Financial Assistance Program Policy

Financial Assistance Program Policy

Policy

In keeping with the philosophy and mission of Ridgecrest Regional Hospital (“RRH”), it is the policy of RRH to offer financial assistance, using the lookback method, to patients who are unable to pay their hospital bills due to difficult financial situations. A RRH Financial Counselor or Business Office Representative will review individual cases and make a determination of financial assistance that may be offered prior to, during, or after services are provided. Upon verifying eligibility for financial assistance, RRH shall offer hospital inpatients and outpatients Charity Care (i.e., free care) or Discounted Care in accordance with this policy and other applicable policies for Medically Necessary Services.

Purpose

To establish policies and procedures to ensure consistent identification, accountability, recording and follow-up of patient’s potentially eligible for Charity Care or Discounted Care in compliance with all applicable laws, including the Hospital Fair Pricing Law and Section 501(r) of the Internal Revenue Code, which was added by the 2010 Affordable Care Act and which imposes specific requirements on tax-exempt hospitals with respect to community benefit obligations.

Definitions

“Charity Care” refers to full financial assistance such that the patient does not have any financial obligation for Medically Necessary Services.

“Discounted Care” refers to financial assistance such that the patient is relieved of a portion of their financial obligation for Medically Necessary Services.

“Federal poverty level” means the poverty guidelines updated periodically in the Federal Register by the United States Department of Health and Human Services (HHS).

“Financial Assistance Program” is the provision of Charity Care or Discounted Care to individuals who cannot afford to pay and who qualify in accordance with this policy. The Financial Assistance Program does not refer to or include insurance policy discounts, administrative adjustments, contractual adjustments and is not available for elective procedures.

“High Medical Costs” are defined as:

1) Annual out of pocket costs incurred by the individual at the hospital that exceed 10% of the patient’s family income in the prior 12 months.

2) Annual of out of pocket expenses that exceed 10% of the patient’s family income if the patient provides documentation of the patient’s medical expenses paid by the patient or patient’s family in the prior 12 months.

“Income” is broadly defined and includes: (i) earnings, wages, salaries, tips, etc., (ii) unemployment compensation, (iii) workers’ compensation, (iv) Social Security benefits, (v) public assistance, (vi) Veterans’ benefits, (vii) survivor benefits, (viii) pension/annuities or retirement income, (ix) IRA distributions, (x) interest, (xi) capital gains, (xii) dividends, (xiii) taxable refunds, (xiv) alimony, (xv) rental income, (xvi) farm income, (xvii) income received from royalties, estates, trusts, S Corporations, and partnerships, (xviii) educational assistance, (xix) child support, (xx) business income, and (xxi) any other type of monetary assistance or other source of income.

“Medically Necessary Services” shall be defined, for purposes of this policy, as

  • emergency medical services provided in the emergency department;
  • non-elective services provided in response to life-threatening circumstances in a non-emergency room setting;
  • services that the hospital determines, in its discretion, qualify as medically necessary such as services for a condition which, if not promptly treated, would lead to an adverse change in the health status of an individual; and
  • shall not include elective procedures.

“Patient’s family” is defined as:

1) For patients 18 years of age and older, patient’s family includes spouse, domestic partner and dependent children under 21 years of age, whether living at home or not.

2) For patients under 18 years of age, patient’s family includes parent, caretaker and other children under 21 years of age of the parent or caretaker.“Self-Pay Patient” is a patient who does not have third-party coverage from a health insurer, health care service plan, Medicare, Medi-Cal/Medicaid, and whose injury/treatment is not a compensable injury for purposes of workers’ compensation, automobile insurance, or other insurance as determined and documented by the hospital.

Procedures

Ridgecrest Regional Hospital determines the need for financial assistance, using the lookback method, by reviewing the particular services requested or received, insurance coverage or other sources of payment, a person’s historical financial profile and current financial situation. This method allows for a fair and accurate method to assist patients who are experiencing financial hardship. Partial and/or full financial assistance may be granted based on the criteria set forth in this policy.

RRH may determine eligibility for financial assistance before or after Medically Necessary Services are provided, as well as before or after discharge. All eligibility determinations related to emergency services shall be conducted in accordance with applicable EMTALA policies.

Eligibility Determination

Patients that may be eligible for Charity Care or Discounted Care in accordance with this policy include:

1) Uninsured, Self-Pay Patients with incomes at or below 300% of the federal poverty level.

2) Insured patients with High Medical Costs and incomes at or below 300% of the federal poverty level, provided that patient does not receive a discounted rate from the hospital as a result of his or her third-party coverage.   Effective as of January 1, 2015, patients that receive a discounted rate from the hospital as a result of his or her third-party coverage are eligible.

As a rural healthcare provider, RRH has determined that 300% of the federal poverty level is appropriate to maintain the hospital’s financial and operational integrity. (H & S Code § 127400(a)((2).)

To be considered for eligibility to participate in the Financial Assistance Program the patient must complete the Financial Assistance Application form set forth in Exhibit A. If the patient is unable to complete the Application or to provide the information required, the Business Office or Registration staff may complete the application with information received through interviews with those who know the patient’s financial status. For insured patients with High Medical Costs, the patient will be required to cooperate with any insurance claim submissions.

The Financial Assistance Program eligibility documentation may be initiated by Patient Access/Admitting, Business Office, or a Financial Counselor. Applications received will be evaluated and approved or denied within thirty days of receipt of a completed application (including all supporting documentation). A letter of determination will be mailed to the patient within two weeks of determination.

In instances where a Self-Pay patient is able to pay a portion of his/her account at time of admission, the patient may none-the-less be eligible for financial assistance in accordance with this policy. In such cases, the patient will be provided with the Financial Assistance Application form and, upon a determination of eligibility, will be reclassified in the Business Office records system as a Financial Assistance patient.

Financial Assistance Program Applications for accounts with balances below $5,000 shall be reviewed and may be approved by the Business Office Manager; balances between $5,000 and $25,000 by the CFO; and balances over $25,000 by the CEO.

Basis For Calculating Eligibility

Income Calculation: RRH requires patients to provide their family’s yearly gross Income (“Family Income”) and provide supporting documentation. In accordance with the Hospital Fair Pricing Law, the documentation of Income for purposes of determining eligibility for Discounted Care is limited to recent pay stubs and/or tax returns. (H & S Code § 127401(e).) The Income calculated shall be compared to the federal poverty guidelines set forth in Exhibit D.

  • For patients 18 years and older: the term “yearly Income” on the application means the sum of the total yearly gross Income of the patient and the patient’s spouse or domestic partner, and dependent children under 21 years of age, whether living at home or not.
  • For patient’s under 18 years old: the term “yearly Income” means the Income from the patient, the patient’s mother/father and/or legal guardian or caretaker relatives, and other children under 21 years of age of the parent or caretaker relative.

Asset Calculation

Monetary Assets (savings and checking accounts, stocks, etc.) may be considered in connection with eligibility to receive Charity Care only and not for eligibility for Discounted Care. (H & S Code 127405(c) & (e)(2).)

Documentation of assets for Charity Care may include information on all monetary assets. However, the following assets shall be excluded:

  • retirement or deferred compensation plans qualified under the Internal Revenue Code, or nonqualified deferred compensation plans;
  • the first ten thousand dollars ($10,000) of a patient’s monetary assets; and
  • fifty percent (50%) of a patient’s monetary assets over the first ten thousand dollars ($10,000).

Additional Procedures:

RRH may require waivers or releases from the patient or the patient’s family, authorizing the hospital to obtain account information from financial or commercial institutions, or other entities that hold or maintain the monetary assets, to verify their value.

Information obtained pursuant to the above paragraphs regarding income verification and assets shall not be used for collection activities. This paragraph does not prohibit the use of information obtained by the hospital, collection agency, or assignee independently of the eligibility process for the Financial Assistance Program.

The guidelines for determining eligibility for the Financial Assistance Program will be calculated in accordance with this policy and based upon the information provided in the Financial Assistance Application, and RRH shall provide Charity Care or Discounted Care in accordance with the sliding scale set forth in Exhibit B.

Acceptance into the RRH Financial Assistance Program for care that was previously provided does not obligate RRH to provide future health care services as Discounted Care or Charity Care. A patient may be required to re-apply and re-qualify for financial assistance for subsequent episodes of care (whether as an outpatient or inpatient).

Discounted Care Payments

For Discounted Care, the hospital shall limit the expected payment for Medically Necessary Services it provides to a patient eligible for a discount under this policy to the amount of payment the hospital would expect, in good faith, to receive for providing services under Medicare (the “Medicare Reimbursement Rate”, see Exhibit C). If the hospital provides a service for which there is no established payment by Medicare, the hospital shall establish an appropriate discounted charge for the service.

Patients offered a Discounted Care payment plan under this policy shall not be charged interest in accordance with the Hospital Fair Pricing Law. (H & S Code §§ 127405(b), 127425(g).) The hospital and the patient may negotiate the terms of the payment plan. Effective January 1, 2015, in the event the hospital and the patient cannot agree upon the terms of the payment plan, the payment shall not exceed 10% of the patient’s family income for a month, excluding deductions for essential living expenses (including rent/house payment and maintenance, food/household supplies, utilities and telephone, clothing, medical and dental payments, insurance, school or child care, child or spousal support, transportation and auto expenses (insurance, gas, repairs), installment payments, laundry and cleaning and other extraordinary expenses. (H & S Code § 127400(i).)

Refund of Charges

Patients qualified under this policy shall receive a refund of any payments made above what is owed in accordance with this policy. (H & S Code § 127440).

Reasons For Denial or Revocation

RRH may deny or revoke a request for financial assistance for a variety of reasons including but not limited to:

  • Sufficient income
  • Patient is uncooperative or unresponsive to requests for information
  • Incomplete application or missing supportive documentation
  • Pending insurance or liability claim
  • Withholding insurance information or personal injury information

RRH reserves the right to reverse financial assistance adjustments made to a patient’s account upon verification of information that the patient was not eligible to participate in the Financial Assistance Program and to henceforth pursue appropriate reimbursement or collections.

Emergency Services

RRH will provide emergency care to patients regardless of their ability to pay. In accordance with EMTALA, following evaluation and stabilizing treatment (if necessary), non-emergent patients requesting financial assistance should complete a Financial Assistance Application, which should be reviewed by the Business Office and approved before additional services are provided.

An emergency physician, as defined in Health & Safety Code Section 127450, who provides emergency medical services in a hospital that provides emergency care is also required by law to provide discounts to patients who are at or below 350 percent of the federal poverty level and are uninsured patients or patients with High Medical Costs. This statement shall not be construed to impose any additional responsibilities upon the hospital. The emergency physicians are solely responsible for compliance with the provisions of Hospital Fair Pricing Law applicable to emergency physicians.

Alternative Assistance

RRH staff will provide the potential Financial Assistance Program patient with a listing of other potential payment programs, including Medicare, Medi-Cal and Covered California insurance plans. In addition, RRH staff may assist patients with applying for such coverage. Many potential Financial Assistance Program patients are not aware they may be eligible for public health insurance programs or have not pursued application for such programs. Notwithstanding the foregoing, the Financial Assistance Program shall be available to any patient that completes the Financial Assistance Program Application and meets the eligibility requirements.

Discretionary Discounts

Nothing contained herein shall prohibit the hospital from providing discretionary discounts (including free care) to patients that do not meet the requirements for Charity Care or Discounted Care as forth in this policy. The hospital may require such patients to complete the Financial Assistance Application. The discount shall be made from the hospital’s undiscounted charges. The discount may differ for inpatient and outpatient services and, in general, the discount will usually be no greater than the hospital’s current average commercial fee-for-service discounts with managed care payers. However, greater discounts may be provided upon approval of the CFO.

Equal Opportunity

RRH is committed to upholding all applicable federal and state laws that preclude discrimination on the basis of race, sex, age, religion, national origin, marital status, sexual orientation, disabilities, military service, or any other classification protected by federal, state or local laws.

Confidentiality

RRH staff will uphold the confidentiality and individual dignity of each and every patient. RRH will meet all HIPAA requirements for handling personal health information.

Notices

As required by the Hospital Fair Pricing Law, signs are located at the facility in areas visible to the public, including but not limited to, the Emergency Department, Admissions Department, Outpatient areas and clinics, as well as the Business Office. These signs inform patients that financially qualified patients may be eligible for Charity Care or Discounted Care.

As required by the Hospital Fair Pricing Law, when the hospital bills a patient that has not provided evidence of third-party coverage, the bill shall include a statement of the charges for services; a request that the patient inform the hospital if the patient has health insurance coverage (Medicare, Medi-Cal/Medicaid, or other coverage); notice that if the patient does not have health insurance coverage, that the patient may be eligible for Medicare, Medi-Cal, coverage through the California Health Benefit Exchange or other state- or county-funded health coverage programs and indicate that the hospital will provide such applications and inform the patient how to obtain the applications for such programs; and information of the availability of the Financial Assistance Program, including a statement that if the patient meets certain low-income requirements, that patient may qualify for the hospital’s Financial Assistance Program. The notice shall include the name and phone number of a hospital employee or department from whom the patient may obtain more information. (H & S Code § § 127410(a) and 1247420(b).)

In addition to the above notices, RRH shall post this policy and the Financial Assistance Application on its website. All of these actions are measures to widely publicize the policy within the community being served by the hospital in accordance with the Affordable Care Act. This policy and the Financial Application form shall be sent to the Office of Statewide Health Planning and Development every two (2) years or upon any significant changes.

Languages

All notices/communications provided under this policy shall be available in the primary language(s) of the hospital’s service area and in a manner consistent with all applicable federal and state laws and regulations.

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