I 116th CONGRESS 2d Session H. R. 5816 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.

1. Short title This Act may be cited as the Continuing Care for Patients Act of 2020 . 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: 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: 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: 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: 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. .