PRIA, Government Policy, Made Personal

Summary

Plans must keep care going for certain patients when a provider’s relationship with the plan ends or the provider stops being in the plan. If a provider’s contract ends, if the provider’s participation changes so benefits stop, or if the insurer’s contract ends and that causes a loss of benefits for that provider, the plan must tell affected patients in time, give them a chance to ask for transition care, and let them keep getting the same covered care under the same rules for up to 90 days or until they are no longer a continuing care patient. Definitions (one line each): continuing care patient — someone getting ongoing or inpatient care, scheduled for nonelective surgery (including follow-up), pregnant and treated for the pregnancy, or terminally ill and in treatment; serious and complex condition — an acute illness needing special care to avoid death or permanent harm, or a chronic life‑threatening/degenerative/ disabling condition needing long-term specialized care; terminated — includes contract expiration or nonrenewal, but not ending for quality failures or fraud.

Title 26, §9818

Internal Revenue Code, Source: USLM XML via OLRC

(a)Ensuring continuity of care with respect to terminations of certain contractual relationships resulting in changes in provider network status

(1)In general

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;

the plan shall meet the requirements of paragraph (2) with respect to such individual.

(2)Requirements

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)Definitions

In this section: (1) Continuing care patient

(2)Serious and complex condition

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)Terminated

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