DEFINITIONS: a. Self-pay patients: Patients not classified as indigent but who demonstrate an inability to pay for services.

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1 I. UHealth the University of Miami Health System has established uniform charity care provision criteria for patients treated at Anne Bates Leach Eye Hospital (Bascom Palmer Eye Institute), University of Miami Hospital and Clinics (UMHC/Sylvester Comprehensive Cancer Center),and University of Miami Medical Group Clinics (UMMG). II. III. POLICY STATEMENT: The University of Miami Health System provides financial assistance for medically necessary care to residents of Miami-Dade County who are in the United States legally, and whose family income level is up to four times the Federal Poverty Income Guidelines. Financial assistance applies to both hospital and physician services. Patients without insurance are to be identified prior to admission as an inpatient or authorization of outpatient services. For patients with insurance, classified as underinsured, identification will be made as close to the time of service as possible. Charity Care will only be considered for non-elective care and will be available each year as long as budgeted funds are available. DEFINITIONS: a. Self-pay patients: Patients not classified as indigent but who demonstrate an inability to pay for services. b. Underinsured Patients: Patients who have insurance, but who demonstrate an inability to pay deductibles, co-insurance and deductibles. c. Non-Elective Care: Medically necessary services that are required for an illness or injury that would not result in further disability or death if not treated immediately, but requires professional attention and has the potential to develop such a threat if treatment is delayed longer than 24 hours. (Urgent Care Association of America) d. Elective Care: Routine care that if not provided is not likely to lead to a deterioration of a patient s health status. IV. SCOPE: This policy applies to University of Miami Health System, its employees, and medical staff involved in any aspect of the revenue cycle for patient appointments. V. RESPONSIBILITY: Practitioners and clinic managers are individually responsible for compliance with these parameters, will be held personally accountable for lack of compliance, and will be subject to corrective action for such failures, as outlined above. Chairs and VCAs are responsible for ensuring compliance for their departments. Chairs are ultimately responsible for ensuring compliance within their departments.

2 VI. VII. POLICY REVIEW: Annual RELATED POLICIES/REFERENCES: UHealth Charity Care Policy CHARITY CARE POLICY UMMG PROCEDURES 1. Charity Care approval will be based on ACHA charity guidelines and annualized budgeted funds allocated for charity care. ACHA defines Charity Care as that portion of patient hospital charges which are uncollectable or non-reimbursable from other sources and which do not represent a contractual allowance. Non-contractual adjustments, including discounts for prepayment, payment at time of service and single case rate and are not to be treated as charity care for budgetary purposes. 2. All self-pay patients will be asked for payment in full by the Registration staff if services and charges are known in advance. If they indicate at check-in that they are unable to pay, contact a Financial Counselor immediately and inform the physician of a delay. The physician may override the delay for medical reasons at their discretion. 3. The Financial Counselor will first ask the patient if they are able to make monthly payments. If not, they will proceed to Medicaid screening. 4. The Financial Counselor will screen the patient for Medicaid or refer to the Public Health Trust (PHT) (if at ABLEH, working in conjunction with the Social Worker) to determine if they qualify for a PHT Card, medically needy or any financial assistance programs available. If the patient is eligible, the patient will be given the number to call and apply by the financial counselor. 5. Any patient/guarantor who is not able to make payment at the time of registration and is not eligible for PHT or Medicaid will be asked by the Financial Counselor to fill out an Application for Charity Assistance. 6. The following items are the only forms of income verification that AHCA has approved and are required for submission with the Charity Care application: a. Current W-2 withholding statement b. Current Pay Stubs c. Income Tax returns from the most recent prior year d. Forms approving or denying unemployment compensation e. Written verification of wage from employer f. Written verification from public welfare agencies or any other governmental agency that can attest to the patient s income status for the past twelve (12) months 2

3 g. A witnessed statement signed by the patient or responsible party as provided for in public law , as amended, known as the Hill Burton Act. This statement must reference Florida Statute , providing false information to defraud a hospital for the purposes of obtaining goods or services, is a misdemeanor in the second degree. h. A Medicaid remittance voucher that reflects that the patient s Medicaid benefits for that Medicaid fiscal year have been exhausted. 7. Poverty guidelines will be reviewed annually based upon income levels published in the Federal Register. 8. All completed applications will be forwarded to the Manager of Self Pay Collections in the CBO. 9. If budgeted funds are available, Charity Care will be approved for patients who provide the required documentation and whose family income for the preceding twelve (12) months falls within 200% of the current Federal Poverty Guidelines. For those that qualify, balances will be allowanced to zero. 10. Patients whose family income is between % of the Federal Poverty Guidelines with an uncollectable balance that exceeds 25% of their annual family income for the preceding 12 months will also be eligible for Charity Care. Discount amount is outlined on the attached discount table. In no case shall the balance for a patient whose family income exceeds four (4) times the Federal Poverty Guidelines be considered Charity Care. 11. Charity Care will also be approved for patients who fall into the category of Underinsured. Underinsured is defined as those patients with some form of third party payer coverage for health care services but such coverage is insufficient to pay the current bill. For Underinsured patients, the balance remaining after third party liability must be $1,000 or more. The family income for the preceding twelve (12) months must be less than or equal to 100% of the Federal Poverty Guidelines or the family income must be between % of the Federal Poverty Guidelines and the uncollectable balance must exceed 25% of their annual family income. 12. All applications will be reviewed for budget compliance by the Executive Director of Revenue Cycle, and approved by (1) the Hospital CFO for services provided in a facility setting and (2) the COO (or the COO s designee) on behalf of UMMG. 13. The decision and terms of payment regarding continuing services will be communicated back to the Financial Counselor by PFS. Notification will be made to the patient first through a phone call and followed up with a standard charity care approval or denial letter. The letter will be scanned into the system. 3

4 Charity Care Sliding Scale with 2016 Federal Poverty Guidelines Size of Family Unit 100% 132% 138% 150% 200% 300% 400% 1 $11, $15, $16, $17, $23, $35, $47, $16, $21, $22, $24, $32, $48, $64, $20, $26, $27, $30, $40, $60, $80, $24, $32, $33, $36, $48, $72, $97, $28, $37, $39, $42, $56, $85, $113, $32, $43, $44, $48, $65, $97, $130, $36, $48, $50, $55, $73, $110, $146, $40, $53, $56, $61, $81, $122, $163, *Discounts over 200% of Federal Poverty Guidelines apply to balances that exceed 25% of total family income for previous year. 4

5 UHealth (University of Miami Health System) Application for Charity Care Assistance Name: Last First MI Address: Street City/State Zipcode Social Security # Home Phone Employer Patient s Gross Income Other Family Income Total Family Income Family Size Last 12 Months Last 3 Months x 4 I certify that the above information is true and accurate to the best of my knowledge. Furthermore, I will complete an application for any assistance (Medicare, Medicaid, Insurance, etc.) that may be available for payment of my hospital charges, and I will take any action reasonably necessary to obtain such assistance and will assign pay to the hospital for the amount recovered for hospital charges. If any information I have given proves to be untrue, I understand that the hospital may re-evaluate my financial status and take whatever action becomes appropriate. of Request: Applicant Signature: ELIGIBILITY DETERMINATION (For Office Use Only) Application Received: Income Verified: Yes No Type of Verification: Application and Documents Reviewed by: Manager, Self Pay Collections Director, Central Business Office Executive Approved by: CFO or COO Designee 5