HR 7227 — Mental Health and MAMA Act of 2026

(a) The Office of Personnel Management may contract with qualified carriers offering plans described by section 8903 or 8903a of this title, without regard to section 6101(b) to (d) of title 41 or other statute requiring competitive bidding. Each contract shall be for a uniform term of at least 1 year, but may be made automatically renewable from term to term in the absence of notice of termination by either party. (b) To be eligible as a carrier for the plan described by section 8903(2) of this title, a company must be licensed to issue group health insurance in all the States and the District of Columbia. (c) A contract for a plan described by section 8903(1) or (2) of this title shall require the carrier— (1) to reinsure with other companies which elect to participate, under an equitable formula based on the total amount of their group health insurance benefit payments in the United States during the latest year for which the information is available, to be determined by the carrier and approved by the Office; or (2) to allocate its rights and obligations under the contract among its affiliates which elect to participate, under an equitable formula to be determined by the carrier and the affiliates and approved by the Office. (d) Each contract under this chapter shall contain a detailed statement of benefits offered and shall include such maximums, limitations, exclusions, and other definitions of benefits as the Office considers necessary or desirable. (e) The Office may prescribe reasonable minimum standards for health benefits plans described by section 8903 or 8903a of this title and for carriers offering the plans. Approval of a plan may be withdrawn only after notice and opportunity for hearing to the carrier concerned without regard to subchapter II of chapter 5 and chapter 7 of this title. The Office may terminate the contract of a carrier effective at the end of the contract term, if the Office finds that at no time during the preceding two contract terms did the carrier have 300 or more employees and annuitants, exclusive of family members, enrolled in the plan. (f) A contract may not be made or a plan approved which excludes an individual because of race, sex, health status, or, at the time of the first opportunity to enroll, because of age. (g) A contract may not be made or a plan approved which does not offer to each employee, annuitant, family member, former spouse, or person having continued coverage under section 8905a of this title whose enrollment in the plan is ended, except by a cancellation of enrollment, a temporary extension of coverage during which he may exercise the option to convert, without evidence of good health, to a nongroup contract providing health benefits. An employee, annuitant, family member, former spouse, or person having continued coverage under section 8905a of this title who exercises this option shall pay the full periodic charges of the nongroup contract. (h) The benefits and coverage made available under subsection (g) of this section are noncancelable by the carrier except for fraud, over-insurance, or nonpayment of periodic charges. (i) Rates charged under health benefits plans described by section 8903 or 8903a of this title shall reasonably and equitably reflect the cost of the benefits provided. Rates under health benefits plans described by section 8903(1) and (2) of this title shall be determined on a basis which, in the judgment of the Office, is consistent with the lowest schedule of basic rates generally charged for new group health benefit plans issued to large employers. The rates determined for the first contract term shall be continued for later contract terms, except that they may be readjusted for any later term, based on past experience and benefit adjustments under the later contract. Any readjustment in rates shall be made in advance of the contract term in which they will apply and on a basis which, in the judgment of the Office, is consistent with the gen...

(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 s...

(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 or group 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— (A) such contractual relationship is terminated (as defined in paragraph (b)); (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 (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 or issuer, respectively, shall meet the requirements of paragraph (2) with respect to such individual. (2) Requirements The requirements of this paragraph are that the plan or issuer— (A) 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; (B) provide such individual with an opportunity to notify the plan or issuer of the individual’s need for transitional care; and (C) 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— (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 provide 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 1395x(dd)(3)(A) of title 42) 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 or group health insurance coverage— (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 (...

(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 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— (A) such contractual relationship is terminated (as defined in subsection (b)); (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 (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 or issuer, respectively, shall meet the requirements of paragraph (2) with respect to such individual. (2) Requirements The requirements of this paragraph are that the plan or issuer— (A) 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; (B) provide such individual with an opportunity to notify the plan or issuer of the individual’s need for transitional care; and (C) 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— (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, 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 1395x(dd)(3)(A) of this title) 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, beneficiary, or enrollee under a group health plan or group or individual health insurance coverage— (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 is— 1 (i) is life-threatening, degenerative, potent...