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Benefits

What Is the “Continuity of Care” Mandate for Group Health Plans?

EBIA  

EBIA  

QUESTION: We have heard from our company’s group health plan insurer that our plan must continue covering certain patients who are undergoing treatment when we change our contractual relationship with their provider. What are the rules, and when do they apply?

ANSWER: The surprise medical billing legislation passed in December 2020 (see our Checkpoint article) included a new patient protection mandate referred to as “continuity of care” that applies when a provider ceases to be an in-network provider during an ongoing course of treatment. For plan years beginning on or after January 1, 2022, a group health plan must provide transitional care for up to 90 days for any individual that is a “continuing care patient” with respect to an in-network health care provider or facility when certain events occur. Specifically, the continuity of care requirements apply when—(1) the contractual relationship between the plan and provider or facility is terminated; (2) benefits provided under the plan with respect to the provider or facility are terminated because of a change in the terms of participation of the provider or facility; or (3) a contract between the plan and its health insurer is terminated, resulting in a loss of benefits with respect to the provider or facility.

An individual covered under a group health plan is considered a continuing care patient with respect to a particular provider or facility if the individual is (1) undergoing a course of treatment for a serious and complex condition, (2) undergoing a course of institutional or inpatient care, (3) scheduled to undergo nonelective surgery (including postoperative care), (4) pregnant and undergoing a course of treatment for the pregnancy, or (5) terminally ill and receiving treatment for that illness.

If these continuity of care conditions are satisfied, the group health plan must—

  • Timely notify continuing care patients of terminations affecting their provider or facility and their right to elect continued transitional care from that provider or facility;
  • Provide each patient an opportunity to notify the plan of the need for transitional care; and
  • Permit the patient to elect to continue to have plan benefits provided under the same terms and conditions as would have applied, and for the items and services that would have been covered, had the termination not occurred.

This transitional care must be provided beginning on the date on which the notice of termination is provided and ending on the earlier of the 90-day period beginning on such date, or the date on which such individual is no longer a continuing care patient with respect to the provider or facility. For more information, see EBIA’s Group Health Plan Mandates manual at Section XIII.B.6 (“Expanded Patient Protections: Continuity of Care”) and EBIA’s Health Care Reform manual at Section XII.B (“Patient Protections”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.C (“Federally Mandated Benefits”).

Contributing Editors: EBIA Staff.

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