Guidelines relating to newborn baby coverage under health maintenance organization contracts

Issued and entered July 26, 1990 by Dhiraj N. Shah, Acting Commissioner of Insurance

BACKGROUND

There has been some confusion among a few health maintenance organizations as to whether a healthy newborn's stay in the hospital should be covered under the mother's maternity coverage or if the newborn must first be enrolled before his/her charges can be covered.

Maternity is inextricably associated with pregnancy and childbirth. Maternity or pregnancy benefits offered through an HMO cover all or a portion of costs arising from pregnancy and childbirth. An inpatient medical or hospital charge for a healthy newborn following delivery is a cost arising from pregnancy and childbirth and should be covered to the same extent as the mother is covered.

APPLICABLE LAW

Inpatient services are a covered item, per the Public Health Code sections 21003 and 21007 which states:

(c) Inpatient hospital services, other than those for the treatment of mental illness.

GUIDELINES

The routine charges of a healthy newborn are part of the mother's maternity benefits until such time that the mother or infant is discharged, whichever comes first. A certificate which excludes the healthy newborn coverage will be disapproved. A health maintenance organization which denies this coverage will be subject to investigation and the appropriate compliance action will be taken.

RIGHTS AND PROCEDURES

In conformity with Section 3(6) of the Administrative Procedures Act of 1969, these guidelines are a statement of policy which the agency intends to follow, which does not have the force or effect of law, and which binds the agency but does not bind any other person. These guidelines will take effect September 15, 1990.

The Bureau shall use these guidelines in the review of certificate filings submitted by all health maintenance organizations. Any filing which excludes inpatient hospital services for a healthy newborn shall be disapproved pursuant to Section 21026 and 21063 of the Public Health Code. The operation of this bulletin does not abrogate the rights of a health maintenance organization to a hearing and appeal of a disapproval as provided in that section.