OGC Opinion No. 08-04-15
The Office of General Counsel issued the following opinion on April 8, 2008, representing the position of the New York State Insurance Department.
RE: Health Insurance Coverage for Newborns
Question Presented:
If a parent does not add a newborn infant to an HMO contract within thirty days following delivery, is an HMO required to pay claims for health services provided to the newborn that arise during the thirty-day period following delivery?
Conclusion:
If a parent does not add a newborn infant within the prescribed thirty-day period following delivery, the HMO is only required to provide inpatient hospital coverage for the mother and the newborn infant for at least 48 hours after a vaginal birth and at least 96 hours after a caesarean birth.
Facts:
The HMO provides coverage for the delivery. The mother and newborn are discharged. The newborn then receives health services during the remainder of the thirty-day period following delivery. The inquirer asks whether the HMO is responsible for paying claims for health services rendered to the newborn that arise during the thirty-day period following delivery, if the parent does not add the newborn to the HMO contract within the prescribed thirty-day period.
Analysis:
In an Opinion from the Department's Office of General Counsel, dated June 19, 2007, the inquirer asked whether a newborn infant would be covered if the parent did not add the newborn to the HMO contract. The inquirer reported that the HMO in question had taken the position that if the parent did not add the newborn child to the HMO contract within thirty days of delivery, the HMO would pay no claims related to the child. The Department opined that, in accordance with N.Y. Ins. Law § 4305 (McKinney 2007), if the insured parent does not add the newborn infant to the coverage within 30 days, the newborn infant would be covered, but only for the period specified in Insurance Law § 4303. See Office of General Counsel Opinion No. 07-06-18, dated June 19, 2007 (available at http://www.ins.state.ny.us)
Insurance Law § 4303(c)(1)(A) regulates contracts issued by not-for-profit health service corporations and HMOs. That statute provides:
(c)(1)(A) Every contract issued by a corporation subject to the provisions of this article which provides hospital service, medical expense indemnity or both shall provide coverage for maternity care including hospital, surgical or medical care to the same extent that hospital service, medical expense indemnity or both are provided for illness or disease under the contract. Such maternity care coverage, other than coverage for perinatal complications, shall include inpatient hospital coverage for mother and for newborn for at least forty-eight hours after childbirth for any delivery other than a caesarean section, and for at least ninety-six hours following a caesarean section. Such coverage for maternity care shall include the services of a midwife licensed pursuant to article one hundred forty of the education law, practicing consistent with a written agreement pursuant to section sixty-nine hundred fifty-one of the education law and affiliated or practicing in conjunction with a facility licensed pursuant to article twenty-eight of the public health law, but no insurer shall be required to pay for duplicative routine services actually provided by both a licensed midwife and a physician. (Emphasis supplied)1
Thus, not-for-profit health service corporations and HMOs must provide inpatient hospital coverage for the mother and newborn infant for a normal delivery for at least 48 hours after a vaginal birth and at least 96 hours after a caesarean birth.
Insurance Law § 4305(c)(1), which governs group contracts issued by not-for-profit health service corporations and HMOs, also is relevant to the inquiry. That statute provides:
(c)(1) Any such contract may provide that benefits will be furnished to a member of a covered group, for himself, his spouse, his child or children, or other persons chiefly dependent upon him for support and maintenance . . . Notwithstanding any rule, regulation or law to the contrary, any contract under which a member elects coverage for himself, his spouse, his children or other persons chiefly dependent upon him for support and maintenance shall provide that coverage of newborn infants. . . shall be
effective from the moment of birth for injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities including premature birth. . . If notification and/or payment of an additional premium or contribution is required to make coverage effective for a newborn infant, the coverage may provide that such notice and/or payment be made within no less than thirty days of the day of birth to make coverage effective from the moment of birth. This election shall not be required in the case of student insurance or where the group's plan does not provide coverage for dependent children. (Emphasis supplied)2
In sum, assuming that the contract that is the subject of this inquiry contains a notification and/or payment of additional premium or contribution requirement to make coverage effective for a newborn infant, the contract may require the parent to provide notice and/or payment within no less than thirty days of the date of birth to make coverage effective from the moment of birth. However, if the parent does not provide notice and/or payment within the prescribed thirty-day period following delivery, the HMO would only be required to provide inpatient hospital coverage for at least 48 hours after a vaginal birth and at least 96 hours after a caesarean birth, as required under Insurance Law § 4303(c)(1)(A).
For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York City Office.
1 Insurance Law §§ 3216(h)(10)(A)(i), which regulates individual policies of commercial health insurers; and 3221(k)(5)(A)(i), which regulates group policies of commercial health insurers, set forth similar requirements.
2 Insurance Law §§ 4304(d)(1), which regulates individual contracts of not-for-profit health service corporations and HMOs; 3216(c)(4)(C), which regulates individual policies of commercial health insurers; and 4235(f)(2), which regulates group policies of commercial health insurers, set forth similar requirements.