Sliding Fee Scales and Caps on Charges

Transcription

1 Ryan White HIV/AIDS Program Fiscal Health Series Systems to Sustainability TM Sliding Fee Scales and Caps on Charges

2 INTRODUCTION Sound fiscal management is critical for organizations to improve access to health care, advance health equity, and build healthy communities. In an ever-changing healthcare landscape, fiscal management, including compliance with federal grants, is difficult to achieve. The Ryan White HIV/AIDS Program Fiscal Health Series aims to strengthen Ryan White HIV/AIDS Program (RWHAP)-funded organizations financial management systems and compliance with fiscal aspects of the RWHAP and other federal requirements. The topics covered in this series are relevant to all RWHAP Parts and geared towards fiscal administrators and program managers, though collaboration across the organization is required to implement strong financial management systems. This publication offers practical, financial management infrastructure recommendations for nonprofit organizations, health departments, and health clinics.

3 OVERVIEW The purpose of this booklet is to provide an overview of sliding fee scales and caps on charges policies and procedures for the Ryan White HIV/AIDS Program (RWHAP). It includes legislative requirements, Fiscal Monitoring Standards related to imposition of client charges, and a ten-step guide to implementing sliding fee scales and caps on charges procedures in RWHAP organizations. POLICY OVERVIEW The Ryan White HIV/AIDS Program legislation requires clients to be charged for services based on ability to pay to reduce the economic burden of utilizing health services acccording to the legislation: In the case of individuals with an income less than or equal to 100 percent of the federal poverty line, the provider will not impose charges on any such individual for the provision of services under the grant In the case of individuals with an income greater than 100 percent of the federal poverty line, the provider Will impose a charge on each such individual for the provision of such services; and Will impose the charge according to a schedule of charges that is made available to the public A fee schedule in which clients are charged based on their ability to pay is known as a sliding fee scale. Clients are charged for RWHAP services based on the sliding fee scale until they reach their annual cap on charges, which is calculated based on income level. If a client reaches the cap, they cannot be charged for additional RWHAP services for the remainder of the year, but will continue to receive services as usual. Caps on charges were written in the original RWHAP legislation, and are still enforced, as follows: Poverty Level Cap on Charges as a Percent of Annual Gross Income <100% FPL 0% % FPL 5% % FPL 7% >300% FPL 10% 1

4 According to the HRSA/HAB Fiscal Monitoring Standards, recipients and subrecipients providing direct services (core medical and support) must meet the following requirements: Develop and implement a policy for a schedule of charges and cap on charges based on the Federal Poverty Level (FPL). This policy must include a publicly posted schedule of charges. Develop and implement client eligibility determination procedures for the between and imposition of charges based on the schedule. The client eligibility determination process must establish individual fees and caps on charges. While eligibility for RWHAP often takes into account household income, sliding fee scales and caps on charges are based on individual income. Document these procedures in client records at recertification. Track client charges made and payments received, and describe the accounting system used to track patient charges, payments, and adjustments. If providing direct services, establish and document fees charged by the provider and payments made to that provider for services. There must be a documented process for obtaining and documenting client charges and payments through an accounting system, either manual or electronic. Document that the schedule of charges (sliding fee scale) does not allow clients below 100% FPL to be charged for services. There must be documentation in client records that the policy is being correctly and consistently enforced. Each RWHAP-funded organization must track clients charges or medical expenses related to HIV care at their organization, including enrollment fees, deductibles, co-pays, and fees for services. Health centers are encouraged to assist clients in tracking charges imposed across RWHAP Parts and funded organizations. There must be a process that alerts the billing system that a client has reached the cap and should not be charged for the remainder of the calendar year. stem, as well as client records, will be monitored to ensure compliance. 2

5 WHAT DO SLIDING FEE SCALES LOOK LIKE? The fee schedule could take the form of discounts on services or nominal fees that do not represent the true value of services performed but allow the client to contribute to care. DISCOUNT FEE SCHEDULE SAMPLE Level Poverty Level Grant Responsibility Patient Responsibility 1 <100% FPL 100% 0% % FPL 80% 20% % FPL 60% 40% % FPL 40% 60% % FPL 20% 80% 6 >300% FPL 0% 100% NOMINAL FEE SCHEDULE SAMPLE Level Poverty Level Patient Responsibility 1 <100% FPL $ % FPL $ % FPL $ % FPL $ % FPL $20 6 >300% FPL $25 DISCOUNT 100% 200% 300% 400% FPL 3

6 10 STEPS TO IMPLEMENT SLIDING FEE SCALES AND CAPS ON CHARGES By following the 10 steps presented in this workbook, you can implement sliding fee scale and caps on charges procedures. Remember that in addition to procedures, all policies need to be written to illustrate compliance. 1. Determine the patient s ability to pay using the updated Federal Poverty Level (FPL) at intake and through recertification every six months. Calculate each client s nominal fee and and caps on charges each year based on the client s individual income FEDERAL POVERTY GUIDELINES Persons in Family/ Household 100% Federal Poverty Guideline 1 $11,880 2 $16,020 3 $20,160 4 $24,300 5 $28,440 6 $32,580 7 $36,730 8 $40,890 Let s say a client in a single-person household has an income of $27,632, they would be 27,632/11,880=2.32, or 232% FPL. Another helpful tool: 2016 RWHAP SLIDING FEE SCALE Federal Poverty Level Annual Gross Income for Individuals 100% or below $11,880 or less % $11,881 - $23, % $23,761 - $35,640 Above 300% $35,641 or more 4

7 2. Determine nominal fees for RWHAP clients based on prevailing local rates and clientele s ability to pay. There are no rules regarding what nominal fees or discount schedules should be. If your organization has another discount schedule or nominal fee schedule, such as one for an FQHC, you can use that as long as it also complies with RWHAP. If your city or state has set scales, you can use those, as well, as long as they are RWHAP compliant. 3. Ensure RWHAP remains the payer of last resort by billing insurance when it is available and charging payments based on the discount fee schedule. RWHAP must always be the payer of last resort, so if a client has insurance, it must be billed. The sliding fee scale is applied to the portion that is the client s responsibility, or the co-payment. For example, let s say a client with Medicare is at 150% FPL, and based on a clinic s sliding fee scale, is responsible for 20% of charges. Clinic X submits to Medicare for services performed Insurance requires co-pay of $50 Client is charged $10 (20% of co-pay) Grant assists client with remainder of the co-payment by writing off the remaining amount, $40 (80%) If the health organization charges nominal fees, it would look a little different: Client X submits to Medicare for services performed Insurance requires co-pay of $50 Client is charged $5 (set nominal fee) Grant assists client with the remainder of the co-pay by writing off the remaining amount, $45 4. Ensure that clients at or below the FPL are not charged for services. Train staff that clients below 100% FPL should not be billed for any services, and make sure this is documented in their charts. BILL

8 5. Establish a system for notifying clients about the sliding fee scale. Many health centers send clients letters and/or discuss sliding fee scales at their bi-annual certification. Here s an example of a letter you can give to clients telling them about sliding fee scales: Date: Client Name: Your application for the Ryan White HIV/AIDS Program has been completed. Your enrollment is effective (write date). Your sliding fee scale level is (if used in clinic/organization). [Your sliding fee scale level refers to how much you pay for HIV-related services here. The amount is based on your income. ] Your out of pocket responsibility is. [This is the dollar amount or percentage that you pay when you receive a billable service here at the clinic.] Your cap on charges is $. [This is the maximum amount that you can pay for Ryan White HIV/AIDS Program services this year. This amount includes services here at our clinic, and other Ryan White HIV/AIDS Program services you might get somewhere else. If you reach this amount in a year, you do not pay anything else for your HIV-related care in that year. Charges that might apply to the cap include: insurance premiums, co-payments, deductibles for medical care and medications, and fees for services. Charges can occur on-site or through other medical providers. IF YOU RECEIVE A BILL: If you receive a bill, contact one of the benefit managers as soon as possible. [put benefits manager contact information here]: * Keep in mind that clients have varying levels of financial literacy. Take the time to assess their understanding of how sliding fee scales work. If necessary, translate this letter into other languages commonly spoken in your region. 6

9 6. Notify clients about their responsibility to keep track of charges across RWHAP organizations. Your accounting system should monitor charges imposed at your organization, but clients need to tell you when they have been charged from other RWHAP organizations or parts, including ADAP and insurance payments. Explain to clients that they need to track these charges. You can use the following tool, provide business reply envelopes to allow them to send receipts and bills directly to your RWHAP financial manager, or develop another mechanism. KEEPING TRACK OF CHARGES ACROSS RWHAP ORGANIZATIONS Patient Name: MRN: Sliding Fee Scale Level: Cap on Out of Pocket Charges: Eligible charges for the cap on out of pocket charges include: insurance premiums, co-payments, and deductibles for medical visits and medications; and outpatient medical care charges, such as laboratory, radiology, diagnostic testing, and physician charges. CAPS ON CHARGES TRACKING SHEET Date of Service Provider Brief Description of Visit Amount Due 7

10 7. Track RWHAP client charges at your organization through an accounting or billing system, or manually. RWHAP organizations do this in different ways, and you can do whatever works best for your system. Some clinics create a billing code for RWHAP, so the accounting system will automatically track what clients have been billed. Others have insurance companies send bills or Explanations of Benefits (EOB) to the financial manager at the clinic, in addition to or instead of the client, so they can easily track what is charged. 8. Ensure that the system is notified when caps on charges are met and that the client is no longer charged. This feature must be built into your accounting system. Once the cap on charges is met, clients should not receive additional bills for services until the next calendaryear. 9. Document policies, procedures, and charges to patients to comply with RWHAP legislation and requirements. See Fiscal Monitoring Standards for more information. In addition to implementation, all of these policies and procedures must be documented. Use the updated Site Visit Assessment Tool (ask your Project Officer for the most updated version) and the Fiscal Monitoring Standards to ensure you have documented all that is required. Recipients must review subrecipients policies and procedures in these areas. 10. Ensure your patients know that they will continue to receive RWHAP services regardless of their ability to pay. 8

11 SOURCES AND ACKNOWLEDGEMENTS Sources: Ryan White HIV/AIDS Program Legislation HIV/AIDS Bureau, Division of State HIV/AIDS Programs National Monitoring Standards for Ryan White A Grantees: Fiscal Part A HIV/AIDS Bureau, Division of State HIV/AIDS Programs National Monitoring Standards for Ryan White B Grantees: Fiscal Part B Acknowledgements: Jana Collins, MS 9

12 Systems to Sustainability TM Fiscal Health: Systems to Sustainability is an education, training, and technical assistance (TA) program led by HealthHIV that addresses the fiscal sustainability of RWHAP organizations by building their fiscal management capacity. Through this HRSA/HAB-supported program, a diverse and culturally competent team of fiscal management experts designs and implements effective Regional Trainings and individual TA, which focuses on fiscal requirements and grants management. To Request Technical Assistance or to Participate in Training, Contact: Training@HealthHIV.org