2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477aa. - Cost-sharing and health care provider reimbursements for emergency services, urgent crisis center services and surprise bills.

(a) As used in this section:
(1) “Emergency condition” has the same meaning as “emergency medical condition”, as provided in section 38a-591a.
(2) “Emergency services” means, with respect to an emergency condition, (A) a medical screening examination as required under Section 1867 of the Social Security Act, as amended from time to time, that is within the capability of a hospital emergency department, including ancillary services routinely available to such department to evaluate such condition, and (B) such further medical examinations and treatment required under said Section 1867 to stabilize such individual that are within the capability of the hospital staff and facilities.
(3) “Health care plan” means an individual or a group health insurance policy or health benefit plan that provides coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469.
(4) “Health care provider” means an individual licensed to provide health care services under chapters 370 to 373, inclusive, chapters 375 to 383b, inclusive, and chapters 384a to 384c, inclusive.
(5) “Health carrier” means an insurance company, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health care plan in this state.
(6) (A) “Surprise bill” means a bill for health care services, other than emergency services or urgent crisis center services, received by an insured for services rendered by an out-of-network health care provider, where such services were rendered by (i) such out-of-network provider at an in-network facility, during a service or procedure performed by an in-network provider or during a service or procedure previously approved or authorized by the health carrier and the insured did not knowingly elect to obtain such services from such out-of-network provider, or (ii) a clinical laboratory, as defined in section 19a-490, that is an out-of-network provider, upon the referral of an in-network provider.
(B) “Surprise bill” does not include a bill for health care services received by an insured when an in-network health care provider was available to render such services and the insured knowingly elected to obtain such services from another health care provider who was out-of-network.
(7) “Urgent crisis center” means a center licensed by the Department of Children and Families that is dedicated to treating children's urgent mental or behavioral health needs.
(8) “Urgent crisis center services” means pediatric mental and behavioral health services provided at an urgent crisis center.
(b) (1) No health carrier shall require prior authorization for rendering emergency services or urgent crisis center services to an insured.
(2) No health carrier shall impose, for emergency services rendered to an insured by an out-of-network health care provider or urgent crisis center services rendered to an insured at an out-of-network urgent crisis center, a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such emergency services were rendered by an in-network health care provider or such urgent crisis center services were rendered at an in-network urgent crisis center.
(3) (A) If emergency services were rendered to an insured by an out-of-network health care provider, such health care provider may bill the health carrier directly and the health carrier shall reimburse such health care provider the greatest of the following amounts: (i) The amount the insured's health care plan would pay for such services if rendered by an in-network health care provider; (ii) the usual, customary and reasonable rate for such services; or (iii) the amount Medicare would reimburse for such services. As used in this subparagraph, “usual, customary and reasonable rate” means the eightieth percentile of all charges for the particular health care service performed by a health care provider in the same or similar specialty and provided in the same geographical area, as reported in a benchmarking database maintained by a nonprofit organization specified by the Insurance Commissioner. Such organization shall not be affiliated with any health carrier.
(B) If urgent crisis center services were rendered to an insured at an out-of-network urgent crisis center, such urgent crisis center may bill the health carrier directly for such urgent crisis center services. The health carrier shall reimburse such out-of-network urgent crisis center or insured, as applicable, for such urgent crisis center services at the in-network rate under the insured's health care plan as payment in full, unless such health carrier and urgent crisis center agree otherwise.
(C) Nothing in subparagraph (A) or (B) of this subdivision shall be construed to prohibit a health carrier and out-of-network health care provider or urgent crisis center from agreeing to a reimbursement amount that is greater than the minimum reimbursement amount established in subparagraph (A) or (B) of this subdivision, as applicable.
(c) With respect to a surprise bill:
(1) An insured shall only be required to pay the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for such health care services if such services were rendered by an in-network health care provider; and
(2) A health carrier shall reimburse the out-of-network health care provider or insured, as applicable, for health care services rendered at the in-network rate under the insured's health care plan as payment in full, unless such health carrier and health care provider agree otherwise.
(d) If health care services were rendered to an insured by an out-of-network health care provider and the health carrier failed to inform such insured, if such insured was required to be informed, of the network status of such health care provider pursuant to subdivision (3) of subsection (d) of section 38a-591b, the health carrier shall not impose a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such services were rendered by an in-network health care provider.
(e) The provisions of this section shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493 or subsection (f) of section 38a-520, as applicable, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this section shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.
(P.A. 15-146, S. 9; P.A. 19-117, S. 240; P.A. 22-47, S. 49; 22-58, S. 30.)
History: P.A. 15-146 effective July 1, 2016; P.A. 19-117 amended Subsec. (a)(6)(A) by redefining “surprise bill”, effective January 1, 2020; P.A. 22-47 amended Subsec. (a) to redefine “surprise bill” in Subdiv. (6)(A) and add definitions of “urgent crisis center” and “urgent crisis center services” in Subdivs. (7) and (8), respectively, and made technical changes, amended Subsec. (b) to provide that cost-sharing and health care provider reimbursement requirements apply to urgent crisis center services, added new Subdiv. (3)(B) re carrier required to reimburse out-of-network urgent crisis center or insured at in-network rate for services, redesignated existing Subdiv. (3)(B) as Subdiv. (3)(C) and made technical and conforming changes, and added Subsec. (e) re applicability to high deductible health plans, effective January 1, 2023; P.A. 22-58 amended Subsec. (a)(6)(A) by replacing “19a-30” with “19a-490”.