hospital Stay Floor.
General information, not legal advice. The overview and the notice page explain how this rule appears in plan materials.
HIPAA Special Enrollment and the Newborns’ Act
The overview of this series, with all five topics, the sources and a first-steps list.
Special Enrollment and Newborns’ Act Notices
The notice at the time of offer, the hospital-stay statement and the plan document terms.
Special Enrollment Windows and Effective Dates
The 30-day floor, the 60-day public program rights and the coverage start dates.
The Minimums.
ERISA section 711(a), 29 U.S.C. 1185(a), bars a group health plan or insurer from restricting benefits for a hospital stay connected with childbirth to less than 48 hours after a normal vaginal delivery, or less than 96 hours after a cesarean section. The regulation, 29 CFR 2590.711, sets the clock: in a hospital delivery it starts at the delivery, or the last delivery in a multiple birth. If the delivery occurs elsewhere, it starts when the mother or newborn is admitted as an inpatient for childbirth-related care.
The rule governs the benefit, not the care. The statute says nothing in it requires a mother to give birth in a hospital or to stay for any fixed period.
It reaches only plans that provide benefits for childbirth hospital stays. A plan that pays nothing for them is outside the section.
The Attending Provider Decision.
The minimum does not apply when the attending provider decides to discharge the mother or newborn earlier, after consulting with the mother. The regulation defines an attending provider as an individual licensed under state law to provide maternity or pediatric care who is directly responsible for that care. A plan, a hospital or a managed care organization is not one.
That definition keeps the decision with a clinician and out of a utilization review desk. A plan cannot treat its own nurse reviewer as the attending provider.
The regulation says readmissions are not covered by the section, so a return to the hospital after discharge falls under the plan’s ordinary terms.
What a Plan Cannot Do.
A plan may not require a provider to obtain authorization to prescribe the 48 or 96 hour stay. It may not deny a mother or newborn eligibility, or continued eligibility, solely to avoid the section. It may not pay mothers a rebate or other payment to accept less.
It may not penalize a provider or cut reimbursement for care given under the section, and it may not give a provider an incentive to discharge a mother or newborn early. The regulation adds that precertification for days beyond the 96 hours is not prohibited.
A self-insured plan is covered directly by the section, so its own claim rules must comply. For a fully insured plan, ask the carrier to confirm in writing how its claim rules treat the minimum stay.
Deductibles and Coinsurance.
Deductibles, coinsurance and other cost sharing are allowed. The limit is that cost sharing for any part of the required stay cannot exceed the cost sharing for an earlier part. The regulation’s example: a plan that raises coinsurance from 20 percent to 50 percent after 24 hours violates the rule. A plan that charges one steady rate, even a high one that depends on advance notice and hospital choice, does not.
When a plan is fully insured, the federal section does not apply if state law meets the criteria in the regulation: at least 48 and 96 hours, care consistent with obstetrics and pediatrics guidelines, or the stay left to the attending provider and the mother. We did not confirm whether Michigan law meets those criteria, so ask your carrier how it applies the rule.
For the notice that must describe all of this to participants, see our page on special enrollment and Newborns’ Act notices.
Related Rules and Tools.
Newborns Act 48 and 96 Hour Hospital Stay Checklist
A short checklist version of the childbirth stay rules.
ERISA Part 7 Group Health Plan Requirements Checklist
The wider checklist of federal group health plan rules this topic sits inside.
Why an Employee Handbook Is Not a Summary Plan Description
Why a handbook cannot stand in for the plan document and SPD.
Laws and Sources
ERISA section 711, 29 U.S.C. 1185: standards relating to benefits for mothers and newborns.
29 CFR 2590.711: the regulation on benefits for mothers and newborns.
General information, not legal or tax advice.
Quick Answers.
Short replies on this page’s topic, each tied to a fuller guide.
How many hours of hospital stay must a plan cover after childbirth?
At least 48 hours after a vaginal delivery and 96 hours after a cesarean section, if the plan provides benefits for childbirth hospital stays.
Can a plan require approval before a doctor orders the 48 or 96 hour stay?
No. The statute says a plan may not require that a provider obtain authorization from the plan or insurer for prescribing a length of stay within the minimum.
Can a mother leave the hospital earlier than 48 hours?
Yes. The minimum does not apply when the attending provider decides on earlier discharge after consulting with the mother. The law does not force a stay.
The Rest of This Series.
Special Enrollment After Loss of Other Coverage
Which losses of other coverage open a special enrollment right, and which do not.
Special Enrollment for Marriage, Birth, and Adoption
New spouses, newborns and adopted children, and when their coverage starts.
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