PRIA, Government Policy, Made Personal

§1185g Continuity of Care

Title 29 › CHAPTER 18 — EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM › SUBCHAPTER I — PROTECTION OF EMPLOYEE BENEFIT RIGHTS › Subtitle B — Regulatory Provisions › part 7 — group health plan requirements › Subpart B — Other Requirements › § 1185g

Last updated Sep 22, 2026|Official source

Summary

When a doctor, hospital, or other in-network provider loses its contract or stops being part of a group health plan or group health insurance network while a person is in the middle of care, the health plan or insurer must act. The plan or insurer must tell the patient quickly about the change and about the right to ask for temporary continued care. The patient must be given a chance to ask for that care. If the patient asks, the plan or insurer must let them keep getting covered care from that provider under the same rules and coverage as before. That coverage lasts from the notice date until the earlier of 90 days or the date the person is no longer in the middle of that care. Continuing care patient: a person who is mid-treatment for a serious or complex condition, getting inpatient care, scheduled for nonelective surgery (including follow-up care), pregnant and treated for the pregnancy, or is terminally ill and being treated. Serious and complex condition: an acute illness needing special treatment to avoid death or permanent harm, or a chronic life‑threatening or disabling condition needing long-term specialized care. Terminated: includes contract expiration or nonrenewal, but not ending a contract for poor quality or fraud.

Title 29, §1185g

Labor, 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 or group health insurance coverage offered by a health insurance issuer and with respect to a health care provider or facility that has a contractual relationship with such plan or such issuer (as applicable) for furnishing items and services under such plan or such coverage, 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 or such health insurance coverage with respect to such provider or facility are terminated because of a change in the terms of the participation of the provider or facility in such plan or coverage; 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 or issuer, respectively, shall meet the requirements of paragraph (2) with respect to such individual.

(2)Requirements

The requirements of this paragraph are that the plan or issuer—

(A)notify each individual enrolled under such plan or coverage 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 or facility 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 or issuer of the individual’s need for transitional care; and

(C)permit the patient to elect to continue to have benefits provided under such plan or such coverage, 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 or coverage 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 or group health insurance coverage—

(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.

Statutory Notes and Related Subsidiaries

Effective Date

Section applicable with respect to plan years beginning on or after Jan. 1, 2022, see section 113(e) of div. BB of Pub. L. 116–260, set out as a note under section 9818 of Title 26, Internal Revenue Code.

§1185g Continuity of Care

Summary

Title 29, §1185g

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Citations & Metadata