[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5816 Introduced in House (IH)]
<DOC>
116th CONGRESS
2d Session
H. R. 5816
To amend title XXVII of the Public Health Service Act, the Internal
Revenue Code of 1986, the Employee Retirement Income Security Act of
1974, and title XI of the Social Security Act to require group health
plans and health insurance issuers to provide for certain coverage in
the case of a change in a provider's network status, and for other
purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
February 7, 2020
Ms. Moore (for herself and Mr. Schweikert) introduced the following
bill; which was referred to the Committee on Energy and Commerce, and
in addition to the Committees on Ways and Means, and Education and
Labor, for a period to be subsequently determined by the Speaker, in
each case for consideration of such provisions as fall within the
jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XXVII of the Public Health Service Act, the Internal
Revenue Code of 1986, the Employee Retirement Income Security Act of
1974, and title XI of the Social Security Act to require group health
plans and health insurance issuers to provide for certain coverage in
the case of a change in a provider's network status, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Continuing Care for Patients Act of
2020''.
SEC. 2. REQUIRING GROUP HEALTH PLANS AND HEALTH INSURANCE ISSUERS TO
PROVIDE FOR CERTAIN COVERAGE IN THE CASE OF A CHANGE IN A
PROVIDER'S NETWORK STATUS.
(a) Group Health Plan and Health Insurance Issuer Requirements.--
(1) Public health service act.--
(A) In general.--Subpart II of part A of title
XXVII of the Public Health Service Act (42 U.S.C.
300gg-11 et seq.) is amended by adding at the end the
following new section:
``SEC. 2730. CONTINUITY OF CARE.
``(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.--For purposes of this
section, 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) 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 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.''.
(B) Effective date.--The amendments made by this
paragraph shall apply with respect to plan years
beginning on or after January 1, 2022.
(2) Internal revenue code of 1986.--
(A) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at
the end the following new section:
``SEC. 9816. CONTINUITY OF CARE.
``(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 health care 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 the 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 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 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.--For purposes of this
section, 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) 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.''.
(B) Conforming amendment.--Section 9815(a) of the
Internal Revenue Code of 1986 is amended--
(i) in paragraph (1), by striking ``(as
amended by the Patient Protection and
Affordable Care Act)'' and inserting ``(other
than the provisions of section 2730 of such
Act)''; and
(ii) in paragraph (2), by inserting
``(other than the provisions of section 2730 of
such Act)'' after the first occurrence of
``such part A''.
(C) Clerical amendment.--The table of sections for
such subchapter is amended by adding at the end the
following new items:
``Sec. 9815. Additional market reforms.
``Sec. 9816. Continuity of care.''.
(D) Effective date.--The amendments made by this
paragraph shall apply with respect to plan years
beginning on or after January 1, 2022.
(3) Employee retirement income security act of 1974.--
(A) In general.--Subpart B of part 7 of subtitle B
of title I of the Employee Retirement Income Security
Act of 1974 (29 U.S.C. 1185 et seq.) is amended by
adding at the end the following new section:
``SEC. 716. CONTINUITY OF CARE.
``(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 health insurance coverage
offered by a health insurance issuer in connection with such
group health plan and with respect to a health care provider or
health care 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
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.--For purposes of this
section, 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) 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 health
insurance coverage offered in connection with such 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.''.
(B) Conforming amendment.--Section 715(a) of the
Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185d(a)) is amended--
(i) in paragraph (1), by striking ``(as
amended by the Patient Protection and
Affordable Care Act)'' and inserting ``(other
than the provisions of section 2730 of such
Act)''; and
(ii) in paragraph (2), by inserting
``(other than the provisions of section 2730 of
such Act)'' after the first occurrence of
``such part A''.
(C) Clerical amendment.--The table of contents in
section 1 of the Employee Retirement Income Security
Act of 1974 is amended by inserting after the item
relating to section 714 the following new items:
``Sec. 715. Additional market reforms.
``Sec. 716. Continuity of care.''.
(D) Effective date.--The amendments made by this
paragraph shall apply with respect to plan years
beginning on or after January 1, 2022.
(b) Health Care Providers.--Part A of title XI of the Social
Security Act (42 U.S.C. 1301 et seq.), as amended by subsection (a), is
further amended by adding at the end the following new sections:
``SEC. 1150C. CONTINUITY OF CARE.
``(a) In General.--A health care provider or health care facility
shall, in the case of an individual furnished items and services by
such provider or facility for which coverage is provided under a group
health plan or group or individual health insurance coverage pursuant
to section 2730 of such Act, section 9816 of the Internal Revenue Code
of 1986, or section 716 of the Employee Retirement Income Security Act
of 1974--
``(1) accept payment from such plan or such issuer (as
applicable) (and cost-sharing from such individual, if
applicable, in accordance with subsection (a)(2)(C) of such
section 2730, 9817, or 717) for such items and services as
payment in full for such items and services; and
``(2) continue to adhere to all policies, procedures, and
quality standards imposed by such plan or issuer with respect
to such individual and such items and services in the same
manner as if such termination had not occurred.
``(b) Penalty.--
``(1) In general.--Each health care provider or health care
facility that violates a provision of subsection (a) shall be
subject to a civil monetary penalty in an amount not to exceed
$10,000 for each such violation.
``(2) Application of provisions.--The provisions of section
1128A (other than subsection (a), subsection (b), the first
sentence of subsection (c)(1), and subsection (o)) shall apply
with respect to a civil monetary penalty imposed under this
subsection in the same manner as such provisions apply with
respect to a penalty or proceeding under subsection (a) of such
section.
``(c) Definitions.--In this section, the terms `health insurance
issuer', `group health plan', `group health insurance coverage', and
`individual health insurance coverage' have the meaning given such
terms, respectively, in section 2791 of the Public Health Service
Act.''.
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