Continuity of Care

Continuity of care is the legal and contractual protection that lets a patient continue to see their current provider — even after that provider leaves the network — for a limited time during an active course of treatment. The protection prevents mid-treatment disruption when a provider terminates their network contract, when an employer changes carriers, or when a member changes plans and their existing provider isn't in the new network.

The specifics vary by state and plan type. Under ACA rules, group health plans must offer continuity-of-care benefits for at least 90 days after a provider goes out-of-network for members who are undergoing treatment for a serious or complex condition, are hospitalized, are pregnant (typically through delivery and postpartum), or are terminally ill. State laws often extend the requirements further. During the continuity-of-care period, the member sees the now-out-of-network provider at in-network cost-share and the plan pays the provider at in-network rates, so the member isn't balance-billed and the plan's cost isn't inflated. The provider has to agree to accept the terms; if they don't, the continuity right may not apply. Employers changing carriers should build continuity provisions into the transition plan and communicate them proactively — otherwise members with active treatment can be surprised by disrupted care or unexpected bills.

The takeaway: if your provider goes out of network mid-treatment, or if your employer changes carriers while you're in active care, ask the plan specifically about continuity-of-care benefits. In most cases you can continue current treatment at in-network rates for a defined period.