MA Appeal – Maternity Coverage

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Dear Director of :

This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to provide coverage for maternity services and care as required by Federal law.

Our investigation has concluded the following:

Under existing Federal Law, 42 CR §422.101(b)(1-2), Medicare Advantage organizations must meet the following requirements:

(b) Comply with –

(1) CMS’s national coverage determinations;

(2) General coverage guidelines included in original Medicare manuals and instructions unless superseded by regulations in this part or related instructions.

has a duty to provide all Medicare-covered services and is mandated by federal law to cover these services pursuant to 45 CFR §146.130(a), which states:

(a) Hospital length of stay –

(1) General rule. Except as provided in paragraph (a)(5) of this section, a group health plan, or a health insurance issuer offering group health insurance coverage, that provides benefits for a hospital length of stay in connection with childbirth for a mother or her newborn may not restrict benefits for the stay to less than –

(i) 48 hours following a vaginal delivery; or

(ii) 96 hours following a delivery by cesarean section.

(2) When stay begins –

(i) Delivery in a hospital. If delivery occurs in a hospital, the hospital length of stay for the mother or newborn child begins at the time of delivery (or in the case of multiple births, at the time of the last delivery).

(ii) Delivery outside a hospital. If delivery occurs outside a hospital, the hospital length of stay begins at the time the mother or newborn is admitted as a hospital inpatient in connection with childbirth. The determination of whether an admission is in connection with childbirth is a medical decision to be made by the attending provider.

(4) Authorization not required –

(i) In general. A plan or issuer is prohibited from requiring that a physician or other health care provider obtain authorization from the plan or issuer for prescribing the hospital length of stay specified in paragraph (a)(1) of this section. (See also paragraphs (b)(2) and (c)(3) of this section for rules and examples regarding other authorization and certain notice requirements.)

failed to comply with 42 CFR §422.101(b) and 45 CFR §146.130(a). Upon the provider rendering maternity services to the patient, became responsible for total billable charges of $ because the services are covered under 42 CFR §146.130(a).

It is our sincere hope that it will not come to this point.




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