In this chapter, the following terms have the meanings indicated. Terms Defined. “Credit and collection policy” means a hospital’s policy on the collection of medical debt. Debt Collector. “Debt collector” means a person who engages directly or indirectly in the business of: Collecting for, or soliciting from another, medical debt; Giving, selling, attempting to give or sell to another, or using, for collection of medical debt, a series or system of forms or letters that indicates directly or indirectly that a person other than the hospital is asserting the medical debt; or Employing the services of an individual or business to solicit or sell a collection system to be used for collection of medical debt. “Debt collector” includes a “collection agency” as defined in Business Regulation Article, §7-101, Annotated Code of Maryland. “Financial hardship” means medical debt, incurred by a family over a 12-month period, that exceeds 25 percent of family income. “Hospital” has the meaning stated in Health-General Article, §19- 301(f), Annotated Code of Maryland. Hospital Services. “Hospital services” means: Inpatient hospital services as enumerated in 42 C.F.R. §409.10, as amended; Emergency services, including services provided at a freestanding medical facility licensed under Health Occupations Article, Title 19, Subtitle 3A, Annotated Code of Maryland Outpatient services provided at a hospital as defined in COMAR 10.37.10.07-2; Outpatient services, as specified by the Commission in COMAR 10.37.10.07-2, provided at a freestanding medical facility licensed under Health-General Article, Title 19, Subtitle 3A, Health-General Article, Annotated Code of Maryland that has received a certificate of need under Health-General Article, §19–120(o)(1), Annotated Code of Maryland, or an exemption from obtaining a certificate of need under Health-General Article, §19–120(o)(3), Annotated Code of Maryland; and Identified physician services for which a facility has Commission–approved rates on June 30, 1985. “Hospital services” includes a hospital outpatient service: Of a hospital that, on or before June 1, 2015, is under a merged asset hospital system; That is designated as a part of another hospital under the same merged asset hospital system to make it possible for the hospital outpatient service to participate in the 340B Program under the federal Public Health Service Act; and That complies with all federal requirements for the 340B Program and applicable provisions of 42 C.F.R. §413.65. “Hospital services” does not include: Outpatient renal dialysis services; Outpatient services provided at a limited service hospital as defined in Health-General Article, §19–301, Annotated Code of Maryland except for emergency services; or Physician services that are billed separately. Household. “Household” means, at a minimum, for an adult patient, the patient and the following individuals that live in the same dwelling: A spouse, regardless of whether the patient and spouse expect to file a joint federal or State tax return; Biological children, adopted children, or stepchildren; and All individuals on the same federal or State tax return, including anyone for whom the patient claims a personal exemption in a federal or State tax return. “Household” means, at a minimum, for a patient who is a child, the patient and the following individuals that live in the same dwelling: Biological parents, adoptive parents, stepparents, or guardians; Biological siblings, adopted siblings, or step siblings; and All individuals on the same federal or State tax return, including anyone for whom the patient’s parents or guardians claim a personal exemption in a federal or State tax return. The terms "household” and “family” are synonymous for the purposes of this chapter. Income. “Income” means total taxable income, before taxes. “Income” includes: If a hospital uses state or federal tax returns to verify income, the adjustments listed on Schedule 1 of Form 1040; and If a hospital utilizes an asset test, the value of household monetary assets, consistent with Regulation 06J of this chapter. “Initial bill” means the first billing statement provided to an individual by a hospital after the care, whether inpatient or outpatient, is provided and the individual has left the hospital. “Medical debt” means out-of-pocket expenses, including co-payments, coinsurance, and deductibles, for hospital services that are regulated by the Commission that are billed to a patient or a co-signer for the patient, excluding amounts contractually paid by another payer such as insurers, including Medicare, Medicaid, or CHIP. “Medically necessary care” including care provided in accordance with the Emergency Medical Treatment and Labor Act of 1986), means care that is: Directly related to diagnostic, preventative, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability or health condition; Consistent with current accepted standards of good medical practice; and Not primarily for the convenience of the patient, the patient’s family, or the provider. Monetary Assets. “Monetary assets” means assets in excess of $100,000 that can readily be converted into a fixed or precisely determinable amount of money, including cash and cash equivalents. “Monetary assets” include cash on hand, bank deposits, investment accounts, accounts receivable, and notes receivable. “Monetary assets” do not include retirement assets to which the Internal Revenue Service has granted preferential tax treatment, including deferred–compensation plans qualified under the Internal Revenue Code or nonqualified deferred–compensation plans. Payment Plan. “Payment plan” means an agreement between a patient, or a guarantor, to pay for a hospital service over a period of time. “Payment plan” includes: An “income-based payment plan” set forth in Regulation .05 of this chapter; and A “non-income-based payment plan” set forth in Regulation .05W of this chapter. “Qualified Maryland resident” means someone who lives in Maryland for more than 6 months of the year or whose primary residence is in Maryland, including those in Maryland for school or work. Written. “Written” means communications in paper form and communications delivered electronically, including through electronic mail, a secure web, or mobile based application such as a patient portal. “Written” does not include oral communications, including communications delivered by phone. A patient may opt out of receiving written communications required by Regulations .03—.08 of this chapter through electronic delivery methods, such as through email or a patient portal. A hospital or debt collector who communicates with a patient electronically must include in such communication, or attempt to communicate, a clear and conspicuous statement describing a reasonable and simple method by which the patient can opt out of further electronic communications by the hospital or debt collector. A hospital or debt collector may not require, directly or indirectly, that the patient, in order to opt out of electronic communication, pay any fee or provide any information other than: The patient’s opt out preferences; and The email address, telephone number for text messages, or other electronic-medium address subject to the opt-out request. If a hospital or debt collector receives notice from a patient that the patient is opting out of receiving written communications through electronic delivery methods, the hospital or the debt collector: May not provide the written communications required by Regulations .03—.08 of this chapter through electronic delivery methods; and Shall deliver the written communications through non-electronic delivery methods. Notice of Patient Opting Out of Written Communications. If a hospital receives notice from a patient that the patient is opting out of receiving written communications through electronic delivery methods, and the hospital uses a debt collector with respect to that patient, the hospital shall immediately inform the debt collector that the patient is opting out of electronic delivery methods. If a debt collector receives notice from a patient that the patient is opting out of receiving written communications through electronic delivery methods, the debt collector shall immediately inform the hospital that controls that patient account that the patient is opting out of electronic delivery methods. Each hospital shall develop an information sheet that: Describes clearly: The hospital's financial assistance policy as required in Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland; and A patient's legal rights and obligations with regard to hospital billing and collection; Informs the patient, the patient’s family, the patient’s authorized representative, or the patient’s legal guardian: That the hospital is permitted to bill outpatients a fee, commonly referred to as a facility fee, for their use of hospital facilities, clinics, supplies, and equipment, and nonphysician services, including but not limited to the services of nonphysician clinicians, in addition to physician fees billed for professional services provided in the hospital; Of the patient’s right to request and receive a written estimate of the total charges for the hospital non-emergency services, procedures, and supplies that reasonably are expected to be provided and billed for by the hospital, in addition to the good faith estimate requirements in 42 U.S.C §2799B-6, the No Surprises Act; Of the patient’s right to file a complaint with the Commission or jointly with the Health Education and Advocacy Unit of the Maryland Attorney General’s Office against a hospital for an alleged violation of Health-General Article, §§19-214.1 and 19-214.2, Annotated Code of Maryland; Of the availability of an income-based payment plan; and That physician charges, to both hospital inpatients and outpatients, are generally not included in the hospital bill and are billed separately; Provides contact information for: The individual or office at the hospital that is available to assist the patient, the patient's family, or the patient's authorized representative in order to understand: The patient's hospital bill; The patient’s rights and obligations with regard to the hospital bill, including the patient’s rights and obligations with regard to reduced-cost medically necessary care due to a financial hardship; How to apply for financial assistance; How to apply for the Maryland Medical Assistance Program and any other programs that may help pay the bill; and How to apply for a payment plan; The Maryland Medical Assistance Program; Filing a complaint with the Commission or jointly with the Health Education and Advocacy Unit of the Maryland Attorney General’s Office against a hospital for an alleged violation of Health-General Article, §§19-214.1 and 19-214.2, Annotated Code of Maryland; and Includes a section that allows the patient to initial that the patient has been made aware of the financial assistance policy. The information sheet shall be written in: Simplified language; At least 12-point type; and The patient’s preferred language or, if no preferred language is specified, each language spoken by a limited English proficient population that constitutes at least 5 percent of the overall population within the city or county in which the hospital is located as measured by the most recent census. The information sheet shall conform with Health-General Article, §19–342(d)(7) and (10), Annotated Code of Maryland. The information sheet shall be provided in writing to the patient, the patient’s family, the patient’s authorized representative, or the patient’s legal guardian: Before the patient receives scheduled medical services; Before discharge; With the hospital bill; On request; and In each written communication to the patient regarding collection of the hospital bill. The hospital bill shall include a reference to the information sheet. The Commission shall: Establish uniform requirements for the information sheet; and Review each hospital's implementation of and compliance with the requirements of this regulation. Each hospital shall submit to the Commission, at times prescribed by the Commission, the hospital's credit and collection policy. The policy shall: Provide for active oversight by the hospital of any contract for collection of debts on behalf of the hospital; Prohibit the hospital from selling any debt, except as permitted by Health-General Article, §19–214.2(m), Annotated Code of Maryland and §O of this regulation; Prohibit the hospital from: Engaging in collection activities on 100 percent of the outstanding amount of the Commission-set charge for debt sold under §O of this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland; and Collecting on judgments entered into on patient debt that was sold under §O of this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland; Reporting adverse information to a consumer reporting agency; Filing a civil action to collect a debt against a patient within 240 days after the initial bill is provided; Filing a civil action to collect a debt against a patient whose outstanding hospital medical debt is at or below $500; Forcing the sale or foreclosure of a patient’s primary residence to collect medical debt; Requesting a lien against a patient’s primary residence in an action to collect medical debt; Requesting the issuance of or otherwise knowingly taking action that would cause a court to issue a body attachment against a patient or an arrest warrant against a patient, if the hospital files an action to collect medical debt; and Requesting a writ of garnishment of wages or filing an action that would result in an attachment of wages against a patient to collect medical debt if the patient is eligible for free or reduced-cost medically necessary care, in accordance with Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland; In accordance with Health-General Article, §19-214.2(c), Annotated Code of Maryland and §G of this regulation, provide for a refund of amounts collected from a patient or the guarantor of a patient who was later found to be eligible for free medically necessary care within 240 days after the initial bill was provided under Health General Article, §19-214.1, Annotated Code of Maryland and §G of this regulation; If the hospital has obtained a judgment against or had reported adverse information to a consumer reporting agency about a patient who later was found to be eligible for free medically necessary care, in accordance with Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland, within 240 days after the initial bill was provided, require the hospital to seek to vacate the judgment or strike the adverse information; Provide a mechanism for a patient to: Request the hospital to reconsider the denial of free or reduced–cost care; and File with the hospital a complaint against the hospital or a debt collector used by the hospital regarding the handling of the patient’s bill; For a patient who is eligible for free or reduced cost-care under the hospital’s financial assistance policy, prohibit the hospital from: Charging interest on the debt owed on a bill for the patient before a court judgement is obtained; or Collecting fees or any other amount that exceeds the approved charge for the hospital service as established by the Commission; Establish a process for making payment plans available to all patients in accordance with Regulation .05 of this chapter and Health-General Article, §19-214.2(e)(3), Annotated Code of Maryland; Provide detailed procedures for the following actions: When garnishments may be applied to a patient’s or patient guarantor’s income in accordance with §I of this regulation and Health-General Article, §19-214.2(f)(4), Annotated Code of Maryland; When a lien on a patient’s or patient guarantor’s personal residence, excluding a primary resident in accordance with §I of this regulation and Health-General Article, §19-214.2(g)(2), Annotated Code of Maryland, or motor vehicle may be placed; The hospital's procedures for collecting any medical debt, consistent this regulation; The circumstances in which the hospital will seek a judgment against a patient for the patient’s medical debt, subject to §I of this regulation and Health-General Article, §19–214.2, Annotated Code of Maryland; The consideration by the hospital of patient income, assets, and other criteria set forth in this regulation; and Comply with Health-General Article, §24-2502, Annotated Code of Maryland. Consistent with Health-General Article, §19-214.2(e)(5), Annotated Code of Maryland, a hospital shall demonstrate that it attempted in good faith to meet the requirements of Health-General Article, §19-214.2(e), Annotated Code of Maryland, and the Guidelines set forth in Regulation .05 of this chapter before the hospital: Files an action to collect the patient’s medical debt; or Delegates collection activity to a debt collector for a patient’s medical debt. The hospital shall be deemed to have demonstrated that it attempted to act in good faith under Health-General Article, §19-214.2(e)(5)(i)(2), Annotated Code of Maryland and §C(2) of this regulation if, before delegating collection of a patient’s medical debt to a debt collector, the hospital: Provides the information sheet before the patient receives scheduled medical services and before discharge in accordance with Health-General Article, §19-214.2(e)(1) and (2), Annotated Code of Maryland, and in Regulation .03D(1) and (2) of this chapter; and Establishes a process for making payment plans available to all patients in accordance with Health-General Article, §19-214.2(e)(3), Annotated Code of Maryland and Regulation .05 of this chapter. In delegating any or all collection to a debt collector for a patient’s medical debt, the hospital may rely on a debt collector to engage in various activities, including: Facilitating and servicing payment plans in accordance with the Guidelines, including receiving and forwarding any payments received under a payment plan approved by the hospital; and Such other activities as the hospital may direct in collecting and forwarding payments under a payment plan. A hospital may not seek legal action to collect a patient’s medical debt until the hospital has established and implemented a payment plan policy that complies with the Guidelines. As provided by Health-General Article, §19-214.2(c), Annotated Code of Maryland: A hospital shall provide: For a refund of amounts exceeding $25 collected from a patient or the guarantor of a patient who was found to be eligible for free medically necessary care within 240 days after the initial bill is provided to the patient; and The refund to the patient not later than 30 days after determining that the patient was eligible for free medically necessary care. If a patient is enrolled in a means-tested government health care plan that requires the patient to pay out-of-pocket for hospital service, a hospital shall have a refund policy that complies with the terms of the patient’s plan. Consumer Reporting. A hospital may not commence civil action against a patient for nonpayment or delegate collection activity to a debt collector, if the hospital: Was notified in accordance with federal law by the patient or the insurance carrier that an appeal or a review of a health insurance decision is pending within the immediately preceding 60 days; Is processing a requested reconsideration of the denial of free or reduced-cost medically necessary care under Regulation .06A(1)(c)(v) of this chapter and Health-General Article, §19-214.1(b)(2)(iv), Annotated Code of Maryland, that was appropriately completed by the patient or has completed the reconsideration within the immediately preceding 60 days; or Sold the debt under §O of this regulation and Health-General Article, §19-214.2(m). A hospital shall comply with Health-General Article, §24-2502, Annotated Code of Maryland. A hospital shall report the fulfillment of a patient’s payment obligation within 60 days after the obligation is fulfilled to any consumer reporting agency to which the hospital had reported adverse information about the patient, including if the debt was sold under §O of this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland. Not later than November 1, 2025, a hospital that had reported adverse information about a patient to a consumer reporting agency shall instruct the consumer reporting agency to delete the adverse information about the patient. Civil Action. Deceased Patients. A hospital may not make a claim against the estate of a deceased patient to collect medical debt if the deceased patient was known by the hospital to be eligible for free medically necessary care, in accordance with Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland, or if the value of the estate after tax obligations are fulfilled is less than half of the medical debt owed. A hospital may offer the family of the deceased patient the ability to apply for financial assistance. A hospital may not file an action to collect medical debt until the hospital determines whether the patient is eligible for free or reduced-cost medically necessary care under Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland. At least 45 days before filing an action against a patient to collect medical debt, but not within 240 days after the initial bill is provided, a hospital shall send written notice of the intent to file an action to the patient. The notice required in §I(3) of this regulation shall: Be sent to the patient by certified mail and first class mail; Be in simplified language; Be in at least 12-point type; Include: The name and telephone number of the hospital, the debt collector, if applicable, and an agent of the hospital authorized to modify the terms of the payment plan, if any; The amount required to cure the nonpayment of medical debt, including past due payments, interest, penalties, and fees; A statement recommending that the patient seek debt counseling services; Telephone numbers and internet addresses of the Health Education Advocacy Unit of the Office of the Attorney General, available to assist patients experiencing medical debt; and An explanation of the hospital's financial assistance policy; Be provided in the patient’s preferred language or, if no preferred language is specified, English and each language spoken by a limited English proficient population that constitutes at least 5 percent of the population within the jurisdiction in which the hospital is located as measured by the most recent federal census; and Be accompanied by: An application for financial assistance under the hospital's financial assistance policy, along with instructions for completing the application for financial assistance, specific instructions about where to send the application, and the telephone number to call to confirm receipt of the application; Language explaining the availability of an income-based payment plan to satisfy the medical debt that is the subject of the hospital debt collection action; and The information sheet required under Regulation .03 of this chapter and Health-General Article, §19-214.1(f), Annotated Code of Maryland. Delegation of Collection to a Debt Collector. If a hospital delegates collection activity to a debt collector, the hospital shall: Specify the collection activity to be performed by the debt collector through an explicit authorization or contract; Require the debt collector to abide by the hospital’s credit and collection policy; Specify procedures the debt collector must follow if a patient appears to qualify for financial assistance under Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland; and Require the debt collector to: In accordance with the hospital’s credit and collection policy, provide a mechanism for a patient to file with the hospital a complaint against the hospital or the debt collector regarding the handling of patient’s bill; If a patient files a complaint with the debt collector, forward the complaint to the hospital; and Along with the hospital, be jointly and severally responsible for meeting the requirements of this regulation, Regulation .06 of this chapter, and Health-General Article, §19-214.2, Annotated Code of Maryland. Consent to Assume Liability for Medical Debt. A spouse or another individual may not be held liable for the medical debt of an individual 18 years old or older unless the individual voluntarily consents to assume liability for the patient’s medical debt. The consent shall be: Made on a separate document signed by the individual; Not solicited in an emergency room or during an emergency situation; and Not required as a condition of providing emergency or non-emergency health care services. The Board of Directors of each hospital shall review and approve the hospital’s financial assistance policy required under Regulation .06 of this chapter and Health-General Article, §19-214.1, Annotated Code of Maryland and debt collection policy required under Regulation .04 of this chapter and Health-General Article, §19-214.2, Annotated Code of Maryland at least every 2 years. A hospital may not alter its financial assistance or credit and collection policies without approval of the Board of Directors. The Commission shall review each hospital's implementation of and compliance with the hospital's policy and the requirements of §B of this regulation. Reporting Requirements. Each hospital shall annually submit to the Commission within 120 days after the end of each hospital’s fiscal year a report including: The total number of patients by race or ethnicity, gender, and zip code of residence against whom the hospital or a debt collector used by the hospital, filed an action to collect medical debt; The total number of patients by race or ethnicity, gender, and zip code of residence with respect to whom the hospital has and has not reported or classified a bad debt; The total dollar amount of charges for hospital services provided to patients but not collected by the hospital for patients covered by insurance, including the out-of-pocket costs for patients covered by insurance, and patients without insurance; and For hospital debts owed by patients of the hospital that the hospital sold to a governmental unit, contractor, or nonprofit organization under Health-General Article, §19-214.2(m), Annotated Code of Maryland and §O of this regulation: The total dollar amount of the debt sold by the hospital for the reporting year; The total dollar amount paid by the hospital to the unit, contractor, or nonprofit organization who purchased the debt; and The total number of patients whose debt was sold, in full or in part, to the unit, contractor, or nonprofit organization who purchased the debt. The Commission shall post the information submitted under §N(1) of this regulation on its website. Selling Medical Debt. Consistent with Health-General Article, §19-214.2(m), Annotated Code of Maryland, a hospital may sell debt owed to the hospital by a patient for hospital services to a governmental unit, an entity that is under contract with the governmental unit, or to a nonprofit organization that is exempt from taxation under 26 U.S.C. §501(c)(3) of the Internal Revenue Code for the sole purpose of canceling the debt. The contract between the hospital and the governmental unit, entity that is under contract with the governmental unit, or nonprofit organization purchasing the debt shall state that the sole purpose of the sale of the debt is to cancel the debt. The patient is not responsible to the hospital, the governmental unit, the entity that is under contract with the governmental unit, or the nonprofit organization for any amount of the debt that is sold, or any interest, fees, or costs associated with the debt or the sale. Debt sold under this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland: Must be for hospital services provided at least 2 years before the date of the sale; May not be expected to yield additional reimbursements from a third-party payor; May not be subject to an open appeal with an insurance company; and Must be for an individual whose family income is at or below 500 percent of the federal poverty level or who has medical debt exceeding 5 percent of the patient’s family income, as determined by the governmental unit, contractor, or nonprofit organization purchasing the debt. Debt sold under this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland, may be sold with a reduction of Commission charges. The Commission shall treat the amount of payments to hospitals under this subsection as an offset to uncompensated care amounts reported by hospitals. The purchaser of the debt shall: Notify the patient that the debt has been canceled; and If the hospital obtained a judgment against the patient or reported adverse information to a consumer reporting agency about the patient, seek to vacate the judgment or strike the adverse information. If a hospital sells hospital medical debt under this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland, the hospital must immediately dismiss actions pending against a patient for collection of that debt. Scope. As described in this regulation, the Guidelines for Hospital Payment Plans apply to any income-based payment plan offered by a hospital to a patient to pay for medically necessary hospital services after the services are provided. “Income” in this regulation means household monthly income. Prepayment Plans. Nothing in the Guidelines prevents a hospital from offering patients arrangements to make payments prior to service, provided that: A hospital may not require or steer a patient to enter into such an arrangement solely to avoid the application of these Guidelines; Before a hospital requests pre-payment for a hospital service, the hospital shall: Comply with the notice provisions of Health-General Article, §19-214.1, Annotated Code of Maryland, and Regulations .03 and .06 of this chapter; Advise the patient about the availability of financial assistance; Process any request for financial assistance; and Advise the patient about the availability of income-based payment plans, including information about the 5 percent cap on monthly payment amounts under §F(1) of this regulation; and Such an arrangement terminates once the hospital service is rendered. Unregulated Services. These Guidelines apply only to hospital services that are regulated by the Commission. These Guidelines do not apply to services that are not regulated by the Commission, including physician services. Limitation of the Guidelines. These Guidelines do not prevent hospitals from extending payment plans for services, such as physician services, or at times that are outside the parameters of the Guidelines. Except as otherwise required by law or regulation, payment plans that are outside the parameters of these Guidelines are not subject to the Guidelines. Access to Income-Based Payment Plans. Availability of Income-Based Payment Plans. Maryland hospitals shall make income-based payment plans available to all patients who are Maryland residents, including individuals temporarily residing in Maryland due to work or school, irrespective of their: Insurance status; Citizenship status; Immigration status; or Eligibility for reduced-cost medically necessary care, including reduced-cost medically necessary care due to financial hardship, under Regulation .06 of this chapter. Treatment of Nonresidents and Unregulated Services. These Guidelines do not prevent a hospital from extending payment plans to patients who are not described in §B(1) of this regulation. These Guidelines do not prevent a hospital from extending payment plans to patients for services that are not regulated by the Commission. Except as required by §U of this regulation or by other law or regulation, payment plans for patients which are not described in §B(1) of this regulation and payment plans for services that are not regulated by the Commission are not subject to the Guidelines under this regulation. Notice Requirements. Notice of Availability of an Income-Based Payment Plan. Posted Notice. A notice shall be posted in conspicuous places throughout the hospital, including the billing office, informing Maryland residents of the availability of an income-based payment plan and whom to contact at the hospital for additional information. If the hospital uses a vendor to assist with financial assistance eligibility, billing, or debt collection, such as a debt collector or eligibility vendor, the hospital shall ensure that the vendor posts a notice in a conspicuous place on their website or online payment portal, informing Maryland residents of the availability of an income-based payment plan and whom to contact at the hospital or debt collector for additional information. Placement on the website or online payment portal should be based on the best interest of the patient. Information Sheet. A written notice of the availability of an income-based payment plan shall be contained in the information sheet required under Regulation .03 of this chapter, including clarity on the availability of income-based payment plans for Maryland residents, and, if payment plans for non-residents are included in the hospital’s credit and collection policy, the availability of such plans for non-residents. Before a Prepayment Plan. Before a patient enters into a prepayment plan as described in §A(2) of this regulation for a medically necessary hospital service, a hospital shall provide a written notice of the availability of an income-based payment plan to a patient. On a Bill. On the same page of the bill that includes the amount due and due date, the hospital shall provide notice that a lower monthly payment amount may be possible through an income-based plan, in the same font and style as the total amount due notification. Online Payment Portal. On both the page of the online payment portal that states the amount due, and where the consumer enters the amount being paid by the consumer, the hospital shall provide, in the same font and style as the amount due notification, notice informing Maryland residents of the availability of an income-based monthly payment plan and information, including a telephone number and email address, in order to contact the hospital for additional information. Notice of Terms Before Execution. A hospital shall provide written notice of the terms of an income-based payment plan to a patient before the patient agrees to enter the income-based payment plan. The terms of the income-based payment plan shall include: The amount of medical debt owed to the hospital; The interest rate applied to the income-based payment plan and the total amount of interest expected to be paid by the patient under the income-based payment plan; The amount of each periodic payment expected from the patient under the income-based payment plan; The number of periodic payments expected from the patient under the income-based payment plan; The expected due dates for each payment from the patient; The expected date by which the account will be paid off in full; The treatment of any missed payments, including missed payments and default as described in §P and T of this regulation; That there are no penalties for early payments; and Whether the hospital plans to apply a periodic recalculation of monthly payment amounts as described in §N of this regulation and the process for such recalculation. Notice of Plan After Execution. A hospital shall promptly provide a written income-based payment plan, including items listed in §C(2) of this regulation, to the patient following execution by all parties. The income-based payment plan shall be provided to the patient at least 20 days before the due date of the patient’s first payment under the income-based payment plan. Financial Assistance. Before entering into an income-based payment plan with a patient, hospitals shall evaluate if the patient is eligible for financial assistance, including free and reduced-cost medically necessary care, including reduced-cost medically necessary care due to financial hardship, in accordance with Regulation .06 of this chapter. Hospitals shall: Apply the financial assistance reduction before entering into an income-based payment plan with a patient; and Use any information collected for determining financial assistance under Regulation .06 of this chapter to establish the 5 percent monthly payment threshold for payment plans under Regulation .05F of this chapter. Offer Required. Hospitals must offer income-based payment plans that meet the requirements of these Guidelines. Monthly Payment Amounts. Under an income-based payment plan subject to these Guidelines, a hospital may not require a patient to make total payments in a month that exceed 5 percent of the lesser of the patient’s household income. §F(1) of this regulation applies to total amounts due under the plan, including both principal and interest, but does not apply to any catch-up payments, such as payments described under §P(1) of this regulation. A hospital shall calculate the monthly payment amount threshold under §F(1) of this regulation by dividing income level by household size and multiplying by .05 percent. Determining the Household Size. The hospital shall determine the size of the patient’s household using the number reported on tax returns, if provided the number of tax filers and dependents listed on the tax return provided by the patient. For example, if a married couple files jointly and has three dependents, the number of tax filers and dependents would equal five. If a patient files as an individual and the patient is not a dependent and has no dependents, the number of tax filers would equal one. If the patient has not provided a tax return, the hospital shall ask the patient to provide the number of individuals in the household. Expenses. A hospital may reduce the amount of the monthly payment due under an income-based payment plan upon consideration of household expense information provided by a patient. Application to Multiple Income-based Payment Plans. Hospitals. A hospital shall ensure that the total monthly payment amount for all income-based payment plans provided to a patient by the hospital, when added up collectively, does not exceed the income limitation under §F(1) of this regulation. Hospital System. A hospital system shall ensure that the total monthly payment amount for all income-based payment plans provided to a patient by all hospitals in the hospital system, when added up collectively, does not exceed the income limitation under §F(1) of this regulation. Duration of Income-Based Payment Plan. The duration of an income-based payment plan, in months, is determined by the total amount owed, and interest, if interest applies, divided by the total amount of the payment due each month, subject to the limitation that no monthly payment may exceed 5 percent of the patient’s income as calculated under §F(1)of this regulation. Solicitation of Early Payments Prohibited. Hospitals may not solicit, steer, or mandate patients to pay an amount in excess of the monthly payment amount provided for in an income-based payment plan. Application of Partial Payments. A hospital shall apply partial payments in a manner most favorable to the patient. Interest and Fees. No Interest for Patients Eligible for Financial Assistance. For a patient who is eligible for free or reduced-cost medically necessary care under the hospital’s financial assistance policy under Regulation .06 of this chapter and Health-General Article, §19–214.1, Annotated Code of Maryland, the hospital may not charge interest or fees on any medical debt amount owed under an income-based payment plan. Allowable Interest. A hospital may charge interest under an income-based payment plan for a patient who is not eligible for free or reduced-cost medically necessary care, as described in §L of this regulation. A hospital is not required to charge interest for a payment plan. Interest Rate. An income-based payment plan may not provide for interest in excess of an effective rate of simple interest of 6 percent per annum on the unpaid principal balance of the payment plan. A hospital may not set an interest rate that results in negative amortization. Payers subject to Insurance Article, §15-1005, Annotated Code of Maryland, shall comply with its provisions. Timing. Interest may not begin before 240 days after the initial bill is provided. Late payments. A hospital may not charge additional fees or interest for late payments. Early Payment. Prepayment Allowed. Patients may, on a voluntary basis, pre-pay, in whole or in part, any amounts owed under an income-based payment plan. Any prepayment made under §M(1) of this regulation is not subject to the monthly income payment limitations of §F(1) of this regulation. No Fees or Penalties. A hospital may not assess fees or otherwise penalize early payment of an income-based payment plan. Limited Modifications of Income-based Payment Plans. Change in Income. If a patient with an income-based payment plan notifies a hospital that the patient’s income has changed, then the hospital shall offer to modify the income-based payment plan to meet the requirement of §N(6) of this regulation. Expenses. Before modifying an income-based payment plan, a hospital shall consider information provided by a patient about changes in household expenses in considering a patient request to modify a payment plan. No Increase in Interest Rate. A hospital may not increase the interest rate on an income-based payment plan when making a modification to an income-based payment plan under this Guideline. Limitation on Payment Amount. A hospital may not modify an income-based payment plan in a way that requires a patient to make a monthly payment that exceeds the percent of the patient’s income used to set the monthly payment amount under the initial income-based payment plan as provided for in §F of this regulation. Change in Duration. The duration of a modified income-based payment plan, in months, is determined by the total amount owed, and interest, if interest applies, divided by the total amount of the payment due each month, subject to the limitation under §F of this regulation. Process for Modifying an Income-Based Payment Plan. Prompt Response to Patient Request. If a patient requests a modification to the terms of the payment plan, the hospital shall respond in a timely manner and may not refer the outstanding balance owed to a collection agency or for legal action until 30 days after providing a written response to the patient’s request for a modification of the payment plan. Reconsideration for Financial Assistance. If a patient makes a request for modification of a payment plan, the hospital shall consider if such patient is eligible for financial assistance, including free medically necessary care, reduced-cost medically necessary care, and reduced-cost care due to financial hardship under Regulation .06 of this chapter. The hospital will apply the financial assistance reduction in its modification of the payment plan. Mutual Agreement. A hospital may not modify a payment plan without mutual agreement between the hospital and the patient before the changes are made. Notice of Terms. The hospital shall provide the patient with a written notice of all payment plan terms, consistent with the requirements of §C of this regulation, upon modifying a payment plan under this Guideline. Hospital-Initiated Changes to Income-Based Payment Plans Based on Changes to Patient Income. Recalculation Allowed. A hospital may, in the terms of an initial income-based payment plan under §C(2) of this regulation that exceeds 3 years in length, provide for periodic recalculations to the amount of the monthly payments and the duration of the payment plan based on changes in the patient’s income as subject to and calculated under §N(5) of this regulation. Notice Included in Initial Income-Based Payment Plan. The hospital may only recalculate payment amounts under an income-based payment plan if the hospital included the process for such recalculation in the notice provided to the patient before they entered into the income-based payment plan, in accordance with §C(2) of this regulation. The patient’s agreement to enter into the income-based payment plan after receiving that notice constitutes consent to the payment recalculations allowed under §P of this regulation. Limitations on Modification Apply. The provisions of §N of this regulation relating to limitations of payment plan modifications apply to payment recalculations for income-based payment plans under §O of this regulation. Frequency of Recalculation. A hospital may not seek a recalculation of the monthly payment amount under an income-based payment plan, as provided for under §O(1) of this regulation more than once every 3 years. Treatment of Missing Information. If a patient does not provide income information on the request of the hospital seeking to make a change to an income-based payment plan under §O of this regulation and the patient is in good standing on the patient's payments under the income-based payment plan, the hospital may not change the monthly payment amounts under the income-based payment plan. Treatment of Missed Payments. First Missed Payment. A hospital may not deem a patient to be noncompliant with an income-based payment plan if the patient makes at least 11 scheduled monthly payments within a 12-month period. Subject to §P(1)(c) of this regulation, the hospital shall permit the patient to repay the missed payment amount at any time, as determined by the patient, including through a set of partial payments. No later than 30 days after the first missed payment in a 12-month period, the hospital shall notify the patient of the missed payment and inform the patient that the patient may be in default if they do not pay the amount of the missed payment within 12 months or if they miss additional payments within the 12-month period. The notice will give the patient the option to pay the missed payment by paying the amount of the missed payments in one of the following ways: 11 increments over the subsequent 11 months; A single payment; or Another approach, as specified by the patient. With respect to a patient that has missed a single monthly payment in a 12-month period, the hospital shall provide the patient with a method to designate whether any amount of a payment paid in the subsequent 12-month period is to be applied to the amount of missed payment or applied in a different manner. With respect to a patient that has missed a single monthly payment in a 12-month period, if the hospital receives a payment and the patient has not designated how that payment is to be applied, the hospital shall first apply the amount to any payment that is due in the 31-day period following the date the payment is received. If there is no payment due in the next month, the hospital shall apply the amount of the payment to the missed payment. If the amount of the payment exceeds the amount of any payment that is due in the 31-day period following the date the payment is received, the excess amount shall be applied to the missed payment. The hospital may consider a patient to be in default on the income-based payment plan if the missed payment is not repaid in full by the end of the 12-month period that begins on the date of the missed payment under §P(1) of this regulation. Additional Missed Payments. A hospital may forbear the amount of any additional missed payments that occur in a 12-month period. If a hospital forbears the amount of any additional missed payments that occur in a 12-month period, the hospital shall allow the patient to continue to participate in the income-based payment plan. If a hospital forbears the amount of any additional missed payments that occur in a 12-month period, the hospital may not refer the outstanding balance owed to a collection agency or for legal action. The hospital shall recapitalize the amount of any missed payments that were subject to forbearance under this §P of this regulation as additional payments at the end of the income-based payment plan, thereby extending the length of the income-based payment plan. The hospital shall provide written notice to the patient of the treatment of the missed payments, including any extension of the length of the income-based payment plan. Treatment of Loans and Extension of Credit. After a hospital service is provided to the patient, a hospital, hospital affiliate, or third-party in partnership with a hospital may not make any loan or extension of credit to the patient in connection with a medically necessary hospital service that is inconsistent with the guidelines for payment plans in this regulation resulting from that service. Application of Credit Provisions of Maryland Commercial Law Article and Licensing Provisions of Financial Institutions Article. An income-based payment plan is an extension of credit subject to Maryland credit regulations under Commercial Law Article, Title 12, Annotated Code of Maryland and any applicable licensing provisions of Financial Institutions Article, Title 11, Annotated Code of Maryland. Books and Records. A hospital shall retain books and records on income-based payment plans for at least 3 years after the income-based payment plan is closed. Default. If a patient defaults on an income-based payment plan and the parties are unable to agree to a modification, then the hospital shall follow the provisions of its credit and collection policy established in accordance with Regulation .04 of this chapter, before a hospital may write this medical debt off as bad debt. With respect to the amounts covered by the income-based payment plans, a patient who is on an income-based payment plan and is not in default on that payment plan may not be considered in arrears on their debt to the hospital when the hospital is making decisions about scheduling health care services. Non-Income-Based Payment Plans. Other Payment Plans Allowed. A hospital may offer a non-income-based payment plan under these Guidelines, but must first offer the patient an income-based payment plan. Application of Guidelines. Consistent with the Guidelines for Hospital Payment Plans and consistent with the intent of Health-General Article, §19-214.2, Annotated Code of Maryland, the following provisions of this regulation apply to non-income-based payment plans in the same manner such provisions apply to income-based payment plans: §A of this regulation, regarding scope; §B of this regulation, regarding access to payment plans; §C(2) of this regulation, regarding notice of payment plan terms before execution; §C(3) of this regulation, regarding notice of plan after execution; §D of this regulation, regarding financial assistance; §L of this regulation, regarding interest and fees; §M(1)(a) and (2) of this regulation, regarding early payments; §N(6) of this regulation, regarding modifications of payment plans; §Q of this regulation, relating to treatment of loans and extensions of credit; §R of this regulation, relating to the application of credit provisions of Maryland Commercial Law Article and the licensing provisions of Financial Institutions Article; §S of this regulation, relating to books and records; and §T of this regulation, relating to default. Notice. Notice of Terms Before Execution. In addition to complying with the terms of §C(2) of this regulation, the hospital must include notice that the patient may apply for an income-based payment plan at any time in the notice of terms before execution of a non-income-based payment plan. Notice of Plan After Execution. The hospital must include the notice required in §U(3)(a) of this regulation in the notice of the payment plan after execution that is required by §C(3) of this regulation. Notice with Bills. Each bill for a non-income-based payment plan shall include a notice that informs the patient that income-based payment plans are available, which could result in lower monthly payments and provides information on how to apply for such plans. Consent. Before entering into a non-income-based repayment plan with a patient, the hospital must obtain consent from the patient that records that the patient affirms the following: The hospital offered the patient an income-based payment plan; The income-based payment plan limits monthly payment amounts to 5 percent of the patient’s monthly income; The income-based payment plan may result in lower monthly payment amounts than the monthly payment amounts under the non-income-based repayment plan; The patient has the opportunity to disclose their income and determine the payment amount under the income-based payment plan; and The patient is declining to enter an income-based payment plan and is consenting to enter a non-income-based repayment plan. Modification of a Non-Income-Based Payment Plan: In addition to complying with the terms of §N(6) of this regulation, before modifying a non-income-based payment plan: The hospital shall offer the patient an income-based payment plan; and, If the patient declines the income-based payment plan, obtain the consent required under §U(4) of this regulation. Default on a Non-Income-Based Payment Plan. If the patient defaults on a non-income-based payment plan, the hospital must offer an income-based payment plan to the patient before the hospital follows the provisions of its credit and collection policy to collect the debt. The offer provided under §U(6)(a) of this regulation must be sent separately from a bill. Steering. A hospital may not steer patients to non-income-based payment plans, or third-party credit providers, in such a manner that discourages patients from entering into income-based payment plans. A hospital may not steer patients to revolving credit products in such a manner that discourages patients from entering into either income-based payment plans or non-income based payment plans under this regulation. Financial Assistance Policy. Requirements. Each hospital and each chronic care hospital under the jurisdiction of the Commission shall develop a written financial assistance policy for providing free and reduced-cost medically necessary care to low-income patients who lack health care coverage or to patients whose health insurance does not pay the full cost of the hospital bill. A hospital shall provide written notice of the hospital's financial assistance policy to the patient, the patient's family, or the patient's authorized representative before discharging the patient and in each communication to the patient regarding collection of the hospital bill. The required notice shall state that the patient has up to 240 days after the day the patient receives the initial hospital bill to apply for financial assistance from the hospital. The hospital shall obtain documentation ensuring that the patient or the patient’s authorized representative acknowledges the patient’s receipt of the notice before discharging the patient. If a patient chooses not to apply for financial assistance, the patient’s documented acknowledgement shall indicate that the patient is not applying for financial assistance on the day of the acknowledgment but may apply within 240 days immediately following the patient’s receipt of the initial hospital bill. The financial assistance policy shall provide at a minimum: Free medically necessary care to patients with family income at or below 200 percent of the federal poverty level, consistent with the provisions of §A(2) of this regulation; Reduced-cost medically necessary care to patients with family income between 200 and 300 percent of the federal poverty level, consistent with the provisions of §A(2) of this regulation; A description of the payment plan required under Health-General Article, §19-214.2(d), Annotated Code of Maryland and Regulation .05 of this chapter; and A mechanism for a patient, irrespective of that patient’s insurance status, to request the hospital to reconsider the denial of free or reduced-cost medically necessary care, including the address, phone number, facsimile number, email address, mailing address, and website of the Health Education and Advocacy Unit, which can assist the patient or patient’s authorized representative in filing and mediating a reconsideration request. If a patient is eligible for reduced-cost medically necessary care under §A(1)(c)(ii) of this regulation, the hospital shall, at a minimum, reduce the patient’s out-of-pocket expenses for the hospital services: For a patient with family income of at least 201 percent but not more than 250 percent of the federal poverty level, by 75 percent; and For a patient with family income of more than 250 percent but not more than 300 percent of the federal poverty level, by 60 percent. The hospital shall provide free and reduced-cost medically necessary care to all qualified Maryland residents, regardless of their citizenship or immigration status. The hospital shall provide free and reduced-cost medically necessary care under §A(1)(c) of this regulation to all qualified Maryland residents, regardless of whether the patient resides in the hospital’s service area. The financial assistance policy applies to all medically necessary hospital services provided to qualified Maryland residents. Hospitals may not exclude non-urgent or elective, but medically necessary, care from their financial assistance policy. The financial assistance policy shall calculate a patient’s eligibility for free medically necessary care under §A(1)(c)(i) of this regulation and Health-General Article, §19-214.1(b)(2)(i), Annotated Code of Maryland, or reduced-cost medically necessary care under §A(1)(c)(ii) of this regulation and Health-General Article, §19-214.1(b)(2)(ii), Annotated Code of Maryland, at the date of service or updated, as appropriate, to account for any change in the financial circumstances of the patient that occurs within 240 days after the initial bill is provided. The hospital shall consider any change in the patient’s financial circumstance in accordance with Health-General Article, §19-214.1(b)(11), Annotated Code of Maryland. Income Documentation. Hospitals shall accept generally acceptable forms of documentation that verify income, such as tax returns, pay stubs, and W2s to evaluate if the patient is eligible for financial assistance, including free and reduced-cost medically necessary care, including reduced-cost medically necessary care due to financial hardship, in accordance with this regulation . Hospitals shall use available information, including information provided by the patient, to approximate the patient’s income if the patient has not provided their tax returns, pay stubs, W2s, or another form of documentation. Income Attestations. Hospitals may accept patient attestation of the patient’s monthly or annual income and the number of filers and dependents on their tax return without documentation. Such an attestation shall include the patient’s income and the number of filers and dependents on their tax return. If the patient provides an attestation of income the hospital is not required to conduct any additional income verification. A hospital’s inability to obtain complete income information does not preclude the hospital's ability to reasonably predict a patient’s income for the purposes of providing financial assistance. For example, a hospital may multiply income reported at the monthly level by 12 to determine income at the annual level, allowing for reasonably predictable changes in income throughout the year. Presumptive Eligibility for Free Medically Necessary Care. Unless otherwise eligible for Medicaid or CHIP, patients who are beneficiaries/recipients of the following means-tested social services programs are deemed eligible for free medically necessary care: Households with a child in the free or reduced lunch program and is eligible for the program based on the household’s income; Supplemental Nutritional Assistance Program (SNAP); Low-income-household energy assistance program; Primary Adult Care Program (PAC), until such time as inpatient benefits are added to the PAC benefit package; Women, Infants and Children (WIC); or Other means-tested social services programs deemed eligible for hospital free medically necessary care policies by the Maryland Department of Health and the Commission, consistent with this regulation. Hospital Reports. Each hospital shall submit to the Commission within 120 days after the end of each hospital’s fiscal year: The hospital’s financial assistance policy developed in accordance with this regulation; and An annual report on the hospital's financial assistance policy that includes: The total number of patients who completed or partially completed an application for financial assistance during the prior year; The total number of inpatients and outpatients who received free medically necessary care during the immediately preceding year and reduced-cost medically necessary care for the prior year; The total number of patients who received financial assistance during the immediately preceding year, by race or ethnicity and gender; The total number of patients who were denied financial assistance during the immediately preceding year, by race or ethnicity and gender; The total cost of hospital services provided to patients who received free medically necessary care; and The total cost of hospital services provided to patients who received reduced-cost medically necessary care that was covered by the hospital as financial assistance or that the hospital charged to the patient. Financial Hardship Policy. Subject to Regulation .05D of this chapter, the financial assistance policy required under §A of this regulation and Health-General Article, §19-214.1, Annotated Code of Maryland, shall provide reduced-cost medically necessary care to patients with family income below 500 percent of the federal poverty level who have a financial hardship. If a patient has received reduced-cost medically necessary care due to a financial hardship, the patient or any immediate family member of the patient living in the same household: Shall remain eligible for reduced-cost medically necessary care when seeking subsequent care at the same hospital during the 12-month period beginning on the date on which the reduced-cost medically necessary care was initially received; and To avoid an unnecessary duplication of the hospital’s determination of eligibility for free and reduced-cost medically necessary care, shall inform the hospital of the patient’s or family member’s eligibility for the reduced-cost medically necessary care. If a patient is eligible for reduced-cost medically necessary care under a hospital’s financial hardship policy, the hospital shall, at a minimum, reduce the patient’s out-of-pocket expenses for hospital services: For a patient with family income of at least 201 percent but not more than 250 percent of the federal poverty level, by 75 percent; For a patient with family income of more than 250 percent but not more than 300 percent of the federal poverty level, by 60 percent; For a patient with family income of more than 300 percent but not more than 350 percent of the federal poverty level, by 50 percent; For a patient with family income of more than 350 percent but not more than 400 percent of the federal poverty level, by 45 percent; For a patient with family income of more than 400 percent but not more than 450 percent of the federal poverty level, by 40 percent; and For a patient with family income of more than 450 percent but not more than 500 percent of the federal poverty level, by 35. The Commission may, by regulation, establish income thresholds higher than those in this regulation: Patient mix; Financial condition; Level of bad debt experienced; Amount of financial assistance provided; and Other relevant factors. Notice Requirements. A notice shall be posted in conspicuous places throughout the hospital including the billing office informing patients of their right to apply for financial assistance and who to contact at the hospital for additional information. If the hospital uses a vendor to assist with financial assistance eligibility, billing, or debt collection, such as a debt collector or eligibility vendor, that vendor shall post a notice in a conspicuous place on their website or online payment portal, informing patients of their right to apply for financial assistance, providing a link to the financial assistance application, and providing information on how to submit the application. Placement on the website or online payment portal should be based on the best interest of the patient. The notice required under §E of this regulation shall be in: Simplified language; At least 10-point type; and The patient’s preferred language or, if no preferred language is specified, each language spoken by a limited English proficient population that constitutes at least 5 percent of the overall population within the city or county in which the hospital is located as measured by the most recent census. Financial Assistance Application. Each hospital shall: Use a Financial Assistance Application in the manner prescribed by the Commission in order to determine eligibility for free and reduced-cost medically necessary care; Use a Financial Assistance Application that meets the requirements of this regulation and is consistent with the Uniform Financial Assistance Application; and Establish a mechanism to provide a Financial Assistance Application to patients regardless of their insurance status. A hospital may require from patients or their guardians only those documents required to validate the information provided on the application. Asset Test Requirements. A hospital may utilize a monetary asset test when determining eligibility for financial assistance, using the definition of monetary assets as defined in Regulation 01B of this chapter. The Commission shall post a process on its website for a patient or a patient’s authorized representative to file with the Commission a complaint against a hospital for an alleged violation of Health-General Article, §§19-214.1 or 19-214.2, Annotated Code of Maryland. The process established by the Commission shall include the option for a patient or a patient’s authorized representative to file the complaint jointly with the Commission and the Health Education and Advocacy Unit. The process shall conform to the requirements of Health-General Article, §19-214.3, Annotated Code of Maryland. In addition to the good faith estimate requirements set forth in the Public Health Service Act, 42 U.S.C §2799B-6, the No Surprises Act, on request of a patient made before or during treatment, a hospital shall provide to the patient a written estimate of the total charges for the hospital services, procedures, and supplies that reasonably are expected to be provided and billed to the patient by the hospital. The written estimate shall state clearly that it is only an estimate and actual charges could vary. A hospital may restrict the availability of a written estimate to normal business office hours. The provisions set forth in §A—C of this regulation do not apply to emergency services. This chapter does not diminish any obligations of a debt collector, as defined under Regulation .01 of this chapter, under other applicable laws or regulations, including, without limitation, any requirement for the debt collector to obtain a collection agency license from the State Collection Agency Licensing Board in accordance with Business Regulation Article, Title 7, Subtitle 3, Annotated Code of Maryland. Health-General Article, §§19-214.2, 19-214.3, 19-207, and 19-219, Annotated Code of Maryland Effective date: December 11, 2025 (52:24 Md. R. 1198)