Patient Accounts/Patient Access POLICY AND PROCEDURE MANUAL. IRS Regulation # (r) (4) Affordable Care Act/ Financial Assistance Process

Transcription

1 POLICY AND PROCEDURE MANUAL SECTION: SUBJECT : Patient Accunts/Patient Access IRS Regulatin # (r) (4) Affrdable Care Act/ Financial Assistance Prcess PURPOSE: T ensure that Raritan Bay Medical Center s hspital facilities (Perth Amby and Old Bridge) are in cmpliance with the guidelines utlined in IRS Regulatin , Internal Revenue Cde 501(r)(4) regarding the written Financial Assistance Plicy ( FAP ) and Emergency Medical Care Plicy, Federal Emergency Medical Treatment and Active Labr Transprt Act f 1986 ( EMTALA ). The hspital will be referred t as RBMC thrughut this plicy. RBMC adheres t the patient ntificatin criteria with regards t the financial assistance prgrams that are available, eligibility requirements, calculatin f amunts charged t patients and the actins taken in the event f nnpayment. RBMC will apply a self-pay discunt rate that is equal t 100% f the Medicare fee schedule, t all uninsured individuals that d nt qualify fr Charity Care fr all emergency and medically necessary healthcare services received as an inpatient r utpatient. This discunt will be reflected in the patient s first billing statement. Uninsured billing limits are in accrdance with NJ P.L.2008 c.60 It is the plicy f RBMC and all physicians with admitting privileges including ER, Trauma, Radilgy, Pathlgy, Anesthesilgy r any prvider delivering emergency r ther medically necessary care t cmply with the standards f EMTALA and the EMTALA regulatins. RBMC will prvide a medical screening examinatin and such further treatment as may be necessary t stabilize an emergency medical cnditin fr any individual cming t the emergency department seeking treatment, regardless f the individual s medical r psychiatric cnditin, race, religin, age, gender, clr, natinal rigin, immigratin status, sexual preference, handicap r ability t pay. Certain physicians prviding emergency r ther medically necessary services t patients (including Emergency Department, Trauma, Radilgy, Pathlgy, Anesthesilgy, r Hspitalists and Intensivists) within the hspital facilities may nt be cvered under the RBMC FAP. Please refer t Exhibit A fr RBMC s prvider listing. This listing specifies, by department, which prviders are cvered under this FAP and which are nt. New Jersey Hspital Care Payment Assistance Prgram ( Charity Care ) is available t thse that d nt qualify fr state r federal prgrams, r are underinsured. Patients earning up t 300% f the Federal Pverty Level (FPL) may be eligible fr New Jersey s Charity Care prgram accrding t the regulatins established in NJAC 10:52, Subchapters 11, 12, 13. Charity Care accunts are reprted t the State f New Jersey at grss charges fr subsidy valuatin.. 1

2 POLICY: Financial Assistance Prcess: Uninsured patients are screened by RBMC Financial Assistance Cunselrs t determine if they qualify fr insurance prir t the determinatin f Charity Care. The screening prcess will nt ccur until a patient has been assessed and stabilized by a physician. In additin, RBMC may request a credit reprt fr patients wh identify that they have n incme r fr thse wh are self-emplyed. Belw summarizes the different prgrams that individuals will be screened fr: Health Insurance Marketplace: In cmpliance with the Affrdable Care Act, RBMC Certified Applicatin Cunselrs will screen patients t determine if they are eligible t purchase insurance thrugh the Marketplace and/r receive a subsidy frm the Federal Gvernment t assist with the purchasing f insurance. Medicaid: RBMC Financial Assistance Cunselrs will assist patients, wh meet the eligibility criteria, with the applicatin prcess. There are several types f Medicaid available thrugh the NJ Department f Health; we will help determine the prgram best suited fr the patient s circumstances. SSI-Medicaid: Supplements Medicaid benefits with a mnthly incme stipend that can help with basic needs. Assistance is available nsite t assist inpatients and certain utpatients wh meet the eligibility criteria with the applicatin prcess. Emergency Medicaid: This prgram will pay fr emergency care prvided by a hspital fr peple wh wuld have been eligible fr NJ FamilyCare/Medicaid but d nt, due t their immigratin status. The care must be fr medical cnditins that happen suddenly with severe symptms that will cause a serius health prblem if immediate medical attentin is nt prvided. If care is received in a hspital fr a cnditin meeting the abve criteria, the hspital, physicians' and ther related csts (including ambulance service) may be cvered by this prgram. NJ FamilyCare ( NJFC ): Insurance prgram designed t prvide cverage fr adults and children up t 138% f the FPL. RBMC s Financial Assistance Cunselrs will assist in cmpleting the nline applicatin. Presumptive Eligibility-Medicaid: Presumptive Eligibility (PE) fr NJFC ffers temprary medical insurance fr services prvided by participating prviders while NJFC applicatins are pending an eligibility determinatin. RBMC s Financial Assistance Cunselrs will assist in cmpleting the applicatin. Charity Care: Prvides assistance t cver the csts f hspital services nly. Patient must be categrically ineligible r present a NJFC denial letter which identifies that the patient has been denied fr NJFC due t being ver incme r des nt meet residency/ther requirements as per NJFC regulatins. Denial due t nn-cmpliance with NJFC is nt sufficient t be granted Charity Care. Patients are asked t dcument incme, family size and asset infrmatin based n the regulatins established in N.J.A.C. 10:52, Subchapters 11, 12 & 13. Patients requesting financial assistance are referred t an nsite Financial Assistance Cunselr fr cnsideratin. 2

3 Uninsured Discunted Rates RBMC will apply a self-pay discunt rate that is equal t 100% f the Medicare fee schedule, t all uninsured individuals that d nt qualify fr insurance r Charity Care fr all emergency and medically necessary healthcare services received as an inpatient r utpatient. This discunt will be taken at the time f billing and will be reflected in the patient s first billing statement. Charity Care Eligibility Requirements Charity Care assistance is free r reduced charge care which is prvided t patients wh receive inpatient and utpatient services at acute care hspitals thrughut the State f New Jersey. Hspital assistance and reduced charge care are available fr emergency r ther medically necessary hspital care. Sme services such as physician fees, anesthesilgy fees, radilgy interpretatin, and utpatient prescriptins are separate frm hspital charges and may nt be eligible fr reductin. Financial need is determined in accrdance with NJAC 10:52, Subchapters 11, 12, 13 Charity Care applicatins, apprval, billing and prcessing. Hspital care payment assistance is available t New Jersey residents wh: 1. Have n health cverage r have cverage that pays nly part f the bill; 2. Are ineligible fr any private r gvernmental spnsred cverage (such as Medicaid): and 3. Meet the incme and assets criteria listed belw. Hspital assistance is als available t nn-new Jersey residents, subject t specific prvisins. Incme Criteria Incme as a Percentage f HHS Pverty Incme Guidelines Percentage f Medicaid Rate Paid by Patient less than r equal t 200% 0% f Medicaid Rate greater than 200% but less than r equal t 20% f Medicaid Rate 225% greater than 225% but less than r equal t 40% f Medicaid Rate 250% greater than 250% but less than r equal t 60% f Medicaid Rate 275% greater than 275% but less than r equal t 80% f Medicaid Rate 300% greater than 300% RBMC Uninsured Discunt Rate If patients n the 20% t 80% sliding fee scale are respnsible fr qualified ut-f-pcket paid medical expenses in excess f 30% f their grss annual incme (i.e. bills unpaid by ther parties), then the amunt in excess f 30% is cnsidered hspital care payment assistance. 3

4 Assets Criteria Individual assets cannt exceed $7,500 and family assets cannt exceed $15,000. Shuld an applicant s assets exceed these limits, he/she may spend dwn the assets t the eligible limits thrugh payment f the excess tward the hspital bill and ther apprved ut-f-pcket medical expenses. Methds Used t Determine Amunts Generally Billed ( AGB ) fr Emergency r Medically Necessary Care RBMC hspital utpatient and inpatient Charity Care claims are priced based n the New Jersey Medicaid prgram s pricing and prgram plicies fr hspital utpatient and inpatient hspital services based n N.J.A.C. 10:52-1.6, Cvered Services (inpatient and utpatient services) and NJAC 10:52-4, Basis f Payment. Under Internal Revenue Cde 501(r)(5), in the case f emergency r ther medically necessary care, FAP-eligible patients will nt be charged mre than an individual wh has insurance cvering such care. Under these regulatins RBMC has adpted the Prspective Medicare Methd t calculate its AGB. The Prspective Medicare Methd is used fr all ther uninsured patients t calculate the amunt that Medicare wuld allw (this includes the amunt reimbursed by Medicare as well as the amunt the beneficiary wuld be persnally respnsible fr paying in the frm f cpayments, c-insurance and deductibles) fr emergency r ther medically necessary care as if the FAP-eligible individual were a Medicare fee-fr-service beneficiary. The billing statement will state the grss charges as a starting pint fr allwances, discunts, and deductins. Any FAP-eligible individual will always be charged the lesser f AGB r any discunted rate available under this FAP. Methd f Applying fr Charity Care RBMC will apply a self-pay discunt rate that is equal t 100% f the Medicare fee schedule, t all uninsured individuals fr all emergency and medically necessary healthcare services received as an inpatient r utpatient. This discunt will be taken at the time f billing and will be reflected in the patient s first statement. Charity Care is available t thse individuals wh still cannt affrd t pay this discunted amunt. A request fr Charity Care and a determinatin f financial need may be dne at any pint in the revenue cycle. Eligibility is frm the date f service and length f eligibility is based n the type f Charity Care received see belw. ER Charity Care Only Fr Inpatients admitted thrugh Emergency Rm, gd fr that hspital stay nly; 3 Mnth Charity Care Fr Outpatient/Observatin - Patients that will qualify fr NJFC. This type f charity care cvers the patients fr any additinal services they need frm the hspital fr the next 3 mnths while they are waiting fr the NJFC apprval; 4

5 Up t One Year Charity Care Patients wh wuld nt qualify fr NJFC (i.e.; already have insurance but n secndary, undcumented, Medicare n secndary, individuals wh wuld qualify fr Marketplace but can t apply due t Marketplace being clsed). Charity Care applicatins and department cntact infrmatin are available at any RBMC facility, by accessing and hspital staff have been prvided with cntact infrmatin. Financial Assistance Cunselrs are available n site fr interviews and t answer questins. Applicants must prvide RBMC with a cmpleted Charity Care Applicatin ( Applicatin ). A cmpleted Applicatin must include certain required dcuments. These required dcuments include identificatin, prf that he/she has been residing in New Jersey since the time f service and intend t remain in the State, prf f incme fr ne mnth prir t the date f service, and bank statements that include the balance n the date f service. Additinal dcuments may be required depending n the individual applicant s circumstance. Cmpleted Applicatins can be mailed t any RBMC facility. Upn receipt f a cmpleted Applicatin (and all required dcumentatin), the request will be prcessed prmptly and the applicant will be infrmed f the status n later than 10 days frm receipt. If the applicatin des nt include sufficient dcumentatin t make the determinatin, the applicatin will be cnsidered incmplete and the applicant will be ntified in writing within 10 wrking days what is needed t cmplete the applicatin. Additinally, RBMC will include a cpy f the Plain Language Summary ( PLS ) (defined belw). Patients will be given a reasnable perid f time t prvide the additinal requested dcumentatin. During this time RBMC, r any third parties acting n their behalf, will suspend any extrardinary cllectin actins ( ECAs ) (defined belw) t btain payment until a FAP-eligibility determinatin is made. An applicant (patient) r guarantr can submit a cmpleted applicatin fr determinatin fr Charity Care r reduced charge Charity Care at any time up t 24 mnths frm the date f utpatient service r inpatient discharge r 240 days frm the date f the first pst-discharge billing statement; whichever is greater. RBMC may grant Charity Care based n evidence ther than what is described in the FAP and may be granted based n attestatin even if the Financial Assistance Prcess r Applicatin des nt describe such evidence. Infrmatin may be btained frm an individual either in writing r rally (r a cmbinatin f bth). RBMC may grant assistance based upn infrmatin prvided by the individual n prir Charity Care Applicatins if such infrmatin is relevant t the current Applicatin. RBMC may utilize infrmatin frm credit bureaus r ther utside surces. Charity Care applicants wh are deemed ineligible fr Charity Care will be ntified in writing f the reasns fr the denial and will be infrmed f the availability f the uninsured discunt. Measures t Widely Publicize the FAP, Applicatin & Plain Language Summary The FAP and Plain language Summary is psted n RBMC s website ( and are available free f charge upn request. The guide cntains infrmatin regarding all NJ Medicaid prgrams, SSI Medicaid, NJ Family Care, Presumptive Eligibility, and Charity Care. The NJ Charity Care Applicatin and New Jersey Hspital Care Payment Assistance Fact Sheet are als available at each campus. Ntices are psted in emergency rms, urgent care centers, admitting and registratin departments, and patient financial services ffices that are lcated at each campus. Ntices are psted in English and in Spanish. 5

6 The FAP and PLS (defined belw) are available in English and in the primary language f ppulatins with limited prficiency in English ( LEP ) that cnstitute the lesser f 1,000 individuals r 5% f RBMC s primary service area. Additinally, RBMC prvides language interpreting and translatin services, and prvides infrmatin t patients with visin, speech, hearing r cgnitive impairments in a manner that meets the patient s needs. The Plain Language Summary ( PLS ) f the FAP is available and will be distributed and psted in Cmmunity Centers, Churches, public gathering areas and cmmunity events. This is a written statement that ntifies an individual that the hspital facility(s) ffers financial assistance under the FAP and prvides additinal infrmatin in language that is clear, cncise and easy t understand. This will help ensure that the cmmunity serviced by RBMC is aware f financial assistance availability. Additinally, Financial Cunselrs may participate in cmmunity utreach prgrams. All patients will be ffered a cpy f the PLS as part f the intake r discharge prcess. The availability f financial assistance will appear n billing statements. Each billing statement will als includes the website f where an individual can btain cpies f the FAP and PLS. They als will include the telephne number that patients can call if they have questins regarding the availability f financial assistance and the applicatin prcess. DEFINITIONS Amunts Generally Billed (AGB): The amunts generally billed fr emergency r ther medically necessary care t individuals wh have insurance cvering such care. Charity Care - NJ Hspital Care Payment Assistance Prgram: is free r reduced charge care which is prvided t patients wh receive inpatient and utpatient services at acute care hspitals thrughut the State f New Jersey. Prvides assistance t cver the csts f hspital services nly. Extrardinary Cllectin Actin (ECA): Actins taken by a hspital facility against an individual related t btaining payment f a bill fr care cvered under the hspital facility's FAP that requires a legal r judicial prcess, invlves selling an individual's debt t anther party, r invlves reprting adverse infrmatin abut an individual t cnsumer credit reprting agencies r credit bureaus (cllectively, "credit agencies"). Financial Assistance Plan (FAP): A written plicy that applies t all emergency and ther medically necessary care prvided by a hspital facility unless excluded in this plicy. The plicy des nt generally apply t physician services. Guarantr: The individual wh is respnsible fr payment f health care services. Husehld Incme: Any funds cming int the husehld frm immediate family members. This is nt limited t wages, but als includes scial security, unemplyment cmpensatin, disability benefits, incme frm investments, rental. Uninsured: A patient/guarantr wh has n level f insurance r third party assistance t prvide fr meeting payment bligatin fr health care services. 6

7 Underinsured: A patient/guarantr wh has sme level f insurance r third-party assistance but the remaining ut-f-pcket respnsibility exceeds their ability t pay withut creating an extreme financial hardship Please refer t ur separate, written billing and cllectins plicy fr prcedures and the actins that may take place in the event f nn-payment. See Patient Accunting IRS Regulatin # (r)(6), Extrardinary Cllectin Actins/ Ntificatin Prcess date 7