§9818 — Title 26 Internal Revenue Code | U.S. Code

Summary

If your doctor, hospital, or other provider leaves your group health plan's network while you are in the middle of care, the plan must protect your treatment from being cut off. The plan has to notify you of the change and your rights, give you a chance to ask for transitional care, and let you keep your benefits with that provider under the same terms as before. This continued coverage lasts up to 90 days from the notice, or until you are no longer a continuing care patient, whichever comes first. You count as a continuing care patient if you are being treated for a serious and complex condition, are getting inpatient or institutional care, are scheduled for nonelective surgery (including the follow-up care), are pregnant and receiving care for the pregnancy, or are terminally ill and receiving treatment. A contract that simply expires or is not renewed counts as terminated, but these protections do not apply when a provider is dropped for fraud or for failing quality standards.

Title 26, §9818

Internal Revenue Code — Source: USLM XML via OLRC

(a)(1)In the case of an individual with benefits under a group health plan and with respect to a health care provider or facility that has a contractual relationship with such plan for furnishing items and services under such plan, if, while such individual is a continuing care patient (as defined in subsection (b)) with respect to such provider or facility—

(A)such contractual relationship is terminated (as defined in paragraph (b));

(B)benefits provided under such plan with respect to such provider or facility are terminated because of a change in the terms of the participation of such provider or facility in such plan; or

(C)a contract between such group health plan and a health insurance issuer offering health insurance coverage in connection with such plan is terminated, resulting in a loss of benefits provided under such plan with respect to such provider or facility;

(2)The requirements of this paragraph are that the plan—

(A)notify each individual enrolled under such plan who is a continuing care patient with respect to a provider or facility at the time of a termination described in paragraph (1) affecting such provider on a timely basis of such termination and such individual’s right to elect continued transitional care from such provider or facility under this section;

(B)provide such individual with an opportunity to notify the plan of the individual’s need for transitional care; and

(C)permit the patient to elect to continue to have benefits provided under such plan, under the same terms and conditions as would have applied and with respect to such items and services as would have been covered under such plan had such termination not occurred, with respect to the course of treatment furnished by such provider or facility relating to such individual’s status as a continuing care patient during the period beginning on the date on which the notice under subparagraph (A) is provided and ending on the earlier of—

(i)the 90-day period beginning on such date; or

(ii)the date on which such individual is no longer a continuing care patient with respect to such provider or facility.

(b)In this section:

(1)The term “continuing care patient” means an individual who, with respect to a provider or facility—

(A)is undergoing a course of treatment for a serious and complex condition from the provider or facility;

(B)is undergoing a course of institutional or inpatient care from the provider or facility;

(C)is scheduled to undergo nonelective surgery from the provider or facility, including receipt of postoperative care from such provider or facility with respect to such a surgery;

(D)is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or

(E)is or was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the Social Security Act) and is receiving treatment for such illness from such provider or facility.

(2)The term “serious and complex condition” means, with respect to a participant or beneficiary under a group health plan—

(A)in the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or

(B)in the case of a chronic illness or condition, a condition that—

(i)is life-threatening, degenerative, potentially disabling, or congenital; and

(ii)requires specialized medical care over a prolonged period of time.

(3)The term “terminated” includes, with respect to a contract, the expiration or nonrenewal of the contract, but does not include a termination of the contract for failure to meet applicable quality standards or for fraud.

Notes & Related Subsidiaries

Editorial Notes

References in Text

section 1861(dd)(3)(A) of the Social Security Act, referred to in subsec. (b)(1)(E), is classified to section 1395x(dd)(3)(A) of Title 42, The Public Health and Welfare.

Statutory Notes and Related Subsidiaries

Effective Date

Pub. L. 116–260, div. BB, title I, § 113(e), Dec. 27, 2020, 134 Stat. 2873, provided that: “The

Amendments

made by subsections (a), (b), and (c) [enacting this section, section 1185g of Title 29, Labor, and section 300gg–113 of Title 42, The Public Health and Welfare] shall apply with respect to plan years beginning on or after January 1, 2022.”

§9818 Continuity of Care