Substitute Senate Bill No. 683
Public Act No. 21-129
AN ACT CONCERNING HOSPITAL BILLING AND COLLECTION
EFFORTS BY HOSPITALS AND COLLECTION AGENCIES.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 19a-673 of the general statutes is repealed and the
following is substituted in lieu thereof (Effective October 1, 2022):
(a) As used in this section:
(1) "Affiliated with" means (A) employed by a hospital or health
system, (B) under a professional services agreement with a hospital or
health system that permits such hospital or health system to bill on
behalf of such entity, or (C) a clinical faculty member of a medical
school, as defined in section 33-182aa, who is affiliated with a hospital
or health system in a manner that permits such hospital or health system
to bill on behalf of such clinical faculty member.
(2) "Collection agent" has the same meaning as provided in section
19a-509b.
[(1)] (3) "Cost of providing services" means a hospital's published
charges at the time of billing, multiplied by the hospital's most recent
relationship of costs to charges as taken from the hospital's most recently
available annual financial filing with the unit. Substitute Senate Bill No. 683
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[(2)] (4) "Hospital" [means an institution licensed by the Department
of Public Health as a short-term general hospital] has the same meaning
as provided in section 19a-490.
(5) "Owned by" means owned by a hospital or health system when
billed under the hospital's tax identification number.
[(3)] (6) "Poverty income guidelines" means the poverty income
guidelines issued from time to time by the United States Department of
Health and Human Services.
[(4)] (7) "Uninsured patient" means any person who is liable for one
or more hospital charges whose income is at or below two hundred fifty
per cent of the poverty income guidelines who (A) has applied and been
denied eligibility for any medical or health care coverage provided
under the Medicaid program due to failure to satisfy income or other
eligibility requirements, and (B) is not eligible for coverage for hospital
services under the Medicare or CHAMPUS programs, or under any
Medicaid or health insurance program of any other nation, state,
territory or commonwealth, or under any other governmental or
privately sponsored health or accident insurance or benefit program
including, but not limited to, workers' compensation and awards,
settlements or judgments arising from claims, suits or proceedings
involving motor vehicle accidents or alleged negligence.
(b) No hospital or entity that is owned by or affiliated with such
hospital that has provided health care [services] to an uninsured patient
may collect from the uninsured patient more than the cost of providing
[services] such health care.
(c) Each collection agent [, as defined in section 19a-509b,] engaged in
collecting a debt from a patient arising from [services] health care
provided at a hospital shall provide written notice to such patient as to
whether the hospital deems the patient an insured patient or [an] Substitute Senate Bill No. 683
Public Act No. 21-129 3 of 16
uninsured patient and the reasons for such determination.
Sec. 2. Section 19a-673b of the general statutes is repealed and the
following is substituted in lieu thereof (Effective October 1, 2022):
(a) As used in this section:
(1) "Affiliated with" means (A) employed by a hospital or health
system, (B) under a professional services agreement with a hospital or
health system that permits such hospital or health system to bill on
behalf of such entity, or (C) a clinical faculty member of a medical
school, as defined in section 33-182aa, who is affiliated with a hospital
or health system in a manner that permits such hospital or health system
to bill on behalf of such clinical faculty member.
(2) "Owned by" means owned by a hospital or health system when
billed under the hospital's tax identification number.
[(a)] (b) No hospital, as defined in section 19a-490, or entity that is
owned by or affiliated with such hospital shall refer to a collection agent,
as defined in section 19a-509b, or initiate an action against an individual
patient or such patient's estate to collect fees arising from health care
provided at a hospital or entity that is owned by or affiliated with such
hospital on or after October 1, 2003, unless the hospital [has made a
determination whether] or entity that is owned by or affiliated with such
hospital has determined that such individual patient is [(1)] an
uninsured patient, as defined in section 19a-673, as amended by this act,
[and (2) not eligible] who is ineligible for the hospital bed fund.
(c) On or after October 1, 2022, no hospital or entity that is owned by
or affiliated with such hospital, as defined in section 19a-490, and no
collection agent, as defined in section 19a-509b, that receives a referral
from a hospital or entity that is owned by or affiliated with such
hospital, shall: Substitute Senate Bill No. 683
Public Act No. 21-129 4 of 16
(1) Report an individual patient to a credit rating agency, as defined
in section 36a-695, for a period of one year beginning on the date that
such patient first receives a bill for health care provided by the hospital
or entity that is owned by or affiliated with such hospital to such patient
on or after October 1, 2022;
(2) Initiate an action to foreclose a lien on an individual patient's
primary residence if the lien was filed to secure payment for health care
provided by the hospital or entity that is owned by or affiliated with
such hospital to such patient on or after October 1, 2022; or
(3) Apply to a court for an execution against an individual patient's
wages pursuant to section 52-361a, or otherwise seek to garnish such
patient's wages, to collect payment for health care provided by the
hospital or entity that is owned by or affiliated with such hospital to
such patient on or after October 1, 2022, if such patient is eligible for the
hospital bed fund.
[(b)] (d) Nothing in [this] subsection (b) or (c) of this section shall
affect [a hospital's] the ability of a hospital or entity that is owned by or
affiliated with such hospital to initiate an action against an individual
patient or such patient's estate to collect coinsurance, deductibles or fees
arising from health care provided at a hospital or entity that is owned
by or affiliated with such hospital where such coinsurance, deductibles
or fees may be eligible for reimbursement through awards, settlements
or judgments arising from claims, suits or proceedings. In addition,
nothing in [this section] said subsections shall affect [a hospital's] the
ability of a hospital or entity that is owned by or affiliated with such
hospital to initiate an action against an individual patient or such
patient's estate where payment or reimbursement has been made, or
likely is to be made, directly to the patient.
Sec. 3. Section 19a-673d of the general statutes is repealed and the
following is substituted in lieu thereof (Effective October 1, 2022): Substitute Senate Bill No. 683
Public Act No. 21-129 5 of 16
(a) As used in this section:
(1) "Affiliated with" means (A) employed by a hospital or health
system, (B) under a professional services agreement with a hospital or
health system that permits such hospital or health system to bill on
behalf of such entity, or (C) a clinical faculty member of a medical
school, as defined in section 33-182aa, who is affiliated with a hospital
or health system in a manner that permits such hospital or health system
to bill on behalf of such clinical faculty member.
(2) "Owned by" means owned by a hospital or health system when
billed under the hospital's tax identification number.
(b) If, at any point in the debt collection process, whether before or
after the entry of judgment, a hospital [, a consumer collection agency
acting on behalf of the hospital, an attorney representing the hospital or
any employee or agent of the hospital] or entity that is owned by or
affiliated with such hospital, as defined in section 19a-490, or a collection
agent, as defined in section 19a-509b, becomes aware that a debtor from
whom the hospital or entity that is owned by or affiliated with such
hospital is seeking payment for [services] health care rendered receives
information that the debtor is eligible for hospital bed funds, free or
reduced price hospital services [,] or any other program which would
result in the elimination of liability for the debt or reduction in the
amount of such liability, [the] such hospital [, collection agency,
attorney, employee or agent] or entity that is owned by or affiliated with
such hospital or collection agent shall promptly discontinue all
collection efforts against such debtor for such health care and refer the
collection file for such health care to [the] such hospital [for
determination of such eligibility. The] or entity that is owned by or
affiliated with such hospital until such hospital or entity determines
whether such debtor is eligible for such elimination or reduction. Such
collection [effort] efforts shall not resume until such hospital or entity
makes such determination. [is made.] Substitute Senate Bill No. 683
Public Act No. 21-129 6 of 16
Sec. 4. Section 19a-508c of the general statutes is repealed and the
following is substituted in lieu thereof (Effective October 1, 2022):
(a) As used in this section:
(1) "Affiliated provider" means a provider that is: (A) Employed by a
hospital or health system, (B) under a professional services agreement
with a hospital or health system that permits such hospital or health
system to bill on behalf of such provider, or (C) a clinical faculty member
of a medical school, as defined in section 33-182aa, that is affiliated with
a hospital or health system in a manner that permits such hospital or
health system to bill on behalf of such clinical faculty member;
(2) "Campus" means: (A) The physical area immediately adjacent to a
hospital's main buildings and other areas and structures that are not
strictly contiguous to the main buildings but are located within two
hundred fifty yards of the main buildings, or (B) any other area that has
been determined on an individual case basis by the Centers for Medicare
and Medicaid Services to be part of a hospital's campus;
(3) "Facility fee" means any fee charged or billed by a hospital or
health system for outpatient services provided in a hospital-based
facility that is: (A) Intended to compensate the hospital or health system
for the operational expenses of the hospital or health system, and (B)
separate and distinct from a professional fee;
(4) "Health system" means: (A) A parent corporation of one or more
hospitals and any entity affiliated with such parent corporation through
ownership, governance, membership or other means, or (B) a hospital
and any entity affiliated with such hospital through ownership,
governance, membership or other means;
(5) "Hospital" has the same meaning as provided in section 19a-490;
(6) "Hospital-based facility" means a facility that is owned or Substitute Senate Bill No. 683
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operated, in whole or in part, by a hospital or health system where
hospital or professional medical services are provided;
(7) "Payer mix" means the proportion of different sources of payment
received by a hospital or health system, including, but not limited to,
Medicare, Medicaid, other government-provided insurance, private
insurance and self-pay patients;
[(7)] (8) "Professional fee" means any fee charged or billed by a
provider for professional medical services provided in a hospital-based
facility; [and]
[(8)] (9) "Provider" means an individual, entity, corporation or health
care provider, whether for profit or nonprofit, whose primary purpose
is to provide professional medical services; and
(10) "Tagline" means a short statement written in a non-English
language that indicates the availability of language assistance services
free of charge.
(b) If a hospital or health system charges a facility fee utilizing a
current procedural terminology evaluation and management (CPT
E/M) code or assessment and management (CPT A/M) code for
outpatient services provided at a hospital-based facility where a
professional fee is also expected to be charged, the hospital or health
system shall provide the patient with a written notice that includes the
following information:
(1) That the hospital-based facility is part of a hospital or health
system and that the hospital or health system charges a facility fee that
is in addition to and separate from the professional fee charged by the
provider;
(2) (A) The amount of the patient's potential financial liability,
including any facility fee likely to be charged, and, where professional Substitute Senate Bill No. 683
Public Act No. 21-129 8 of 16
medical services are provided by an affiliated provider, any professional
fee likely to be charged, or, if the exact type and extent of the
professional medical services needed are not known or the terms of a
patient's health insurance coverage are not known with reasonable
certainty, an estimate of the patient's financial liability based on typical
or average charges for visits to the hospital-based facility, including the
facility fee, (B) a statement that the patient's actual financial liability will
depend on the professional medical services actually provided to the
patient, (C) an explanation that the patient may incur financial liability
that is greater than the patient would incur if the professional medical
services were not provided by a hospital-based facility, and (D) a
telephone number the patient may call for additional information
regarding such patient's potential financial liability, including an
estimate of the facility fee likely to be charged based on the scheduled
professional medical services; and
(3) That a patient covered by a health insurance policy should contact
the health insurer for additional information regarding the hospital's or
health system's charges and fees, including the patient's potential
financial liability, if any, for such charges and fees.
(c) If a hospital or health system charges a facility fee without
utilizing a current procedural terminology evaluation and management
(CPT E/M) code for outpatient services provided at a hospital-based
facility, located outside the hospital campus, the hospital or health
system shall provide the patient with a written notice that includes the
following information:
(1) That the hospital-based facility is part of a hospital or health
system and that the hospital or health system charges a facility fee that
may be in addition to and separate from the professional fee charged by
a provider;
(2) (A) A statement that the patient's actual financial liability will Substitute Senate Bill No. 683
Public Act No. 21-129 9 of 16
depend on the professional medical services actually provided to the
patient, (B) an explanation that the patient may incur financial liability
that is greater than the patient would incur if the hospital-based facility
was not hospital-based, and (C) a telephone number the patient may call
for additional information regarding such patient's potential financial
liability, including an estimate of the facility fee likely to be charged
based on the scheduled professional medical services; and
(3) That a patient covered by a health insurance policy should contact
the health insurer for additional information regarding the hospital's or
health system's charges and fees, including the patient's potential
financial liability, if any, for such charges and fees.
(d) [On and after January 1, 2016, each] Each initial billing statement
that includes a facility fee shall: (1) Clearly identify the fee as a facility
fee that is billed in addition to, or separately from, any professional fee
billed by the provider; (2) provide the corresponding Medicare facility
fee reimbursement rate for the same service as a comparison or, if there
is no corresponding Medicare facility fee for such service, (A) the
approximate amount Medicare would have paid the hospital for the
facility fee on the billing statement, or (B) the percentage of the hospital's
charges that Medicare would have paid the hospital for the facility fee;
(3) include a statement that the facility fee is intended to cover the
hospital's or health system's operational expenses; (4) inform the patient
that the patient's financial liability may have been less if the services had
been provided at a facility not owned or operated by the hospital or
health system; and (5) include written notice of the patient's right to
request a reduction in the facility fee or any other portion of the bill and
a telephone number that the patient may use to request such a reduction
without regard to whether such patient qualifies for, or is likely to be
granted, any reduction. Not later than October 15, 2022, and annually
thereafter, each hospital, health system and hospital-based facility shall
submit to the Health Planning Unit of the Office of Health Strategy a Substitute Senate Bill No. 683
Public Act No. 21-129 10 of 16
sample of a billing statement issued by such hospital, health system or
hospital-based facility that complies with the provisions of this
subsection and which represents the format of billing statements
received by patients. Such billing statement shall not contain patient
identifying information.
(e) The written notice described in subsections (b) to (d), inclusive,
and (h) to (j), inclusive, of this section shall be in plain language and in
a form that may be reasonably understood by a patient who does not
possess special knowledge regarding hospital or health system facility
fee charges. On and after October 1, 2022, such notices shall include tag
lines in at least the top fifteen languages spoken in the state indicating
that the notice is available in each of those top fifteen languages. The
fifteen languages shall be either the languages in the list published by
the Department of Health and Human Services in connection with
section 1557 of the Patient Protection and Affordable Care Act, P.L. 111-
148, or, as determined by the hospital or health system, the top fifteen
languages in the geographic area of the hospital-based facility.
(f) (1) For nonemergency care, if a patient's appointment is scheduled
to occur ten or more days after the appointment is made, such written
notice shall be sent to the patient by first class mail, encrypted electronic
mail or a secure patient Internet portal not less than three days after the
appointment is made. If an appointment is scheduled to occur less than
ten days after the appointment is made or if the patient arrives without
an appointment, such notice shall be hand-delivered to the patient when
the patient arrives at the hospital-based facility.
(2) For emergency care, such written notice shall be provided to the
patient as soon as practicable after the patient is stabilized in accordance
with the federal Emergency Medical Treatment and Active Labor Act,
42 USC 1395dd, as amended from time to time, or is determined not to
have an emergency medical condition and before the patient leaves the
hospital-based facility. If the patient is unconscious, under great duress Substitute Senate Bill No. 683
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or for any other reason unable to read the notice and understand and
act on his or her rights, the notice shall be provided to the patient's
representative as soon as practicable.
(g) Subsections (b) to (f), inclusive, and (l) of this section shall not
apply if a patient is insured by Medicare or Medicaid or is receiving
services under a workers' compensation plan established to provide
medical services pursuant to chapter 568.
(h) A hospital-based facility shall prominently display written notice
in locations that are readily accessible to and visible by patients,
including patient waiting or appointment check-in areas, stating: (1)
That the hospital-based facility is part of a hospital or health system, (2)
the name of the hospital or health system, and (3) that if the hospital-
based facility charges a facility fee, the patient may incur a financial
liability greater than the patient would incur if the hospital-based
facility was not hospital-based. On and after October 1, 2022, such
notices shall include tag lines in at least the top fifteen languages spoken
in the state indicating that the notice is available in each of those top
fifteen languages. The fifteen languages shall be either the languages in
the list published by the Department of Health and Human Services in
connection with section 1557 of the Patient Protection and Affordable
Care Act, P.L. 111-148, or, as determined by the hospital or health
system, the top fifteen languages in the geographic area of the hospital-
based facility. Not later than October 1, 2022, and annually thereafter,
each hospital-based facility shall submit a copy of the written notice
required by this subsection to the Health Systems Planning Unit of the
Office of Health Strategy.
(i) A hospital-based facility shall clearly hold itself out to the public
and payers as being hospital-based, including, at a minimum, by stating
the name of the hospital or health system in its signage, marketing
materials, Internet web sites and stationery. Substitute Senate Bill No. 683
Public Act No. 21-129 12 of 16
(j) A hospital-based facility shall, when scheduling services for which
a facility fee may be charged, inform the patient (1) that the hospital-
based facility is part of a hospital or health system, (2) of the name of the
hospital or health system, (3) that the hospital or health system may
charge a facility fee in addition to and separate from the professional fee
charged by the provider, and (4) of the telephone number the patient
may call for additional information regarding such patient's potential
financial liability.
(k) (1) [On and after January 1, 2016, if any transaction, as] If any
transaction described in subsection (c) of section 19a-486i, results in the
establishment of a hospital-based facility at which facility fees [will
likely] may be billed, the hospital or health system, that is the purchaser
in such transaction shall, not later than thirty days after such transaction,
provide written notice, by first class mail, of the transaction to each
patient served within the [previous] three years preceding the date of
the transaction by the health care facility that has been purchased as part
of such transaction.
(2) Such notice shall include the following information:
(A) A statement that the health care facility is now a hospital-based
facility and is part of a hospital or health system, the health care facility's
full legal and business name and the date of such facility's acquisition
by a hospital or health system;
(B) The name, business address and phone number of the hospital or
health system that is the purchaser of the health care facility;
(C) A statement that the hospital-based facility bills, or is likely to bill,
patients a facility fee that may be in addition to, and separate from, any
professional fee billed by a health care provider at the hospital-based
facility;
(D) (i) A statement that the patient's actual financial liability will Substitute Senate Bill No. 683
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depend on the professional medical services actually provided to the
patient, and (ii) an explanation that the patient may incur financial
liability that is greater than the patient would incur if the hospital-based
facility were not a hospital-based facility;
(E) The estimated amount or range of amounts the hospital-based
facility may bill for a facility fee or an example of the average facility fee
billed at such hospital-based facility for the most common services
provided at such hospital-based facility; and
(F) A statement that, prior to seeking services at such hospital-based
facility, a patient covered by a health insurance policy should contact
the patient's health insurer for additional information regarding the
hospital-based facility fees, including the patient's potential financial
liability, if any, for such fees.
(3) A copy of the written notice provided to patients in accordance
with this subsection shall be filed with the Health Systems Planning
Unit of the Office of Health Strategy, established under section 19a-612.
Said unit shall post a link to such notice on its Internet web site.
(4) A hospital, health system or hospital-based facility shall not collect
a facility fee for services provided at a hospital-based facility that is
subject to the provisions of this subsection from the date of the
transaction until at least thirty days after the written notice required
pursuant to this subsection is mailed to the patient or a copy of such
notice is filed with the Health Systems Planning Unit, whichever is later.
A violation of this subsection shall be considered an unfair trade
practice pursuant to section 42-110b.
(5) Not later than July 1, 2023, and annually thereafter, each hospital-
based facility that was the subject of a transaction, as described in
subsection (c) of section 19a-486i, during the preceding calendar year
shall report to the Health Systems Planning Unit the number of patients Substitute Senate Bill No. 683
Public Act No. 21-129 14 of 16
served by such hospital-based facility in the preceding three years.
(l) Notwithstanding the provisions of this section, no hospital, health
system or hospital-based facility shall collect a facility fee for (1)
outpatient health care services that use a current procedural
terminology evaluation and management (CPT E/M) code or
assessment and management (CPT A/M) code and are provided at a
hospital-based facility located off-site from a hospital campus, or (2)
outpatient health care services provided at a hospital-based facility
located off-site from a hospital campus, received by a patient who is
uninsured of more than the Medicare rate. Notwithstanding the
provisions of this subsection, in circumstances when an insurance
contract that is in effect on July 1, 2016, provides reimbursement for
facility fees prohibited under the provisions of this section, a hospital or
health system may continue to collect reimbursement from the health
insurer for such facility fees until the date of expiration, renewal or
amendment of such contract, whichever such date is the earliest. A
violation of this subsection shall be considered an unfair trade practice
pursuant to chapter 735a. The provisions of this subsection shall not
apply to a freestanding emergency department. As used in this
subsection, "freestanding emergency department" means a freestanding
facility that (A) is structurally separate and distinct from a hospital, (B)
provides emergency care, (C) is a department of a hospital licensed
under chapter 368v, and (D) has been issued a certificate of need to
operate as a freestanding emergency department pursuant to chapter
368z.
(m) (1) Each hospital and health system shall report not later than July
1, [2016] 2023, and annually thereafter to the executive director of the
Office of Health Strategy, on a form prescribed by the executive director,
concerning facility fees charged or billed during the preceding calendar
year. Such report shall include (A) the name and [location] address of
each facility owned or operated by the hospital or health system that Substitute Senate Bill No. 683
Public Act No. 21-129 15 of 16
provides services for which a facility fee is charged or billed, (B) the
number of patient visits at each such facility for which a facility fee was
charged or billed, (C) the number, total amount and range of allowable
facility fees paid at each such facility [by Medicare, Medicaid or under
private insurance policies] disaggregated by payer mix, (D) for each
facility, the total amount of facility fees charged and the total amount of
revenue received by the hospital or health system derived from facility
fees, (E) the total amount of facility fees charged and the total amount of
revenue received by the hospital or health system from all facilities
derived from facility fees, (F) a description of the ten procedures or
services that generated the greatest amount of facility fee gross revenue,
disaggregated by current procedural terminology category (CPT) code
for each such procedure or service and, for each such procedure or
service, patient volume and the total amount of gross and net revenue
received by the hospital or health system derived from facility fees, and
(G) the top ten procedures or services for which facility fees are charged
based on patient volume and the gross and net revenue received by the
hospital or health system for each such procedure or service. For
purposes of this subsection, "facility" means a hospital-based facility
that is located outside a hospital campus.
(2) The executive director shall publish the information reported
pursuant to subdivision (1) of this subsection, or post a link to such
information, on the Internet web site of the Office of Health Strategy.
Sec. 5. (Effective from passage) (a) The Office of Health Strategy shall,
within available appropriations:
(1) Study methods to improve oversight and regulation of mergers
and acquisitions of physician practices to improve health care quality
and choice in Connecticut, including, but not limited to, a review of
sections 19a-486i, 19a-639 and 19a-630 of the general statutes;
(2) Study methods to ensure the viability of physician practices; and Substitute Senate Bill No. 683
Public Act No. 21-129 16 of 16
(3) Develop legislative recommendations to improve reporting and
oversight of physician practice mergers and acquisitions, including, but
not limited to, the necessity for any amendments to section 19a-486i,
19a-639 or 19a-630 of the general statutes.
(b) Not later than February 1, 2023, the executive director of the Office
of Health Strategy shall report, in accordance with the provisions of
section 11-4a of the general statutes, to the joint standing committee of
the General Assembly having cognizance of matters relating to public
health regarding the outcome of the study and any recommendations
for legislative action as a result of such study.