EFFECTIVE DATE: 02/10/16

Transcription

1 POLICY/PROCEDURE: Financial Assistance Policy SUBJECT/TITLE: Financial Assistance Policy POLICY: Financial Assistance Policy APPLICABLE TO: Business Office WRITTEN BY: APPROVED BY/DATE: Senior Leadership 02/10/16 EFFECTIVE DATE: 02/10/16 REVISION/REVIEW DATE: 02/10/16 Purpose Grand Itasca Clinic & Hospital has a long history of providing quality health care to patients within our community regardless of their ability to pay. Grand Itasca recognizes that some patients may be unable to pay all or a portion of the cost of medically necessary health care services received because they did not have health insurance coverage or because their health care costs exceed their ability to pay. In order to provide appropriate financial assistance to those who are truly in need, Grand Itasca has a process to evaluate a patient s eligibility. Definitions Federal Poverty Guidelines (FPG) - Income guidelines published annually by the U.S. Department of Health and Human Services that are used for determining financial eligibility for certain programs. Guidelines vary by family size. Grand Itasca FAP income guidelines will be updated at the beginning of each fiscal year based upon the prevailing FPG. Guarantor - A person who accepts the legal obligation to pay for medical services. The term patient in this policy includes the guarantor. Household - A group of two (2) or more persons who reside together and are related by birth, marriage, adoption, civil union, domestic partnership or otherwise and are financially responsible for each other which is indicated by either (1) jointly filing or claiming the other person (s) as a dependent on the most recent federal tax return or (2) submission of some other legal documents to indicate joint financial responsibility for person expenses. Household Income - Includes earnings, unemployment compensation, workers compensation, Social Security, Supplemental Security Income, public assistance, veterans payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, education assistance, alimony, child support, assistance from outside the household and other miscellaneous sources: 1. Non cash benefits (such as food stamps and housing subsidies) do not count 2. Income is determine on a pre- tax basis

2 3. Excludes capital gains or losses Medically Necessary Services - These include but are not limited to the following: 1. Trauma and emergency medical service 2. Any diagnostic study, procedure or treatment needed to prevent, diagnose, correct, cure, alleviate, or prevent the onset or worsening of conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, or may result in overall illness or infirmity 3. Services defined under a patient s health insurance coverage as covered items or services, including items and services covered by Medicare 4. Other services scheduled in advance, with physician orders, and assessed on a case- by- case basis and determined to be medically necessary by a physician may be approved at Grand Itasca s discretion. Most Favored Insurer - A nongovernmental third- party payor that provided the most revenue to the provider during the previous calendar year. Patient - The individual who received medical services and who is responsible for payment of the medical bill. If there is a guarantor that is separate from the patient, the term patient refers to the guarantor as well. Presumptive Charity Care Eligibility - Process of proactively classifying charity care on the basis of limited financial information. A determination that a patient is presumed eligible for Community Care when adequate information is provided by the patient or through other sources not provided directly by the patient, which allows Grand Itasca to presume that the patient qualifies for Financial Assistance. Uninsured Patient - An individual having no third- party payor coverage by a commercial third- party insurer, an ERISA plan, a Federal Health Care Program such as Medicare, Medicaid, Tricare and CHAMPUS, Worker s Compensation, third- party liability (e.g. auto), Medical Savings Accounts or other third- party assistance to assist with meeting their payment obligations. Underinsured Patient - An individual with insurance coverage for whom it would be a financial hardship to fully pay the expected out- of- pocket expenses for medical services. This would also include benefit exclusions in the insurance policy such as pre- existing conditions or mental health benefits. Policy In order to manage its resources responsibly and to allow Grand Itasca to provide the appropriate level of assistance to the greatest number of patients in need, the following guidelines apply: Community Care is not considered to be a substitute for personal responsibility. Patients are expected to cooperate with Grand Itasca s procedures for obtaining Community Care, other

3 forms of payment, or financial assistance, and to contribute to the cost of their health care based on their individual ability to pay. Services are provided under Community Care only when deemed medically necessary, and after patients are found to have met all financial criteria based on the disclosure of proper information and documentation. Patients are expected to contribute payment for care based on their individual financial situation; therefore, each case will be reviewed separately. Individuals with the financial capacity to purchase health insurance shall be encouraged to do so, as a means of assuring access to health care services for their overall personal health, and for the protection of their individual assets. Procedure Informing patients about financial assistance policy (FAP): A. Grand Itasca will make the FAP readily available and at no cost to the patient. i. The FAP documents (policy, plain language statement, application) will be available on the Grand Itasca website Information and application will be easily accessible. At a patient s request, the documents will be printed and provided at no charge at designated admission areas or by calling ii. iii. iv. Notices on the availability of financial assistance will be conspicuously posted in the emergency room departments in all admission area. Postings and notices will be in English, and will also be translated into the primary language of any population in the communities served by the hospital facilities that constitutes more than 5% or 1000 individuals, whichever is less. Interpreter services will be used as needed to discuss the program further with patients or their guarantors. A plain language summary (PLS) of the Financial Assistance Policy will be offered to each patient prior to a hospital discharge. v. Information about the FAP will be on all patient billing statements. vi. FAP information will be made available to appropriate community health services agencies and other organizations that assist people in need. 2. Grand Itasca has trained personnel available to provide information about the FAP and assist with the application process upon request.

4 Community Care Program A. Eligibility Criteria Services eligible for Community Care include: all services deemed medically necessary by Grand Itasca, and care that is non- elective and needed in order to prevent death or adverse effects to the patient s health. Patients who are uninsured, underinsured, ineligible for government assistance programs, or unable to pay based on their individual financial situation are eligible for Community Care. Determinations for eligibility are made on a case- by case basis and may require appointments or discussion with the Financial Counselors and Advocates. Grand Itasca provides assistance for deductibles, co- insurance, or co- payments in the form of free and/or discounted services. When determining patient eligibility, Grand Itasca does not take into account race, gender, age, sexual orientation, religious affiliation, social or immigrant status, or age of the patient s account. Additionally, Grand Itasca may refer to or rely on external sources and/or other programs of resources in the case of patients lacking documentation to support eligibility or individual circumstance. Grand Itasca may provide free or discounted services when: Patient is homeless or incarcerated Patient is eligible for other state and local assistance programs that are unfunded Extenuating circumstances deemed by the approval body. B. Determining Discount Amount Patients who can demonstrate their family income is below 150% of the federal poverty line are eligible for a 100% discount on any patient balance. At the hospital s discretion, patients with a family income exceeding 300% of the federal poverty line may still be eligible for discounts on an individual basis, taking into account extenuating circumstances, including financial or medical indigence or catastrophic infirmity. Initial eligibility for Community Care may cover all outstanding medically necessary patient balances at the time of application for Community Care, and will be reviewed on a case by case basis. If approved for Community Care, patients must wait twelve (12) months to be eligible to re- apply for additional assistance. A minimum payment may be requested even if qualified at 100%. All previous paid accounts will remain as such and are not eligible for refunds. Community Care awards must be approved by the Business Services Manager. Community Care awards in excess of $ must be approved by the Chief Financial Officer. The decision will be communicated to the patient within a reasonable time. In all cases, the determination will be documented in writing.

5 NOTE: Grand Itasca will limit the amounts charged to individuals eligible for financial assistance who receive medically necessary care to the amounts generally billed to individuals with insurance coverage that covers such care. Sliding Scale based on Federal Poverty Guidelines: Size of Family 150% 180% 210% 240% 270% 300% Poverty Line $17, $21, $24, $28, $31, $35, $11, $23, $28, $33, $38, $43, $47, $15, $30, $36, $42, $48, $54, $60, $20, $36, $43, $50, $58, $65, $72, $24, $42, $51, $59, $68, $76, $85, $28, $48, $58, $68, $78, $87, $97, $32, $55, $66, $77, $88, $99, $110, $36, $61, $73, $85, $98, $110, $122, $40, For ea. Addt'l $6, $7, $8, $9, $11, $12, $4, % 90% 80% 70% 60% 50% C. Applying for Financial Assistance: To be considered eligible for Community Care, patients must cooperate with the hospital to explore alternative means of assistance if necessary, including Medicare and Medicaid. Patients will be required to provide necessary information and documentation when applying for a discount, Community Care, or other private or public payment programs. In addition to completing an application, documentation that may need to be provided may include but not limited to: Denial letter for Medical Healthcare Programs, which must include all pages of the Medical Assistance denial. Proof of income for the last 3 months, for all members of your household to include check stubs or a letter from the employer showing proof of wages. This would include any statements from social security/disability, or unemployment. If you are self- employed, we need copies of your company's income statement. Tax returns from the previous year, including all schedules.

6 Previous 2 month's bank statements on all bank accounts Copies of the previous month's bills on expenses if not shown on the bank statements. Current property tax statements Proof of available assets or other financial resources External, public sources which may be utilized, including credit scores D. Collection Practices for Community Care Patients Internal and external collection practices and procedures will take into account the extent to which a patient is qualified for Community Care or discounts. In addition, patients who qualify for partial discounts are required to make a good faith effort to honor payment arrangements with Grand Itasca, including payment plans and discounted bills. Grand Itasca is committed to working with patients to resolve their accounts, and at its discretion, may provide extended payment plans to eligible patients. The hospital will not impose a lien nor force the sale or foreclosure of a Community Care patient s primary residence for outstanding medical bills. Reporting to credit agencies and legal action, such as the garnishing of wages, may be taken in order to enforce terms of a payment plan if clear evidence exists that the patient has sufficient income and/or assets to honor the agreement. For Community Care patients meeting all requirements, Grand Itasca will cease all collection efforts on their eligible accounts. Patient expectations for receiving preferential treatment under collections: To retain preferential treatment under collection practices as described above, patients will have qualified for a discount under the Grand Itasca Community Care Policy by providing all necessary information and documentation, cooperating with the organization in establishing a reasonable agreement and/or payment plan, and communicating any changes in their financial situation that may further effect their ability to pay any discounted bills or agreed upon monthly payments. Patients will be asked to certify all information provided is true. If any information is determined to be false, all discounts afforded to the patient may be revoked, making them responsible for the full charges for services rendered. E. Communication of Community Care Program Grand Itasca communicates the availability and terms of its Community Care Program to all patients, through means which include, but are not limited to: Posted signs within waiting rooms, registration kiosks, and financial services departments Notifications on patient bills or statements Posted policies on the organization s website

7 Brochures given to patients by staff or with other paperwork Reference with the Grand Itasca patient handbook Designated staff knowledgeable on the Community Care policy to answer questions or who may refer patients to the program. Requests can be made by the patient, their family members, friend or associate, but will be subject to applicable private laws. Patients concerned about their ability to pay for services or would like to know more about financial assistance should be directed to the Financial Advocates at , option 7. Regulatory Requirements: In implementing this policy, Grand Itasca shall comply with all other federal, state, and local laws, rules, and regulations that may apply to activities conducted to this policy. Grand Itasca s Finance Committee reserves the right to adjust allowable community care at any time based upon community need and financial constraints on the medical facility. Where the Finance Committee allows an increase in the total amount of allowable community care, the intent is to shift the table limits to the right while maintaining the maximum allowable income consistent with annual changes in the income guidelines. All information gathered for the purposes of determining community care, and the decision regarding the amount of community care, if any, will be kept in confidence by the medical facility and not shared with any third party without the written consent of the patient or guarantor.