Substitute House Bill No. 5404
          Substitute House Bill No. 5404

              PUBLIC ACT NO. 98-163


AN   ACT  CONCERNING   HEALTH   PROVIDER   BILLING
PRACTICES AND REQUIRING  HEALTH INSURERS TO PAY OR
REIMBURSE PROVIDERS ON A TIMELY BASIS.


    Be it enacted  by  the  Senate  and  House  of
Representatives in General Assembly convened:
    Section 1. (NEW)  (a)  For  purposes  of  this
section:
    (1) "Request payment"  includes,  but  is  not
limited to, submitting  a  bill  for  services not
actually owed or  submitting  for such services an
invoice or other  communication detailing the cost
of the services  that  is  not clearly marked with
the phrase "This is not a bill".
    (2)  "Health care  provider"  means  a  person
licensed to provide  health  care  services  under
chapters 370 to  373,  inclusive,  chapters 375 to
383b, inclusive, chapters 384a to 384c, inclusive,
or chapter 400j of the general statutes.
    (3)  "Enrollee"  means   a   person   who  has
contracted for or  who  participates  in a managed
care plan for himself or his eligible dependents.
    (4)  "Managed  care   organization"  means  an
insurer, health care  center,  hospital or medical
service   corporation   or    other   organization
delivering,  issuing  for  delivery,  renewing  or
amending any individual  or  group  health managed
care plan in this state.
    (5)  "Copayment  or   deductible"   means  the
portion of a  charge  for  services  covered  by a
managed care plan that, under the plan's terms, it
is the obligation of the enrollee to pay.
    (b) It shall  be  an  unfair trade practice in
violation of chapter  735a of the general statutes
for any health  care  provider  to request payment
from  an  enrollee,  other  than  a  copayment  or
deductible, for medical  services  covered under a
managed care plan.
    (c) It shall  be  an  unfair trade practice in
violation of chapter  735a of the general statutes
for any health care provider to report to a credit
reporting agency an  enrollee's  failure  to pay a
bill for medical  services  when  a  managed  care
organization   has  primary   responsibility   for
payment of such services.
    Sec. 2. Subsection  (c)  of section 38a-193 of
the general statutes is repealed and the following
is substituted in lieu thereof:
    (c) (1) Every  contract  between a health care
center and a participating provider of health care
services shall be  in  writing and shall set forth
that in the  event the health care center fails to
pay for health  care  services as set forth in the
contract, the subscriber  or enrollee shall not be
liable to the  provider  for  any sums owed by the
health care center.  (2)  In  the  event  that the
participating  provider  contract   has  not  been
reduced to writing  as required by this subsection
or that the contract fails to contain the required
prohibition, the participating  provider shall not
collect or attempt  to collect from the subscriber
or enrollee sums  owed  by the health care center.
(3) No participating  provider,  or agent, trustee
or assignee thereof,  may: [maintain] (A) MAINTAIN
any action at law against a subscriber or enrollee
to collect sums owed by the health care center; OR
(B) REQUEST PAYMENT  FROM A SUBSCRIBER OR ENROLLEE
FOR SUCH SUMS.  FOR  PURPOSES  OF THIS SUBDIVISION
"REQUEST PAYMENT" INCLUDES, BUT IS NOT LIMITED TO,
SUBMITTING A BILL  FOR  SERVICES NOT ACTUALLY OWED
OR SUBMITTING FOR  SUCH  SERVICES  AN  INVOICE  OR
OTHER  COMMUNICATION DETAILING  THE  COST  OF  THE
SERVICES  THAT IS  NOT  CLEARLY  MARKED  WITH  THE
PHRASE "THIS IS NOT A BILL".
    Sec. 3. Subdivision (15) of section 38a-816 of
the general statutes,  as  amended  by  public act
97-95, section 3 of public act 97-126, and section
13 of public  act  97-202,  is  repealed  and  the
following is substituted in lieu thereof:
    (15)  Failure  to   pay  accident  and  health
claims, INCLUDING, BUT  NOT LIMITED TO, CLAIMS FOR
PAYMENT OR REIMBURSEMENT TO HEALTH CARE PROVIDERS,
within forty-five days, OR AS OTHERWISE STIPULATED
BY CONTRACT, of  receipt  by  an  insurer  of  the
claimant's proof of  loss  form OR THE HEALTH CARE
PROVIDER'S REQUEST FOR PAYMENT FILED IN ACCORDANCE
WITH THE INSURER'S PRACTICES OR PROCEDURES, unless
the  Insurance  Commissioner   determines  that  a
legitimate   dispute  exists   as   to   coverage,
liability or damages  or  that  the  claimant  has
fraudulently caused or  contributed  to  the loss.
Any insurer who  fails  to  pay  such  a  claim OR
REQUEST with the  forty-five  day period shall pay
the claimant OR HEALTH CARE PROVIDER the amount of
such claim plus  interest  at  the rate of fifteen
per cent per  annum,  in  addition  to  any  other
penalties  which  may   be   imposed  pursuant  to
sections 38a-11, AS  AMENDED,  38a-25, AS AMENDED,
38a-41 to 38a-53,  inclusive,  38a-57  to  38a-60,
inclusive, 38a-62 to  38a-65,  inclusive,  38a-76,
38a-83,  38a-84, 38a-117  to  38a-124,  inclusive,
38a-129 to 38a-140, inclusive, 38a-146 to 38a-155,
inclusive, 38a-283, 38a-288 to 38a-290, inclusive,
AS AMENDED, 38a-319, 38a-320, AS AMENDED, 38a-459,
AS   AMENDED,   38a-464,   38a-815   to   38a-819,
inclusive,  AS  AMENDED,   38a-824   to   38a-826,
inclusive,  and  38a-828  to  38a-831,  inclusive.
Whenever the interest  due  a  claimant  OR HEALTH
CARE PROVIDER pursuant  to  this  section  is less
than one dollar,  the  insurer  shall deposit such
amount in a  separate  interest-bearing account in
which all such  amounts shall be deposited. At the
end of each  calendar year each such insurer shall
donate [one-half of] such amount to The University
of Connecticut Health  Center.  [and  one-half  of
such amount to Uncas-on-Thames Hospital.]
    Sec. 4. This  act shall take effect October 1,
1998, except that  section  3  shall  take  effect
January  1,  1999,  and  shall  be  applicable  to
contracts entered into or renewed after that date.

Approved June 4, 1998