26 U.S.C. § 9818 — Continuity of care
submitted 6 years ago by Pub. L. 116-260 to r/title-26-INTERNAL-REVENUE-CODE · 651 words · no verdicts yet
This section requires a group health plan to provide transitional coverage to certain continuing-care patients when a provider’s or facility’s network status changes. It defines “continuing care patient,” “serious and complex condition,” and “terminated”; this section does not define those terms beyond the definitions stated here.
(a) Ensuring continuity of care. (1) If a person has group-plan benefits and is a continuing care patient with an in-network provider or facility, and (A) the contract ends, (B) benefits end because participation terms change, or (C) the plan’s contract with the issuer ends and the person loses benefits for that provider or facility, the plan must meet paragraph (2). (2) It must: (A) promptly notify each affected continuing care patient of the termination and the right to choose continued transitional care; (B) give the person a chance to tell the plan that transitional care is needed; and (C) allow the person to continue benefits on the same terms and for the same covered items and services that would have applied if the termination had not happened, for the treatment course related to the continuing-care status, from notice until the earlier of 90 days after notice or the date the person stops being a continuing care patient.
(b) Definitions. (1) “Continuing care patient” means a person who, with a provider or facility: (A) is receiving treatment for a serious and complex condition; (B) is receiving institutional or inpatient care; (C) is scheduled for nonelective surgery, including postoperative care; (D) is pregnant and receiving pregnancy treatment; or (E) is or was determined to be terminally ill under section 1395x(dd)(3)(A) of title 42 and is receiving treatment for that illness. (2) “Serious and complex condition” means, for a plan participant or beneficiary, an acute illness serious enough to require specialized treatment to avoid a reasonable possibility of death or permanent harm, or a chronic illness or condition that is life-threatening, degenerative, potentially disabling, or congenital and requires specialized care over a long period. (3) “Terminated” includes a contract’s expiration or nonrenewal, but not termination for failure to meet applicable quality standards or for fraud.
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—
such contractual relationship is terminated (as defined in paragraph (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
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.
The requirements of this paragraph are that the plan—
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;
provide such individual with an opportunity to notify the plan of the individual’s need for transitional care; and
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—
the 90-day period beginning on such date; or
the date on which such individual is no longer a continuing care patient with respect to such provider or facility.
In this section:
The term “continuing care patient” means an individual who, with respect to a provider or facility—
is undergoing a course of treatment for a serious and complex condition from the provider or facility;
is undergoing a course of institutional or inpatient care from the provider or facility;
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;
is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or
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.
The term “serious and complex condition” means, with respect to a participant or beneficiary under a group health plan—
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
in the case of a chronic illness or condition, a condition that—
is life-threatening, degenerative, potentially disabling, or congenital; and
requires specialized medical care* over a prolonged period of time.
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.
Source credit: (Added Pub. L. 116–260, div. BB, title I, § 113(b)(1), Dec. 27, 2020, 134 Stat. 2870.)
- 2020Enacted · Pub. L. 116-260 · 134 Stat. 2870
A history note hasn’t been published yet. The record shows enactment by Pub. L. 116-260 on 2020-12-27.
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