SLIDING FEE SCALE AND CAP ON OUT OF POCKET CHARGES. Gail Williams Glasser, Project Officer, Southeastern Branch

Transcription

1 SLIDING FEE SCALE AND CAP ON OUT OF POCKET CHARGES Gail Williams Glasser, Project Officer, Southeastern Branch

2 Presentation Agenda Review of objectives Review of key definitions and concepts Basics of RWHAP charges for services/fees RWHAP Eligibility process Use of the Federal poverty level Sliding Fee Scale Requirements Nominal fees Annual limitation on charges (Cap on charges) How to implement sliding fee scale and cap on charges Monitoring Tips for Project Officers 2

3 Objectives Understand the RWHAP legislative and regulatory requirements for imposition of charges for services, Limitation on charges regarding individuals subject to charges, Assessment of charge, and applicability of limitation on amount of charge and relationship to items and services under other programs, as described in the RW legislation Understand how to assess the quality of recipient client charge activities (client eligibility, sliding fee and caps on charges ) Understand the complexities of sliding fee scale and caps on charges in different health settings such as universities, 330 health centers. Learn tips for monitoring and providing technical assistance. 3

4 Review of Key Concepts Costs are the accrued expenditures incurred by the recipient /subrecipient during a given period requiring the provision of funds for: (1) goods and other tangible property received; (2) services performed by employees, contractors, sub-recipient, subcontractors, and other payees Charges are the imposition of fees upon payers for the delivery of billable services Payments are the collection of fees from payers that are applied to cover some aspect of costs of billable services Billable services are those for which there is a payer source Charge Master/Schedule of Charges is a comprehensive listing of prices for billable services and/or procedures 4

5 Basics of RWHAP on charges for services the Ryan White legislation speaks about both charges and payments RWHAP Legislation 300 ff-64 (e) establishes requirements regarding imposition of charges for services For Part C and D eligible recipients, no charges are to be imposed on clients with incomes at or below 100% of the FPL (Federal Poverty Level) Charges to clients with incomes greater than 100% of the FPL are to be based on a discounted fee schedule and sliding fee scale CAPS on total annual charges for HIV services are to be based on a percentage of the client s annual income. Ryan White funds cannot be charged for payments for any items or service if payment has been or can be reasonably be expected to be made under any insurance policy or under any Federal or State health benefits program or by an entity that provides prepaid health care. 5

6 Language from program FOAs (Funding Opportunity Announcements) regarding Patient Payment Patient Payment for Services and Recipient Practices Applicants must develop consistent and equitable policies and procedures related to verification of patients financial status, implementation of a sliding fee scale, and ensuring a cap on patient charges for HIV-related services. In order to comply with these requirements, the program may need to provide additional staff training, develop patient education materials, and/or place notices in patient waiting rooms and reception areas. 6

7 Language from the Program FOAs Sliding Fee Scale and Nominal Fee Patients cannot be denied primary care if they are not able to pay for services. Part C EIS programs must provide a system to discount patient payment for charges by developing and utilizing a sliding discounted fee schedule that is published and made readily available. While the fee schedule may be based on the patient s income or household size and income, the organization must track the patient s income and charges imposed. The law prohibits imposing a first-party charge on individuals whose income is at or below 100 percent of the Federal Poverty Level and requires that individuals with incomes above the official poverty level be charged for services. Each program is responsible for creating its own sliding fee scale in accordance with the most recent Federal Poverty Level guidelines. *The RW Legislation does not mention a sliding fee scale which is the standard term for describing the discount applied to charges of clients receiving care under Public Health Service Act programs. 7

8 Language from the Program RWHAP Parts C and D FOA regarding Cap on Charges This is the table in the FOA that reflects this legislative requirement! Individual Income Maximum Charge At or below 100% of Poverty $0 101% to 200% of Poverty No more than 5% of gross annual income 201% to 300% of Poverty No more than 7% of gross annual income Over 300% of Poverty No more than 10% of gross annual income 8

9 RWHAP Financial Eligibility - The use of MAGI (modified adjusted gross income) Policy recommends that recipients use the modified adjusted gross income (MAGI) for determining financial eligibility for RWHAP services. The Affordable Care Act provides this simplified method for calculating income eligibility for Medicaid, CHIP and financial assistance available through the health insurance Marketplace. This creates one set of income eligibility rules across all insurance programs and this PCN encourages recipients to use this as part of income determination. 9

10 Policy sources for RWHAP eligibility HAB Policy Clarification Notice pcn1303eligibilityconsiderations.pdf HAB Policy (Client eligibility) 10

11 Let s Put this together! RWHAP funded programs are required to have (HAB Policy 13-02): Schedule of fees for provision of service Fees consistent with locally prevailing rates Fees designed to cover reasonable costs A schedule of discounts applied to fees A discount system based on patient s ability to pay No patient denied care due to inability to pay A system to waive or reduce fees to assure care is received Pursue payment from third party sources as applicable Eligibility Process in place with written policies and procedures Federal Poverty Level (FPL) used to determine ability to pay fees/charges Nominal Fee for clients above 100% FPL plus adjusted sliding fee scale Annual Limitation on Charges (Cap on Charges 11

12 RWHAP Eligibility Process starts at Client Registration Clients provide documentation on HIV status, residency, and income Recipients perform recertification every six months Using the Federal Poverty level, recipient determines client s ability to pay fees and charges for services (nominal fee should be charged for clients above 100% of FPL)* Recipient should specify documentation required for proof of income/family Size. Annual limitation on charges depending on client s annual gross income and process to track the cap and cut off charges once the cap is met *Note: Designated free clinics are exempt and can receive a waiver 12

13 US Poverty guidelines Guidelines for the 48 contiguous states and DC. Hawaii and Alaska have different levels and can be found at the mentioned site. Househol d Size 100% 133% 150% 200% 250% 300% 400% 1 $11,770 $15,654 $17,655 $23,540 $29,425 $35,310 $47, ,930 21,187 23,895 31, ,090 26,720 30,135 40, ,250 32,253 36,375 48, ,410 37,785 42,615 56, ,570 43,318 48,855 65, ,730 48,851 55,095 73,460 39,825 50,225 60,625 71,025 81,425 91,825 47,790 63,720 60,270 80,360 72,750 97,000 85, ,640 97, , , , ,890 54,384 61,335 81, , , ,560 13

14 Expectations for implementing a Sliding Fee Schedule Recipients should have the following: An approved Schedule of fees which is also called a charge master, Established fees that are reasonable and necessary, Establishment of a discount of charges based on ability to pay according to the sliding fee scale A Sliding fee means that costs change according to the patient s income, lack of income, or ability to pay Have a written statement no patient is denied care due to an inability to pay Program guidance is a good source for all of the requirements associated with the sliding fee schedule 14

15 Sample Sliding Fee Scale COMMWELL HEALTH RYAN WHITE SLIDING FEE DISCOUNT SCALE Effective: February 20, 2015 Slide Fee Discount Scale L A B C D E F G Household Size Annual Income Annual Income Annual Income Annual Income Annual Income Annual Income Annual Income 1 $0 - $ 11,770 $ 11,771 - $ 14,713 $ 14,714 - $ 17,655 $ 17,656 - $ 20,598 $ 20,599 - $ 23,540 $ 23,541 - $ 35,310 $ 35,311 - $ 999,999 2 $0 - $ 15,930 $ 15,931 - $ 19,913 $ 19,914 - $ 23,895 $ 23,896 - $ 27,878 $ 27,879 - $ 31,860 $ 31,861 - $ 47,790 $ 47,791 - $ 999,999 3 $0 - $ 20,090 $ 20,091 - $ 25,113 $ 25,114 - $ 30,135 $ 30,136 - $ 35,158 $ 35,159 - $ 40,180 $ 40,181 - $ 60,270 $ 60,271 - $ 999,999 4 $0 - $ 24,250 $ 24,251 - $ 30,313 $ 30,314 - $ 36,375 $ 36,376 - $ 42,438 $ 42,439 - $ 48,500 $ 48,501 - $ 72,750 $ 72,751 - $ 999,999 5 $0 - $ 28,410 $ 28,411 - $ 35,513 $ 35,514 - $ 42,615 $ 42,616 - $ 49,718 $ 49,719 - $ 56,820 $ 56,821 - $ 85,230 $ 85,231 - $ 999,999 6 $0 - $ 32,570 $ 32,571 - $ 40,713 $ 40,714 - $ 48,855 $ 48,856 - $ 56,998 $ 56,999 - $ 65,140 $ 65,141 - $ 97,710 $ 97,711 - $ 999,999 7 $0 - $ 36,730 $ 36,731 - $ 45,913 $ 45,914 - $ 55,095 $ 55,096 - $ 64,278 $ 64,279 - $ 73,460 $ 73,461 - $ 110,190 $ 110,191 - $ 999,999 8 $0 - $ 40,890 $ 40,891 - $ 51,113 $ 51,114 - $ 61,335 $ 61,336 - $ 71,558 $ 71,559 - $ 81,780 $ 81,781 - $ 122,670 $ 122,671 - $ 999,999 RYAN WHITE SERVICES Poverty level 0% < 100% 101% < 125% 126% < 150% 151% < 175% 176% < 200% 201% < 300% > 300% Nominal Charge $0 $1 $2 $3 $3 $3 $4 Maximum Annual Charges 0% of gross annual income 5% of gross annual income 5% of gross annual income 5% of gross annual income 5% of gross annual income 7% of gross annual income 10% of gross annual income 15

16 Sliding Fee Requirements in different Health Care Settings RWHAP Schedule of Charges (Sliding Fee Scale) Requirements have a historical connection to Public Health Service Act Section 330 -Health Center Programs such as: Community health centers, Federally Qualified Health Centers and Look-Alikes, Migrant Health Centers, Health Care for the Homeless settings. However, our RWHAP programs are unique because they are often located in very different settings: Any where from a free standing program to a hospital based entity. Implementing the requirements of a sliding fee scale and cap on charges may present challenges to our programs. In many cases, the parent organization may have a fee scale that does not meet the requirements of RW. 16

17 Annual Limitation on Charges Caps on the total annual charges for HIV services (including ADAP) must be based on a percentage of the client s annual income. Cumulative charges include charges for HIV-related services, including providers other than the recipient or its provider network Charges include enrollment fees, premiums, deductibles, cost sharing, co- payments, or similar charges. Applies to all services for which the provider imposes a charge. If the provider charges health insurers for a service, the provider must impose the same charge and provide a discount to uninsured clients using the service. 17

18 Recipient responsibilities for implementing sliding Fee scale and cap on charge process Establishment of a fee scale policy and fee schedule Established eligibility criteria and sliding fee eligibility application form Establishment of a health information system that records client charges, payments and adjustments Systems in place to ensure that clients with incomes < 100 % of the FPL are not charged for services A system for verifying client s annual income Evidence that the recipient s staff understands the policies and procedures and there is client education on the protocol. A process for alerting the billing system that the client has reached the cap and should not be charged for the remainder of the year. 18

19 Tips for monitoring and providing technical assistance During your monitoring calls, discuss the client eligibility process with your recipient Ask to see copies of P&Ps for the program Ask about the cap on charges process If your recipient does not have a system in place, direct them to the Target Center for best practices Ask about mechanisms in place to inform patients that no one will be denied care due to inability to pay. 19

20 Sample Scenario Recipient asks you: We've been working on developing new provider training materials and had some questions about the Ryan White CAP. I have done some searching on the HAB website, but couldn't find a PAL (Program Assistance Letter) or PIN (Policy Information Notice) that specifically addresses it so was hoping you could clarify a couple of items: 20

21 Sample Scenario 1. The CAP is assessed bed on total charges the participant accrues, not how much they have spent on services, right? Meaning, if their bills for services reach their CAP, they would no longer be charged for additional services, even if they haven't paid for any of them? 2. When determining how much the participant is charged for services, should we be evaluating their total charges based on how much the service costs? Or how much they would pay for it given their sliding fee discount? Meaning, if the service costs $100, but they slide to 20%, would that count as a $20 charge toward their CAP or an $100 charge? 21

22 Sample Scenario The language in the funding announcement says "for HIV-related services." How are we to determine what counts as HIV-related and what does not? Does HRSA provide guidance on determining what should be included in the CAP? 22

23 QUESTIONS? 23