Financial Assistance PGR

Transcription

1 Financial Assistance PGR Facility: Palmetto Health Effective: 01/2014 Reviewed: 01/2015, 06/2018 Revised: 11/2015, 10/2017, 06/2018 Name of associated policy: Financial Assistance Policy (FAP) Definitions Annual Family Income includes but is not limited to wages, interest income, investment income, disability and other recurring sources of income. Assets includes but is not limited to assets such as bank account balances, trusts, investments, and personal property but excludes primary residence. Children includes patients under the age of eighteen. Emergency Care shall mean the care or treatment for an Emergency Medical Condition, as defined by EMTALA. EMTALA is the Emergency Medical Treatment and Active Labor Act (42 U.S.C. 1395dd). Family shall mean the patient, patient s spouse (regardless of whether they live in the home) and all of the patient s children, natural or adoptive, under the age of eighteen who live at home. If the patient is under the age of eighteen, the family shall include the patient, the patient s natural or adoptive parent(s) (regardless of whether they live in the home), and the parent(s) children, natural or adoptive, under the age of eighteen who live at home. FAP shall mean this Financial Assistance Policy and PGR. Financial Counselors are Palmetto Health employees specifically trained to guide patients through their financial responsibilities and coverage options. FPG shall mean the Federal Poverty Income Guidelines that are published from time to time by the U.S. Department of Health and Human Services and in effect at the date of service for awards of financial assistance under this FAP. Limited Financial Assistance shall mean an individual who receives approval under the program based on income and assets levels but who is outside of the primary service area or had to receive services at Palmetto Health because the services were not available in their area. These patients will receive the appropriate FAP adjustments and co payments, but they will not receive a FAP card and a six (6) month eligibility. Management shall mean generally a director or above who is directly or indirectly involved in patient access and/ or billing, or their designee. Primary Service Area shall mean the counties of Richland, Lexington, Fairfield, and Sumter. Secondary Service Area shall mean the counties of Newberry, Kershaw, Lee, Orangeburg, Calhoun, Clarendon and Saluda. Uninsured Patients are individuals who do not have governmental health care coverage or private health insurance. Responsible Positions Corporate Directors of Patient Access and Patient Financial Services Patient Access Staff Financial Counselors Equipment Needed Not applicable

2 Page 2 Procedure Steps, Guidelines or Recommendation (PGR) Subject to all the terms and conditions hereinafter set forth, Palmetto Health has adopted the FAP to be fully compliant for hospitals, and we follow the policy for all other non-covered areas as closely as possible with the intent of providing FAP to all qualifying patients in our system. 1. All Palmetto Health locations and providers in the Palmetto Health System are committed to providing Emergency Care and medical care that cannot be delayed to patients without regard to their ability to pay. 2. The principal beneficiaries of the FAP are intended to be uninsured residents of our Primary Service Area whose Annual Family Income does not exceed 100% of the FPG as published from time to time by the U.S. Department of Health and Human Services and in effect at the date of service for awards of financial assistance under this FAP. 3. Other residents of our Primary Service Area whose Annual Family Income is 101% to 200% of FPG, who are ineligible for employer coverage, governmental coverage, or subsidized Marketplace coverage (through the Affordable Care Act (ACA)), and who are not required to pay the individual responsibility payment under the ACA, are also eligible for limited assistance. 4. For all patients, Palmetto Health will provide financial guidance, including assistance with applications for obtaining third party coverage and/or referral to the appropriate resources given the patients individual situations. As provided for in the ACA, Palmetto Health supports efforts whereby most patients with income levels over 101% of FPG will have governmental or other third party coverage. 5. Palmetto Health will provide care for children without regard to their ability to pay. However, Palmetto Health expects parents or guardians to cooperate with financial counselors in obtaining available coverage or paying for services rendered. 6. Management may make exceptions to the criteria of this PGR using reasonable judgment, with primary consideration given to the patient s ability to pay and any unique circumstances. 7. FAP to Provide Care on a Nondiscriminatory Basis: This FAP is designed to provide Emergency Care and medical care that cannot be delayed to patients without regard to ability to pay. Subject to the terms and conditions set forth below, Uninsured Patients who do not have the means to pay for services provided at Palmetto Health facilities may request to be considered for awards of financial assistance under the FAP. The eligibility criteria for financial assistance and the procedures for applying for financial assistance set out in this FAP are intended to ensure that Palmetto Health will have the financial resources necessary to meet its commitment to providing care to patients who are in the greatest financial need. 8. FAP Relating to Emergency Medical Care: Consistent with EMTALA, when applicable, Palmetto Health facilities will provide an appropriate medical screening to any individual, regardless of ability to pay. If, following an appropriate medical screening, Palmetto Health personnel determine that the individual has an emergency medical condition, Palmetto Health will provide services, within the capability of the Palmetto Health facility, necessary to stabilize the individual s emergency medical condition, or will effect an appropriate transfer as defined by EMTALA. 9. Providers Covered Under FAP: The following services and providers are covered under this FAP: Palmetto Health hospital services (excluding those noted in section 11), Palmetto Health employed physicians, Palmetto Health contracted emergency department physicians, Palmetto Health lab services, and Palmetto Health owned ambulance

3 Page 3 and other transport services are covered under this policy. All other medical services and providers that may assist with care in a Palmetto Health facility are not explicitly covered by this policy. 10. Eligibility Criteria for Financial Assistance General: Uninsured patients whose Annual Family Income does not exceed 100% of the FPG, who meet the other criteria set forth in this FAP, and who apply for assistance as required in paragraph 11 below are eligible for financial assistance under this FAP Geographic Requirements: This PGR is intended to cover citizens of the residents of the Primary Service Area. Applicants will be asked to provide documentation related to their residency Limited FAP may be applied to United States citizens who are residents of our Secondary Service Area when services are not available in their county of residence or when emergency services were required, to people visiting the Midlands of South Carolina, or in other unique situations with management approval. 11. Care Not Included in this PGR: Some services are uniformly excluded from this PGR and are ineligible for financial assistance, including but not limited to plastic surgery, gastric bypass, fertility treatments, ventricular assistance devices (VAD), procedures not covered by Affordable Care Act(ACA-Health Insurance Exchange plans, dental services, and other elective services and procedures. 12. Method of Applying for Financial Assistance To be eligible for financial assistance under this FAP, individuals must apply for financial assistance and cooperate with Palmetto Health in determining whether or not the individual is eligible for assistance under this FAP. Individuals can apply in person, over the phone, or by mailing a completed application to the following addresses based on their situation: Columbia Based Facilities Palmetto Health Richland ATTN: Financial Navigation/Patient Access Five Medical Park Columbia, SC Phone number: CARE (2273) Tuomey Location Palmetto Health Tuomey ATTN: Financial Counselors/Patient Access 129 N. Washington St. Sumter, SC Phone number: Presumptive eligibility: Palmetto Health may approve an individual for presumptive coverage under the FAP based on certain factors like homelessness or other social or community data that may indicate a presumed income level under the 100% FPG limit Proof of income and financial documentation will be required based on the patient s Annual Family Income at the time of service. Annual Family Income determination should be based on the two-month or eight(8) weeks period immediately preceding the date of service Palmetto Health Financial Counseling staff will proceed through the following hierarchy in an effort to secure the best evidence available from the patient or guarantor (responsible party) at the time of their encounter:

4 Page A completed Financial Assistance Application inclusive of the patient s or guarantor s signature and hard copy proof of income, such as pay stubs, bank statements, or a notarized letter from the applicant s employer supporting the income thereon. If this information is unavailable, then, A completed Financial Assistance Application inclusive of the patient s or guarantor s signature and W2s from the most recent year supporting the income or a tax return. If this information is unavailable, then, A completed Financial Assistance Application inclusive of the patient s or guarantor s signature and verification of income and family size from governmental or other verified third party sites. If this information is unavailable, then, A completed Financial Assistance Application inclusive of the patient s or guarantor s signature, unless there is a documented reason the patient or a person legally authorized to speak for the patient could not sign the form or provide proof of income documentation If there is a discrepancy with the information that was provided from the patient, a Palmetto Health Financial Counselor may request additional information to support the document or the application for financial assistance may be denied In addition to income, assets will also be verified Individuals who meet the income requirements for financial assistance but have equity of more than $50,000 (excluding their primary residence) or liquid assets (typically checking and savings accounts) in excess of $1,000 will not be eligible for assistance Individuals with excess assets may make partial payment for their services such that their asset level drops below equity and liquid asset limits Once the asset level is below both $50,000 in equity and $1,000 in liquid assets, full financial assistance is available Assets will be verified by the following: For property (land, cars, boats, homes, etc.), there will be a review of the County Assessor s website, and/or a copy of mortgage documents will be requested Retirement and other non-liquid investments will be verified against investment statements and are considered as equity for purposes of determining asset levels noted above For liquid assets, copies of all bank and investment statements will be reviewed for the last two months to ascertain the average daily balance (ADB). Liquid assets include all bank accounts (checking and savings), CDs and non-retirement investment accounts The following steps will be followed to evaluate a patient s request for consideration under the FAP Financial Interview Palmetto Health Financial Counselors will discuss with patients their individual financial positions and obtain from them information regarding their finances. This information will be recorded on the Financial Assistance Application. Patients will be required to sign the Application. Financial Counselors will determine the level of assistance based on the proof of income documents provided. The signed document and proof of income information will be scanned and maintained by the Financial Counselors Determination of Eligibility Financial Counselors will review each Application and proof of income documents to make an assessment of eligibility under the FAP. For qualifying patients, Financial Counselors will work to get those patients appointments scheduled (if appropriate), and adjustments will be recorded in the patient accounting system as adjustments for Palmetto Health financial assistance Incomplete Applications If treatment is non-emergent, admission will be deferred until the application process has been completed Separate Procedures For our Primary Service Area patients who have Annual Family Income of less than 100% of FPG and qualify for this assistance, they will be issued a card with their name, card number, and effective dates. Except for care excluded in section 11, this card may be used for subsequent inpatient, outpatient or physician practice encounters for six(6) months from the effective date of the card, assuming there

5 Page 5 are no changes that would impact the original determination for financial assistance At each separate encounter, patient access staff will (at a minimum) verbally inquire about the following: Changes in employment status Changes in family size/composition Changes in residence Any other asset changes from the initial charity application If there are changes in any of the above, access staff will rescreen the patient to determine if he/she still qualifies for financial assistance. A full Financial Assistance Application must be completed at least every six months, and verbal inquiry will be done at all interim visits. A patient will only receive financial assistance for those visits that qualify Requests for Information If an individual requests information regarding financial assistance by phone or , the Financial Counselor will mail the Financial Assistance Application to the individual or direct him/ her to the Palmetto Health website for an online version. Applications may be submitted in person or mailed to the addresses listed in Section The FAP, FAP application, and Plain Language Summary are available in English and Spanish upon request in the Main Admissions locations, the Emergency Department (ED) locations, and the Palmetto Health website Paper copies of the FAP documents must be provided unless the individual requests to receive or access the document electronically Communication of FAP Denial or FAP Ineligibility: The Financial Counselors will communicate denials under the program as needed. Communications can be in person, via a mailed denial letter, or both. 13. Basis for Calculating Amounts Charged to Patients. The basis for calculating amounts charged to patients eligible for awards of financial assistance under this FAP will be as set forth in this paragraph. All patients are expected to make some payment toward the cost of their care Patients eligible for awards of financial assistance under the FAP will receive assistance according to the following sliding scale: Annual Family Income Amount Charged to Patient <100% FPG Co-payment of $5 for Clinic/Physician Office Visit/Outpatient Service, $25 for Emergency Department Visit, and $50 for Inpatient Hospitalization Palmetto Health s FAP provides for a nominal co-payment to be applied toward care. Remaining charges above the co-payment amounts will be written off for individuals who meet the criteria noted. Given the limited co-payment requirements, this PGR fully complies with the requirements of 501(r)(5), which outlines that patients qualifying for financial assistance may not be charged more than the amounts generally billed to patients with insurance. 14. Actions under Billing and Collection FAP in the Event of Non-Payment. The actions Palmetto Health may take with regard to non-payment by a patient who is able to pay for services, including collections action and reporting to credit agencies, are set forth in separate policies. Palmetto Health will attempt to collect per visit co-payments at point of service or point of scheduling in compliance with the insurance benefit terms. Patients not eligible for financial assistance and not making per visit co-payments are subject to cancellation of non-emergent appointments. 15. Determination of Eligibility for Financial Assistance Prior to Collection Action. Notwithstanding any other provision of any other FAP at Palmetto Health regarding billing and collection matters, including the policies referred to in paragraph 13 above, Palmetto Heath will not engage in extraordinary collection actions before it makes reasonable efforts to determine whether an individual who has an unpaid amount from

6 Page 6 Palmetto Health is eligible for financial assistance under this FAP. As used in this FAP, (i) extraordinary collection actions include lawsuits, liens on residences, or other similar collection processes, and will include such other actions as may be set forth in future guidance from the United States Department of Treasury or the Internal Revenue Service; and (ii) reasonable efforts includes notification to all uninsured patients by Palmetto Health of the FAP upon admission and in written and oral communications with the patient regarding the patient s bill, including statements, telephone calls, and such other communications as may be set forth in future guidance from the United States Department of Treasury or the Internal Revenue Service. 16. Calculation Method: Palmetto Health uses the perspective method to determine the self pay adjustment portion for their customers.