“(2) Reimbursement—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 who is a participant, beneficiary, or enrollee of such plan or coverage at an amount equal to the greatest of—
“(A) the median amount negotiated with in-network providers for the emergency service;
“(B) the amount for the emergency service calculated using the same method the plan or issuer uses to determine payments for out-of-network services that are not emergency services; or
“(C) 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.”
“(e) Coverage of services by out-of-Network providers based on plan or issuer error
“(1) In general—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 who is a participant, beneficiary, or enrollee of such plan or coverage if—
“(A) the plan or issuer would have provided coverage of the service if the service was provided by an in-network provider; and
“(B) in choosing such provider, the individual reasonably relied on a materially inaccurate, incomplete, or misleading statement of information contained in a directory of in-network providers compiled by the plan or issuer.
“(2) Cost-sharing—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 requirement that would apply if the services were provided in-network.
“(f) Coverage for enrollees in active course of treatment
“(1) In general—A group health plan or health insurance issuer offering group or individual health insurance coverage shall, at the request of an individual who is a participant, beneficiary, or enrollee of such plan or coverage and in accordance with paragraphs (4) and (5), provide to such individual coverage of services for an active course of treatment provided by a provider that is an out-of-network provider with respect to such plan or coverage if—
“(A) coverage of such services would be provided under the group health plan or health insurance coverage if the services were provided by an in-network provider; and
“(B) a circumstance described in paragraph (3) applies.
“(2) Cost-sharing—A group health plan or health insurance issuer offering group or individual health insurance coverage shall ensure that any cost-sharing requirements for coverage of services for an active course of treatment provided by an out-of-network provider under paragraph (1) are the same requirements as if such services were provided by an in-network provider.
“(3) Circumstance—A circumstance described in this paragraph is a circumstance in which—
“(A) with respect to a health insurance issuer offering group or individual health insurance coverage—
“(i) the individual was receiving services for the active course of treatment described in paragraph (1) from the out-of-network provider described in such paragraph during the prior plan year when—
“(I) the individual was a participant, beneficiary, or enrollee of a different health insurance coverage offered by such health insurance issuer; and
“(II) such provider was an in-network provider with respect to such different health insurance coverage; and
“(ii) the health insurance issuer decided to cancel or discontinue offering such different health insurance coverage for the plan year for which the individual makes the request, including a case in which such different health insurance coverage is withdrawn from the market for such plan year; and
“(B) the individual was receiving services for the active course of treatment described in paragraph (1) from the out-of-network provider described in such paragraph while the provider was an in-network provider for the group health plan or health insurance coverage for the plan year, and, during such plan year, the provider became a terminated provider with respect to such plan or coverage for the remainder of such plan year.
“(4) Duration—A group health plan or health insurance issuer offering group or individual health insurance coverage shall provide coverage of services for an active course of treatment under paragraph (1) until the earlier of—
“(A) the date on which the treatment is complete; or
“(B) the date that is 180 days following the first date on which the provider described in paragraph (1) is no longer an in-network provider of the plan or coverage in providing such services to the individual.
“(5) Request for continuity of care—A request made under paragraph (1) shall be subject to any internal or external grievance or appeals process of the group health plan or health insurance issuer, in accordance with any applicable State or Federal law.
“(6) Definitions—For purposes of this subsection:
“(A) Active course of treatment—The term active course of treatment means any of the following:
“(i) An ongoing course of treatment for—
“(I) a life-threatening condition;
“(II) a serious, acute condition; or
“(III) a serious, chronic condition.
“(ii) Care provided with respect to pregnancy, including until the completion of postpartum care directly related to the delivery.
“(iii) An ongoing course of treatment for a child between birth and 36 months.
“(iv) The performance of a surgery or other procedure that, as documented prior to the time the provider became an out-of-network provider with respect to the group health plan or health insurance coverage—
“(I) the plan or issuer offering such coverage authorized as part of a course of treatment for the individual; and
“(II) the provider recommended for such individual.
“(B) Terminated provider—The term terminated provider—
“(i) means a provider that had a contract with a group health plan or health insurance issuer offering group or individual health insurance coverage to provide services as an in-network provider with respect to such plan or coverage for a plan year, and, during such plan year, the plan or issuer terminated such contract or did not renew such contract for the remainder of the plan year; and
“(ii) does not include—
“(I) any provider that voluntarily terminated or did not renew such contract for the remainder of the plan year; and
“(II) any provider whose contract with the plan or issuer terminated, or was not renewed, for the remainder of the plan year for reasons relating to a medical disciplinary cause, fraud, or other criminal activity.
“(g) Limitations on changes in coverage of prescription drugs
“(1) In general—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:
“(A) Remove a prescription drug from a formulary of prescription drugs covered by such plan or coverage, except as provided in paragraph (2)(C).
“(B) Increase the obligation of a participant, beneficiary, or enrollee with respect to cost-sharing, as defined in section 1302(c)(3) of the Patient Protection and Affordable Care Act, for a prescription drug covered under such plan or coverage.
“(2) Rule of construction—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 under the plan or health insurance coverage for such plan year:
“(A) Changing the policy of the plan or health insurance coverage to require a participant, beneficiary, or enrollee to use a generic substitution for a branded prescription drug.
“(B) Adding a new prescription drug to a formulary of prescription drugs covered by such plan or health insurance coverage.
“(C) Removing a prescription drug from such a formulary due to patient safety concerns, or a prescription drug recall, or removing a prescription drug from interstate commerce as determined necessary by the Secretary.”
“2730. Notification of provider terminations
“(a) In general—Beginning January 1, 2020, a group health plan or health insurance issuer offering group or individual health insurance coverage shall inform individuals described in subsection (b) of the termination of any provider as an in-network provider under the plan or health insurance coverage. Such notice shall be provided not later than 30 days prior to the termination.
“(b) Individuals—The individuals described in this subsection are any individuals enrolled in the group health plan or health insurance coverage described in subsection (a) who have seen the provider described in such subsection on a regular basis or who have received primary care from such provider.”
“(E) ensure that, to be treated as providing coverage for the essential health benefits described in paragraph (1), a qualified health plan—
“(i) shall not substitute benefits between categories described such paragraph, as described in section 156.115(b)(2)(ii) of title 45, Code of Federal Regulations, as in effect on the day before the date of enactment of the Consumer Health Insurance Protection Act of 2019;
“(ii) shall provide a wide variety of classes of prescription drugs on the prescription drug formulary of such plan;
“(iii) shall, if a medically necessary drug is not on the prescription drug formulary of such plan, allow individuals enrolled in such plan to have access to the drug through an exceptions process established by the plan; and
“(iv) shall not impose limits on coverage of habilitative services and devices that are less favorable than any such limits imposed on coverage of rehabilitative services and devices.”