HB 5488 — AN ACT CONCERNING VARIOUS REVISIONS TO THE PUBLIC HEALTH STATUTES.

(3) "Facility fee" means any fee charged or billed by a hospital or health system for outpatient services provided in a hospital-based facility that is:

(A) Intended to compensate the hospital or health system for the operational expenses of the hospital or health system, and (B) separate and distinct from a professional fee;

(4) "Health care provider" means an individual, entity, corporation, person or organization, whether for-profit or nonprofit, that furnishes, bills or is paid for health care service delivery in the normal course of business, including, but not limited to, a health system, a hospital, a hospital-based facility, a freestanding emergency department and an urgent care center;

(5) "Health system" means:

(A) A parent corporation of one or more hospitals and any entity affiliated with such parent corporation through ownership, governance, membership or other means, or (B) a hospital and any entity affiliated with such hospital through ownership, governance, membership or other means;

(6) "Hospital" has the same meaning as provided in section 19a-490, as amended by this act;

(7) "Hospital-based facility" means a facility that is owned or operated, in whole or in part, by a hospital or health system where hospital or professional medical services are provided;

(8) "Medicaid" means the program operated by the Department of Social Services pursuant to section 17b-260 and authorized by Title XIX of the Social Security Act, as amended from time to time;

sHB5488 / File No.

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423 (9) "Observation" means services furnished by a hospital on the hospital's campus, regardless of length of stay, including use of a bed and periodic monitoring by the hospital's nursing or other staff to evaluate an outpatient's condition or determine the need for admission to the hospital as an inpatient;

(10) "Payer mix" means the proportion of different sources of payment received by a hospital or health system, including, but not limited to, Medicare, Medicaid, other government-provided insurance, private insurance and self-pay patients;

(11) "Professional fee" means any fee charged or billed by a provider for professional medical services provided in a hospital-based facility;

(12) "Provider" means an individual, entity, corporation or health care provider, whether for profit or nonprofit, whose primary purpose is to provide professional medical services;

and (13) "Tagline" means a short statement written in a non-English language that indicates the availability of language assistance services free of charge.

(b) If a hospital or health system charges a facility fee utilizing a current procedural terminology evaluation and management (CPT E/M) code, [or] assessment and management (CPT A/M) code, injection and infusion (CPT) code or drug administration (CPT) code for outpatient services provided at a hospital-based facility where a professional fee is also expected to be charged, the hospital or health system shall provide the patient with a written notice that includes the following information:

(2) (A) The amount of the patient's potential financial liability, including any facility fee likely to be charged, and, where professional medicalservicesareprovidedbyanaffiliatedprovider,anyprofessionalsHB5488 fee/ likelyFile toNo. be charged, or, if the exact type and extent of the professional medical services needed are not known or the terms of a patient's health insurance coverage are not known with reasonable certainty, an estimate of the patient's financial liability based on typical or average charges for visits to the hospital-based facility, including the facility fee, (B) a statement that the patient's actual financial liability will depend on the professional medical services actually provided to the patient, (C) an explanation that the patient may incur financial liability that is greater than the patient would incur if the professional medical services were not provided by a hospital-based facility, and (D) a telephone number the patient may call for additional information regarding such patient's potential financial liability, including an estimate of the facility fee likely to be charged based on the scheduled professional medical services;

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423 medicalservicesareprovidedbyanaffiliatedprovider, anyprofessional fee likely to be charged, or, if the exact type and extent of the professional medical services needed are not known or the terms of a patient's health insurance coverage are not known with reasonable certainty, an estimate of the patient's financial liability based on typical or average charges for visits to the hospital-based facility, including the facility fee, (B) a statement that the patient's actual financial liability will depend on the professional medical services actually provided to the patient, (C) an explanation that the patient may incur financial liability that is greater than the patient would incur if the professional medical services were not provided by a hospital-based facility, and (D) a telephone number the patient may call for additional information regarding such patient's potential financial liability, including an estimate of the facility fee likely to be charged based on the scheduled professional medical services;

(c) If a hospital or health system charges a facility fee without utilizing a current procedural terminology evaluation and management (CPT E/M) code, assessment and management (CPT A/M) code, injection and infusion (CPT) code or drug administration (CPT) code for outpatient services provided at a hospital-based facility, located outside the hospital campus, the hospital or health system shall provide the patient with a written notice that includes the following information:

(1) That the hospital-based facility is part of a hospital or health system and that the hospital or health system charges a facility fee that may be in addition to and separate from the professional fee charged by a provider;

(2) (A) A statement that the patient's actual financial liability will depend on the professional medical services actually provided to the patient, (B) an explanation that the patient may incur financial liability sHB5488 / File No.

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423 that is greater than the patient would incur if the hospital-based facility wasnot hospital-based, and(C)atelephone number thepatient maycall for additional information regarding such patient's potential financial liability, including an estimate of the facility fee likely to be charged based on the scheduled professional medical services;

and (3) That a patient covered by a health insurance policy should contact the health insurer for additional information regarding the hospital's or health system's charges and fees, including the patient's potential financial liability, if any, for such charges and fees.

(d) Each initial billing statement that includes a facility fee shall:

(1) Clearly identify the fee as a facility fee that is billed in addition to, or separately from, any professional fee billed by the provider;

(2) provide thecorresponding Medicare facility feereimbursement rate for thesame service asa comparisonor,ifthere isno corresponding Medicare facility fee for such service, (A) the approximate amount Medicare would have paid the hospital for the facility fee on the billing statement, or (B) the percentage of the hospital's charges that Medicare would have paid the hospital for the facility fee;

(3) include a statement that the facility fee is intended to cover the hospital's or health system's operational expenses;

(4) inform the patient that the patient's financial liability may have been less if the services had been provided at a facility not owned or operated by the hospital or health system;

and (5) include written notice of the patient's right to request a reduction in the facility fee or any other portion of the bill and a telephone number that the patient may use to request such a reduction without regard to whether such patient qualifies for, or is likely to be granted, any reduction.

Not later than October 15, 2022, and annually thereafter, each hospital, health system and hospital-based facility shall submit to the Health Systems Planning Unit of the Office of Health Strategy a sample of a billing statement issued by such hospital, health system or hospital-based facility that complies with the provisions of this subsection and which represents the format of billing statements received by patients.

Such billing statement shall not contain patient identifying information.

sHB5488 / File No.

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423 (e) The written notice described in subsections (b) to (d), inclusive, and (h) to (j), inclusive, of this section shall be in plain language and in a form that may be reasonably understood by a patient who does not possess special knowledge regarding hospital or health system facility fee charges.

On and after October 1, 2022, such notices shall include tag lines in at least the top fifteen languages spoken in the state indicating that the notice is available in each of those top fifteen languages.

The fifteen languages shall be either the languages in the list published by the Department of Health and Human Services in connection with section 1557 of the Patient Protection and Affordable Care Act, P.L.

111- 148, or, as determined by the hospital or health system, the top fifteen languages in the geographic area of the hospital-based facility.

(f) (1) For nonemergency care, if a patient's appointment is scheduled to occur ten or more days after the appointment is made, such written notice shall be sent to the patient by first class mail, encrypted electronic mail or a secure patient Internet portal not less than three days after the appointment is made.

If an appointment is scheduled to occur less than ten days after the appointment is made or if the patient arrives without anappointment, suchnotice shallbehand-deliveredtothepatient when the patient arrives at the hospital-based facility.

(2) For emergency care, such written notice shall be provided to the patient as soon as practicable after the patient is stabilized in accordance with the federal Emergency Medical Treatment and Active Labor Act, 42 USC 1395dd, as amended from time to time, or is determined not to have an emergency medical condition and before the patient leaves the hospital-based facility.

If the patient is unconscious, under great duress or for any other reason unable to read the notice and understand and act on his or her rights, the notice shall be provided to the patient's representative as soon as practicable.

(g) Subsections (b) to (f), inclusive, and (l) of this section shall not apply if a patient is insured by Medicare or Medicaid or is receiving services under a workers' compensation plan established to provide medical services pursuant to chapter 568.

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423 (h) A hospital-based facility shall prominently display written notice in locations that are readily accessible to and visible by patients, including patient waiting or appointment check-in areas, stating:

(1) That the hospital-based facility is part of a hospital or health system, (2) the name of the hospital or health system, and (3) that if the hospital- based facility charges a facility fee, the patient may incur a financial liability greater than the patient would incur if the hospital-based facility was not hospital-based.

On and after October 1, 2022, such notices shall include tag lines in at least thetop fifteen languages spoken in the state indicating that the notice is available in each of those top fifteen languages.

The fifteen languages shall be either the languages in the list published by the Department of Health and Human Services in connection with section 1557 of the Patient Protection and Affordable Care Act, P.L.

111-148, or, as determined by the hospital or health system, the top fifteen languages in the geographic area of the hospital- based facility.

Not later than October 1, 2022, and annually thereafter, each hospital-based facility shall submit a copy of the written notice required by this subsection to the Health Systems Planning Unit of the Office of Health Strategy.

(i) A hospital-based facility shall clearly hold itself out to the public and payers as being hospital-based, including, at a minimum, by stating the name of the hospital or health system in its signage, marketing materials, Internet web sites and stationery.

(j) A hospital-based facility shall, when scheduling services for which a facility fee may be charged, inform the patient (1) that the hospital- based facility is part of a hospital or health system, (2) of the name of the hospital or health system, (3) that the hospital or health system may charge a facility fee in addition to and separate from the professional fee charged by the provider, and (4) of the telephone number the patient may call for additional information regarding such patient's potential financial liability.

(k) (1) If any transaction described in subsection (c) of section 19a- 486i, results in the establishment of a hospital-based facility at which sHB5488 / File No.

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423 facility fees may be billed, the hospital or health system, that is the purchaser in such transaction shall, not later than thirty days after such transaction, provide written notice, by first class mail, of the transaction to each patient served within the three years preceding the date of the transaction by the health care facility that has been purchased as part of such transaction.

(2) Such notice shall include the following information:

(A) A statement that the health care facility is now a hospital-based facility andis part ofa hospitalor healthsystem,thehealthcare facility's full legal and business name and the date of such facility's acquisition by a hospital or health system;

(B) The name, business address and phone number of the hospital or health system that is the purchaser of the health care facility;

(C)A statement that thehospital-based facility bills, or is likely to bill, patients a facility fee that may be in addition to, and separate from, any professional fee billed by a health care provider at the hospital-based facility;

(D) (i) A statement that the patient's actual financial liability will depend on the professional medical services actually provided to the patient, and (ii) an explanation that the patient may incur financial liability that is greater than the patient would incur if the hospital-based facility were not a hospital-based facility;

(E) The estimated amount or range of amounts the hospital-based facility may bill for a facility fee or an example of the average facility fee billed at such hospital-based facility for the most common services provided at such hospital-based facility;

and (F) A statement that, prior to seeking services at such hospital-based facility, a patient covered by a health insurance policy should contact the patient's health insurer for additional information regarding the hospital-based facility fees, including the patient's potential financial liability, if any, for such fees.

sHB5488 / File No.

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423 (3) A copy of the written notice provided to patients in accordance with this subsection shall be filed with the Health Systems Planning Unit of the Office of Health Strategy, established under section 19a-612.

Said unit shall post a link to such notice on its Internet web site.

(4)Ahospital,healthsystemorhospital-basedfacilityshallnotcollect a facility fee for services provided at a hospital-based facility that is subject to the provisions of this subsection from the date of the transaction until at least thirty days after the written notice required pursuant to this subsection is mailed to the patient or a copy of such notice is filed with the Health Systems Planning Unit of the Office of Health Strategy, whichever is later.

A violation of this subsection shall be considered an unfair trade practice pursuant to section 42-110b.

(5) Not later than July 1, 2023, and annually thereafter, each hospital- based facility that was the subject of a transaction, as described in subsection (c) of section 19a-486i, during the preceding calendar year shall report to the Health Systems Planning Unit of the Office of Health Strategy the number of patients served by such hospital-based facility in the preceding three years.

(l) (1) Notwithstanding the provisions of this section, no hospital, health system or hospital-based facility shall collect a facility fee for (A) outpatient health care services that use a current procedural terminology evaluation and management (CPT E/M) code, [or] assessment and management (CPT A/M) code, injection and infusion (CPT) code or drug administration (CPT) code and are provided at a hospital-based facility located off-site from a hospital campus, or (B) outpatient health care services provided at a hospital-based facility located off-site from a hospital campus received by a patient who is uninsured of more than the Medicare rate.

(2) Notwithstanding the provisions of this section, on and after July 1, 2024, no hospital or health system shall collect a facility fee for outpatient health care services that use a current procedural terminology evaluation and management (CPT E/M) code or assessment and management (CPT A/M) code and are provided on the sHB5488 / File No.

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423 hospital campus.

The provisions of this subdivision shall not apply to (A) an emergency department located on a hospital campus, or (B) observation stays on a hospital campus and (CPT E/M) and (CPT A/M) codes when billed for the following services:

(i) Wound care, (ii) orthopedics, (iii) anticoagulation, (iv) oncology, (v) obstetrics, and (vi) solid organ transplant.

(3) Notwithstanding the provisions of subdivisions (1) and (2) of this subsection, in circumstances when an insurance contract that is in effect on July 1, 2016, provides reimbursement for facility fees prohibited under the provisions of subdivision (1) of this subsection, and in circumstances when an insurance contract that is in effect on July 1, 2024, provides reimbursement for facility fees prohibited under the provisions of subdivision (2) of this subsection, a hospital or health system may continue to collect reimbursement from the health insurer for such facility fees until the applicable date of expiration, renewal or amendment of such contract, whichever such date is the earliest.

(4) The provisions of this subsection shall not apply to a freestanding emergency department.

As used in this subdivision, "freestanding emergency department" means a freestanding facility that (A) is structurally separate and distinct from a hospital, (B) provides emergency care, (C) is a department of a hospital licensed under chapter 368v, and (D) has been issued a certificate of need to operate as a freestanding emergency department pursuant to chapter 368z.

(5) (A) On and after July 1, 2024, if the executive director of the Office ofHealth Strategyreceivesinformationandhasareasonablebelief,after evaluating such information, that any hospital, health system or hospital-based facility charged facility fees, other than through isolated clerical or electronic billing errors, in violation of any provision of this section, or rule or regulation adopted thereunder, such hospital, health system or hospital-based facility shall be subject to a civil penalty of up to one thousand dollars.

The executive director may issue a notice of violation and civil penalty by first class mail or personal service.

Such notice shall include:

(i) A reference to the section of the general statutes, sHB5488 / File No.

423 18 sHB5488 File No.

423 rule or section of the regulations of Connecticut state agencies believed or alleged to have been violated;

(ii) a short and plain language statement of the matters asserted or charged;

(iii) a description of the activity to cease;

(iv) a statement of the amount of the civil penalty or penalties that may be imposed;

(v) a statement concerning the right to a hearing;

and (vi) a statement that such hospital, health system or hospital-based facility may, not later than tenbusiness days after receipt of such notice, make a request for a hearing on the matters asserted.

(B) The hospital, health system or hospital-based facility to whom such notice is provided pursuant to subparagraph (A) of this subdivision may, not later than ten business days after receipt of such notice, make written application to the Office of Health Strategy to request a hearing to demonstrate that such violation did not occur.

The failure to make a timely request for a hearing shall result in the issuance of a cease and desist order or civil penalty.

All hearings held under this subsection shall be conducted in accordance with the provisions of chapter 54.

(C) Following any hearing before the Office of Health Strategy pursuant to this subdivision, if said office finds, by a preponderance of the evidence, that such hospital, health system or hospital-based facility violated or is violating any provision of this subsection, any rule or regulation adopted thereunder or any order issued by said office, said office shall issue a final cease and desist order in addition to any civil penalty said office imposes.

(m) (1) Each hospital and health system shall report not later than October 1, 2023, and thereafter not later than July 1, 2024, and annually thereafter, to the executive director of the Office of Health Strategy, on a form prescribed by the executive director, concerning facility fees charged or billed during the preceding calendar year.

Such report shall include, but need not be limited to, (A) the name and address of each facility owned or operated by the hospital or health system that provides services for which a facility fee is charged or billed, and an indication as to whether each facility is located on or outside of the sHB5488 / File No.

423 19 sHB5488 File No.

423 hospital or health system campus, (B) the number of patient visits at each such facility for which a facility fee was charged or billed, (C) the number, total amount and range of allowable facility fees paid at each such facility disaggregated by payer mix, (D) for each facility, the total amount offacility feeschargedandthetotalamount ofrevenuereceived by the hospital or health system derived from facility fees, (E) the total amount offacility feeschargedandthetotalamount ofrevenuereceived by the hospital or health system from all facilities derived from facility fees, (F) a description of the ten procedures or services that generated the greatest amount of facility fee gross revenue, disaggregated by current procedural terminology category (CPT) code for each such procedure or service and, for each such procedure or service, patient volume and the total amount of gross and net revenue received by the hospital or health system derived from facility fees, disaggregated by on-campus and off-campus, and (G) the top ten procedures or services for which facility fees are charged based on patient volume and the gross and net revenue received by the hospital or health system for each such procedure or service, disaggregated by on-campus and off- campus.

For purposes of this subsection, "facility" means a hospital- based facility that is located on a hospital campus or outside a hospital campus.

(2) The executive director shall publish the information reported pursuant to subdivision (1) of this subsection, or post a link to such information, on the Internet web site of the Office of Health Strategy.

Subdivision(1)ofsubsection(l)ofsection19a-508cofthe2024 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2024):

(l) (1) Notwithstanding the provisions of this section, no hospital, health system or hospital-based facility shall collect a facility fee for (A) LCO No.

2753 10 of 18 Raised Bill No.5488 outpatient health care services that use a current procedural terminology evaluation and management (CPT E/M) code, [or] assessment and management (CPT A/M) code, injection and infusion (CPT) code or drug administration (CPT) code and are provided at a hospital-based facility located off-site from a hospital campus, or (B) outpatient health care services provided at a hospital-based facility located off-site from a hospital campus received by a patient who is uninsured of more than the Medicare rate.

Sec.

13.

14.13.

Subsection (c) of section 17a-674h of the 2024 supplement to the general statutes is repealed and the following is substituted in lieu thereofsHB5488 (Effective/ fromFile passage):No.

423 20 sHB5488 File No.

423 thereof (Effective from passage):

Emergency medical services personnel shall distribute an opioid antagonist kit containing a personal supply of opioid antagonists and the one-page fact sheet developed by the Connecticut Alcohol and Drug Policy Council pursuant to section 17a-667a regarding the risks of taking an opioid drug, symptoms of opioid use disorder and services available in the state for persons who experience symptoms of or are otherwise affected by opioid use disorder to a patient who (1) is treated by such personnel for an overdose of an opioid drug, (2) displays symptoms to such personnel of opioid use disorder, or (3) is treated at a location LCOwhere No.such personnel observes evidence of illicit use of an opioid drug, or to such patient's family member, caregiver or friend who is present at the location.

2753 11 of 18 Raised Bill No.5488 where such personnel observes evidence of illicit use of an opioid drug, or to such patient's family member, caregiver or friend who is present at the location.

15.14.

16.15.

(q) The Commissioner of Public Health may order an audit of the nurse staffing assignments of each hospital to determine compliance with the nurse staffing assignments for each hospital unit set forth inthe nursesHB5488 staffing/ planFile developedNo. pursuant to subsections (d) and (e) of this section.

423 21 sHB5488 File No.

423 nurse staffing plan developed pursuant to subsections (d) and (e) of this section.

17.16.

LCO(a) No.As used in this section, "structural racism" means a system that structures opportunity and assigns value in a way that disproportionally and negatively impacts Black, Indigenous, Latino or Asian people or other people of color, and "state agency" has the same meaning as provided in section 1-79.

2753 12 of 18 Raised Bill No.5488 (a) As used in this section, "structural racism" means a system that structures opportunity and assigns value in a way that disproportionally and negatively impacts Black, Indigenous, Latino or Asian people or other people of color, and "state agency" has the same meaning as provided in section 1-79.

18.17.

(k) (1) If any transaction described in subsection (c) of section 19a- 486i [,] results in the establishment of a hospital-based facility at which facility fees may be billed, the hospital or health system, that is the purchaser in such transaction shall, not later than thirty days after such transaction, provide written notice, by first class mail, of the transaction tosHB5488 each/ patientFile servedNo. within the three years preceding the date of the transaction by the health care facility that has been purchased as part of such transaction.

423 22 sHB5488 File No.

423 to each patient served within the three years preceding the date of the transaction by the health care facility that has been purchased as part of such transaction.

19.18.

20.19.

(B) An advanced practice registered nurse having been issued a LCOlicense No.pursuant to subsection (d) of section 20-94a who collaborated, priortotheissuanceof suchlicense, withaphysicianlicensedtopractice medicine in another state may count the time of such collaboration toward the three-year requirement set forth in subparagraph (A) of this [subsection] subdivision, provided such collaboration otherwise satisfies the requirements set forth in said subparagraph.

2753 13 of 18 Raised Bill No.5488 license pursuant to subsection (d) of section 20-94a who collaborated, priortotheissuanceof suchlicense, withaphysicianlicensedtopractice medicine in another state may count the time of such collaboration toward the three-year requirement set forth in subparagraph (A) of this [subsection] subdivision, provided such collaboration otherwise satisfies the requirements set forth in said subparagraph.

21.20.

22.21.

(b) On and after January 1, 2024, a contract entered into between a pharmacysHB5488 [benefit]benefitsmanager/ andaFile 340BcoveredentityNo. shall not contain any of the following provisions:

423 23 sHB5488 File No.

423 pharmacy [benefit]benefitsmanager anda 340Bcoveredentity shall not contain any of the following provisions:

(4) Any provision that prevents or interferes with a patient's choice to receive a prescription drug from a 340B covered entity, including the LCOadministration No.of the drug;

2753 14 of 18 Raised Bill No.5488 administration of the drug;

23.22.

24.23.

(c)sHB5488 When/ developingFile theNo. program, said commissioners and executive director [,] shall (1) consult with insurers that offer health benefit plans in the state, hospitals, local public health authorities, existing early childhood home visiting programs, community-based organizations and social service providers;

423 24 sHB5488 File No.

423 (c) When developing the program, said commissioners and executive director [,] shall (1) consult with insurers that offer health benefit plans in the state, hospitals, local public health authorities, existing early childhood home visiting programs, community-based organizations and social service providers;

25.24.

(g) Notwithstanding any provision of the general statutes, the commissioner, or the commissioner's designee, may provide the infant mortality review committee, established pursuant to section 19a-59k, with information as is necessary, in the commissioner's discretion, for LCOthe No.committee to make recommendations regarding the prevention of infant deaths.

2753 15 of 18 Raised Bill No.5488 the committee to make recommendations regarding the prevention of infant deaths.

26.25.

27.26.

(l)sHB5488 "Assisted/ livingFile servicesNo. agency" means an agency that provides chronic and stable individuals with services that include, but need not be limited to, nursing services and assistance with activities of daily living and may have a dementia special care unit or program as defined in section 19a-562;

423 25 sHB5488 File No.

423 (l) "Assisted living services agency" means an agency that provides chronic and stable individuals with services that include, but need not be limited to, nursing services and assistance with activities of daily living and may have a dementia special care unit or program as defined in section 19a-562;

28.27.

and LCO(3) No.Each authorized emergency medical [service] services vehicle shall comply with all state and federal safety, design and equipment requirements.

2753 16 of 18 Raised Bill No.

5488 (3) Each authorized emergency medical [service] services vehicle shall comply with all state and federal safety, design and equipment requirements.

29.28.

30.29.

(2) If a patient receiving birth center services no longer presents with a low-risk pregnancy, as defined in section 19a-490, as amended by this act, or otherwise fails to meet the patient eligibility criteria described in subparagraphsHB5488 (A)/ ofFile subdivisionNo. (1) of this subsection, the birth center providing such services shall ensure the patient's care is transferred to a licensed health care provider capable of providing the appropriate level of obstetrical care for the patient.

423 26 sHB5488 File No.

423 subparagraph (A) of subdivision (1) of this subsection, the birth center providing such services shall ensure the patient's care is transferred to a licensed health care provider capable of providing the appropriate level of obstetrical care for the patient.

Sec.

30.

(Effective from passage) The Commissioner of Public Health shall conduct a scope of practice review pursuant to sections 19a-16d to 19a-16f, inclusive, of the general statutes, to determine whether naturopathic physicians licensed pursuant to chapter 373 of the general statutes should be permitted to prescribe, dispense and administer prescription medication and, if so, whether the Department of Public Health should (1) establish educational and examination requirements or other qualifications to permit a naturopathic physician to prescribe, dispense and administer prescription medication, or (2) develop a naturopathic formulary of prescription medication that a naturopathic physician who meets such educational and examination requirements or other qualifications may use.

Not later than January 1, 2025, the commissioner shall report, in accordance with the provisions of section 11-4a of the general statutes, the findings of such review and any recommendations to the joint standing committee of the General Assembly having cognizance of matters relating to public health.

7 from passage New section LCOSec. No.

2753 17 of 18 Raised Bill No.

5488 Sec.

9 October 1, 2024 20-252 October 1, 2024 Sec.

10 October 1, 2024 20-12i Sec.

11 October 1, 2024 19a-508c(b)19a-508c Sec.

12 Octoberfrom 1,passage 202417a-673c(d) 19a-508c(l)(1) Sec.

13 from passage 17a-673c(d)17a-674h(c) Sec.sHB5488 / File No.

14423 from27 passagesHB5488 17a-674h(c)File Sec.No.

15423 from passage 19a-77(a)(5) Sec.

1614 from passage 19a-89e(q)19a-77(a)(5) Sec.

1715 from passage 19a-133c(a)19a-89e(q) from passage Sec.

1816 19a-508c(k)(1)from passage 19a-133c(a) Sec.

1917 from passage 20-73e(21)19a-508c(k)(1) from passage Sec.

2018 from20-73e(21) passage 20-87a(b)(2)(B) Sec.

2119 from passage 20-185aa(d)20-87a(b)(2)(B) Sec.

2220 from passage 38a-479jjj(b)20-185aa(d) Sec.

2321 from passage 38a-518v(d)38a-479jjj(b) Sec.

2422 Octoberfrom 1,passage 202438a-518v(d) 10-532(c) Sec.

2523 October 1, 2024 19a-59j(g)10-532(c) Sec.

2624 October 1, 2024 19a-111b(3)19a-59j(g) October 1, 2024 Sec.

2725 October19a-111b(3) 1, 2024 19a-490(l) Sec.

2826 October 1, 2024 19a-181(b)(2)19a-490(l) and (3) Sec.

2927 October 1, 2024 19a-493(c)(9)19a-181(b)(2) and (3) Sec.

3028 October 1, 2024 19a-566(c)(2)19a-493(c)(9) StatementSec. of Purpose:

To29 makeOctober various1, revisions2024 to19a-566(c)(2) theSec. public health statutes.

[Proposed30 deletionsfrom arepassage enclosedNew insection brackets.PH Joint Favorable Subst.

ProposedsHB5488 additions/ areFile indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.] LCO No.

2753423 1828 ofsHB5488 18File No.

423 The following Fiscal Impact Statement and Bill Analysis are prepared for the benefit of the members of the General Assembly, solely for purposes of information, summarization and explanation and do not represent the intent of the General Assembly or either chamber thereof for any purpose.

In general, fiscal impacts are based upon a variety of informational sources, including the analyst’s professional knowledge.

Whenever applicable, agency data is consulted as part of the analysis, however final products do not necessarily reflect an assessment from any specific department.

OFA Fiscal Note State Impact:

Agency Affected Fund-Effect FY 25 $ FY 26 $ UConn;

UConn Health Ctr.

GF - Cost See Below See Below Note:

GF=General Fund Municipal Impact:

Municipalities Effect FY 25 $ FY 26 $ Various Municipalities STATE See Below See Below MANDATE 1 - Cost Explanation The bill makes various changes to the public health statutes and results in the following fiscal impact.

Section 3 results in annual costs beginning in FY 25 to the University of Connecticut (UConn), the University of Connecticut Health Center, and various municipalities.

It requires ambulances to carry glucagon nasal powder for emergency medical services, affecting some municipalities as well as UConn and UConn Health, which both own ambulances.

Glucagon nasal powder has an approximate per unit cost of $300 and will need to be replaced about every 18 months unless State mandate is defined in Sec.

2-32b(2) of the Connecticut General Statutes, "state mandate" means any state initiated constitutional, statutory or executive action that requires a local government to establish, expand or modify its activities in such a way as to necessitate additional expenditures from local revenues.

Less than 40% of municipalities own ambulances, with most towns being serviced by non-profit ambulance agencies.

sHB5488 / File No.

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423 administered sooner.

3 This section is not anticipated to result in a cost to municipal police departments, even though many police officers are certified emergency medical responders (EMR).

The bill does not specify that EMRs or their vehicles need to be equipped with glucagon nasal powder.

The Out Years The annualized ongoing fiscal impact identified above would continue into the future subject to the shelf-life and usage of glucagon nasal powder and inflation.

3These costs may not be fully recouped through ambulance billing, as such billing rates are set by the Department of Public Health and are not typically itemized.

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423 OLR Bill Analysis sHB 5488 AN ACT CONCERNING VARIOUS REVISIONS TO THE PUBLIC HEALTH STATUTES.

TABLE OF CONTENTS:

SUMMARY § 1 — MEDICAL ASSISTANTS Adds to the list of organizations from whom a clinical medical assistant may be certified for purposes of qualifying to administer vaccines in non-hospital settings § 2 — ADVERSE EVENT REPORTING Allows DPH to impose disciplinary action on a hospital, birth center, or outpatient surgical facility that fails to report an adverse event § 3 — EMS ADMINISTRATION OF GLUCAGON NASAL POWDER Requires ambulances to be equipped with glucagon nasal powder, and under certain conditions, EMS personnel to administer it to patients § 4 — MARITAL AND FAMILY THERAPIST LICENSURE Increases, from 12 to 24 months, the duration of the postgraduate experience generally required for MFT licensure §§ 5 & 11 — FACILITY FEES Reinstatesaprovisionmakingitanunfairtradepracticeforahospital, health system, or hospital-based facility to violate facility fee limits;

adds injection and infusion and drug administration to the list of outpatientproceduresforwhichtheseentitiesgenerally cannotcollect facility fees, and makes related changes to notice requirements § 6 — LIMITS ON BALANCE BILLING AND CREDIT REPORTING Makes it an unfair trade practice for EMS organizations or health care institutions to (1) request payments (other than out-of-pocket expenses, such as copayments) in certain situations, such as for sHB5488 / File No.

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423 covered facility fees, or (2) report to a credit reporting agency if the patient fails to pay for these services § 7 — STATE-TRIBAL AGREEMENT ON VITAL RECORDS FILING Allows the governor to enter into an agreement with the state’s federally recognized tribes to allow birth and death certificates to be issued by, and filed with, the tribe instead of the municipality § 8 — MASTER SOCIAL WORKER LICENSURE Allowsa master social worker licensure candidate’sdegree to befrom a program that is in the process of getting accredited, before the fall semester § 9 — HAIRDRESSER AND COSMETICIAN LICENSURE TESTING ACCOMMODATIONS Requires the DPH commissioner to notify hairdresser and cosmetician licensure applicants that they may be eligible for certain testing accommodations § 10 — FLUOROSCOPY BY ADVANCED PRACTICE REGISTERED NURSES Allows APRNs meeting certain requirements to use fluoroscopy for diagnostic and therapeutic procedures §§ 12-29 — TECHNICAL CHANGES Makes technical changes in various statutes § 30 — NATUROPATH SCOPE OF PRACTICE COMMITTEE Requires DPH to conduct a scope of practice review on whether naturopathic physicians should be allowed to prescribe, dispense, and administer prescription medication and if so, whether DPH should establish qualifications for this or develop a naturopathic formulary SUMMARY This bill makes various substantive, minor, and technical changes in public health-related statutes and programs.

EFFECTIVE DATE:

Various;

see below.

§ 1 — MEDICAL ASSISTANTS Adds to the list of organizations from whom a clinical medical assistant may be certified for purposes of qualifying to administer vaccines in non-hospital settings sHB5488 / File No.

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423 By law, clinical medical assistants meeting specified certification, education, training, and supervision requirements may administer vaccines in any setting other than a hospital.

The bill adds the American Medical Certification Association (AMCA) to the list of organizations from whom a clinical medical assistant may be certified for this purpose.

It makes a corresponding change by adding the AMCA to the list of organizations from whom the Department of Public Health (DPH) must annually obtain a list of state residents certified as medical assistants.

Under existing law, to qualify to administer vaccines, medical assistants may also be certified by the American Association of Medical Assistants, National Healthcareer Association, National Center for Competency Testing, or American Medical Technologists.

EFFECTIVE DATE:

Upon passage § 2 — ADVERSE EVENT REPORTING Allows DPH to impose disciplinary action on a hospital, birth center, or outpatient surgical facility that fails to report an adverse event By law, hospitals, birthcenters,andoutpatient surgicalfacilitiesmust report adverse events to DPH in a specified format and generally within seven days after the event.

The bill allows DPH to impose disciplinary action if any of these institutions fail to report.

By law, these actions include, among other things, revoking or suspending a license, issuing a letter of reprimand, or placing the licensee on probationary status.

DPH may only impose this discipline after a hearing.

Existing law already allows DPH to impose these actions if any of these institutions, after an adverse event, fails to implement a corrective action plan as required.

EFFECTIVE DATE:

October 1, 2024 Background — Adverse Events By law, an adverse event is any event that is identified on the National Quality Forum’s (NQF) “List of Serious Reportable Events” or sHB5488 / File No.

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423 on a list compiled by DPH (CGS § 19a-127n(a)).

NQF’s list includes 29 events in seven categories (e.g., surgical or invasive procedure events).

§ 3 — EMS ADMINISTRATION OF GLUCAGON NASAL POWDER Requires ambulances to be equipped with glucagon nasal powder, and under certain conditions, EMS personnel to administer it to patients The bill requires licensed or certified ambulances to have glucagon nasal powder for emergency medical services (EMS) personnel to administer.

(Glucagon nasal powder is used to treat severely low blood sugar in people with diabetes.) Specifically, it requires EMS personnel to administer glucagon nasal powder when each of the following conditions are met:

1.

the EMS professional has been trained to do so under DPH- recognized national standards, 2.

the medication is administered according to written protocols and standing orders of a physician serving as an emergency department director, and 3.

the EMS professional determines that administering the medication is necessary to treat the person.

The bill requires all EMS personnel to receive this training from a DPH-designated organization.

Under the bill, “EMS personnel” include emergency medical technicians (EMTs), including advanced EMTs;

paramedics;

and emergency medical responders.

EFFECTIVE DATE:

October 1, 2024 § 4 — MARITAL AND FAMILY THERAPIST LICENSURE Increases, from 12 to 24 months, the duration of the postgraduate experience generally required for MFT licensure The bill increases, from 12 to 24 months, the duration of the postgraduate experience generally required for initial licensure as a marital and family therapist (MFT).

(This change generally corresponds to a recent change in federal law allowing MFTs who meet certain sHB5488 / File No.

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423 criteria to bill Medicare independently for their mental health services.) Under existing law, this postgraduate experience must include at least (1)1,000 hours of direct client contact meeting certainrequirements and (2) 100 hours of postgraduate clinical supervision by an MFT.

EFFECTIVE DATE:

July 1, 2024 §§ 5 & 11 — FACILITY FEES Reinstates a provision making it an unfair trade practice for a hospital, health system, or hospital-based facility to violate facility fee limits;

adds injection and infusion and drug administration to the list of outpatient procedures for which these entities generally cannot collect facility fees, and makes related changes to notice requirements Existing law limits when hospitals, health systems, and hospital- based facilities may charge facility fees for outpatient services provided off-site from a hospital campus.

Starting July 1, 2024, the law also prohibits hospitals or health systems from charging facility fees for certain on-campus outpatient procedures that are not performed in the emergency department.

The bill reinstates a provision, repealed by PA 23-171, making it an unfair trade practice (see Background — ConnecticutUnfair Trade Practices Act (CUTPA)) to violate facility fee limits.

Starting July 1, 2024, PA 23- also allows the Office of Health Strategy to impose civil penalties of up to $1,000 for certain violations of these limits.

Among other limits on off-site outpatient services, existing law generally prohibits hospitals, health systems, and hospital-based facilities from charging facility fees for these services that use a current procedural terminology evaluation and management (CPT E/M) code or CPT assessment and management (CPT A/M) code.

The bill additionally prohibits them from charging facility fees for injection and infusion or drug administration CPT codes at these locations.

As under existing law, these limits do not apply to Medicare and Medicaid patients, patients receiving services under a workers’ compensation plan, or freestanding emergency departments.

The bill also adds these new codes to the list of codes for which sHB5488 / File No.

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423 facility fee notices must include more information than is otherwise required.

By law, a “facility fee” is any fee a hospital or health system charges or bills for outpatient hospital services provided in a hospital-based facility that is (1) intended to compensate the hospital or health system for its operational expenses and (2) separate and distinct from the provider’s professional fee.

EFFECTIVE DATE:

October 1, 2024 Patient Notification Requirements (§ 11(b) & (c)) Under existing law, hospitals or health systems that charge facility fees must give patients receiving outpatient services written notice about their potential financial liability.

The notice must include additional information when the hospital or health system (1) uses CPT E/M or A/M codes for these services and (2) expects to charge a separate fee for professional medical services.

The bill also applies the additional notice requirements if the hospital or health system uses injection and infusion or drug administration CPT codes in these situations.

(As noted above, under the bill, these fees are generally prohibited at off-campus facilities.) Generally, the notice must include, among other things, (1) the amount of the patient’s potential financial liability or (2) an estimate, based on the facility’s typical or average charges, if the exact type and extent of services are unknown or the terms of the patient’s insurance coverage are not known with reasonable certainty.

As under existing law, these notice requirements do not apply to Medicare or Medicaid patients or patients receiving services under a workers’ compensation plan.

Background — Connecticut Unfair Trade Practices Act (CUTPA) The law prohibits businesses from engaging in unfair and deceptive acts or practices.

CUTPA allows the Department of Consumer Protection (DCP) commissioner to issue regulations defining what sHB5488 / File No.

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423 constitutes an unfair trade practice, investigate complaints, issue cease and desist orders, order restitution in cases involving less than $10,000, enter into consent agreements, ask the attorney general to seek injunctive relief, and accept voluntary statements of compliance.

It also allows individuals to sue.

Courts may issue restraining orders;

award actual and punitive damages, costs, and reasonable attorney’s fees;

and impose civil penalties of up to $5,000 for willful violations and $25,000 for violation of a restraining order.

Background — Related Bill sHB 5236 (File 103), § 25, favorably reported by the General Law Committee, among other things, allows DCP to impose a civil penalty of up to $5,000 for CUTPA violations, after an administrative hearing.

§ 6 — LIMITS ON BALANCE BILLING AND CREDIT REPORTING Makes it an unfair trade practice for EMS organizations or health care institutions to (1) request payments (other than out-of-pocket expenses, such as copayments) in certain situations, such as for covered facility fees, or (2) report to a credit reporting agency if the patient fails to pay for these services The bill makes it a CUTPA violation for a licensed EMS organization or health care institution to “balance bill” an insured (i.e., bill more than the collectable cost-sharing under the policy) for the following:

1.

covered health care services or facilities fees, or 2.

covered emergency services, or services at a Department of Children and Families (DCF)-licensed urgent crisis center, provided by an out-of-network provider.

The bill also makes it a CUTPA violation for licensed EMS organizations or health care institutions to bill an insured for a surprise bill (see Background — Surprise Bills), other than collectable cost-sharing.

Finally, it makes it a CUTPA violation for these organizations or institutions to report to a credit reporting agency when an enrollee fails to pay for any of the above when a health carrier (e.g., insurer or HMO) has primary responsibility for paying.

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423 Under existing law, these restrictions already apply to most health care providers.

EFFECTIVE DATE:

October 1, 2024 Background — Surprise Bills Generally, a “surprise bill” is a bill for health care services (other than emergency services or DCF-licensed crisis center services) received by an insured for services by an out-of-network provider at an in-network facility during a service or procedure that was performed by an in- network provider or previously approved by the health carrier, if the insured did not knowingly elect to receive the services from the out-of- network provider (CGS § 38a-477aa).

§ 7 — STATE-TRIBAL AGREEMENT ON VITAL RECORDS FILING Allows the governor to enter into an agreement with the state’s federally recognized tribes to allow birth and death certificates to be issued by, and filed with, the tribe instead of the municipality Existing law requires the governor to submit any compact between the state and an Indian tribe to the legislature for approval or rejection (CGS § 3-6c).

Regardless of this provision, the bill allows the governor to enter into a compact, memorandum of understanding, or agreement withanyfederallyrecognizedtribeinthestateovercertificatesforbirths or deaths occurring on tribal land.

Specifically, they may enter an agreement allowing these certificates to be issued by, and filed with, the tribe’s clerk or registrar of vital statistics, instead of the municipality’s registrar.

EFFECTIVE DATE:

Upon passage § 8 — MASTER SOCIAL WORKER LICENSURE Allows a master social worker licensure candidate’s degree to be from a program that is in the process of getting accredited, before the fall 2027 semester By law, an applicant for a master social worker license must have a master’s degree in social work.

The bill allows the degree to be from a program that (1) is in the process of getting accredited by the Council on Social Work Education and (2) was offered from the spring 2024 semester and before the fall 2027 semester.

Under current law, the sHB5488 / File No.

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423 program must already be accredited.

Existing law requires applicants educated outside of the country to have passed an educational program that the council deems equivalent.

EFFECTIVE DATE:

Upon passage § 9 — HAIRDRESSER AND COSMETICIAN LICENSURE TESTING ACCOMMODATIONS Requires the DPH commissioner to notify hairdresser and cosmetician licensure applicants that they may be eligible for certain testing accommodations The bill requires the DPH commissioner to notify hairdresser and cosmetician licensure applicants approved to take the written licensure examination that they may be eligible for testing accommodations under the federal Americans with Disabilities Act or other accommodations determined by the state Examining Board for Barbers, Hairdressers and Cosmeticians.

Under the bill, these accommodations may include (1) using a dictionary while taking the licensure examination or (2) additional time to complete it.

EFFECTIVE DATE:

October 1, 2024 § 10 — FLUOROSCOPY BY ADVANCED PRACTICE REGISTERED NURSES Allows APRNs meeting certain requirements to use fluoroscopy for diagnostic and therapeutic procedures The bill authorizes advanced practice registered nurses (APRN) to use fluoroscopy to guide diagnostic and treatment procedures if they meet certain training, experience, and examination requirements.

Under the bill, to use fluoroscopy, an APRN must do the following:

1.

complete 40 hours of relevant instruction that includes radiation biology and physics, exposure reduction, equipment operation, image evaluation, quality control, and patient considerations;

2.

complete 40 hours of supervised clinical experience that includes a demonstration of patient dose reduction, occupational dose reduction, image recording, and equipment quality control;

and sHB5488 / File No.

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423 3.

pass a DPH-prescribed test.

Under the bill, documentation that an APRN has met these requirements must be kept at the APRN’s worksite and be available to DPH upon request.

EFFECTIVE DATE:

October 1, 2024 §§ 12-29 — TECHNICAL CHANGES Makes technical changes in various statutes The bill makes technical changes in various public health-related statutes.

EFFECTIVE DATE:

Upon passage (§§ 12-22) or October 1, 2024 (§§ 23-29).

§ 30 — NATUROPATH SCOPE OF PRACTICE COMMITTEE Requires DPH to conduct a scope of practice review on whether naturopathic physicians should be allowed to prescribe, dispense, and administer prescription medication and if so, whether DPH should establish qualifications for this or develop a naturopathic formulary The bill requires the DPH commissioner to conduct a scope of practice review, under the existing process for scope of practice review committees, to determine whether (1) naturopathic physicians should be allowed to prescribe, dispense, and administer prescription medication and (2) if so, DPH should establish educational, examination, or other qualifications for this or develop a naturopathic formulary.

The commissioner must report the committee’s findings and recommendations to the Public Health Committee by January 1, 2025.

Existing law establishes a process to review requests from health care professions seeking to establish or revise a scope of practice prior to consideration by the legislature.

Within available appropriations, DPH appoints members to scope of practice review committees.

The committees consist of (1) the DPH commissioner or her designee (who serves as the committee chairperson and in a non-voting capacity);

(2) two members representing the profession making the request;

and (3) two members recommended by each person or entity that submitted a written impact statement to represent the professions directly impacted sHB5488 / File No.

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423 by the request.

DPH may also appoint additional members representing health care professions with a close relationship to the underlying scope of practice request (CGS § 19a-16e).

EFFECTIVE DATE:

Upon passage COMMITTEE ACTION Public Health Committee Joint Favorable Substitute Yea 23 Nay 13 (03/22/2024) sHB5488 / File No.

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