(a) Except as provided in subsection (b) of this section, all individual and group health policies providing maternity and newborn care coverage on an expense-incurred basis and individual and group service or indemnity type contracts issued by a nonprofit health service plan, including policies issued by Group Hospitalization and Medical Services, Inc., shall provide coverage for inpatient postpartum treatment in accordance with the medical criteria outlined in the most current version of or an official update to the Guidelines for Perinatal Care (“Guidelines”) prepared by the American Academy of Pediatrics and the American College of Obstetricians or the Standards for Obstetric-Gynecologic Services (“Standards”) prepared by the American College of Obstetricians and Gynecologists, and such coverage must include an in-hospital stay of a minimum of 48 hours after a vaginal delivery, and 96 hours after a Caesarian delivery.
(b) A private review agent or health maintenance organization may authorize a shorter length of stay if the physician, in consultation with the mother, determines that the newborn and mother meet the criteria for medical stability in accordance with the Guidelines or Standards.
(c) In all cases of early discharge pursuant to subsection (b) of this section, the insurer shall provide coverage for post-delivery care within the minimum time periods established in subsection (a) of this section, to be delivered in the patient’s home, or, in a provider’s office, as determined by the physician in consultation with the mother. The at-home post-delivery care shall be provided by a registered professional nurse, physician, nurse practitioner, nurse midwife, or physician assistant experienced in maternal and child health, and shall include:
(1) Parental education;
(2) Assistance and training in breast or bottle feeding; and
(3) Performance of any medically necessary and clinically appropriate tests, including the collection of an adequate sample for hereditary and metabolic newborn screening.
(d) Upon notification of the pregnancy of the insured, the insurer shall:
(1) Encourage and assist the insured, prior to the delivery date, to select and contact a primary care provider for the expected newborn prior to delivery; and,
(2) Provide the insured prior to the delivery date with information on postpartum home visits for the mother and child that includes the names of providers that are available for postpartum home visits.
(e) No insurer may deselect, terminate the services of, require additional documentation from, require additional utilization review, reduce payments, or otherwise provide financial disincentives to any attending provider who orders care consistent with this chapter.
(f) Every insurer shall provide notice to policyholders regarding the coverage required under this chapter. The notice shall be in writing and shall be transmitted at the earliest of either the next mailing to the policyholder, the yearly summary of benefits sent to the policyholder, or January 1 of the year following April 9, 1997.
(Oct. 20, 1979, D.C. Law 3-33, § 3a; as added Apr. 9, 1997, D.C. Law 11-241, § 3, 44 DCR 1125.)
Prior Codifications1981 Ed., § 35-1102.1.
Editor's NotesPurpose of Law 11-241
Section 2 of D.C. Law 11-241 provided:
“(a) The Council of the District of Columbia finds that:
“(1) Phenylketonuria (”PKU“) is a cause of severe mental retardation that can be prevented if diagnosed within the first 3 weeks of childbirth.
“(2) The District’s statutes and regulations direct the screening of newborn infants for hereditary and congenital disorders in the hospital prior to discharge.
“(3) Hospital stays of less than 24 hours after childbirth typically result in unsatisfactory PKU specimens as a result of insufficient milk feedings.
“(4) Insurers, both indemnity and managed care plans, have implemented benefit plans covering no more than 24 hours of postpartum stay in a hospital, despite little or no scientific support for the efficacy of this policy for the general population.
“(5) The Guidelines for Perinatal Care, prepared by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology, recommends a hospital stay of at least 48 hours after childbirth.
“(b) In the interest of maximizing the prevention of mental retardation from PKU and other hereditary and congenital disorders, the Council of the District of Columbia hereby establishes a policy to require all individual and group health insurance policies to provide coverage for a minimum hospital stay for a mother and child following the birth of a child.”