42 U.S.C. § 300gg–113: Continuity of care

Summary

Health plans and insurers must let a patient keep getting care from a provider when that provider’s contract ends or the patient would lose benefits because the provider left the plan. If the patient is a continuing care patient, the plan or insurer must tell the patient in a timely way about the change and that they can choose to keep getting transitional care. The plan must give the patient a chance to ask for that care and must cover the provider’s treatment the same way it would have before the change. This continued coverage lasts from the notice date until either 90 days have passed or the patient is no longer a continuing care patient, whichever happens first. Continuing care patient: someone getting ongoing treatment, inpatient care, nonelective surgery (including follow-up), pregnancy care, or care for a terminal illness. Serious and complex condition: an acute problem needing special treatment to avoid death or permanent harm, or a chronic, serious condition that is life‑threatening, degenerative, disabling, or congenital and needs long‑term specialized care. Terminated: a contract that expired or was not renewed, but not a contract ended for fraud or failing quality standards.

Title 42, §300gg–113

The Public Health and Welfare, 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 or individual 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 subsection (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 such 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, beneficiary, or enrollee under a group health plan or group or individual 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 is—

(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.

§300gg–113 Continuity of Care

Summary

Title 42, §300gg–113

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Citations & Metadata