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the general statutes is repealed and the following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