Connecticut Surprise Billing Law

Overview

Connecticut Senate Bill 5 (CGS §38a-477aa, effective July 1, 2021) provides state-level surprise billing protection. The federal No Surprises Act (effective January 1, 2022) provides additional federal protections for all plans. Connecticut Public Act 23-197 (effective January 1, 2024) adds a requirement that health plan denials of claims and prior authorizations cannot be based on AI analysis alone—human clinical review is mandatory for all adverse determinations.

Key Requirements

1. Emergency Care Protection: Patients pay in-network cost-sharing for emergency care regardless of provider network status under both state and federal law.
2. Scheduled Services at In-Network Facilities: Out-of-network providers cannot balance bill for scheduled services at in-network facilities without 72-hour advance written consent.
3. Human Review Requirement: Connecticut PA 23-197 mandates human clinical review for all claim and prior authorization denials. AI-only decisions are prohibited.
4. Good Faith Estimates: Providers must provide cost estimates for scheduled services to help patients understand their financial obligation.
5. Payment Disputes: Provider-insurer disputes are resolved through federal Independent Dispute Resolution (IDR) and Connecticut arbitration processes.

Penalties and Enforcement

The Connecticut Insurance Department enforces both state and federal surprise billing protections. Violations include failing to adjust claims to in-network rates, refusing to honor advance consent rules, and issuing denials without human clinical review. Violators are subject to enforcement action, required refunds, and civil penalties. Connecticut PA 23-197 violations specifically can result in citations for AI-only determinations.

Appeals and Exceptions

Patients have appeal rights for any claim determination related to surprise billing. The primary exception is advance written consent for elective out-of-network services (72 hours). Connecticut PA 23-197 provides no exception to human review—all denials require human clinical evaluation. Emergency and post-stabilization services are fully covered without exception.

Interaction with Federal Law

Connecticut state law and the federal No Surprises Act provide overlapping protections. Connecticut's PA 23-197 adds an additional layer by requiring human clinical review. For state-regulated plans, both Connecticut law and federal NSA apply; for ERISA self-funded plans, federal law governs but Connecticut PA 23-197 human review requirements may apply depending on plan administration.

Common Questions