Administrative and Operational Policies and Procedures. Title: Financial Assistance Policy Date Revised: 01/01/ /01/2016

Transcription

1 Administrative and Operatinal Plicies and Prcedures Plicy 1.10 Original Date 01/15/2013 Number: Issued: Sectin: Finance Date Reviewed: 04/29/2013 Title: Financial Assistance Plicy Date Revised: 01/01/ /01/2016 Regulatry Agency: Department f Treasury, IRS I. POLICY: Children's Healthcare f Atlanta, Inc. ("Children's") understands that patients and/r guarantrs may nt be able t pay fr hspital/medical expenses due t unfreseen circumstances, a lack f health insurance cverage r self-pay amunts due beynd their financial means. Children s ffers financial assistance ptins fr patients and/r guarantrs and this plicy utlines the prcess fr requesting financial assistance and the criteria used t determine eligibility. This plicy cvers prvider based services including emergency services--prvided by Children's Healthcare f Atlanta; hwever, it des nt include physician prfessinal charges. The list f specific lcatins and cvered services cvered by this plicy is included in Appendix A. Fr the purpses f this plicy the phrase "patients and/r guarantrs" reflects the persn(s) with financial respnsibility fr a Children's Healthcare f Atlanta accunt--the patient, a parent r guardian r anyne else identified as a guarantr n a Children's accunt. Medically Necessary is defined per Centers f Medicare & Medicaid Services (CMS) as: Service r supplies that: are prper and needed fr the diagnsis r treatment f a patient s medical cnditin, are prvided fr the diagnsis, direct care and treatment f the medical cnditin, meet the standards f gd medical practice in the lcal area and aren t mainly fr the cnvenience f the patient r his/her dctr. CMS defines Prvider-based entity as: a prvider f health care services that is either created r acquired by the main prvider fr the purpse f furnishing health care services f a different type frm thse f the main prvider under the name, wnership, administrative and financial cntrl f the main prvider. A prvider-based entity cmprises bth the specific physical facility that serves as the site f services f a type fr which payment culd be claimed under the Medicare r Medicaid prgram, and the persnnel and equipment needed t deliver the services at the facility. Prvider based services are rendered in a hspital department r lcatin that the hspital wns r leases space frm and emplys physicians and ther supprt persnnel wh are invlved in patient care. 1

2 Administrative and Operatinal Plicies and Prcedures II. PROCEDURE: Children s takes apprpriate steps t prvide fr cmmunicatin t patients and/r guarantrs regarding its Financial Assistance Prgram and the assciated applicatin prcess. A. Eligibility Criteria fr Children s Financial Assistance Prgram Eligibility fr Children s Financial Assistance Prgram requires the fllwing criteria: The patient and/r guarantr's financial status meets a needs testing. Children's uses a sliding scale cnsistent with the current pverty guidelines published in the Federal Register. Patients and/r guarantrs are eligible fr full r partial financial assistance where husehld incme is at r belw 340% f the published Federal Pverty Guidelines. The service prvided t the patient was medically necessary but nt cvered r fully cvered by any insurance. Where the patient/guarantr had a remaining financial bligatin after insurance payment. Patient was nt apprved fr any Federal, State agency r private fundatin funding prgram. Patient/guarantr fully cmplied with the applicatin prcess seeking funding frm a Federal, State r private fundatin prgram. Patient and/r guarantr exhausted all ther surces f financial assistance frm private fundatins and r ther health-related and scial service rganizatins. Patient and/r guarantrs meeting the abve criteria may apply fr assistance at any pint befre, during r after care is prvided. Children's has discretin t grant assistance n evidence ther than that described in the Financial Assistance Plicy (FAP). B. Methd fr applying fr Children s Financial Assistance Prgram 1. Children s rutinely screens all patients with limited financial resurces fr eligibility in the fllwing prgrams: Grup Health Insurance Plans Individual Health Insurance Plans COBRA Health Cverage Tax Credits Peachcare fr Kids Medicaid (including Emergency Medicaid, Medically Needy, Katie Beckett, Presumptive Medicaid, etc.) 2. Patients wh qualify under any f the abve prgrams must enrll in the prgram r fully cmply with the applicatin prcess, submitting all required dcuments, r such patients may nt be eligible fr Children s Financial Assistance Prgram. Specific prgram requirements can be fund at 2

3 Administrative and Operatinal Plicies and Prcedures 3. If it is determined that the patient and/r guarantr is nt eligible fr State r Federal assistance r frm private fundatins and/r ther health-related and scial service rganizatins, the patient and/r guarantr may cmplete a Children s Financial Applicatin Frm fr financial assistance. Financial Applicatin Frms can be btained freely at any f Children s Hspital facilities r requested via telephne, fax r mail r walk-in during business hurs at the Financial Cunseling Department ffice: Tel: 404/785/5060, Fax: 404/785/9236, Address: 1644 Tullie Circle, Atlanta GA Children s Financial Applicatin Frm is available in English and Spanish and can be dwnladed frm Children s website at: 4. The cmpleted Financial Applicatin frm shuld be submitted alng with required dcuments t the attentin f Children s Financial Resurce Crdinatr fr cnsideratin fr Children s financial assistance. Refer t Appendix B fr dcumentatin required by Children s Financial. Applicatin Frm. 5. Any incmplete applicatin will nt be cnsidered and a letter requesting missing dcuments will be mailed t applicant. 6. Once the cmpleted applicatin and all supprting dcuments have been received, the Financial Resurce Crdinatr will flag the accunt in Children s billing system t stp all cllectins effrts while the applicatin is being reviewed. 7. The review prcess may take up t ninety (90) days frm date f receipt f the cmpleted applicatin and all supprting dcuments. 8. If the financial assistance applicatin is nt cmplete and all supprting dcumentatin nt prvided within thirty (30) days f a fllw up request frm a financial cunselr, the applicatin will be clsed, and the patient and/r guarantr will receive a bill fr the utstanding balance. 9. Once a cmpleted applicatin is received, the Financial Resurce Crdinatr will review the fully cmpleted applicatin and all supprting dcumentatin under the fllwing guidelines: If the patient and/r guarantr is uninsured, the eligibility screening shall be based n family size and incme using the then-current Federal pverty level guidelines. Financial assistance shall be awarded t eligible patient and/r guarantr n a tiered basis frm zer percent (0%) t ne hundred percent (100%) t be applied t the utstanding balance. 3

4 Administrative and Operatinal Plicies and Prcedures If the patient and/r guarantr is insured, eligibility is determined by a review f the Financial Assistance applicatin and Federal pverty level guidelines, as nted abve. Patient accunts that d nt meet the criteria fr ne hundred percent (100%) discunt are reviewed by the Charity Exceptin Cmmittee fr any discunt available based n the specific patient and/r guarantr circumstances. 10. Fllwing the cnclusin f the review prcess, a letter f eligibility determinatin shall be sent t the patient and/r guarantr cmmunicating the status f the applicant s Financial Applicatin alng with Children s basis fr the determinatin. 11. If apprved fr Children s financial assistance, the effective date f apprval, and level f assistance will be cmmunicated via letter including the percentage discunt n any utstanding balance and the amunt due. 12. Once apprved, the adjustment f the patient s hspital bill shall be prcessed. 13. If the patient and/r guarantr is due a refund as a result f the discunt applied, a refund will be issued. 14. If a partial discunt is granted, the remaining balance is required t be paid in full r have an ptin t set up an interest-free payment plan. 15. The patient and/r guarantr may chse t appeal Children s financial assistance's decisin. The request fr appeal is reviewed by the Charity Exceptin Cmmittee, which has the respnsibility fr determining that reasnable effrts were taken t determine if the patient and/r guarantr was eligible and cnfirming that Children's plicies have been applied cnsistently. Shuld the patient and/r guardian chses nt t appeal the decisin, the applicatin shall be clsed and cllectin activities will resume as payment shall be expected n the utstanding balance. 16. A patient and/r guarantr may submit a new applicatin if their care needs r financial circumstances change. C. Cllectin and billing practices in the event f partial apprval r nnapprval f financial assistance. 1. The patient and/r guarantr will be billed if the entire balance is patient respnsibility (self-pay) and The self-pay balance is greater than r equal t $ The patient s accunt des nt have any statement hlds r billing indicatrs n the accunt, which prevent these bills frm being generated, including a pending Financial Assistance Applicatin. 4

5 Administrative and Operatinal Plicies and Prcedures A valid mailing address is n file with n returned mail. 2. Accunts qualify fr in-huse cllectin activities within Children's fr nn-payment. After exhausting all effrts thrugh in-huse cllectin activities, if still unpaid, accunt may be placed with an utside cllectin vendr as Bad Debt. Children's takes apprpriate steps t cnfirm that patients and guardians are aware f the effrts that are taken befre sending accunts t a bad debt vendr. A summary f activities cmpleted are as fllws: a. "In Huse" Cllectins Guarantr receives statements r and cllectin letters mnthly. After apprximately ninety (90) days, after the first statement is sent, if balance is nt paid in full and n payment arrangement has been made, a final cllectin letter/statement is issued. b. "Bad Debt " Cllectin After apprximately ne hundred and twenty (120) days f internal in-huse cllectin effrts -including sending the final cllectin letter/statement, the accunt will be utsurced t a bad debt cllectin agency. Accunts are placed with the agency fr six (6) t twelve (12) mnths, during which time the cllectin agency will make additinal effrts t cllect n remaining balances. If still unable t cllect, balance may be written ff t bad debt. c. Children s is gverned by the Fair Debt Cllectin Practices Act. Children s des nt implre any extrardinary cllectin actin as defined by the IRS. At n time des Children s r vendrs acting n Children s behalf, reprt t any credit bureau (e.g., Equifax, Transunin, Experian) r use legal r judicial prcesses t cllect self- pay debt. This plicy applies t all self-pay balances fr hspital and prfessinal billing fr all Children s entities. Additinally, Children s des nt sell its accunts receivables t utside vendrs. D. Hw We Charge Fr Services Basis fr Determining Amunts Charged t Patients Amunts charged fr emergency and medically necessary hspital-based medical services (excludes physician prfessinal fees) t patients eligible fr Financial Assistance will nt be mre than the amunts generally billed t individuals with insurance cvering such services. 5

6 Administrative and Operatinal Plicies and Prcedures Financial hardship and charity care adjustments may be cnsidered fr thse patients whse incme and assets will nt allw full payment within a reasnable time. The amunt that a patient and/r guarantr is expected t pay is determined by his r her eligibility fr Children s Financial Assistance Prgram, as determined by the Eligibility Criteria utlined in II. A. Eligibility Criteria fr children s Financial Assistance Prgram. Children s may deny a request fr financial assistance fr a variety f reasns including, but nt limited t: Sufficient incme. Sufficient asset level. Lack f patient and/r guarantr cperatin r unrespnsive t reasnable effrts t respnsibly reslve the balance wed r secure Medicaid eligibility r ther financial cverage. Requests fr care when there is n identifiable means f btaining lng-term supprt (e.g. medicatin r implantable devices) needed t sustain the initial successful utcmes f care des nt include care fr an emergency cnditin. Incmplete Financial Assistance applicatin despite reasnable effrts t wrk with the patient. Pending insurance r liability claim. Withhlding insurance infrmatin r payment and/r insurance settlement funds, including insurance payments sent t the patient t cver services prvided, and persnal injury and/r accident related claims. Prviding inaccurate infrmatin as a means f securing apprval fr financial assistance. E. Measures t Publicize Children s Financial Assistance Prgram Include: Infrmatin abut Children s Assistance Prgram is prvided t patients and/r guarantrs: upn a patient's registratin r admissin t the hspital, including a flyer placed in the Admissin packet prvided t patients upn admissin. during Children s Financial Cunselrs visit t a patient's rm. Psting the availability f Financial Assistance in the waiting rm areas. On Children s external website, On billing statements and cllectin letters t patients and/r guarantrs. During calls t Children s Custmer Service Department. In advertisements f Children s Financial Assistance Prgram in the Atlanta Jurnal- Cnstitutin annually. 6

7 Administrative and Operatinal Plicies and Prcedures APPENDIX A Children s Financial Assistance Prgram cvers prvider based services perfrmed at any Children s facilities/entities: Children s Healthcare f Atlanta Children s Healthcare f Atlanta at Eglestn (Inpatient and Outpatient) Children s Healthcare f Atlanta at Scttish rite (Inpatient and Outpatient) Freestanding Ambulatry Surgery Center Children s Healthcare f Atlanta Surgery Center at Meridian Mark Plaza Prfessinal Services (Prfees) are nt cvered under this plicy except Emergency Department prfees. Services prvided by Children s Healthcare f Atlanta at Hughes Spalding are NOT cvered under this plicy. (Children's Healthcare f Atlanta at Hughes Spalding is wned by Grady Health System and managed by HSOC Inc., an affiliate f Children's. Care prvided is cvered by the separate Grady Health System Financial Assistance/Charity Plicy.) 7

8 Administrative and Operatinal Plicies and Prcedures APPENDIX B Children s Financial Applicatin Frm Children's Healthcare f Atlanta at Eglestn and Scttish Rite prvide financial assistance fr families t help pay children s medical bills. T apply fr free r a reduced rate n medical services that have already been prvided by Children s Healthcare f Atlanta, please supply all the infrmatin requested n the attached frm: prf f incme, including yur mst recently cmpleted tax frms, W2's, as well as cpies f yur mst recent paycheck stubs. If we d nt receive all infrmatin requested, as well as prf f incme, we will nt be able t prcess the applicatin and the applicatin will be clsed, and the patient and/r guarantr will receive a bill fr the utstanding balance. Residents f Gergia may qualify fr funds prvided by the Gergia Indigent Care Trust Fund (Trust Fund), as well as ther funding surces. A persn is a resident if he r she has entered the state with a jb cmmitment r is actively seeking emplyment and nt receiving assistance frm anther state. If yu are nt a resident f Gergia r there are any special cnsideratins yu wuld like us t cnsider, please use this same frm t request cnsideratin fr financial assistance t the Trust Fund. Cnsideratin f these requests will be determined by the availability f ther funding surces fr qualified applicants. Please nte that cmpletin f the applicatin is nt a guarantee f financial assistance frm any surce. Within 60 days, yu will be ntified f the Cmmittee s decisin. While the decisin is being made, yur accunts will be put n hld. Please remember that yur applicatin cvers nly medical services that have already taken place. If medical services ccur after yur applicatin is submitted, please ntify us s we can determine whether r nt yu need t cmplete anther applicatin. If yu have any questins regarding Children s financial assistance, please call us at (404) , Mnday thrugh Friday, 8:30am - 4:00pm. Infrmatin is als available n-line at Please mail the cmpleted applicatin t: Financial Resurce Crdinatr, Children s Healthcare f Atlanta 1644 Tullie Circle Atlanta, Gergia As nted abve, please attach the fllwing as prf f incme: mst recent 1040 tax frm with the accmpanying W-2 s as well as tw mst recent pay stubs. Yu may als fax the cmpleted applicatin and prf f incme t (404) Applicatins withut prf f incme will nt be cnsidered fr financial assistance. 8

9 Administrative and Operatinal Plicies and Prcedures Financial Statement (Please Print) Accunt #(s): MR #: Patient Name: Male Female Last First Middle Patient Date f Birth Date f Admissin (s): Applicant Infrmatin Name: Dr. Mr. Mrs. Ms. Scial Security Number: Street Address: City: State: Zip: N. Years at This Address: Marital Status: Married Divrced Single Separated 9 Fr Office Use Number f Children: Name f Emplyer: Address f Emplyer: City: State: Zip: N f Years with This Emplyer: Psitin/Title: Type f Business: Advisry Bard: Hme Phne: Business Phne: Spuse r C-applicant Infrmatin Name: Dr. Mr. Mrs. Ms. Scial Security Number: Street Address: City: State: Zip: N. Years at This Address: Marital Status: Married Divrced Single Separated Number f Children: Name f Emplyer: Address f Emplyer: City: State: Zip: N f Years with This Emplyer: Psitin/Title: Type f Business: Hme Phne: Business Phne: Cmments:

10 Administrative and Operatinal Plicies and Prcedures Mnthly Incme befre Taxes Please attach the fllwing as prf f incme: Mst recent 1040 tax frm with accmpanying W-2s as well as tw mst recent pay stubs. Applicatins withut prf f incme will nt be cnsidered fr financial assistance. Applicant Spuse r C-Applicant * Wage per Hur $ Wage per Hur $ Hurs wrk per week Hurs wrk per week Scial Security per mnth $ Scial Security per mnth $ Disability per mnth $ Disability per mnth $ Net Rental Incme $ Net Rental Incme $ Unemplyment per mnth $ Unemplyment per mnth $ Child Supprt per mnth $ Child Supprt per mnth $ Alimny per mnth $ Alimny per mnth $ Public Assistance $ Public Assistance $ Other $ Other $ Mnthly Ttal $ Mnthly Ttal $ * If married, spuse infrmatin must be included n applicatin. Mnthly Living Expenses Hme Mrtgage Pymt $ Unpaid Balance $ Rent Pymt $ Unpaid Balance $ Utilities $ Unpaid Balance $ Autmbile $ Unpaid Balance $ Lans $ Unpaid Balance $ Credit Cards $ Unpaid Balance $ (list) (reasn) Insurance $ Unpaid Balance $ Dctr $ Unpaid Balance $ Hspital $ Unpaid Balance $ Other $ Unpaid Balance $ Ttal $ Ttal $ If yu have nt listed incme, please explain hw are yu paying fr fd and husing: Cnsent and Agreement I cnfirm that the infrmatin in this applicatin is crrect and cmplete and that Children s Healthcare f Atlanta has my permissin t duble-check it fr accuracy. I understand that if Children s Healthcare f Atlanta finds any f this infrmatin t be intentinally false, I will nt be eligible fr financial assistance and will be respnsible fr all charges. Signature f Applicant: Date: Signature f Spuse r C-Applicant: Date: 10

11 Administrative and Operatinal Plicies and Prcedures APPENDIX C Family Size and Incme FPL Chart 2016 INCOME LEVELS - YEARLY FEDERAL POVERTY GUIDELINES (FPG) & SELECTED PERCENTAGES THEREOF (Per Federal Register, Vlume 81, Number 15 (Mnday, January 25, 2016, n pages ) Mnthly incme under 125% 145% 165% 185% 200% 235% 270% 305% 340% Family FPG FPG FPG FPG FPG FPG FPG FPG FPG Family Size A B C D E F G H I Size 1 $1,238 $1,436 $1,634 $1,832 $1,980 $2,327 $2,673 $3,020 $3, $1,669 $1,936 $2,203 $2,470 $2,670 $3,137 $3,605 $4,072 $4, $2,100 $2,436 $2,772 $3,108 $3,360 $3,948 $4,536 $5,124 $5, $2,531 $2,936 $3,341 $3,746 $4,050 $4,759 $5,468 $6,176 $6, $2,963 $3,437 $3,911 $4,385 $4,740 $5,570 $6,399 $7,229 $8, $3,394 $3,937 $4,480 $5,023 $5,430 $6,380 $7,331 $8,281 $9, $3,826 $4,438 $5,050 $5,663 $6,122 $7,193 $8,264 $9,336 $10, $4,259 $4,941 $5,622 $6,304 $6,815 $8,008 $9,200 $10,393 $11, $4,693 $5,444 $6,194 $6,945 $7,508 $8,822 $10,136 $11,450 $12, $5,126 $5,946 $6,766 $7,587 $8,202 $9,637 $11,072 $12,508 $13, $5,559 $6,449 $7,338 $8,228 $8,895 $10,452 $12,008 $13,565 $15, $5,993 $6,952 $7,910 $8,869 $9,588 $11,266 $12,944 $14,622 $16, $6,426 $7,454 $8,482 $9,511 $10,282 $12,081 $13,880 $15,680 $17, $6,859 $7,957 $9,054 $10,152 $10,975 $12,896 $14,816 $16,737 $18, $7,293 $8,460 $9,626 $10,793 $11,668 $13,710 $15,752 $17,794 $19, $7,726 $8,962 $10,198 $11,435 $12,362 $14,525 $16,688 $18,852 $21, * $433 $503 $572 $641 $693 $815 $936 $1,057 $1,179 * * Fr family units ver 8, the amunt shwn has been added fr each additinal member. J Incme Over 340% f Federal Pverty Guidelines 11