V asks J for evidence of increased risk of breast cancer, such as the results of a genetic test, before the claim for the mammogram is paid. J undergoes a mammogram and promptly submits a claim to V for reimbursement. J is 33 years old and has the BRCA2 mutation. Individual J has an individual health insurance policy through Issuer V that covers a yearly mammogram for participants starting at age 40, or at age 30 for those with increased risk for breast cancer, including individuals with BRCA1 or BRCA2 gene mutations. Therefore, R's collection of H's family medical history (which is genetic information with respect to H), violates the rule against collection of genetic information and does not qualify for the incidental collection exception under paragraph (f)(2)(ii). However, R's materials did not state that genetic information should not be provided. In this Example 2, R's request was for health information solely about its applicant, H, which is not genetic information with respect to H. The physician's office administrator includes part of H's family medical history in the package to R. Although the request for information does not ask for genetic information, including family medical history, it does not state that no genetic information should be provided. R forwards a request for health information about H, including the signed release, to his primary care physician. ![]() The application includes a release which authorizes the physicians to furnish information to R. R's application materials request that an applicant provide information on his or her individual medical history, including the names and contact information of physicians from whom the applicant sought treatment. Individual H applies for a health insurance policy through Issuer R. For information on precertification, contact your issuer. However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. In addition, an issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). , your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.Īlso, under federal law, issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. However, the issuer may pay for a shorter stay if the attending provider ( e.g. Under federal law, health insurance issuers generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. Statement of Rights Under the Newborns' and Mothers' Health Protection Act (However, this section does not prohibit an issuer from requiring precertification for any period after the first 96 hours.) In addition, the requirement to obtain precertification from the issuer based on medical necessity for a hospital length of stay within the 96-hour period would also violate paragraph (a) of this section. In this Example, the requirement to obtain precertification for the two 24-hour periods immediately following the initial 48-hour stay is prohibited by this paragraph (b)(2) because benefits for the latter part of the stay are restricted in a manner that is less favorable than benefits for a preceding portion of the stay. If this approval is not obtained, the issuer will not provide benefits for any succeeding 24-hour period. With respect to each succeeding 24-hour period, the covered individual must call the issuer to obtain precertification from a utilization reviewer, who determines if an additional 24-hour period is medically necessary. In the case of a delivery by cesarean section, the issuer automatically pays for the first 48 hours. An issuer subject to the requirements of this section provides benefits for hospital lengths of stay in connection with childbirth. Periods during which eligible States may apply for a grant. Grants to States for Operation of Qualified High Risk Pools Prohibition of discrimination based on genetic information. Standards relating to benefits for mothers and newborns. State flexibility in individual market reforms - alternative mechanisms. ![]() Guaranteed renewability of individual health insurance coverage.Ĭertification and disclosure of coverage. Guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage. Requirements Relating to Access and Renewability of Coverage Requirements for the Individual Health Insurance Market
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