[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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