GRANDE RONDE HOSPITAL Version #: 5 Department: Board of Trustees Title: Financial Assistance Page 1 of 8

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1 Page 1 of 8 Document Owner: Bob Seymour (Sr. Director of Finance/CFO) Date Created: 02/17/2010 Approver(s): Wendy Roberts (Senior Director Administrative Services) Date Approved: 11/16/2016 Printed copies of this policy are for reference only. Please refer to the electronic copy for the latest version. 1.0 PURPOSE To ensure that Grande Ronde Hospital, Inc. (Corporation) meets its community obligations and fulfills Corporation s mission to provide access to health services for all those in need. 2.0 POLICY It is both the philosophy and practice of Corporation that medically necessary healthcare services should be available to all individuals, regardless of their ability to pay. Financial Assistance is offered to uninsured persons and individuals with demonstrated financial need by waiving all or part of the gross charges for services provided by Corporation. 3.0 DEFINITIONS 3.1 Amounts Generally Billed (AGB) Discount: Corporation s Accounting Department will calculate and publish the AGB Discount for each calendar year based on Corporation s most recent audited financial statements, using the following formula: 1 [(Total Costs Bad Debt Expense)/(Gross Patient Revenues - Charity)] 3.2 Application Period: This period begins on the date care is provided to the patient and ends on the 240 th day after Corporation provides the individual with the first billing for care. 3.3 Automatic Uninsured Self-Pay Discount: Uninsured patients will automatically receive the AGB discount. This discount is designed to assure that uninsured patients are charged at a payment rate generally comparable to that of insured patients. There is no means testing or application process for the patient to receive the uninsured self-pay discount. The discount is based only on the patient s self-pay/uninsured status. If a patient is subsequently approved for Financial Assistance/charity care the automatic uninsured self-pay discount will be reversed by the amount of charity care approved, so that it can be recognized as charity care.

2 Page 2 of Emergency Medical Conditions: Emergency medical conditions are defined as follows: Any circumstance where the absence of immediate medical attention could reasonably be expected to place the health of the individual or the health of an unborn child) in serious jeopardy, cause serious impairment to bodily functions, or cause serious dysfunction of any bodily organ or part; Any circumstance involving a pregnant woman who is having contractions when there is inadequate time to effect a safe transfer to another hospital before delivery, or transfer may pose a threat to the health or safety of the woman or the unborn child. 3.5 Extraordinary Collection Efforts (ECE): ECE include, but are not limited to the following: (i) (ii) (iii) (iv) (v) (vi) (vii) Placement of lien on an individual s property; Foreclose on an individual s real property; Attach or seize an individual s bank account or any other personal property; Commence a civil action against an individual; Cause an individual s arrest; Cause an individual to be subject to a writ of body attachment; and Garnish an individual s wages. 3.6 Financial Assistance: Financial Assistance is a sliding scale discount, up to a discount of 100%, of the gross charges for medically necessary services. 3.7 Insurance: Financial coverage for medical care. 3.8 Maximum Collection Limitation: Financial responsibility for any net amount owing after payment by third-party payers, may not exceeds 20% of the guarantor s annual household gross income. It is the guarantor s responsibility to notify Corporation when this threshold is exceeded. 3.9 Notification Period: Corporation will inform the patient of the Financial Assistance policy during each billing cycle for a period of 120 days Provider Coverage Guide: Contains a list of providers who render care at Grande Ronde Hospital facilities and indicates whether or not their services are covered under Financial Assistance.

3 Page 3 of Presumptive Eligibility: Presumptive eligibility for Financial Assistance for uninsured patients will be determined on the basis of certain factors that indicate financial need as outlined in the Presumptive Eligibility Criteria in Section 4.6 below Uninsured Patient: A patient will be considered uninsured if they do not have medical insurance. 4.0 PROCEDURE 4.1 Language: Financial Assistance Applications will be available in English; Corporation will provide interpretation services for anyone who does not speak English. 4.2 Confidentiality: All applications and supporting documentation will be kept confidential to the extent allowed by law. 4.3 Public/Patient Awareness: Corporation will strive to create awareness of the Financial Assistance Policy and related documents and processes. Signage: Notices, Informational Brochures, Financial Assistance Applications, Policy Summary, Frequently Asked Questions and Provider Coverage Guide will be available in the following key areas of Corporation: o Admitting Department; o Emergency Department; o Outpatient registration areas; o Outpatient Clinics; o Patient Financial Services Department. Contact Information: A Financial Counselor can be reached, Monday through Friday, at (541) Website: Financial Assistance Application, Policy Summary, Frequently Asked Questions and Provider Coverage Guide will be available at Distribution of Applications during Registration: All patients identified as uninsured will be provided a plain language summary of the Financial Assistance Policy and Financial Assistance Application at the point of service, or prior to discharge, and offered the opportunity to apply for Financial Assistance.

4 Page 4 of 8 Distribution & Availability after Discharge: If uninsured status is not determined until after the patient leaves the hospital or clinic, a Patient Financial Services representative will mail a Financial Assistance Application to the uninsured patient upon request. Financial Assistance Applications will be sent to every patient whose account is turned over to Corporation s Internal Collections Department. Corporation Bill/Invoice: Patient bills will inform patients of the availability of Financial Assistance during the notification period. 4.4 Oral Communications with Patients: Corporation will inform the individual about the Financial Assistance Policy in all verbal communications during the notification period. Notice of ECE: Corporation will provide guarantor with written notification of any ECE that will be taken because of failure to complete a Financial Assistance Application or make payment arrangements prior to the end of the application period. Notification to the Guarantor must occur at least 30 days before the end of the application period. Other Sources: o Staff: Patient Access (Registration), Case Management and Patient Financial Services staff will be trained to answer Financial Assistance Questions and will direct any unanswered questions to a Financial Counselor. o Requests for Financial Assistance: Requests for Financial Assistance may be made at any point prior to an account being sent to a third party collection agency. Financial Assistance requests may be proposed by sources other than the patient, such as the patient s physician, family members, community or religious groups, social services or Corporation personnel. Anyone patient expressing desire to apply for Financial Assistance will be given an application and instructions on how to complete it. 4.5 Eligibility: Financial Assistance is secondary to all other third-party resources available to the patient, including insurance, government programs, and other third-party liability. 4.6 Presumptive Eligibility Criteria: Presumptive Eligibility will be granted to an uninsured patient if any of the following conditions are met: Patient is deceased with no estate;

5 Page 5 of 8 Patient is mentally or physically incapacitated and has no one to act on his/her behalf; Patient is enrolled in the Women, Infants and Children Nutrition Program (WIC); Patient is enrolled in the Supplemental Nutrition Assistance Program or Food Stamp Program; Patient is presumed eligible for Medicaid under the Medicaid presumptive eligibility guidelines; or Corporation has evidence from an independent third-party reporting agency that indicates family income is 300% or less of the applicable FPG. 4.7 Sliding Fee Discounts: A 100% discount from gross charges is available if the patient meets the Presumptive Eligibility criteria, outlined above. The following sliding-fee scale will be used to determine Financial Assistance discounts for qualifying applicants. Discounts are based on the current calendar year s Federal Poverty Guidelines and are updated annually. See Addendum 2016 Annual Income Thresholds by Sliding Fee Discount Gross Family Income as a Percentage of Federal Poverty Guidelines Sliding Fee Discount Below 300% 100% 301%-350% 60% 351%-400% 40% 401%-450% 20% 451%-500% 10% above 501% 0% 4.8 Extenuating Circumstances: Allowances may be made for extenuating circumstances, such as when the applicant is in need of Financial Assistance despite income exceeding Corporation s Financial Assistance guidelines, subject to approval by Corporation s Senior Director Finance/CFO.

6 Page 6 of Income Verification Requirements: Consideration for Financial Assistance includes a review of the responsible party s annual household income, number of people in the home, existing debt and other indicators of the party s ability to pay. These are merely guidelines; each individual situation will be reviewed independently. Acceptable verification of income includes the following: Three months of the following: current pay stubs, bank statements, and proof of income for every working member of your household; Proof of any unemployment compensation; Proof of any Social Security benefits; Proof of any government assistance: Food Stamps, WIC, housing assistance, unemployment etc. Proof of any Financial Aid for Schooling: School Loans and grants; A copy of most recent tax return or W-2(s); If self-employed a complete copy of current business tax return; Applicants without insurance coverage will be required to apply for insurance coverage and provide proof of the outcome before the Financial Assistance Application will be processed; A letter explaining any extenuating circumstances (example: why income information is missing); In the absence of income, a letter of support from individuals providing support for the applicant s basic living needs Financial Assistance Determinations: All applications receive a receipt date stamp. Financial Assistance determinations will generally be made within twenty (20) calendar days of receipt date Incomplete Applications: Incomplete applications may be denied and returned with a written statement of what information is needed and how to re-apply. Corporation will suspend any collection efforts against the individual until the completion deadline has passed, after this time, collection efforts will continue. Financial Assistance will not be considered without a completed Financial Assistance Application Notification: Notification of Financial Assistance determinations will be mailed to the responsible party, along with the Financial Assistance Policy Summary and Frequently Asked Questions within 20 calendar days of receipt.

7 Page 7 of Appeals: The responsible party may appeal any Financial Assistance determination by submitting in writing additional information, such as income verification or an explanation of extenuating circumstances, to the Director of Business Services within 30 days of the application determination letter. The Senior Director Finance/CFO will review and rule on all appeals. The responsible party will be notified in writing of the final determination Refunds: In the event that a patient is found to be eligible for Financial Assistance, any payments received after the application approval date that are in excess of the discounted amount owing will be refunded to the patient or other appropriate payor Balances Remaining after Financial Assistance: Payment arrangements may be extended for any balance owing after Financial Assistance discounts are applied. Patient/Guarantor must contact Corporation to set up payment arrangements. The following table reflects the available payment plans: ACCOUNT BALANCE $0.00-$500 $50 $ $1000 $100 $ $5000 $200 MINIMUM MONTHLY PAYMENT* $ Greater of $300 or the balance 36months *Payment Plans may not exceed 36 months. Exceptions must be authorized by the Director of Business Services Collections after Financial Assistance: If an application for Financial Assistance is submitted within the Application Period all Extraordinary Collections Efforts must be suspended until an eligibility determination is made. In the event that balances remain, after Financial Assistance, and are not resolved with an acceptable payment plan, the balances will go through Corporation s collection process.

8 Page 8 of 8 Statement schedules are automated within the Health Information System for all unpaid balances. Patient balances will be sent a ten (10) day collection notice when the account reaches the end of the collection schedule. Accounts without a payment in the prior two (2) months will be turned over to Corporation s collection department. Patient accounts may be turned over to Corporation s collection agency at any time if it is determined by the Patient Financial Services Manager that the account is uncollectible or difficult to collect. Third Party collections will not be pursued until the Application Period has ended Approval Limits: The Clinic Billing Manager and the Director of Business Services must both approve determinations that meet income guidelines and the account balance does not exceed $5,000. Determinations over $5,000 and exceptions for earnings over the poverty guidelines must be approved by both the Director of Business Services and the Senior Director Finance/CFO Additional Documentation: Addendum - Financial Assistance Policy Summary and FAQ Addendum 2016 Annual Income Thresholds by Sliding Fee Discount. Addendum Provider Coverage Guide LEVEL OF APPROVAL: Community Benefit Subcommittee 11/14/2016 Board of Trustees 11/16/2016