republic-os/legal/us/code/title-26/chapter-100/section-9818.md

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LegalText	26 U.S.C. § 9818	Continuity of care	us	united_states_code	code_section	26	INTERNAL REVENUE CODE	100	GROUP HEALTH PLAN REQUIREMENTS	9818	26 U.S.C. § 9818	current	119-100	2026-06-26	official	https://uscode.house.gov/download/releasepoints/us/pl/119/100/xml_usc26@119-100.zip	/us/usc/t26/s9818	data/legal/raw/us/code/title-26/usc26.xml	2e8673480360ef92a67733243cf4632a0e383932d8b9d3e048c459a25070cadc	a261f094809116f42a96648a3d5eee80fa010379d67412551c21dd5c900b27f4	384b496ddfc005d3089a00f7104726201b33fa879454ff4ec55f113b260210c5	2026-07-04	official	legal us-code

26 U.S.C. § 9818 - Continuity of care

Text

(a) Ensuring continuity of care with respect to terminations of certain contractual relationships resulting in changes in provider network status (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—

(A) such contractual relationship is terminated (as defined in paragraph (b));

(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

(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.

(2) Requirements The requirements of this paragraph are that the plan—

(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;

(B) provide such individual with an opportunity to notify the plan of the individual’s need for transitional care; and

(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) the 90-day period beginning on such date; or

(ii) the date on which such individual is no longer a continuing care patient with respect to such provider or facility.

(b) Definitions In this section:

(1) Continuing care patient The term “continuing care patient” means an individual who, with respect to a provider or facility—

(A) is undergoing a course of treatment for a serious and complex condition from the provider or facility;

(B) is undergoing a course of institutional or inpatient care from the provider or facility;

(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;

(D) is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or

(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.

(2) Serious and complex condition The term “serious and complex condition” means, with respect to a participant or beneficiary under a group health plan—

(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

(B) in the case of a chronic illness or condition, a condition that—

(i) is life-threatening, degenerative, potentially disabling, or congenital; and

(ii) requires specialized medical care over a prolonged period of time.

(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 Pub. L. 116–260, div. BB, title I, § 113(b)(1), Dec. 27, 2020, 134 Stat. 2870.)

Notes

Editorial Notes

References in TextSection 1861(dd)(3)(A) of the Social Security Act, referred to in subsec. (b)(1)(E), is classified to section 1395x(dd)(3)(A) of Title 42, The Public Health and Welfare.

Statutory Notes and Related Subsidiaries

Effective DatePub. L. 116–260, div. BB, title I, § 113(e), Dec. 27, 2020, 134 Stat. 2873, provided that: “The amendments made by subsections (a), (b), and (c) [enacting this section, section 1185g of Title 29, Labor, and section 300gg–113 of Title 42, The Public Health and Welfare] shall apply with respect to plan years beginning on or after January 1, 2022.”