CA HMO Appeal – Maternity Coverage

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Dear Director of :

This office has been asked to file a formal complaint with the Department of Managed Health Care (DMHC) for ’s failure to provide coverage for maternity services and care as required by state law.

Our investigation has concluded the following:

As you may know, Health and Safety Code §1317.1(a)(1) states:

“Emergency services and care” means medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility.

Further, please be advised that 28 CCR § 1300.67(g)(2) adds:

“…Emergency services defined in section 1317.1 include active labor. “Urgently needed services” are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plan’s service area. “Urgently needed services” includes maternity services necessary to prevent serious deterioration of the health of the enrollee or the enrollee’s fetus, based on the enrollee’s reasonable belief that she has a pregnancy-related condition for which treatment cannot be delayed until the enrollee returns to the plan’s service area.”

Under existing CA law, has a duty to provide all Maternity-covered services and is mandated by state law to cover these services. Health and Safety Code §1367.62(a) states:

(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

Here, upon the provider rendering maternity services to the patient, became financially liable for these services because the services are covered under Health and Safety Code §1367.62(a).

Therefore, we hereby demand immediate payment of the above referenced claim(s) plus interest pursuant to 28 CCR §1300.71(i).  Should you fail to remit payment to the undersigned within ten (10) days, be advised that we may draft a formal complaint to the Department of Managed Health Care (DMHC) to ensure our rights under state law are preserved.

Please make any further action on our part unnecessary, by remitting payment in full immediately.




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