Connecticut Balance Billing Law

Overview

Connecticut Senate Bill 5, codified in CGS §38a-477aa, effective July 1, 2021, protects patients from balance billing for emergency services and scheduled non-emergency services at in-network facilities provided by out-of-network providers. Patients are responsible only for in-network cost-sharing amounts. Out-of-network providers must bill the insurer directly; disputes between provider and insurer are resolved through Connecticut's arbitration process.

Key Requirements

1. Emergency Service Coverage: Patients pay only in-network cost-sharing for emergency care regardless of provider network status.
2. Scheduled Services at In-Network Facilities: Out-of-network providers at in-network facilities cannot balance bill patients; they bill the insurer directly.
3. Patient Cost-Sharing: Patients are responsible only for their deductible, copay, and coinsurance amounts applicable to in-network services.
4. Provider-Insurer Negotiation: Provider and insurer have 30 days to negotiate payment. If unresolved, either party may request arbitration through the Connecticut Insurance Department.
5. Insurer Compliance: Connecticut insurers must adjust claims to in-network rates and educate members about their protections.

Penalties and Enforcement

The Connecticut Insurance Department enforces balance billing protections under CGS §38a-477aa. Health insurers that violate the law are subject to enforcement action. Violations include continuing to process claims at out-of-network rates, refusing to adjust claims upon request, or failing to honor arbitration outcomes. Violators are required to refund balance bills to patients and are subject to citations and fines.

Appeals and Exceptions

Patients have the right to appeal any claim adjustment or denial related to balance billing protection. The arbitration process resolves provider-insurer disputes over appropriate payment rates. Exceptions are limited; emergency services and scheduled services at in-network facilities are fully covered without exception.

Interaction with Federal Law

Connecticut SB 5 applies to state-regulated fully insured plans. The federal No Surprises Act (effective January 1, 2022) applies to all health plans, including self-funded ERISA plans. For ERISA plans, federal NSA governs; for state-regulated plans, both Connecticut law and federal law apply, with the strongest protections controlling.

Common Questions