EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
Underlining indicates amendments to bill.
Strike out indicates matter stricken from the bill by amendment or deleted from the law by
amendment.
*hb0268*
HOUSE BILL 268
J3 5lr1369
(PRE–FILED) CF SB 981
By: Delegate Charkoudian Delegates Charkoudian, Pena –Melnyk, Cullison,
Bagnall, Bhandari, Guzzone, Hill, S. Johnson, Kaiser, Kerr, Lopez,
Martinez, Rosenberg, Taveras, White Holland, Woods, and Woorman
Requested: October 25, 2024
Introduced and read first time: January 8, 2025
Assigned to: Health and Government Operations
Committee Report: Favorable with amendments
House action: Adopted
Read second time: February 25, 2025
CHAPTER ______
AN ACT concerning 1
Hospitals – Financial Assistance and Collection of Debts – Policies 2
FOR the purpose of excluding a civil action on a certain contract between a hospital and a 3
consumer from a certain provision of law establishing the statute of limitations on 4
civil actions on certain specialties; altering provisions of law related to a hospital’s 5
financial assistance and collection of debts policies; specifying the percentage by 6
which a hospital is required to reduce a patient’s out–of–pocket expenses under 7
certain circumstances; adding to the notice requirements relating to a hospital’s 8
financial assistance policy; prohibiting a hospital from filing a civil action to collect 9
a debt against a patient whose outstanding debt is at or below a certain amount; 10
altering the monthly payment amount for an income–based payment plan for 11
medical debt; increasing the number of days before interest payments on medical 12
debt may be assessed; increasing the number of days before a hospital is authorized 13
to commence civil action against a patient to collect a debt; and generally relating to 14
hospital financial assistance and collection of debts policies. 15
BY repealing and reenacting, without amendments, 16
Article – Courts and Judicial Proceedings 17
Section 5–101 and 5–1201(a) and (e) 18
Annotated Code of Maryland 19
(2020 Replacement Volume and 2024 Supplement) 20
2 HOUSE BILL 268
BY repealing and reenacting, with amendments, 1
Article – Courts and Judicial Proceedings 2
Section 5–102 3
Annotated Code of Maryland 4
(2020 Replacement Volume and 2024 Supplement) 5
BY repealing and reenacting, without amendments, 6
Article – Health – General 7
Section 19–201(a) and (e) and 19–301(a) and (f) 8
Annotated Code of Maryland 9
(2023 Replacement Volume and 2024 Supplement) 10
BY repealing and reenacting, with amendments, 11
Article – Health – General 12
Section 19–214.1 and 19–214.2 13
Annotated Code of Maryland 14
(2023 Replacement Volume and 2024 Supplement) 15
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 16
That the Laws of Maryland read as follows: 17
Article – Courts and Judicial Proceedings 18
5–101. 19
A civil action at law shall be filed within three years from the date it accrues unless 20
another provision of the Code provides a different period of time within which an action 21
shall be commenced. 22
5–102. 23
(a) An action on one of the following specialties shall be filed within 12 years after 24
the cause of action accrues, or within 12 years from the date of the death of the last to die 25
of the principal debtor or creditor, whichever is sooner: 26
(1) Promissory note or other instrument under seal; 27
(2) Bond except a public officer’s bond; 28
(3) Judgment; 29
(4) Recognizance; 30
(5) Contract under seal; or 31
(6) Any other specialty. 32
HOUSE BILL 268 3
(b) A payment of principal or interest on a specialty suspends the operation of 1
this section as to the specialty for three years after the date of payment. 2
(c) This section does not apply to: 3
(1) A specialty taken for the use of the State; [or] 4
(2) A deed of trust, mortgage, or promissory note that has been signed 5
under seal and secures or is secured by owner–occupied residential property, as defined in 6
§ 7–105.1 of the Real Property Article; OR 7
(3) A CONTRACT, INCLUDING A CONT RACT UNDER SEAL , OR A 8
PROMISSORY NOTE OR O THER INSTRUMENT UNDE R SEAL THAT IS: 9
(I) RELATED TO AN OBLIGAT ION OF A CONSUMER TO PAY 10
CONSUMER DEBT , AS DEFINED IN § 5–1201 OF THIS TITLE, THAT ARISES FROM 11
HOSPITAL SERVICES , AS DEFINED IN § 19–201 OF THE HEALTH – GENERAL 12
ARTICLE; AND 13
(II) BETWEEN A CONSUMER AN D A HOSPITAL, AS DEFINED IN § 14
19–301 OF THE HEALTH – GENERAL ARTICLE. 15
5–1201. 16
(a) In this subtitle the following words have the meanings indicated. 17
(e) “Consumer debt” means a secured or an unsecured debt that: 18
(1) Is for money owed or alleged to be owed; and 19
(2) Arises from a consumer transaction. 20
Article – Health – General 21
19–201. 22
(a) In this subtitle the following words have the meanings indicated. 23
(e) (1) “Hospital services” means: 24
(i) Inpatient hospital services as enumerated in Medicare 25
Regulation 42 C.F.R. § 409.10, as amended; 26
(ii) Emergency services, including services provided at a 27
freestanding medical facility licensed under Subtitle 3A of this title; 28
4 HOUSE BILL 268
(iii) Outpatient services provided at a hospital; 1
(iv) Outpatient services, as specified by the Commission in 2
regulation, provided at a freestanding medical facility licensed under Subtitle 3A of this 3
title that has received: 4
1. A certificate of need under § 19–120(o)(1) of this title; or 5
2. An exemption from obtaining a certificate of need under § 6
19–120(o)(3) of this title; and 7
(v) Identified physician services for which a facility has 8
Commission–approved rates on June 30, 1985. 9
(2) “Hospital services” includes a hospital outpatient service: 10
(i) Of a hospital that, on or before June 1, 2015, is under a merged 11
asset hospital system; 12
(ii) That is designated as a part of another hospital under the same 13
merged asset hospital system to make it possible for the hospital outpatient service to 14
participate in the 340B Program under the federal Public Health Service Act; and 15
(iii) That complies with all federal requirements for the 340B 16
Program and applicable provisions of 42 C.F.R. § 413.65. 17
(3) “Hospital services” does not include: 18
(i) Outpatient renal dialysis services; or 19
(ii) Outpatient services provided at a limited service hospital as 20
defined in § 19–301 of this title, except for emergency services. 21
19–214.1. 22
(a) (1) In this section the following words have the meanings indicated. 23
(2) “Financial hardship” means medical debt, incurred by a family over a 24
12–month period, that exceeds 25% of family income. 25
(3) “Medical debt” means out–of–pocket expenses, [excluding] INCLUDING 26
co–payments, coinsurance, and deductibles, for medical costs [billed by a hospital]. 27
(4) “MEDICALLY NECESSARY C ARE” MEANS CARE THAT IS : 28
HOUSE BILL 268 5
(I) DIRECTLY RELATED TO D IAGNOSTIC, PREVENTIVE, 1
CURATIVE, PALLIATIVE, REHABILITATIVE , OR AMELIORATIVE TREATME NT OF AN 2
ILLNESS, INJURY, DISABILITY, OR HEALTH CONDITION ; 3
(II) CONSISTENT WITH ACCEP TED STANDARDS OF GOO D 4
MEDICAL PRACTICE ; AND 5
(III) NOT PRIMARILY FOR THE CONVENIENCE OF THE P ATIENT, 6
THE PATIENT’S FAMILY, OR THE PROVIDER . 7
(b) (1) The Commission shall require each acute care hospital and each chronic 8
care hospital in the State under the jurisdiction of the Commission to develop a financial 9
assistance policy for providing free and reduced–cost care to patients who lack health care 10
coverage or whose health care coverage does not pay the full cost of the hospital bill. 11
(2) The financial assistance policy shall provide, at a minimum: 12
(i) Free medically necessary care to patients with family income at 13
or below 200% of the federal poverty level, calculated at the time of service or updated, as 14
appropriate, to account for any change in financial circumstances of the patient that occurs 15
within 240 days after the initial hospital bill is provided; 16
(ii) Reduced–cost medically necessary care to low–income patients 17
with family income above 200% of the federal poverty level, calculated at the time of service 18
or updated, as appropriate, to account for any change in financial circumstances of the 19
patient that occurs within 240 days after the initial hospital bill is provided; 20
(iii) [A payment plan that is available to uninsured patients with 21
family income between 200% and 500% of the federal poverty level] A DESCRIPTION OF 22
THE AVAILABILITY OF THE PAYMENT PLAN REQ UIRED UNDER § 19–214.2(D) OF THIS 23
SUBTITLE; and 24
(iv) A mechanism for a patient to request the hospital to reconsider 25
the denial of free or reduced–cost care that includes in the request: 26
1. The Health Education and Advocacy Unit is available to 27
assist the patient or the patient’s authorized representative in filing and mediating a 28
reconsideration request; and 29
2. The address, phone number, facsimile number, e–mail 30
address, mailing address, and website of the Health Education and Advocacy Unit. 31
(3) (i) The Commission by regulation may establish income thresholds 32
higher than those under [paragraph] PARAGRAPHS (2) AND (4) of this subsection. 33
6 HOUSE BILL 268
(ii) In establishing income thresholds that are higher than those 1
under paragraph (2) of this subsection for a hospital, the Commission shall take into 2
account: 3
1. The patient mix of the hospital; 4
2. The financial condition of the hospital; 5
3. The level of bad debt experienced by the hospital; and 6
4. The amount of charity care provided by the hospital. 7
(4) [(i)] Subject to [subparagraphs (ii) and (iii) of this paragraph] 8
INCOME THRESHOLDS SE T UNDER PARAGRAPH (3) OF THIS SUBSECTION , the 9
financial assistance policy required under this subsection shall provide reduced–cost 10
medically necessary care to patients with family income below 500% of the federal poverty 11
level who have a financial hardship. 12
[(ii) A hospital may seek and the Commission may approve a family 13
income threshold that is different than the family income threshold under subparagraph 14
(i) of this paragraph. 15
(iii) In establishing a family income threshold that is different than 16
the family income threshold under subparagraph (i) of this paragraph, the Commission 17
shall take into account: 18
1. The median family income in the hospital’s service area; 19
2. The patient mix of the hospital; 20
3. The financial condition of the hospital; 21
4. The level of bad debt experienced by the hospital; 22
5. The amount of charity care provided by the hospital; and 23
6. Other relevant factors.] 24
(5) (I) If a patient is eligible for reduced–cost medically necessary care 25
under [paragraphs] PARAGRAPH (2)(ii) [and (4)] of this subsection, the hospital shall 26
[apply the reduction that is most favorable to the patient], AT A MINIMUM, REDUCE THE 27
PATIENT’S OUT–OF–POCKET EXPENSES FOR THE REGULATED HOSPIT AL SERVICE: 28
1. FOR A PATIENT WITH FAMILY INCOME OF AT LEAST 29
201% BUT NOT MORE THAN 250% OF THE FEDERAL POVER TY LEVEL, BY 75%; AND 30
HOUSE BILL 268 7
2. FOR A PATIENT WITH FAMILY INCOME OF MORE THAN 1
250% BUT NOT MORE THAN 300% OF THE FEDERAL POVER TY LEVEL, BY 60%. 2
(II) IF A PATIENT IS ELIGIBLE FOR REDUCED –COST MEDICALLY 3
NECESSARY CARE UNDER PARAGRAPH (4) OF THIS SUBSECTION , THE HOSPITAL 4
SHALL, AT A MINIMUM , REDUCE THE PATIENT ’S OUT–OF–POCKET EXPENSES FOR 5
THE REGULATED HOSPIT AL SERVICE: 6
1. FOR A PATIENT WITH FAMILY INCOME OF AT LEAST 7
201% BUT NOT MORE THAN 250% OF THE FEDERAL POVER TY LEVEL, BY 75%; 8
2. FOR A PATIENT WITH FAMILY INCOME OF MORE THAN 9
250% BUT NOT MORE THAN 300% OF THE FEDERAL POVERTY LEVEL , BY 60%; 10
3. FOR A PATIENT WITH FAMILY INCOME OF MORE THAN 11
300% BUT NOT MORE THAN 350% OF THE FEDERAL POVER TY LEVEL, BY 50%; 12
4. FOR A PATIENT WITH FAMILY INCOME OF MORE THAN 13
350% BUT NOT MORE THAN 400% OF THE FEDERAL POVER TY LEVEL, BY 45%; 14
5. FOR A PATIENT WITH FAMILY INCOME OF MORE THAN 15
400% BUT NOT MORE THAN 450% OF THE FEDERAL POVER TY LEVEL, BY 40%; AND 16
6. FOR A PATIENT WITH FAMILY INCOME OF MORE THAN 17
450% BUT NOT MORE THAN 500% OF THE FEDERAL POVER TY LEVEL, BY 35%. 18
(6) If a patient has received reduced–cost medically necessary care due to 19
a financial hardship, the patient or any immediate family member of the patient living in 20
the same household: 21
(i) Shall remain eligible for reduced–cost medically necessary care 22
when seeking subsequent care at the same hospital during the 12–month period beginning 23
on the date on which the reduced–cost medically necessary care was initially received; and 24
(ii) To avoid an unnece ssary duplication of the hospital’s 25
determination of eligibility for free and reduced–cost care, shall inform the hospital of the 26
patient’s or family member’s eligibility for the reduced–cost medically necessary care. 27
(7) The financial assistance policy required under this subsection shall 28
provide presumptive eligibility for free medically necessary care to a patient who is not 29
eligible for the Maryland Medical Assistance Program or Maryland Children’s Health 30
Program and: 31
8 HOUSE BILL 268
(i) Lives in a household with [children] A CHILD WHO IS enrolled 1
in the free and reduced–cost meal program AND IS ELIGIBLE FOR THE PROGRAM BASED 2
ON THE HOUSEHOLD ’S INCOME; 3
(ii) Receives benefits through the federal Supplemental Nutrition 4
Assistance Program; 5
(iii) Receives benefits through the State’s Energy Assistance 6
Program; 7
(iv) Receives benefits through the federal Special Supplemental Food 8
Program for Women, Infants, and Children; or 9
(v) Receives benefits from any other social service program as 10
determined by the Department and the Commission. 11
(8) (i) A hospital may consider only household monetary assets in 12
excess of $100,000 when determining eligibility for free and reduced–cost care under the 13
hospital’s financial assistance policy. 14
(ii) If a hospital considers household monetary assets under 15
subparagraph (i) of this paragraph, retirement assets that the Internal Revenue Service 16
has granted preferential tax treatment as a retirement account, including 17
deferred–compensation plans qualified under the Internal Revenue Code or nonqualified 18
deferred–compensation plans shall be excluded. 19
(9) (i) In determining the family income of a patient, a hospital shall 20
apply a definition of household size that consists of the patient and, at a minimum, the 21
following individuals: 22
1. A spouse, regardless of whether the patient and spouse 23
expect to file a joint federal or State tax return; 24
2. Biological children, adopted children, or stepchildren; and 25
3. Anyone for whom the patient claims a personal exemption 26
in a federal or State tax return. 27
(ii) For a patient who is a child, the household size shall consist of 28
the child and the following individuals: 29
1. Biological parents, adopted parents, or stepparents or 30
guardians; 31
2. Biological siblings, adopted siblings, or stepsiblings; and 32
HOUSE BILL 268 9
3. Anyone for whom the patient’s parents or guardians claim 1
a personal exemption in a federal or State tax return. 2
(10) (I) A hospital shall provide notice of the hospital’s financial 3
assistance policy to the patient, the patient’s family, or the patient’s authorized 4
representative before discharging the patient and in each communication to the patient 5
regarding collection of the hospital bill. 6
(II) THE NOTICE REQUIRED U NDER SUBPARAGRAPH (I) OF THIS 7
PARAGRAPH SHALL STAT E THAT THE PATIENT H AS UP TO 240 DAYS AFTER THE DAY 8
THE PATIENT RECEIVES THE INITIAL HOSPITAL BILL TO APPLY FOR FI NANCIAL 9
ASSISTANCE FROM THE HOSPITAL. 10
(III) 1. THE HOSPITAL SHALL EN SURE THAT THE PATIEN T, 11
THE PATIENT’S FAMILY, OR THE PATIENT’S AUTHORIZED REPRESENT ATIVE SIGNS 12
AND DATES THE NOTICE REQUIRED UNDER SUBPA RAGRAPH (I) OF THIS PARAGRAPH 13
TO ACKNOWLEDGE THE P ATIENT’S RECEIPT OF THE NOT ICE BEFORE DISCHARGI NG 14
THE PATIENT. 15
2. IF A PATIENT CHOOSES NOT TO APPLY FOR FINANCIAL 16
ASSISTANCE, THE SIGNATURE SHALL INDICATE THAT THE PATIENT IS NOT APPLYING 17
ON THE DAY OF THE SIGNING BUT MAY APPLY WITHIN 240 DAYS IMMEDIATELY 18
FOLLOWING THE PATIENT’S RECEIPT OF THE INI TIAL HOSPITAL BILL THE HOSPITAL 19
SHALL OBTAIN DOCUMEN TATION ENSURING THAT THE PATIENT OR THE PATIE NT’S 20
AUTHORIZED REPRESENT ATIVE ACKNOWLEDGES T HE PATIENT’S RECEIPT OF THE 21
NOTICE BEFORE DISCHA RGING THE PATIENT . 22
2. IF A PATIENT CHOOSES NOT TO APPLY FOR FIN ANCIAL 23
ASSISTANCE, THE PATIENT’S DOCUMENTED ACKNOWLEDGMENT SHALL INDICATE 24
THAT THE PATIENT IS NOT APPLYING ON THE DAY OF THE ACKNOWLED GMENT BUT 25
MAY APPLY WITHIN 240 DAYS IMMEDIATELY FOL LOWING THE PATIENT ’S RECEIPT 26
OF THE INITIAL HOSPI TAL BILL. 27
(11) THE HOSPITAL SHALL CO NSIDER ANY CHANGE IN THE PATIENT’S 28
FINANCIAL CIRCUMSTAN CE THAT OCCUR S DURING THE 240–DAY PERIOD 29
FOLLOWING THE PATIEN T’S RECEIPT OF THE INI TIAL HOSPITAL BILL IF THE 30
PATIENT INFORMS THE HOSPITAL OF TH E CHANGE IN FINANCIAL CIRCUMSTANCE 31
ON OR BEFORE THE CONCLUSION OF THE 240–DAY PERIOD. 32
(c) (1) A hospital shall post a notice in conspicuous places throughout the 33
hospital, including the billing office, informing patients of their right to apply for financial 34
assistance and who to contact at the hospital for additional information. 35
(2) The notice required under paragraph (1) of this subsection shall: 36 10 HOUSE BILL 268
(i) Be in simplified language in at least 10 point type; and 1
(ii) Be provided in the patient’s preferred language or, if no preferred 2
language is specified, each language spoken by a limited English proficient population that 3
constitutes at least 5% of the overall population within the city or county in which the 4
hospital is located as measured by the most recent census. 5
(d) The Commission shall: 6
(1) Develop a uniform financial assistance application; and 7
(2) Require each hospital to use the uniform financial assistance 8
application to determine eligibility for free and reduced–cost care under the hospital’s 9
financial assistance policy. 10
(e) The uniform financial assistance application: 11
(1) Shall be written in simplified language; and 12
(2) May not require documentation that presents an undue barrier to a 13
patient’s receipt of financial assistance. 14
(f) (1) Each hospital shall develop an information sheet that: 15
(i) Describes the hospital’s financial assistance policy and includes 16
a section that allows for a patient to initial that the patient has been made aware of the 17
financial assistance policy; 18
(ii) Describes a patient’s rights and obligations with regard to 19
hospital billing and collection under the law; 20
(iii) Provides contact information for the individual or office at the 21
hospital that is available to assist the patient, the patient’s family, or the patient’s 22
authorized representative in order to understand: 23
1. The patient’s hospital bill; 24
2. The patient’s rights and obligations with regard to the 25
hospital bill; 26
3. How to apply for free and reduced–cost care; and 27
4. How to apply for the Maryland Medical Assistance 28
Program and any other programs that may help pay the bill; 29
HOUSE BILL 268 11
(iv) Provides contact information for the Maryland Medical 1
Assistance Program; 2
(v) Includes a statement that physician charges are not included in 3
the hospital bill and are billed separately; and 4
(vi) Informs patients of the right to request and receive a written 5
estimate of the total charges for hospital nonemergency services, procedures, and supplies 6
that reasonably are expected to be provided for professional services by the hospital. 7
(2) The information sheet shall: 8
(i) Be in simplified language in at least 10 point type; and 9
(ii) Be in the patient’s preferred language or, if no preferred 10
language is specified, each language spoken by a limited English proficient population that 11
constitutes at least 5% of the overall population within the city or county in which the 12
hospital is located as measured by the most recent census. 13
(3) The information sheet shall be provided to the patient, the patient’s 14
family, or the patient’s authorized representative: 15
(i) Before discharge; 16
(ii) With the hospital bill; 17
(iii) On request; and 18
(iv) In each written communication to the patient regarding 19
collection of the hospital bill. 20
(4) The hospital bill shall include a reference to the information sheet. 21
(5) The Commission shall: 22
(i) Establish uniform requirements for the information sheet; and 23
(ii) Review each hospital’s implementation of and compliance with 24
the requirements of this subsection. 25
(g) Each hospital shall ensure the availability of staff who are trained to work 26
with the patient, the patient’s family, and the patient’s authorized representative in order 27
to understand: 28
(1) The patient’s hospital bill; 29
12 HOUSE BILL 268
(2) The patient’s rights and obligations with regard to the hospital bill, 1
including the patient’s rights and obligations with regard to reduced–cost medically 2
necessary care due to a financial hardship; 3
(3) How to apply for the Maryland Medical Assistance Program and any 4
other programs that may help pay the hospital bill; and 5
(4) How to contact the hospital for additional assistance. 6
(h) Each hospital shall develop a procedure to determine a patient’s eligibility 7
under the hospital’s financial assistance policy in which the hospital: 8
(1) Determines whether the patient has health insurance; 9
(2) Determines whether the patient is presumptively eligible for free or 10
reduced–cost care under subsection (b)(7) of this section; 11
(3) Determines whether uninsured patients are eligible for public or 12
private health insurance; 13
(4) To the extent practicable, offers assistance to uninsured patients if the 14
patient chooses to apply for public or private health insurance; 15
(5) To the extent practicable, determines whether the patient is eligible for 16
other public programs that may assist with health care costs; 17
(6) Uses information in the possession of the hospital, if available, to 18
determine whether the patient is qualified for free or reduced–cost care under the hospital’s 19
financial assistance policy; and 20
(7) When a patient submits a completed application for financial 21
assistance, determines the patient’s eligibility under the hospital’s financial assistance 22
policy within 14 days after the patient applies for financial assistance and suspends any 23
billing or collections actions while eligibility is being determined. 24
(i) A hospital may not: 25
(1) Use a patient’s citizenship or immigration status as an eligibility 26
requirement for financial assistance; or 27
(2) Withhold financial assistance or deny a patient’s application for 28
financial assistance on the basis of race, color, religion, ancestry or national origin, sex, age, 29
marital status, sexual orientation, gender identity, genetic information, or on the basis of 30
disability. 31
(j) Each hospital shall submit to the Commission annually at times prescribed by 32
the Commission: 33 HOUSE BILL 268 13
(1) The hospital’s financial assistance policy developed under this section; 1
and 2
(2) An annual report on the hospital’s financial assistance policy that 3
includes: 4
(i) The total number of patients who completed or partially 5
completed an application for financial assistance during the prior year; 6
(ii) The total number of inpatients and outpatients who received: 7
1. Free care during the immediately preceding year; and 8
2. Reduced–cost care for the prior year; 9
(iii) The total number of patients who received financial assistance 10
during the immediately preceding year by race or ethnicity and gender; 11
(iv) The total number of patients who were denied financial 12
assistance during the immediately preceding year by race or ethnicity and gender; 13
(v) The total amount of the costs of hospital services provided to 14
patients who received free care; and 15
(vi) The total amount of the costs of hospital services provided to 16
patients who received reduced–cost care that was either covered by the hospital as financial 17
assistance or that the hospital charged to the patient. 18
(k) (1) The Commission shall post on its website each hospital’s financial 19
assistance policy and annual report. 20
(2) The Commission shall compile the reports required under subsection (j) 21
of this section and issue a hospital financial assistance report. 22
(3) The hospital financial assistance report required under paragraph (2) 23
of this subsection shall be made available to the public free of charge. 24
(4) On or before December 1 each year, the Commission shall submit a copy 25
of the annual hospital financial assistance report issued under paragraph (2) of this 26
subsection, in accordance with § 2–1257 of the State Government Article, to the Senate 27
Finance Committee and the House Health and Government Operations Committee. 28
19–214.2. 29
(a) (1) Each hospital annually shall submit to the Commission: 30
14 HOUSE BILL 268
(i) At times prescribed by the Commission, the hospital’s policy on 1
the collection of debts owed by patients; and 2
(ii) A report including: 3
1. The total number of patients by race or ethnicity, gender, 4
and zip code of residence against whom the hospital, or a debt collector used by the hospital, 5
filed an action to collect a debt owed on a hospital bill; 6
2. The total number of patients by race or ethnicity, gender, 7
and zip code of residence with respect to whom the hospital has and has not reported or 8
classified a bad debt; and 9
3. The total dollar amount of the charges for hospital services 10
provided to patients but not collected by the hospital for patients covered by insurance, 11
including the out–of–pocket costs for patients covered by insurance, and patients without 12
insurance. 13
(2) The Commission shall post the information submitted under paragraph 14
(1) of this subsection on its website. 15
(b) The policy submitted under subsection (a)(1) of this section shall: 16
(1) Provide for active oversight by the hospital of any contract for collection 17
of debts on behalf of the hospital; 18
(2) Prohibit the hospital from selling any debt; 19
(3) [Prohibit the charging of interest on bills incurred by self–pay patients 20
before a court judgment is obtained; 21
(4)] Describe in detail the consideration by the hospital of patient income, 22
assets, and other criteria; 23
[(5)] (4) Prohibit the hospital from reporting ADVERSE INFORMATION 24
to a consumer reporting agency [or]; 25
(5) PROHIBIT THE HOSPITAL FROM filing a civil action to collect a debt 26
within [180] 240 days after the initial bill is provided; 27
(6) PROHIBIT THE HOSPITAL FROM FILING A CIVIL ACTION TO 28
COLLECT A DEBT AGAIN ST A PATIENT WHOSE O UTSTANDING DEBT IS AT OR BELOW 29
$500; 30
[(6)] (7) Describe the hospital’s procedures for collecting a debt; 31
HOUSE BILL 268 15
[(7)] (8) Describe the circumstances in which the hospital will seek a 1
judgment against a patient; 2
[(8)] (9) In accordance with subsection (c) of this section, provide for a 3
refund of amounts collected from a patient or the guarantor of a patient who was later 4
found to be eligible for free care within 240 days after the initial bill was provided; 5
[(9)] (10) If the hospital has obtained a judgment against or reported 6
adverse information to a consumer reporting agency about a patient who later was found 7
to be eligible for free care within 240 days after the initial bill was provided for which the 8
judgment was awarded or the adverse information was reported, require the hospital to 9
seek to vacate the judgment or strike the adverse information; 10
[(10)] (11) Provide a mechanism for a patient to: 11
(i) Request the hospital to reconsider the denial of free or 12
reduced–cost care; 13
(ii) File with the hospital a complaint against the hospital or a debt 14
collector used by the hospital regarding the handling of the patient’s bill; and 15
(iii) Allow the patient and the hospital to mutually agree to modify 16
the terms of a payment plan offered under subsection [(e)] (D) of this section or entered 17
into with the patient; and 18
[(11)] (12) [Prohibit] FOR A PATIENT WH O IS ELIGIBLE FOR FR EE OR 19
REDUCED–COST CARE UNDER THE HOSPITAL’S FINANCIAL ASSISTAN CE POLICY, 20
PROHIBIT the hospital from [collecting additional]: 21
(I) CHARGING INTEREST ON THE DEBT OWED ON A B ILL FOR 22
THE PATIENT BEFORE A COURT JUDGMENT IS OBTAINED; OR 23
(II) COLLECTING fees [in an] OR ANY OTHER amount that exceeds 24
the approved charge for the hospital service as established by the Commission [for which 25
the medical debt is owed on a bill for a patient who is eligible for free or reduced–cost care 26
under the hospital’s financial assistance policy] OR A PROFESSIONAL FE E. 27
(c) (1) (I) [Beginning October 1, 2010, a] A hospital shall provide for a 28
refund of amounts exceeding $25 collected from a patient or the guarantor of a patient 29
who[, within a 2–year period after the date of service,] was found to be eligible for free care 30
[on the date of service] WITHIN 240 DAYS AFTER THE INITI AL BILL IS PROVIDED TO 31
THE PATIENT. 32
16 HOUSE BILL 268
(II) THE HOSPITAL SHALL PR OVIDE THE REFUND TO THE 1
PATIENT NOT LATER THAN 30 DAYS AFTER DETERMINING THAT THE PATIENT WAS 2
ELIGIBLE FOR FREE CA RE. 3
(2) [A hospital may reduce the 2–year period under paragraph (1) of this 4
subsection to no less than 30 days after the date the hospital requests information from a 5
patient, or the guarantor of a patient, to determine the patient’s eligibility for free care at 6
the time of service, if the hospital documents the lack of cooperation of the patient or the 7
guarantor of a patient in providing the requested information. 8
(3)] If a patient is enrolled in a means–tested government health care plan 9
that requires the patient to pay out–of–pocket for hospital services, a hospital’s refund 10
policy shall provide for a refund that complies with the terms of the patient’s plan. 11
[(d) A hospital may not charge interest or fees on any debt incurred on or after the 12
date of service by a patient who is eligible for free or reduced–cost care under § 19–214.1 of 13
this subtitle.] 14
[(e)] (D) (1) Subject to paragraph (2) of this subsection, a hospital shall 15
provide in writing to each patient who incurs medical debt information about the 16
availability of an installment payment plan for the debt. 17
(2) A hospital shall provide the information under paragraph (1) of this 18
subsection to the patient, the patient’s family, the patient’s authorized representative, or 19
the patient’s legal guardian: 20
(i) Before the patient is discharged; 21
(ii) With the hospital bill; 22
(iii) On request; and 23
(iv) In each written communication to the patient regarding 24
collection of hospital debt. 25
(3) (i) The Commission shall develop guidelines, with input from 26
stakeholders, for an income–based payment plan offered under this subsection that 27
includes: 28
1. The amount of medical debt owed to the hospital; 29
2. The duration of the payment plan based on a patient’s 30
annual gross income; 31
3. Guidelines for requiring appropriate documentation of 32
income level; 33 HOUSE BILL 268 17
4. Guidelines for the payment amount that: 1
A. May not exceed 5% of the [individual] patient’s federal or 2
State adjusted gross monthly HOUSEHOLD income THAT TAKES INTO CONSIDERA TION 3
ALL INDIVIDUALS ON T HE SAME FEDERAL OR STATE TAX RETURN ; and 4
B. Shall consider financial hardship, as defined in § 5
19–214.1(a) of this subtitle; 6
5. Guidelines for: 7
A. The determination of possible interest payments for 8
patients who do not qualify for free or reduced–cost care, which may not begin before [180] 9
240 days after the [due date of the first payment] INITIAL BILL IS PROVIDED; and 10
B. A prohibition on interest payments for patients who 11
qualify for free or reduced–cost care AS REQUIRED UNDER SU BSECTION (B)(12) OF THIS 12
SECTION; 13
6. Guidelines for modification of a payment plan that does 14
not create a greater financial burden on the patient; and 15
7. A prohibition on penalties or fees for prepayment or early 16
payment. 17
(ii) A hospital may not seek legal action against a patient on a debt 18
owed until the hospital has established and implemented a payment plan policy that 19
complies with the guidelines developed under subparagraph (i) of this paragraph. 20
(4) (i) A patient shall be deemed to be compliant with a payment plan 21
if the patient makes at least 11 scheduled monthly payments within a 12–month period. 22
(ii) If a patient misses a scheduled monthly payment, the patient 23
shall contact the health care facility and identify a plan to make up the missed payment 24
within 1 year after the date of the missed payment. 25
(iii) The health care facility may, but may not be required to, waive 26
any additional missed payments that occur within a 12–month period and allow the patient 27
to continue to participate in the income–based payment plan and not refer the outstanding 28
balance owed to a collection agency or for legal action. 29
(5) (i) A hospital shall demonstrate that it attempted in good faith to 30
meet the requirements of this subsection and the guidelines developed by the Commission 31
under paragraph (3) of this subsection before the hospital: 32
18 HOUSE BILL 268
1. Files an action to collect a debt owed on a hospital bill by 1
a patient; or 2
2. Delegates collection activity to a debt collector for a debt 3
owed on a hospital bill by a patient. 4
(ii) Subparagraph (i) of this paragraph does not prohibit a hospital 5
from using an eligibility vendor to provide outreach to a patient for purposes of assisting 6
the patient in qualifying for financial assistance. 7
[(f)] (E) (1) For at least [180] 240 days after [issuing an] THE initial patient 8
bill WAS PROVIDED, a hospital may not report adverse information about a patient to a 9
consumer reporting agency or commence civil action against a patient for nonpayment. 10
(2) A hospital shall report the fulfillment of a patient’s payment obligation 11
within 60 days after the obligation is fulfilled to any consumer reporting agency to which 12
the hospital had reported adverse information about the patient. 13
(3) A hospital may not report adverse information to a consumer reporting 14
agency regarding a patient who at the time of service was uninsured or eligible for free or 15
reduced–cost care under § 19–214.1 of this subtitle. 16
(4) A hospital may not report adverse information about a patient to a 17
consumer reporting agency, commence a civil action against a patient for nonpayment, or 18
delegate collection activity to a debt collector: 19
(i) If the hospital was notified in accordance with federal law by the 20
patient or the insurance carrier that an appeal or a review of a health insurance decision 21
is pending within the immediately preceding 60 days; or 22
(ii) If the hospital [has completed] IS PROCESSING a requested 23
reconsideration of the denial of free or reduced–cost care that was appropriately completed 24
by the patient OR HAS COMPLETED THE RECONSIDERATION within the immediately 25
preceding 60 days. 26
(5) If a hospital has reported adverse information about a patient to a 27
consumer reporting agency, the hospital shall instruct the consumer reporting agency to 28
delete the adverse information about the patient: 29
(i) If the hospital was informed by the patient or the insurance 30
carrier that an appeal or a review of a health insurance decision is pending, and until 60 31
days after the appeal is complete; or 32
(ii) Until 60 days after the hospital has completed a requested 33
reconsideration of the denial of free or reduced–cost care. 34
HOUSE BILL 268 19
[(g)] (F) (1) A hospital may not force the sale or foreclosure of a patient’s 1
primary residence to collect a debt owed on a hospital bill. 2
(2) A hospital may not request a lien against a patient’s primary residence 3
in an action to collect debt owed on a hospital bill. 4
(3) (i) A hospital may not [file an action against a patient to collect a 5
debt owed on a hospital bill or] give notice to a patient under subsection [(i)] (H) of this 6
section until after [180] 240 days after the initial bill was provided. 7
(ii) If a hospital files an action to collect the debt owed on a hospital 8
bill, the hospital may not request the issuance of or otherwise knowingly take action that 9
would cause a court to issue: 10
1. A body attachment against a patient; or 11
2. An arrest warrant against a patient. 12
(4) A hospital may not request a writ of garnishment of wages or file an 13
action that would result in an attachment of wages against a patient to collect debt owed 14
on a hospital bill if the patient is eligible for free or reduced–cost care under § 19–214.1 of 15
this subtitle. 16
(5) (i) A hospital may not make a claim against the estate of a deceased 17
patient to collect a debt owed on a hospital bill if the deceased patient was known by the 18
hospital to be eligible for free care under § 19–214.1 of this subtitle or if the value of the 19
estate after tax obligations are fulfilled is less than half of the debt owed. 20
(ii) A hospital may offer the family of the deceased patient the ability 21
to apply for financial assistance. 22
(6) A hospital may not file an action to collect a debt owed on a hospital bill 23
by a patient until the hospital determines whether the patient is eligible for free or 24
reduced–cost care under § 19–214.1 of this subtitle. 25
[(h)] (G) (1) Except as provided in paragraph (2) of this subsection, a spouse 26
or another individual may not be held liable for the debt owed on a hospital bill of an 27
individual who is at least 18 years old. 28
(2) An individual may voluntarily consent to assume liability for the debt 29
owed on a hospital bill of any other individual if the consent is: 30
(i) Made on a separate document signed by the individual; 31
(ii) Not solicited in an emergency room or during an emergency 32
situation; and 33
20 HOUSE BILL 268
(iii) Not required as a condition of providing any emergency or 1
nonemergency health care services. 2
[(i)] (H) (1) Subject to paragraph (2) of this subsection, at least 45 days before 3
filing an action against a patient to collect on the debt owed on a hospital bill, a hospital 4
shall send written notice of the intent to file an action to the patient. 5
(2) The notice required under paragraph (1) of this subsection shall: 6
(i) Be sent to the patient by certified mail and first–class mail; 7
(ii) Be in simplified language and in at least 10 point type; 8
(iii) Include: 9
1. The name and telephone number of: 10
A. The hospital; 11
B. If applicable, the debt collector; and 12
C. An agent of the hospital authorized to modify the terms of 13
the payment plan, if any; 14
2. The amount required to cure the nonpayment of debt, 15
including past due payments, INTEREST, penalties, and fees; 16
3. A statement recommending that the patient seek debt 17
counseling services; 18
4. Telephone numbers and Internet addresses of the Health 19
Education Advocacy Unit in the Office of the Attorney General, available to assist patients 20
experiencing medical debt; 21
5. An explanation of the hospital’s financial assistance 22
policy; and 23
6. Any other relevant information prescribed by the 24
Commission; and 25
(iv) Be provided in the patient’s preferred language or, if no preferred 26
language is specified, each language spoken by a limited English proficient population that 27
constitutes at least 5% of the population within the jurisdiction in which the hospital is 28
located as measured by the most recent federal census. 29
(3) The notice required under this subsection shall be accompanied by: 30
HOUSE BILL 268 21
(i) An application for financial assistance under the hospital’s 1
financial assistance policy, along with instructions for completing the application for 2
financial assistance, and the telephone number to call to confirm receipt of the application; 3
(ii) The availability of [a] AN INCOME–BASED payment plan to 4
satisfy the medical debt that is the subject of the hospital debt collection action; and 5
(iii) The information sheet required under § 19–214.1(f) of this 6
subtitle. 7
[(j)] (I) A complaint by a hospital in an action to collect a debt owed on a 8
hospital bill by a patient shall: 9
(1) Include an affidavit stating: 10
(i) The date on which the [180–day] 240–DAY period required 11
under subsection [(g)(3)] (F)(3) of this section elapsed and the nature of the nonpayment; 12
(ii) That a notice of intent to file an action under subsection [(i)] (H) 13
of this section: 14
1. Was sent to the patient and the date on which the notice 15
was sent; and 16
2. Accurately reflected the contents required to be included 17
in the notice; 18
(iii) That the hospital provided: 19
1. The patient with a copy of the information sheet on the 20
financial assistance policy in accordance with subsection [(i)(3)(ii)] (H)(3)(II) of this 21
section; and 22
2. Notice of the financial assistance policy as documented 23
under § 19–214.1(f) of this subtitle; 24
(iv) That the hospital made a determination regarding whether the 25
patient is eligible for the hospital’s financial assistance policy in accordance with § 19–214.1 26
of this subtitle; and 27
(v) That the hospital made a good –faith effort to meet the 28
requirements of subsection [(e)] (D) of this section; and 29
(2) Be accompanied by: 30
(i) The original or a certified copy of the hospital bill; 31 22 HOUSE BILL 268
(ii) A statement of the remaining due and payable debt supported by 1
an affidavit of the plaintiff, the hospital, or the agent or attorney of the plaintiff or hospital; 2
(iii) A copy of the most recent hospital bill sent to the patient; 3
(iv) If the defendant is eligible for federal Service Members Civil 4
Relief Act benefits, an affidavit that the hospital is in compliance with the Act; 5
(v) A copy of the notice of intent to file an action on a hospital bill; 6
and 7
(vi) A copy of the patient’s signed certified mail acknowledgment of 8
receipt of the written notice of intent to file an action, if received by the hospital. 9
[(k)] (J) If a hospital delegates collection activity to a debt collector, the hospital 10
shall: 11
(1) Specify the collection activity to be performed by the debt collector 12
through an explicit authorization or contract; 13
(2) Require the debt collector to abide by the hospital’s credit and collection 14
policy; 15
(3) Specify procedures the debt collector must follow if a patient appears to 16
qualify for financial assistance; and 17
(4) Require the debt collector to: 18
(i) In accordance with the hospital’s policy, provide a mechanism for 19
a patient to file with the hospital a complaint against the hospital or the debt collector 20
regarding the handling of the patient’s bill; 21
(ii) Forward the complaint to the hospital if a patient files a 22
complaint with the debt collector; and 23
(iii) Along with the hospital, be jointly and severally responsible for 24
meeting the requirements of this section. 25
[(l)] (K) (1) The board of directors of each hospital shall review and approve 26
the HOSPITAL’S financial assistance POLICY REQUIRED UNDER § 19–214.1 OF THIS 27
SUBTITLE and debt collection [policies of the hospital] POLICY REQUIRED UNDER THIS 28
SECTION at least every 2 years. 29
(2) A hospital may not alter its financial assistance or debt collection 30
policies without approval by the board of directors. 31
HOUSE BILL 268 23
[(m)] (L) The Commission shall review each hospital’s implementation of and 1
compliance with the hospital’s policies and the requirements of this section. 2
[(n)] (M) (1) On or before February 1 each year, beginning in 2023, the 3
Commission shall compile the information required under subsection (a) of this section and 4
prepare a medical debt collection report based on the compiled information. 5
(2) The report required under paragraph (1) of this subsection shall be: 6
(i) Made available to the public free of charge; and 7
(ii) Submitted to the Senate Finance Committee and the House 8
Health and Government Operations Committee in accordance with § 2–1257 of the State 9
Government Article. 10
19–301. 11
(a) In this subtitle the following words have the meanings indicated. 12
(f) “Hospital” means an institution that: 13
(1) Has a group of at least 5 physicians who are organized as a medical 14
staff for the institution; 15
(2) Maintains facilities to provide, under the supervision of the medical 16
staff, diagnostic and treatment services for 2 or more unrelated individuals; and 17
(3) Admits or retains the individuals for overnight care. 18
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 19
October 1, 2025. 20
Approved:
________________________________________________________________________________
Governor.
________________________________________________________________________________
Speaker of the House of Delegates.
________________________________________________________________________________
President of the Senate.