Sec. 403. Patient protections

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Section 2719A of the Public Health Service Act ( 42 U.S.C. 300gg–19a ) is amended— in subsection (b)— in paragraph (1), by striking paragraph (2)(B) and inserting paragraph (3)(B) ; by redesignating paragraph

(2)as paragraph (3); and by inserting after paragraph

(1)the following: A group health plan or health insurance issuer offering group or individual health insurance coverage shall reimburse an out-of-network provider providing emergency services to an individual enrolled in such plan or coverage at an amount equal to the greatest of— the median amount negotiated with in-network providers for the emergency service; the amount for the emergency service calculated using the same method the plan or issuer generally uses to determine payments for out-of-network services; or the amount that would be paid to a provider of services or supplier with respect to the furnishing of such service under title XVIII of the Social Security Act. ; and by adding at the end the following: A group health plan or health insurance issuer offering group or individual health insurance coverage shall provide coverage of a service provided by an out-of-network provider to an individual enrolled in such plan or coverage if— the plan or issuer would have provided coverage for the service if the service was provided by an in-network provider; and in choosing such provider, the individual reasonably relied on a materially inaccurate, incomplete, or misleading statement of information contained in a directory, compiled by the plan or issuer, of in-network providers. A group health plan or health insurance issuer that provides coverage of a service provided by an out-of-network provider under paragraph

(1)shall provide such coverage with the same cost-sharing requirements as if the service was provided by an in-network provider. A group health plan or health insurance issuer offering group or individual health insurance coverage shall, at the request of an individual enrolled in such plan or coverage and subject to paragraph (3), provide covered services (as defined in paragraph (4)) by an out-of-network provider for such individual in accordance with paragraph

(2)if— the individual is receiving an active course of treatment from such out-of-network provider that was occurring while the individual was enrolled in a different health plan offered by such plan or issuer for the prior plan year that has been discontinued by such plan or issuer, including a case where such plan is withdrawn from the market, and such provider was an in-network provider under such different health plan; or the individual is receiving an active course of treatment from such out-of-network provider for a plan year in which the provider was an in-network provider of the plan or issuer but became a terminated provider with respect to such plan or issuer for such plan year. The coverage for an active course of treatment described in paragraph

(1)shall be continued until the earlier of— the date on which the treatment is complete; or the date that is 180 days following the date on which— in the case of an individual described in subparagraph

(A)of paragraph (1), the individual enrolls in such group health plan or health insurance coverage; or in the case of an individual described in subparagraph

(B)of paragraph (1), the contract of the terminated provider with the group health plan or health insurance issuer is no longer in effect. The coverage for an active course of treatment provided by an out-of-network provider as described in paragraph

(1)shall be provided with cost-sharing requirements that are the same as if such coverage was provided by an in-network provider. Any request made under paragraph

(1)shall be subject to any internal or external grievance or appeals process of the plan or issuer, in accordance with any applicable State or Federal law. For purposes of this subsection: The term active course of treatment means any of the following that is occurring on the first day on which, with respect to an individual described in paragraph (1)(A), the individual's prior health plan described in such paragraph has been discontinued by the plan or issuer or, with respect to an individual described in paragraph (1)(B), the provider providing the treatment becomes a terminated provider: An ongoing course of treatment for a life-threatening condition, serious acute condition, or serious chronic condition. Services provided with respect to pregnancy, including until the completion of postpartum care directly related to the delivery. An ongoing course of treatment for a child between birth and 36 months. The performance of a surgery or other procedure that, prior to the applicable time described in this subparagraph, has been authorized by the plan or coverage as part of a documented course of treatment for such individual and has been recommended and documented by the provider for such individual. The term covered services means services that— would be covered by the group health plan or health insurance issuer offering group or individual health insurance coverage if such services were provided by an in-network provider; and are for an active course of treatment. The term terminated provider means a provider that had a contract for participation with the plan or coverage during a plan year while the individual was enrolled in such plan or coverage and receiving covered services from such provider and, during such plan year, the plan or issuer terminates such contract or does not renew such contract for the remainder of the plan year. Such term does not include— any provider that voluntarily terminates or does not renew such contract for the remainder of the plan year; and any provider whose contract with the plan or issuer has terminated, or was not renewed, for the remainder of the plan year for reasons relating to a medical disciplinary cause or fraud or other criminal activity. A group health plan or health insurance issuer offering group or individual health insurance coverage shall not, during a plan year, take any of the following actions with respect to coverage for such plan year: Removing a prescription drug from a formulary of prescription drugs covered by such plan or issuer, except as provided in paragraph (2)(C). Increasing the obligation of an enrollee with respect to cost-sharing, as defined in section 1302(c)(3) of the Patient Protection and Affordable Care Act, required for a prescription drug covered by such plan or issuer. Nothing in this subsection shall prohibit a group health plan or health insurance issuer offering group or individual health insurance coverage from, during a plan year, taking any of the following actions with respect to coverage for such plan year: Changing the policy of the plan or issuer to require an enrollee to use a generic substitution for a branded prescription drug. Adding a new prescription drug to a formulary of prescription drugs covered by such plan or issuer. Removing a prescription drug from such a formulary due to patient safety concerns, a prescription drug recall, or the removal of a prescription drug from interstate commerce as determined necessary by the Secretary. . The amendments made by this section shall apply to plan years beginning after December 31, 2019.

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42 USC 300gg–19a

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Sec. 403

Patient protections

Cite42 USC 300gg–19a

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