Sec. 9. Additional consumer protections

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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 sections: 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— such contractual relationship is terminated (as defined in subsection (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 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. The requirements of this paragraph are that the plan or issuer— 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; provide such individual with an opportunity to notify the plan or issuer of the individual’s need for transitional care; and 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— 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 such provider or facility. In this section: The term continuing care patient means an individual who, with respect to a provider or facility— is undergoing a course of treatment for a serious and complex condition from the provider or facility; is undergoing a course of institutional or inpatient care from the provider or facility; is scheduled to undergo nonelective surgery from the provider, including receipt of postoperative care from such provider or facility with respect to such a surgery; is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or 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. The term serious and complex condition means, with respect to a participant, beneficiary, or enrollee under a group health plan or health insurance coverage— 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 in the case of a chronic illness or condition, a condition that is— is life-threatening, degenerative, potentially disabling, or congenital; and requires specialized medical care over a prolonged period of time. 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. In the case of a group health plan or health insurance issuer offering group or individual health insurance coverage that provides a physical or electronic card indicating membership in such plan or coverage to an individual enrolled under such plan or coverage, such group health plan or issuer shall include on such card each of the following: The nearest hospital to the primary residence of such individual that has in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage. A telephone number or Internet website address through which such individual may seek consumer assistance information, such as information related to hospitals and urgent care facilities that have in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage. Any deductible applicable to such individual. Any out-of-pocket maximum applicable to such individual. Any cost-sharing obligation applicable to such individual for a visit at an emergency department, or urgent care facility, that has in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage. In connection with the offering of a group health plan or group or individual health insurance coverage in a geographic region for a plan year, a plan sponsor or health insurance issuer, respectively, shall employ an individual to offer price comparison guidance, or make available on an Internet website a price comparison tool, that (to the extent practicable) allows an individual enrolled under such plan or coverage, with respect to such plan year and such geographic region, to compare the amount (determined by historic claims data of participating providers with respect to such plan or coverage) of cost-sharing (including deductibles, copayments, and coinsurance) that the individual would be responsible for paying under such plan or coverage with respect to the furnishing of a specific item or service by any such provider. . Subchapter B of chapter 100 of the Internal Revenue Code of 1986, as amended by the previous sections, is further amended by adding at the end the following new sections: 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— such contractual relationship is terminated (as defined in paragraph (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 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. The requirements of this paragraph are that the plan— 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; provide such individual with an opportunity to notify the plan of the individual’s need for transitional care; and 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— 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 such provider or facility. In this section: The term continuing care patient means an individual who, with respect to a provider or facility— is undergoing a course of treatment for a serious and complex condition from the provider or facility; is undergoing a course of institutional or inpatient care from the provider or facility; 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; is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or 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. The term serious and complex condition means, with respect to a participant, beneficiary, or enrollee under a group health plan— 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 in the case of a chronic illness or condition, a condition that— is life-threatening, degenerative, potentially disabling, or congenital; and requires specialized medical care over a prolonged period of time. 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. In the case of a group health plan that provides a physical or electronic card indicating membership in such plan to an individual enrolled under such plan, such group health plan shall include on such card each of the following: The nearest hospital to the primary residence of such individual that has in effect a contractual relationship with such plan for furnishing items and services under such plan. A telephone number or Internet website address through which such individual may seek consumer assistance information, such as information related to hospitals and urgent care facilities that have in effect a contractual relationship with such plan for furnishing items and services under such plan. Any deductible applicable to such individual. Any out-of-pocket maximum applicable to such individual. Any cost-sharing obligation applicable to such individual for a visit at an emergency department, or urgent care facility, that has in effect a contractual relationship with such plan for furnishing items and services under such plan. In connection with the offering of a group health plan in a geographic region for a plan year, a plan sponsor shall employ an individual to offer price comparison guidance, or make available on an Internet website a price comparison tool, that (to the extent practicable) allows an individual enrolled under such plan, with respect to such plan year and such geographic region, to compare the amount (determined by historic claims data of participating providers with respect to such plan) of cost-sharing (including deductibles, copayments, and coinsurance) that the individual would be responsible for paying under such plan with respect to the furnishing of a specific item or service by any such provider. . Section 9815(a) of the Internal Revenue Code of 1986, as amended by section 2(b), is further amended— in paragraph (1), by striking section 2719A and inserting section 2719A, 2730, 2731, or 2732 ; and in paragraph (2), by striking section 2719A and inserting section 2719A, 2730, 2731, or 2732 . The table of sections for such subchapter, as amended by section 2(b), is further amended by adding at the end the following new items: Sec. 9817. Continuity of care. Sec. 9818. Information required to be included on health insurance membership cards. Sec. 9819. Maintenance of price comparison tool. . 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.), as amended by section 2(c), is further amended by adding at the end the following new sections: 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 a group health plan 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— such contractual relationship is terminated (as defined in paragraph (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 the provider or facility in such plan or coverage; or 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

(A)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 such provider or facility. In this section: The term continuing care patient means an individual who, with respect to a provider or facility— is undergoing a course of treatment for a serious and complex condition from the provider or facility; is undergoing a course of institutional or inpatient care from the provider or facility; is scheduled to undergo nonelective surgery from the provide or facility, including receipt of postoperative care from such provider or facility with respect to such a surgery; is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or 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. The term serious and complex condition means, with respect to a participant, beneficiary, or enrollee under a group health plan or health insurance coverage— 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 in the case of a chronic illness or condition, a condition that— is life-threatening, degenerative, potentially disabling, or congenital; and requires specialized medical care over a prolonged period of time. 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. In the case of a group health plan or health insurance issuer offering group health insurance coverage that provides a physical or electronic card indicating membership in such plan or coverage to an individual enrolled under such plan or coverage, such group health plan or issuer shall include on such card each of the following: The nearest hospital to the primary residence of such individual that has in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage. A telephone number or Internet website address through which such individual may seek consumer assistance information, such as information related to hospitals and urgent care facilities that have in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage. Any deductible applicable to such individual. Any out-of-pocket maximum applicable to such individual. Any cost-sharing obligation applicable to such individual for a visit at an emergency department, or urgent care facility, that has in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage. In connection with the offering of a group health plan or group health insurance coverage in a geographic region for a plan year, a plan sponsor or health insurance issuer, respectively, shall employ an individual to offer price comparison guidance, or make available on an Internet website a price comparison tool, that (to the extent practicable) allows an individual enrolled under such plan or coverage, with respect to such plan year and such geographic region, to compare the amount (determined by historic claims data of participating providers with respect to such plan or coverage) of cost-sharing (including deductibles, copayments, and coinsurance) that the individual would be responsible for paying under such plan or coverage with respect to the furnishing of a specific item or service by any such provider. . Section 715(a) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185d(a) ), as amended by section 2(c), is further amended— in paragraph (1), by striking section 2719A and inserting section 2719A, 2730, 2731, or 2732 ; and in paragraph (2), by striking section 2719A and inserting section 2719A, 2730, 2731, or 2732 . 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 716 the following new items: Sec. 717. Continuity of care. Sec. 718. Information required to be included on health insurance membership cards. Sec. 719. Maintenance of price comparison tool. . The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2022.

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U.S. Code

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42 USC 300gg–11

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Sec. 9

Additional consumer protections

U.S.C.§ 1185

U.S.C.§ 1185d

Cite42 USC 300gg–11

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