H.R.5816

            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

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•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

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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

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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

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•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

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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

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•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

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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

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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

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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

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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

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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 plan and 18

with respect to a health care provider or health care 19

facility that has a contractual relationship with such 20

plan or such issuer (as applicable) for furnishing 21

items and services under such plan or such coverage, 22

if, while such individual is a continuing care patient 23

(as defined in subsection (b)) with respect to such 24

provider or facility— 25

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13 

•HR 5816 IH

‘‘(A) such contractual relationship is termi-1

nated (as defined in subsection (b)); 2

‘‘(B) benefits provided under such plan or 3

such health insurance coverage with respect to 4

such provider are terminated because of a 5

change in the terms of the participation of such 6

provider or facility in such plan or coverage; or 7

‘‘(C) a contract between such group health 8

plan and a health insurance issuer offering 9

health insurance coverage in connection with 10

such plan is terminated, resulting in a loss of 11

benefits provided under such plan with respect 12

to such provider or facility, 13

the plan or issuer, respectively, shall meet the re-14

quirements of paragraph (2) with respect to such in-15

dividual. 16

‘‘(2) REQUIREMENTS.—The requirements of 17

this paragraph are that the plan or issuer— 18

‘‘(A) notify each individual enrolled under 19

such plan or coverage who is a continuing care 20

patient with respect to a provider or facility at 21

the time of a termination described in para-22

graph (1) affecting such provider or facility on 23

a timely basis of such termination and such in-24

dividual’s right to elect continued transitional 25

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14 

•HR 5816 IH

care from such provider or facility under this 1

section; 2

‘‘(B) provide such individual with an op-3

portunity to notify the plan or issuer of the in-4

dividual’s need for transitional care; and 5

‘‘(C) permit the patient to elect to continue 6

to have benefits provided under such plan or 7

such coverage, under the same terms and condi-8

tions as would have applied and with respect to 9

such items and services as would have been cov-10

ered under such plan or coverage had such ter-11

mination not occurred, with respect to the 12

course of treatment furnished by such provider 13

or facility relating to such individual’s status as 14

a continuing care patient during the period be-15

ginning on the date on which the notice under 16

subparagraph (A) is provided and ending on the 17

earlier of— 18

‘‘(i) the 90-day period beginning on 19

such date; or 20

‘‘(ii) the date on which such individual 21

is no longer a continuing care patient with 22

respect to such provider or facility. 23

‘‘(b) DEFINITIONS.—In this section: 24

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15 

•HR 5816 IH

‘‘(1) CONTINUING CARE PATIENT.—For pur-1

poses of this section, the term ‘continuing care pa-2

tient’ means an individual who, with respect to a 3

provider or facility— 4

‘‘(A) is undergoing a course of treatment 5

for a serious and complex condition from the 6

provider or facility; 7

‘‘(B) is undergoing a course of institu-8

tional or inpatient care from the provider or fa-9

cility; 10

‘‘(C) is scheduled to undergo nonelective 11

surgery from the provider or facility, including 12

receipt of postoperative care from such provider 13

or facility with respect to such a surgery; 14

‘‘(D) is pregnant and undergoing a course 15

of treatment for the pregnancy from the pro-16

vider or facility; or 17

‘‘(E) is or was determined to be terminally 18

ill (as determined under section 1861(dd)(3)(A) 19

of the Social Security Act) and is receiving 20

treatment for such illness from such provider or 21

facility. 22

‘‘(2) SERIOUS AND COMPLEX CONDITION.—The 23

term ‘serious and complex condition’ means, with re-24

spect to a participant, beneficiary, or enrollee under 25

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16 

•HR 5816 IH

a group health plan or health insurance coverage of-1

fered in connection with such plan— 2

‘‘(A) in the case of an acute illness, a con-3

dition that is serious enough to require special-4

ized medical treatment to avoid the reasonable 5

possibility of death or permanent harm; or 6

‘‘(B) in the case of a chronic illness or con-7

dition, a condition that— 8

‘‘(i) is life-threatening, degenerative, 9

potentially disabling, or congenital; and 10

‘‘(ii) requires specialized medical care 11

over a prolonged period of time. 12

‘‘(3) TERMINATED.—The term ‘terminated’ in-13

cludes, with respect to a contract, the expiration or 14

nonrenewal of the contract, but does not include a 15

termination of the contract for failure to meet appli-16

cable quality standards or for fraud.’’. 17

(B) CONFORMING AMENDMENT.—Section 18

715(a) of the Employee Retirement Income Se-19

curity Act of 1974 (29 U.S.C. 1185d(a)) is 20

amended— 21

(i) in paragraph (1), by striking ‘‘(as 22

amended by the Patient Protection and Af-23

fordable Care Act)’’ and inserting ‘‘(other 24

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17 

•HR 5816 IH

than the provisions of section 2730 of such 1

Act)’’; and 2

(ii) in paragraph (2), by inserting 3

‘‘(other than the provisions of section 2730 4

of such Act)’’ after the first occurrence of 5

‘‘such part A’’. 6

(C) CLERICAL AMENDMENT.—The table of 7

contents in section 1 of the Employee Retire-8

ment Income Security Act of 1974 is amended 9

by inserting after the item relating to section 10

714 the following new items: 11

‘‘Sec. 715. Additional market reforms. 
‘‘Sec. 716. Continuity of care.’’. 

(D) EFFECTIVE DATE.—The amendments 12

made by this paragraph shall apply with respect 13

to plan years beginning on or after January 1, 14

2022. 15

(b) HEALTH CARE PROVIDERS.—Part A of title XI 16

of the Social Security Act (42 U.S.C. 1301 et seq.), as 17

amended by subsection (a), is further amended by adding 18

at the end the following new sections: 19

‘‘SEC. 1150C. CONTINUITY OF CARE. 20

‘‘(a) IN GENERAL.—A health care provider or health 21

care facility shall, in the case of an individual furnished 22

items and services by such provider or facility for which 23

coverage is provided under a group health plan or group 24

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18 

•HR 5816 IH

or individual health insurance coverage pursuant to sec-1

tion 2730 of such Act, section 9816 of the Internal Rev-2

enue Code of 1986, or section 716 of the Employee Retire-3

ment Income Security Act of 1974— 4

‘‘(1) accept payment from such plan or such 5

issuer (as applicable) (and cost-sharing from such 6

individual, if applicable, in accordance with sub-7

section (a)(2)(C) of such section 2730, 9817, or 8

717) for such items and services as payment in full 9

for such items and services; and 10

‘‘(2) continue to adhere to all policies, proce-11

dures, and quality standards imposed by such plan 12

or issuer with respect to such individual and such 13

items and services in the same manner as if such 14

termination had not occurred. 15

‘‘(b) PENALTY.— 16

‘‘(1) IN GENERAL.—Each health care provider 17

or health care facility that violates a provision of 18

subsection (a) shall be subject to a civil monetary 19

penalty in an amount not to exceed $10,000 for each 20

such violation. 21

‘‘(2) APPLICATION OF PROVISIONS.—The provi-22

sions of section 1128A (other than subsection (a), 23

subsection (b), the first sentence of subsection 24

(c)(1), and subsection (o)) shall apply with respect 25

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19 

•HR 5816 IH

to a civil monetary penalty imposed under this sub-1

section in the same manner as such provisions apply 2

with respect to a penalty or proceeding under sub-3

section (a) of such section. 4

‘‘(c) DEFINITIONS.—In this section, the terms ‘health 5

insurance issuer’, ‘group health plan’, ‘group health insur-6

ance coverage’, and ‘individual health insurance coverage’ 7

have the meaning given such terms, respectively, in section 8

2791 of the Public Health Service Act.’’. 9

Æ 

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		Superintendent of Documents
	2020-02-19T22:25:13-0500
	US GPO, Washington, DC 20401
	Superintendent of Documents
	GPO attests that this document has not been altered since it was disseminated by GPO