Continuing Care for Patients Act of 2020

I 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 jurisdic- tion of the committee concerned A BILL To amend title XXVII of the Public Health Service Act, the Internal Revenue Code of 1986, the Employee Retire- ment 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 Representa- 1 tives of the United States of America in Congress assembled, 2 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 2 •HR 5816 IH SECTION 1. SHORT TITLE. 1 This Act may be cited as the ‘‘Continuing Care for 2 Patients Act of 2020’’. 3 SEC. 2. REQUIRING GROUP HEALTH PLANS AND HEALTH 4 INSURANCE ISSUERS TO PROVIDE FOR CER- 5 TAIN COVERAGE IN THE CASE OF A CHANGE 6 IN A PROVIDER’S NETWORK STATUS. 7 (a) GROUP HEALTH PLAN AND HEALTH INSURANCE 8 ISSUER REQUIREMENTS.— 9 (1) PUBLIC HEALTH SERVICE ACT.— 10 (A) IN GENERAL.—Subpart II of part A of 11 title XXVII of the Public Health Service Act 12 (42 U.S.C. 300gg–11 et seq.) is amended by 13 adding at the end the following new section: 14 ‘‘SEC. 2730. CONTINUITY OF CARE. 15 ‘‘(a) ENSURING CONTINUITY OF CARE WITH RE- 16 SPECT TO TERMINATIONS OF CERTAIN CONTRACTUAL 17 RELATIONSHIPS RESULTING IN CHANGES IN PROVIDER 18 NETWORK STATUS.— 19 ‘‘(1) IN GENERAL.—In the case of an individual 20 with benefits under a group health plan or group or 21 individual health insurance coverage offered by a 22 health insurance issuer and with respect to a health 23 care provider or facility that has a contractual rela- 24 tionship with such plan or such issuer (as applica- 25 ble) for furnishing items and services under such 26 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 3 •HR 5816 IH plan or such coverage, if, while such individual is a 1 continuing care patient (as defined in subsection (b)) 2 with respect to such provider or facility— 3 ‘‘(A) such contractual relationship is termi- 4 nated (as defined in subsection (b)); 5 ‘‘(B) benefits provided under such plan or 6 such health insurance coverage with respect to 7 such provider or facility are terminated because 8 of a change in the terms of the participation of 9 such provider or facility in such plan or cov- 10 erage; or 11 ‘‘(C) a contract between such group health 12 plan and a health insurance issuer offering 13 health insurance coverage in connection with 14 such plan is terminated, resulting in a loss of 15 benefits provided under such plan with respect 16 to such provider or facility, 17 the plan or issuer, respectively, shall meet the re- 18 quirements of paragraph (2) with respect to such in- 19 dividual. 20 ‘‘(2) REQUIREMENTS.—The requirements of 21 this paragraph are that the plan or issuer— 22 ‘‘(A) notify each individual enrolled under 23 such plan or coverage who is a continuing care 24 patient with respect to a provider or facility at 25 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 4 •HR 5816 IH the time of a termination described in para- 1 graph (1) affecting such provider or facility on 2 a timely basis of such termination and such in- 3 dividual’s right to elect continued transitional 4 care from such provider or facility under this 5 section; 6 ‘‘(B) provide such individual with an op- 7 portunity to notify the plan or issuer of the in- 8 dividual’s need for transitional care; and 9 ‘‘(C) permit the patient to elect to continue 10 to have benefits provided under such plan or 11 such coverage, under the same terms and condi- 12 tions as would have applied and with respect to 13 such items and services as would have been cov- 14 ered under such plan or coverage had such ter- 15 mination not occurred, with respect to the 16 course of treatment furnished by such provider 17 or facility relating to such individual’s status as 18 a continuing care patient during the period be- 19 ginning on the date on which the notice under 20 subparagraph (A) is provided and ending on the 21 earlier of— 22 ‘‘(i) the 90-day period beginning on 23 such date; or 24 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 5 •HR 5816 IH ‘‘(ii) the date on which such individual 1 is no longer a continuing care patient with 2 respect to such provider or facility. 3 ‘‘(b) DEFINITIONS.—In this section: 4 ‘‘(1) CONTINUING CARE PATIENT.—For pur- 5 poses of this section, the term ‘continuing care pa- 6 tient’ means an individual who, with respect to a 7 provider or facility— 8 ‘‘(A) is undergoing a course of treatment 9 for a serious and complex condition from the 10 provider or facility; 11 ‘‘(B) is undergoing a course of institu- 12 tional or inpatient care from the provider or fa- 13 cility; 14 ‘‘(C) is scheduled to undergo nonelective 15 surgery from the provider or facility, including 16 receipt of postoperative care from such provider 17 or facility with respect to such a surgery; 18 ‘‘(D) is pregnant and undergoing a course 19 of treatment for the pregnancy from the pro- 20 vider or facility; or 21 ‘‘(E) is or was determined to be terminally 22 ill (as determined under section 1861(dd)(3)(A) 23 of the Social Security Act) and is receiving 24 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 6 •HR 5816 IH treatment for such illness from such provider or 1 facility. 2 ‘‘(2) SERIOUS AND COMPLEX CONDITION.—The 3 term ‘serious and complex condition’ means, with re- 4 spect to a participant, beneficiary, or enrollee under 5 a group health plan or health insurance coverage— 6 ‘‘(A) in the case of an acute illness, a con- 7 dition that is serious enough to require special- 8 ized medical treatment to avoid the reasonable 9 possibility of death or permanent harm; or 10 ‘‘(B) in the case of a chronic illness or con- 11 dition, a condition that— 12 ‘‘(i) is life-threatening, degenerative, 13 potentially disabling, or congenital; and 14 ‘‘(ii) requires specialized medical care 15 over a prolonged period of time. 16 ‘‘(3) TERMINATED.—The term ‘terminated’ in- 17 cludes, with respect to a contract, the expiration or 18 nonrenewal of the contract, but does not include a 19 termination of the contract for failure to meet appli- 20 cable quality standards or for fraud.’’. 21 (B) EFFECTIVE DATE.—The amendments 22 made by this paragraph shall apply with respect 23 to plan years beginning on or after January 1, 24 2022. 25 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 7 •HR 5816 IH (2) INTERNAL REVENUE CODE OF 1986.— 1 (A) IN GENERAL.—Subchapter B of chap- 2 ter 100 of the Internal Revenue Code of 1986 3 is amended by adding at the end the following 4 new section: 5 ‘‘SEC. 9816. CONTINUITY OF CARE. 6 ‘‘(a) ENSURING CONTINUITY OF CARE WITH RE- 7 SPECT TO TERMINATIONS OF CERTAIN CONTRACTUAL 8 RELATIONSHIPS RESULTING IN CHANGES IN PROVIDER 9 NETWORK STATUS.— 10 ‘‘(1) IN GENERAL.—In the case of an individual 11 with benefits under a group health plan and with re- 12 spect to a health care provider or health care facility 13 that has a contractual relationship with such plan 14 for furnishing items and services under such plan, if, 15 while such individual is a continuing care patient (as 16 defined in subsection (b)) with respect to such pro- 17 vider or facility— 18 ‘‘(A) such contractual relationship is termi- 19 nated (as defined in paragraph (b)); 20 ‘‘(B) benefits provided under such plan 21 with respect to such provider or facility are ter- 22 minated because of a change in the terms of the 23 participation of the provider or facility in such 24 plan; or 25 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 8 •HR 5816 IH ‘‘(C) a contract between such group health 1 plan and a health insurance issuer offering 2 health insurance coverage in connection with 3 such plan is terminated, resulting in a loss of 4 benefits provided under such plan with respect 5 to such provider or facility, 6 the plan shall meet the requirements of paragraph 7 (2) with respect to such individual. 8 ‘‘(2) REQUIREMENTS.—The requirements of 9 this paragraph are that the plan— 10 ‘‘(A) notify each individual enrolled under 11 such plan who is a continuing care patient with 12 respect to a provider or facility at the time of 13 a termination described in paragraph (1) affect- 14 ing such provider or facility on a timely basis 15 of such termination and such individual’s right 16 to elect continued transitional care from such 17 provider or facility under this section; 18 ‘‘(B) provide such individual with an op- 19 portunity to notify the plan of the individual’s 20 need for transitional care; and 21 ‘‘(C) permit the patient to elect to continue 22 to have benefits provided under such plan, 23 under the same terms and conditions as would 24 have applied and with respect to such items and 25 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 9 •HR 5816 IH services as would have been covered under such 1 plan had such termination not occurred, with 2 respect to the course of treatment furnished by 3 such provider or facility relating to such indi- 4 vidual’s status as a continuing care patient dur- 5 ing the period beginning on the date on which 6 the notice under subparagraph (A) is provided 7 and ending on the earlier of— 8 ‘‘(i) the 90-day period beginning on 9 such date; or 10 ‘‘(ii) the date on which such individual 11 is no longer a continuing care patient with 12 respect to such provider or facility. 13 ‘‘(b) DEFINITIONS.—In this section: 14 ‘‘(1) CONTINUING CARE PATIENT.—For pur- 15 poses of this section, the term ‘continuing care pa- 16 tient’ means an individual who, with respect to a 17 provider or facility— 18 ‘‘(A) is undergoing a course of treatment 19 for a serious and complex condition from the 20 provider or facility; 21 ‘‘(B) is undergoing a course of institu- 22 tional or inpatient care from the provider or fa- 23 cility; 24 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 10 •HR 5816 IH ‘‘(C) is scheduled to undergo nonelective 1 surgery from the provider or facility, including 2 receipt of postoperative care from such provider 3 or facility with respect to such a surgery; 4 ‘‘(D) is pregnant and undergoing a course 5 of treatment for the pregnancy from the pro- 6 vider or facility; or 7 ‘‘(E) is or was determined to be terminally 8 ill (as determined under section 1861(dd)(3)(A) 9 of the Social Security Act) and is receiving 10 treatment for such illness from such provider or 11 facility. 12 ‘‘(2) SERIOUS AND COMPLEX CONDITION.—The 13 term ‘serious and complex condition’ means, with re- 14 spect to a participant or beneficiary under a group 15 health plan— 16 ‘‘(A) in the case of an acute illness, a con- 17 dition that is serious enough to require special- 18 ized medical treatment to avoid the reasonable 19 possibility of death or permanent harm; or 20 ‘‘(B) in the case of a chronic illness or con- 21 dition, a condition that— 22 ‘‘(i) is life-threatening, degenerative, 23 potentially disabling, or congenital; and 24 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 11 •HR 5816 IH ‘‘(ii) requires specialized medical care 1 over a prolonged period of time. 2 ‘‘(3) TERMINATED.—The term ‘terminated’ in- 3 cludes, with respect to a contract, the expiration or 4 nonrenewal of the contract, but does not include a 5 termination of the contract for failure to meet appli- 6 cable quality standards or for fraud.’’. 7 (B) CONFORMING AMENDMENT.—Section 8 9815(a) of the Internal Revenue Code of 1986 9 is amended— 10 (i) in paragraph (1), by striking ‘‘(as 11 amended by the Patient Protection and Af- 12 fordable Care Act)’’ and inserting ‘‘(other 13 than the provisions of section 2730 of such 14 Act)’’; and 15 (ii) in paragraph (2), by inserting 16 ‘‘(other than the provisions of section 2730 17 of such Act)’’ after the first occurrence of 18 ‘‘such part A’’. 19 (C) CLERICAL AMENDMENT.—The table of 20 sections for such subchapter is amended by 21 adding at the end the following new items: 22 ‘‘Sec. 9815. Additional market reforms. ‘‘Sec. 9816. Continuity of care.’’. (D) EFFECTIVE DATE.—The amendments 23 made by this paragraph shall apply with respect 24 VerDate Sep 11 2014 20:16 Feb 19, 2020 Jkt 099200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H5816.IH H5816 pamtmann on DSKBC07HB2PROD with BILLS 12 •HR 5816 IH to plan years beginning on or after January 1, 1 2022. 2 (3) EMPLOYEE RETIREMENT INCOME SECURITY 3 ACT OF 1974.— 4 (A) IN GENERAL.—Subpart B of part 7 of 5 subtitle B of title I of the Employee Retirement 6 Income Security Act of 1974 (29 U.S.C. 1185 7 et seq.) is amended by adding at the end the 8 following new section: 9 ‘‘SEC. 716. CONTINUITY OF CARE. 10 ‘‘(a) ENSURING CONTINUITY OF CARE WITH RE- 11 SPECT TO TERMINATIONS OF CERTAIN CONTRACTUAL 12 RELATIONSHIPS RESULTING IN CHANGES IN PROVIDER 13 NETWORK STATUS.— 14 ‘‘(1) IN GENERAL.—In the case of an individual 15 with benefits under a group health plan or health in- 16 surance coverage offered by a health insurance 17 issuer in connection with such group health [Text truncated for display. Full text available on Congress.gov.]