1. A. Each hospital shall submit to the Commission, at times prescribed by the Commission, the hospital's credit and collection policy.

2. B. The policy shall:

   1. (1) Provide for active oversight by the hospital of any contract for collection of debts on behalf of the hospital;
   2. (2) 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;

   3. (3) Prohibit the hospital from:

      1. (a) 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
      2. (b) 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;
      3. (c) Reporting adverse information to a consumer reporting agency;
      4. (d) Filing a civil action to collect a debt against a patient within 240 days after the initial bill is provided;
      5. (e) Filing a civil action to collect a debt against a patient whose outstanding hospital medical debt is at or below $500;
      6. (f) Forcing the sale or foreclosure of a patient’s primary residence to collect medical debt;
      7. (g) Requesting a lien against a patient’s primary residence in an action to collect medical debt;
      8. (h) 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
      9. (i) 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;
   4. (4) 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;
   5. (5) 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;

   6. (6) Provide a mechanism for a patient to:

      1. (a) Request the hospital to reconsider the denial of free or reduced–cost care; and
      2. (b) 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;

   7. (7) For a patient who is eligible for free or reduced cost-care under the hospital’s financial assistance policy, prohibit the hospital from:

      1. (a) Charging interest on the debt owed on a bill for the patient before a court judgement is obtained; or
      2. (b) Collecting fees or any other amount that exceeds the approved charge for the hospital service as established by the Commission;
   8. (8) 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;

   9. (9) Provide detailed procedures for the following actions:

      1. (a) 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;
      2. (b) 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;
      3. (c) The hospital's procedures for collecting any medical debt, consistent this regulation;
      4. (d) 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;
      5. (e) The consideration by the hospital of patient income, assets, and other criteria set forth in this regulation; and
   10. (10) Comply with Health-General Article, §24-2502, Annotated Code of Maryland.

3. C. 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:

   1. (1) Files an action to collect the patient’s medical debt; or
   2. (2) Delegates collection activity to a debt collector for a patient’s medical debt.

4. D. 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:

   1. (1) 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
   2. (2) 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.

5. E. 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:

   1. (1) 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
   2. (2) Such other activities as the hospital may direct in collecting and forwarding payments under a payment plan.
6. F. 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.

7. G. As provided by Health-General Article, §19-214.2(c), Annotated Code of Maryland:

   1. (1) A hospital shall provide:

      1. (a) 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
      2. (b) The refund to the patient not later than 30 days after determining that the patient was eligible for free medically necessary care.
   2. (2) 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.

8. H. Consumer Reporting.

   1. (1) A hospital may not commence civil action against a patient for nonpayment or delegate collection activity to a debt collector, if the hospital:

      1. (a) 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;
      2. (b) 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
      3. (c) Sold the debt under §O of this regulation and Health-General Article, §19-214.2(m).
   2. (2) A hospital shall comply with Health-General Article, §24-2502, Annotated Code of Maryland.
   3. (3) 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.
   4. (4) 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.

9. I. Civil Action.

   1. (1) Deceased Patients.

      1. (a) 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.
      2. (b) A hospital may offer the family of the deceased patient the ability to apply for financial assistance.
   2. (2) 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.
   3. (3) 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.

   4. (4) The notice required in §I(3) of this regulation shall:

      1. (a) Be sent to the patient by certified mail and first class mail;
      2. (b) Be in simplified language;
      3. (c) Be in at least 12-point type;

      4. (d) Include:

         1. (i) 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;
         2. (ii) The amount required to cure the nonpayment of medical debt, including past due payments, interest, penalties, and fees;
         3. (iii) A statement recommending that the patient seek debt counseling services;
         4. (iv) 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
         5. (v) An explanation of the hospital's financial assistance policy;
      5. (e) 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

      6. (f) Be accompanied by:

         1. (i) 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;
         2. (ii) 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
         3. (iii) The information sheet required under Regulation .03 of this chapter and Health-General Article, §19-214.1(f), Annotated Code of Maryland.

10. J. Delegation of Collection to a Debt Collector. If a hospital delegates collection activity to a debt collector, the hospital shall:

    1. (1) Specify the collection activity to be performed by the debt collector through an explicit authorization or contract;
    2. (2) Require the debt collector to abide by the hospital’s credit and collection policy;
    3. (3) 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

    4. (4) Require the debt collector to:

       1. (a) 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;
       2. (b) If a patient files a complaint with the debt collector, forward the complaint to the hospital; and
       3. (c) 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.

11. K. Consent to Assume Liability for Medical Debt.

    1. (1) 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.

    2. (2) The consent shall be:

       1. (a) Made on a separate document signed by the individual;
       2. (b) Not solicited in an emergency room or during an emergency situation; and
       3. (c) Not required as a condition of providing emergency or non-emergency health care services.
12. L. 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.
13. M. The Commission shall review each hospital's implementation of and compliance with the hospital's policy and the requirements of §B of this regulation.

14. N. Reporting Requirements.

    1. (1) Each hospital shall annually submit to the Commission within 120 days after the end of each hospital’s fiscal year a report including:

       1. (a) 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;
       2. (b) 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;
       3. (c) 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

       4. (d) 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:

          1. (i) The total dollar amount of the debt sold by the hospital for the reporting year;
          2. (ii) The total dollar amount paid by the hospital to the unit, contractor, or nonprofit organization who purchased the debt; and
          3. (iii) 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.
    2. (2) The Commission shall post the information submitted under §N(1) of this regulation on its website.

15. O. Selling Medical Debt.

    1. (1) 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.
    2. (2) 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.
    3. (3) 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.

    4. (4) Debt sold under this regulation and Health-General Article, §19-214.2(m), Annotated Code of Maryland:

       1. (a) Must be for hospital services provided at least 2 years before the date of the sale;
       2. (b) May not be expected to yield additional reimbursements from a third-party payor;
       3. (c) May not be subject to an open appeal with an insurance company; and
       4. (d) 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.
    5. (5) 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.
    6. (6) The Commission shall treat the amount of payments to hospitals under this subsection as an offset to uncompensated care amounts reported by hospitals.

    7. (7) The purchaser of the debt shall:

       1. (a) Notify the patient that the debt has been canceled; and
       2. (b) 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.
    8. (8) 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.

Authority: 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)