EL CAMINO HOSPITAL ADMINISTRATIVE POLICIES AND PROCEDURES

Transcription

1 EL CAMINO HOSPITAL ADMINISTRATIVE POLICIES AND PROCEDURES CHARITY CARE POLICY A. Coverage This policy applies to patients who have healthcare needs and are uninsured, ineligible for a government program, or otherwise unable to pay for medically necessary care based on their individual financial situation. B. Reviewed/Revised 4/00, 7/03, 6/04, 1/07, 6/07, 4/08, 06/09, 02/11, 12/11, 10/12, 6/13 C. References Patient Protection and Affordable Care Act of 2010 and California AB 774. In accordance with regulations proposed by the Internal Revenue Service pursuant to the Patient Protection and Affordable Care Act, and by the State of California pursuant to AB 774, this policy sets forth (1) the eligibility criteria for financial assistance and (2) the basis for calculating amounts charged to patients who are eligible for financial assistance. In addition, the policy provides information on how members of the public can readily obtain information on (a) the method of applying for financial assistance and (b) measures used to widely publicize the financial assistance policy. D. Policy Summary El Camino Hospital (ECH) is committed to providing financial assistance (also known as charity) to persons who have healthcare needs and are uninsured, ineligible for a government program, or otherwise unable to pay for medically necessary care based on their individual financial situation. Consistent with its mission, ECH strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. ECH s financial assistance programs are not substitutes for personal responsibility. Patients are expected to cooperate with ECH s procedures for obtaining financial assistance and to contribute to the cost of their care based on their ability to pay. In order to manage its resources responsibly and to allow ECH to provide the appropriate level of assistance to the greatest number of persons in need, the Board of Directors establishes these guidelines for the provision of charity care.

2 Page 2 of 9 E. Definitions For the purpose of this policy, the terms below are defined as follows: Charity Care: All discounts provided under this Board-approved policy are based on financial need. As such, they are to be recorded as Charity Care in the hospital s financial statements. Discretionary Assets: The fair market value of the family s savings and investments, excluding amounts held in bona-fide retirement plans. Eligible Services: The following services are ineligible for the application of Financial Assistance under this policy, except as required by law: Purchases from ECH retail operations, such as gift shops & cafeteria; Bariatric surgery services; Cosmetic surgery; and Any products or services that are: Inconsistent with the symptom(s) or diagnosis and treatment of the condition, disease or injury. Primarily for the convenience of the patient, the patient s family, the physician or other provider. Not the most appropriate level of services that can safely be provided to the patient. Services which are programmatically bundled and discounted. Some examples of these bundled services include packages for cosmetic and bariatric surgery. Excluding any services specifically listed as ineligible, the following healthcare services are eligible for ECH s financial assistance program: Emergency medical services provided in an emergency room setting; Services for a condition which, in the opinion of the treating physician or other health care professional, would lead to an adverse change in the health status of an individual if not treated promptly; and Non-elective services provided in response to life-threatening or health-threatening circumstances. In addition, in its sole discretion, ECH management may elect to make other services eligible for Financial Assistance. Family: Using the Census Bureau definition, a family is group of two or more people who reside together and who are related by birth, marriage, or adoption. For purposes of this policy, independence is evidenced by living away from home and being married, in the military, or meeting any of the other conditions for independence as defined in Free Application for Federal Student Aid (FASFA) which is available at Family Income: Family Income is determined using the Census Bureau definition, which uses the following income when computing federal poverty

3 Page 3 of 9 guidelines: Includes earnings, unemployment compensation, workers compensation, Social Security, Supplemental Security Income, public assistance, veterans payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources; Noncash benefits (such as food stamps and housing subsidies) do not count; Determined on a before-tax basis; Excludes capital gains or losses; and If a person lives with a family, includes the income of all family members. (The income of non-relatives, such as housemates, does not count.) Medical Indigence / Catastrophic Illness: In order to help ensure that medical costs are manageable and consistent with the requirements of California AB 774, ECH will provide financial assistance for a patient with high medical costs, which for purposes of this policy means a person whose family income does not exceed 350 percent of the federal poverty level and: 1) Has annual out-of-pocket costs incurred by the individual at the hospital that exceeded 10 percent of the patient s family income in the prior 12 months; or 2) has annual out-of-pocket expenses that exceed 10 percent of the patient s family income, if the patient provides documentation of the patient s medical expenses paid by the patient of the patient s family in the prior 12 month s; or 3) A lower level determined by the hospital in accordance with the hospital s charity care policy. ECH management shall ensure observance of this requirement of California AB 774 through the establishment of a maximum out-of-pocket amount, based on a sliding scale percentage of income and subject to a maximum income limitation. ECH may, on a case by case basis, provide financial assistance to individuals whose family income exceeds the normal limits as described herein, yet the family is unable to meet its financial obligations for medical care, as noted in the Exceptions and Limitations provision of this policy. Minimum Uninsured Charity Discount: All persons who are uninsured shall have their bills discounted by no less than a minimum uninsured charity discount, without regard to their discretionary assets. ECH management shall establish its minimum uninsured discount at the beginning of every fiscal year, which shall be no less than (but may exceed) the discount level required under federal or state law. A person who has insurance but

4 Page 4 of 9 choose not to use it is not considered uninsured under this policy. Out-of-network: Certain insurance carriers and governmental health care programs may reduce or eliminate benefits unless care is provided at designated facilities. In cases where ECH is not one of the designated facilities, any non-emergency care provided is considered to be out-ofnetwork. Out-of-network care will not be eligible for charity discounts except that ECH may, on a case-by-case basis, grant assistance in the case of medical indigence. Uninsured: The patient has no level of insurance or third party assistance to assist with meeting his/her payment obligations. A patient who has insurance or third party assistance to provide medical services but whose insurance or assistance does not include services provided at ECH will be considered as out-of-network, not as uninsured. Underinsured: A patient is underinsured if the patient has some level of insurance or third-party assistance but still has out-of-pocket expenses that exceed his/her financial abilities. A patient who has insurance or third party assistance to provide medical services but whose insurance or assistance does not include services provided at ECH will be considered as out-of-network, not as underinsured. F. Uninsured Charity Discount Program Information in this section applies to the provision of charity discounts when a patient has no health insurance or coverage by a governmental program. 1. Eligibility Criteria for Uninsured Charity Discounts. Eligibility for uninsured charity discounts will be considered for those individuals who are uninsured and ineligible for any government health care benefit program. The granting of uninsured charity discounts shall be based on an individualized determination of insured status, and shall not take into account age, gender, race, social or immigrant status, sexual orientation or religious affiliation. Although many insurance carriers contractually prohibited ECH from providing discounts for deductibles, co-insurance, or other patient payment responsibilities in a programmatic fashion, ECH may consider providing such discounts on a case-by-case basis upon receipt of documentation setting forth unusual hardship and circumstances. Any such determination is solely at the discretion of ECH. 2. Determination of Eligibility for Uninsured Charity Discounts. The cooperation of the patient and/or the patient s family is generally necessary in order for ECH to determine eligibility. a) Eligibility will be determined in accordance with procedures that involve an individual assessment of insured status and may:

5 Page 5 of 9 Include an application process, in which the patient or the patient s guarantor are required to cooperate and supply documentation relevant to making a determination of the patient s insured status; Include the use of external data sources that provide information on a patient s insured status; Include reasonable efforts by ECH to explore appropriate alternative sources of payment and coverage from public and private payment programs, and to assist patients to apply for such programs; and Include a review of the patient s outstanding accounts receivable for prior services rendered and the patient s previous insured status. b) Eligibility determination may be done at any point in the collection cycle. The eligibility for the uninsured charity discount shall be based on the patient s insured status at the time services are rendered, and shall give consideration to any retroactive denial or granting of insurance. That is, if the patient is believed to be insured at the time services are rendered but is subsequently found to have been uninsured at that time, then the patient is eligible for an uninsured charity discount. Similarly, if the patient is believed to be uninsured at the time services are rendered but is subsequently found to have been insured at that time, then the patient is not eligible for an uninsured charity discount. Discounts which are found to have been provided inappropriately will be reversed. c) If at any time information relevant to the eligibility of the patient changes, it is the patient s responsibility to notify ECH of the updated information. d) ECH s values of respect and integrity shall be reflected in the application process, eligibility determination and granting of an uninsured discount. Requests for uninsured charity discounts shall be processed promptly and ECH shall notify the patient or applicant in writing of its decision on a completed application. Such notice may be in the form of a statement which shows the discount applied to the patient s account. G. Financial Assistance Program Information in this section applies to the provision of charity discounts based on financial need, irrespective of coverage by insurance. 1. Eligibility Criteria for Financial Assistance. Eligibility for financial assistance will be considered for those individuals who are uninsured, underinsured, ineligible for any government health care benefit program, and who are unable to pay for their care, based upon a determination of financial need in accordance with this policy. The granting of financial assistance shall be based on an individualized determination of financial need, and shall not take into account age, gender, race, social or immigrant status, sexual orientation or religious affiliation. Although many insurance carriers

6 Page 6 of 9 contractually prohibited ECH from providing discounts for deductibles, coinsurance, or other patient payment responsibilities in a programmatic fashion, ECH may consider providing such discounts on a case-by-case basis, upon receipt of documentation setting forth unusual hardship and circumstances. Any such determination is solely at the discretion of ECH. 2. Determination of Eligibility for Financial Assistance. The assistance and cooperation of the patient is ordinarily necessary in order for ECH to determine financial need. a) Financial need will be determined in accordance with procedures that involve an individual assessment of financial need and may: Include an application process, in which the patient or the patient s guarantor are required to cooperate and supply personal, financial and other information and documentation relevant to making a determination of financial need; Include the use of external data sources that provide information on a patient s or a patient s guarantor s ability to pay, such as credit scoring; Include reasonable efforts by ECH to explore appropriate alternative sources of payment and coverage from public and private payment programs, and to assist patients to apply for such programs; Take into account the patient s available assets; and Include a review of the patient s outstanding accounts receivable for prior services rendered, and the patient s payment history. b) The determination of financial need shall be done consistently with the requirements of California AB 774, including the requirement that the first ten thousand dollars ($10,000 of a patient s monetary assets shall not be counted in determining eligibility, nor shall 50 percent of a patient s monetary assets over the first ten thousand dollars ($10,000) be counted in determining eligibility. ECH management shall ensure observance of this requirement of California AB 774 through the establishment of a sliding scale percentage of assets which will be counted in determining eligibility. c) The determination of financial need may be done at any point in the collection cycle. The need for payment assistance shall be re-evaluated at each subsequent time of services if the last financial evaluation was completed more than six months prior, or at any time additional information relevant to the eligibility of the patient becomes known. It such information does change, it is the patient s responsibility to notify ECH of the updated information. d) An application for financial assistance, or additional information provided in support of such application, will be considered at any point in the collection cycle, so there is no deadline after which consideration will not be provided. However, there is a completion deadline after which an account

7 Page 7 of 9 may be referred for additional collection action, as provided for in the ECH billings and collections policies. e) ECH s values of respect and integrity shall be reflected in the application process, financial need determination and granting of financial assistance. Requests for financial assistance shall be processed promptly and ECH shall notify the patient or applicant in writing of its decision on a completed application. Such notice may be in the form of a billing statement which shows the amount of financial assistance applied to the patient s account(s). 3. Presumptive Financial Assistance Eligibility. ECH may use outside agencies in determining estimated income amounts for the basis of determining financial assistance eligibility and potential discount amounts. Presumptive eligibility may be determined on the basis of individual life circumstances that may include: State-funded prescription programs; Homelessness or received care from a homeless clinic; Participation in Women, Infants and Children programs (WIC); Food stamp eligibility; Subsidized school lunch program eligibility; Eligibility for other state or local assistance programs that are unfunded (e.g., Medicaid spend-down); Low income/subsidized housing is provided as a valid address; Patient is deceased with no known estate. 4. Patient Financial Assistance Guidelines. Services eligible for financial assistance under this Policy will be made available to the patient in accordance with financial need, as determined in reference to Federal Poverty Levels in effect at the time of the determination and such other factors are as determined under ECH s policies and procedures, as follows: a. The minimum uninsured discount is calculated, and b. Financial assistance is calculated, as shown in ECH Patient Financial Services Financial Assistance Procedure. c. The patient is granted the larger of the discount amounts. H. Other Provisions 1. Communication of this Policy to Patients and the Public. Notification about financial assistance available from ECH, which shall include a contact number, shall be disseminated by ECH by various means, which may include, but are not limited to, the publication of notices on facility websites or on patient bills, and by posting notices in the emergency room, admitting and registration departments, hospital business offices, and patient financial services offices that are located on facility campuses, and at other public places as ECH may elect. Such information shall be provided in the primary languages spoken by the population serviced by ECH. Referral of patients for financial assistance may be made by anyone, subject to applicable privacy laws.

8 Page 8 of 9 2. Relationship to Collection Policies. ECH management shall develop policies and procedures for internal and external collection practices that take into account the extent to which the patient qualifies for financial assistance, a patient s good faith effort to apply for a governmental program or for financial assistance from ECH, a patient s good faith effort to comply with his or her payment agreements with ECH, and all applicable laws and regulations. For patients who qualify for financial assistance and who are cooperating in good faith to resolve their hospital bills, ECH may offer extended payment plans to eligible patients, will not impose wage garnishments or liens on primary residences, and will not send unpaid bills to outside collection agencies. Any agency performing routine monitoring and follow-up for such accounts on ECH s behalf shall be instructed not to report such accounts to any credit monitoring agency, and shall not be considered to be an outside collection agency under this policy. In the event ECH should err in following these policies, ECH will take appropriate steps to correct its error in a timely fashion. 3. Errors and Misrepresentations. ECH may deny an application for Financial Assistance and/or may reverse previously applied discounts if it learns of information which it believes supports a conclusion that information previously provided was inaccurate. In addition, ECH may elect to pursue legal actions, including criminal charges, against persons who it believes knowingly misrepresented their financial condition, including those who accept financial assistance after an improvement in their financial circumstances which was not made known to ECH. 4. Regulatory Requirements. In implementing this Policy, ECH shall comply with all federal, state, and local laws, rules, and regulations that may apply to activities conducted pursuant to this Policy. I. Exceptions and Limitations The Chief Executive Officer and Chief Financial Officer of ECH are each granted the authority to provide exceptions to these policies and procedures as appropriate to the individual patient s circumstances and as appropriate to the financial ability and needs of ECH. These individuals are also each granted the authority to adjust the parameters of the financial assistance program in order to ensure the total amount of financial assistance provided is consistent with the organization s financial ability and to ensure the facility is able to meet its financial obligations. This policy is intended to be a statement of general intent, setting forth the basic principles to be followed by the organization in administration of its programs to provide charity care to its patients. However, because the complexities of human existence can present myriad possible individual

9 Page 9 of 9 circumstances, and because of the challenges present in managing a health care organization, it is recognized that some degree of flexibility is appropriate in administering these programs. As such, nothing in this policy shall be construed to create an affirmative obligation for ECH to grant financial assistance to any particular patient, other than as required under the law.