QUESTION:
As of last week, we no longer maintain a contract with a particular insurer, resulting in a change of network status. How do we handle patients who are now considered “out-of-network”?
OUR ANSWER FROM HORTYSPRINGER ATTORNEY MARY PATERNI:
The No Surprises Act has anticipated this issue. Moving forward, if a contract terminates between a plan and provider or facility, the NSA applies continuity of care protections to individuals who are considered a “continuing care patient” and who are in the process of receiving items or services from the facility for which their insurance would cover.
In the event a plan’s contract is terminated with a provider or facility, the plan will notify its enrollees who are continuing care patients. These patients will have the right to elect continued transitional care from the provider and can choose to have the same benefits as they would have had under the plan had the contract not terminated. This election would only apply to the course of treatment currently being furnished by the provider or facility that qualifies the individual as a continuing care patient.
If the patient elects to continue treatment with their provider or facility, then the provider or facility must (1) accept payment from the plan for items or services furnished to the continuing care patient as payment in full and (2) continue to adhere to the policies, procedures and standards imposed by the plan for the individual as if the termination has not occurred.
According to CMS, this election may continue for the earlier of 90 days from the time the patient is notified of the plan’s termination or until the date on which the patient no longer qualifies as a continuing care patient with the provider or facility.
As an example, if a pregnant woman learns at her next obstetrician appointment that her physician no longer maintains a contract with her insurance, she would be eligible for continuity of care protections because she is receiving ongoing treatment for her pregnancy.
If you have a quick question about this, e-mail Mary Paterni at mpaterni@hortyspringer.com.