Editor's Note: Sec. 9818, added by Pub. L. 116-260, Div. BB, Sec. 113(b)(1), is effective for plan years beginning on or after January
1, 2022.
I.R.C. § 9818(a) Ensuring Continuity Of Care With Respect To Terminations Of Certain Contractual Relationships
Resulting In Changes In Provider Network Status
I.R.C. § 9818(a)(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 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—
I.R.C. § 9818(a)(1)(A) —
such contractual relationship is terminated
(as defined in paragraph (b));
I.R.C. § 9818(a)(1)(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
I.R.C. § 9818(a)(1)(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.
I.R.C. § 9818(a)(2) Requirements —
The requirements of this paragraph are that the plan—
I.R.C. § 9818(a)(2)(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 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;
I.R.C. § 9818(a)(2)(B) —
provide such individual with an opportunity to notify the plan of the individual's
need for transitional care; and
I.R.C. § 9818(a)(2)(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.R.C. § 9818(a)(2)(C)(i) —
the 90-day period beginning on such date;
or
I.R.C. § 9818(a)(2)(C)(ii) —
the date on which such individual is no longer a continuing care patient with respect
to such provider or facility.
I.R.C. § 9818(b) Definitions —
In this section:
I.R.C. § 9818(b)(1) Continuing Care Patient —
The term “continuing care patient” means an individual who, with respect to a provider
or facility—
I.R.C. § 9818(b)(1)(A) —
is undergoing a course of treatment for a serious and complex condition from the provider
or facility;
I.R.C. § 9818(b)(1)(B) —
is undergoing a course of institutional or inpatient care from the provider or facility;
I.R.C. § 9818(b)(1)(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;
I.R.C. § 9818(b)(1)(D) —
is pregnant and undergoing a course of treatment for the pregnancy from the provider
or facility; or
I.R.C. § 9818(b)(1)(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.
I.R.C. § 9818(b)(2) Serious And Complex Condition —
The term “serious and complex condition”
means, with respect to a participant or beneficiary under a group health plan—
I.R.C. § 9818(b)(2)(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
I.R.C. § 9818(b)(2)(B) —
in the case of a chronic illness or condition, a condition that—
I.R.C. § 9818(b)(2)(B)(i) —
is life-threatening, degenerative, potentially disabling, or congenital; and
I.R.C. § 9818(b)(2)(B)(ii) —
requires specialized medical care over a prolonged period of time.
I.R.C. § 9818(b)(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.
(Added by Pub. L. 116-260, Div. BB, title I, Sec. 113(b)(1), Dec. 27, 2020, 134 Stat. 1182.)
BACKGROUND NOTES
EFFECTIVE DATE
Effective with respect to plan years beginning on or after January 1, 2022.
