CA HMO Affidavit – Maternity

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AFFIDAVIT OF COMPLIANCE

Maternity Services

Incorporated by Reference in 28 US Code § 1746

Patient/Multiple Patients:         DOS:

I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Knox-Keene Licensed Plan or Contracted Entity has met the provisions of Health and Safety Code §1367.62(a) which states, in pertinent part:

(a) No health care service plan contract that is issued, amended, renewed, or delivered on or after the effective date of the act adding this section, that provides maternity coverage, shall do any of the following:

(1) Restrict benefits for inpatient hospital care to a time period less than 48 hours following a normal vaginal delivery and less than 96 hours following a delivery by caesarean section.  However, coverage for inpatient hospital care may be for a time period less than 48 or 96 hours if both of the following conditions are met:

(A) The decision to discharge the mother and newborn before the 48- or 96-hour time period is made by the treating physicians in consultation with the mother.

(2) Reduce or limit the reimbursement of the attending provider for providing care to an individual enrollee in accordance with the coverage requirements.

(7) Require the treating physician to obtain authorization from the health care service plan prior to prescribing any services covered by this section.

I fully understand that this affidavit constitutes an official statement under penalty of perjury under the laws of the United States subject to possible audit and investigation by the State of California.

 

Knox-Keene Plan:

_________________________________________________

 

Knox-Keene Plan Representative Signature:

_________________________________________________

 

Knox Keene Plan Representative Title:

_________________________________________________

 

Date:

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