Williamson Medical Center Charitable Care, Prompt Payment, Uninsured/Underinsured Discount Policy

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1 Williamson Medical Center Charitable Care, Prompt Payment, Uninsured/Underinsured Discount Policy Effective January 1, Policy: Williamson Medical Center is committed to provide high quality patient care for services. This policy provides for treatment of uninsured and/or underinsured patients, who are non-elective and/or in a life-threatening condition or illness. Elective cases will be evaluated on a case-bycase basis. Williamson Medical Center has guidelines for providing relief for patients who do not have the ability to pay medical bills incurred at WMC. Charity is not considered to be a substitute for personal responsibility. Patients are expected to cooperate with WMC s procedures for obtaining charity or other forms of payment or financial assistance, and to contribute to the cost of their care based on their individual ability to pay. Patients will be required to assign or pay, to the Medical Center, all insurance payments or liability settlements designated as remuneration for medical expenses. Payments received on an account with a charity adjustment will be applied to the account and the adjustment reversed up to the amount of the charity adjustment. Credit reports will be pulled when it is necessary to substantiate data on file and will be considered in the approval process. WMC reserves the right to amend and/or update this policy at any time. 2. Definitions: Charity Care: Charity care results from a provider s policy to provide health care services free or at a discount to individuals who meet the established criteria. Family: A group of two or more people who reside together and who are related by birth, marriage, or adoption. According to the Internal Revenue Service rules, if the patient claims someone as a dependent on their income tax return, they may be considered a dependent for the purposes of the provision of financial assistance. Family Income: Family Income is determined using the following 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; Non-cash benefits (such as food stamps and housing subsidies) do not count; Determined on a before-tax basis; Excludes capital gains or losses; Non-relatives, such as housemates, do not count; Self-employed applicants income will be calculated using the most recent federal income tax return. Uninsured: The patient has no level of insurance or third party assistance to assist with meeting his/her payment obligations. Underinsured: The patient has some level of insurance or third party assistance but still has out-of-pocket expenses that exceed his/her financial abilities. 3. Procedures: A. Services Eligible Under this Policy: Emergency medical services provided in an emergency room setting; Services for a condition, which, if not promptly treated, would lead to an adverse change in the health status of an individual; Non-elective services provided in response to life-threatening circumstances in a nonemergency room setting; Medically necessary services.

2 B. Eligibility for Charity: Eligibility for charity will be considered for any U.S. citizen or legal immigrant (in the event citizenship or immigration status cannot be determined based on the application, the applicant will be asked to provide information to prove citizenship and/or immigration status) with active accounts at WMC 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 charity shall be based on an individualized determination of financial need, and shall not take into account, age, gender, race, social status, sexual orientation, or religious affiliation. C. Determination of Financial Need: 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 guarantors 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 publicly available data sources that provide information on a patient s or a guarantor s ability to pay (such as credit reports); Include reasonable efforts by WMC to explore appropriate alternative sources of payment and coverage from public and private sources and to assist patient to apply for such programs; Take into account the patient's available assets. It is preferred but not required that a request for charity and a determination of need occur prior to rendering of services. However, the determination may be done at any point in the collection cycle. The need for payment assistance shall be re-evaluated every 6 months, meaning that accounts occurring within 6 months of a previous approval may be added to the previous approval. WMC reserves the right to require a new application within the 6-month period of a patient s financial situation appears to, or has been suspected to change. WMC shall process requests for financial assistance promptly and will notify the applicant upon their determination. If an applicant returns an incomplete application, WMC will contact the patient to notify them of the need for additional information, and the patient will have 20 days to return the required information to WMC. Failure to do so will result in a denial of the application. WMC understands that a patient s financial situation may change during the course of an account; therefore, WMC reserves the right to re-evaluate previous financial aid approvals based on more current information. The re-evaluations will be handled on a case-by-case basis. D. Patient Charity Guidelines: Services eligible under this Policy will be made available to the patient on a sliding fee scale, in accordance with financial need, as determined in reference to Federal Poverty Levels (FPL) in effect at the time of the determination, as follows: Charity Care Guidelines Family Size 100% 150% 175% 200% 250% 1 $0 - $11,670 $11,671 - $17,505 $17,506 - $20,423 $20,424 - $23,340 $23,341 - $29,175 2 $0 - $15,730 $15,731 - $23,595 $23,596 - $27,528 $27,529 - $31,460 $31,461 - $39,325 3 $0 - $19,790 $19,791 - $29,685 $29,686 - $34,633 $34,634 - $39,580 $39,581 - $49,475 4 $0 - $23,850 $23,851 - $35,775 $35,776 - $41,738 $41,739 - $47,700 $47,701 - $59,625 5 $0 - $27,911 - $41,866 - $48,844 - $55,821 -

3 $27,910 $41,865 $48,843 $55,820 $69,775 6 $0 - $31,970 $31,971 - $47,955 $47,956 - $55,948 $55,949 - $63,940 $63,941 - $79,925 7 $0 - $36,030 $36,031 - $54,045 $54,046 - $63,053 $63,054 - $72,060 $72,061 - $90,075 8 $0 - $40,090 $40,091 - $60,135 $60,136 - $70,158 $70,159 - $81,180 $80,181 - $100,225 For each additional person add $4, Discount Inpatient or Outpatient 100% 90% 80% 70% 60% E. Appeals Procedure: If an applicant is denied, the applicant may appeal the denial, in writing, within 30 days of the denial date. Once a written appeal is received, the application will be re-evaluated by a Financial Counselor and their direct supervisor. A written response to the denial will be provided to the patient and will indicate either approval or the upholding of the denial. F. Deceased Patients and Estates: If WMC finds that a patient is deceased, they will follow applicable laws for the handling of the deceased patient s account. If WMC s research finds that the patient has no estate, or that the time to file on the estate has passed, WMC will adjust the account as an indigent estate and documentation will be maintained (hard copy if available, or notes in system if hard copy is not available) to verify the adjustment(s) made. G. Communication of the Charity Program to Patients and the Public: Notification about charity available from WMC shall be disseminated by various means, which may include, but are not limited to, the publication of notices on patient bills and by posting notices in emergency rooms, urgent care centers, admitting and registration departments, business offices, and patient financial services offices that are located on facility campuses, and at other public places as WMC may elect. Referral of patients for charity may be made by any member of the WMC staff or medical staff, including physicians, nurses, financial counselors, social workers, case managers, chaplains, etc. H. Catastrophic Medical Event: A major catastrophic health care event is defined as un-reimbursed medical expenses incurred at WMC during a one year period (using a rolling 12 month calendar) that exceed the annual household income of the patient or responsible party. Assistance under this policy is not available for elective services that are not medically necessary. Partial payment of the total outstanding balance is required as follows: Income Level Household Up to $50,000 annually Payment Required 15% of gross annual income $50,001 - $75,000 annually 20% of gross annual income $75,001 - $100,000 annually 25% of gross annual income Over $100,000 annually 30% of gross annual income Note: These limitations are applicable to each date of service for each admission or procedures.

4 PAYMENT PLAN: The following guidelines are to be used when a customer requests to set up a payment plan: WMC Payment Plan $ 0 - $50 Payment in full $ 51-$100 Payment in full within 2 months $101-$300 Payment in full within 4 months $301-$500 Payment in full within 6 months $501-$1000 Payment in full within 9 months $1001-$3000 Payment in full within 18 months $3001-$5000 Payment in full within 24 months $5001+ Payment amount approved by Supervisor/Director Note: In the event that collection efforts are unsuccessful, a collection agency may be utilized to assist in the collection of any patient or guarantor responsible balance. Uninsured/Self-Pay Discount: In accordance with TCA , Williamson Medical Center is prohibited from requiring an uninsured patient to pay for services in an amount that exceeds one hundred seventy-five percent (175%) of the cost of services provided. UNINSURED patients will not be charged more than one hundred seventy-five percent (175%) of the cost for services provided. Therefore, each self-pay patient will be given an automatic 40% discount. Periodic internal audits will be conducted within the Finance Department of Williamson Medical Center to ensure that WMC is in compliance with TCA Prompt Payment Discounts: Patients, during normal contact with WMC personnel, will be offered a 10% discount for paying their identified portion of the bill in full prior to or at the time of service. Any discounts or adjustments outside of this policy must be approved based on WMC policy. Effective Date: January 1, 2013 Instructions to determine eligibility for reduced payments or financial assistance To determine if you are eligible for reduced payments or financial assistance, you must complete the financial assistance application listed below and return it along with the following information: Attach copies of any income received within the household. This would consist of two most recent pay stubs, two most recent and consecutive bank statements, social security checks, pension funds, support payments, etc. List amounts in checking, savings and CD accounts, IRAs, stocks and bonds.

5 REQUEST FOR FINANCIAL ASSISTANCE I hereby request that Williamson Medical Center, make a written determination of my eligibility for financial assistance for services rendered. I understand that the information that I submit is subject to verification by Williamson Medical Center. I also understand that if the information that I submit is determined to be false, that my request for financial assistance will be denied and the charges for services rendered will be my full responsibility. 1. FULL NAME: 2. ADDRESS: CITY: ZIP: 3. PHONE NO: SOCIAL SECURITY NO: 4. MARITAL STATUS (please check the appropriate box) Married Divorced Single Widow/Widower Legally Separated* 5. APPLICANT S EMPLOYMENT STATUS (please check the appropriate box) Employed Full Time Employed Part Time Retired Disabled Not Employed 6. EMPLOYER: YEARS EMP: (If less than 1 year, please list previous employer and employment dates below) PREVIOUS EMPLOYER: DATES: 7. SPOUSE S EMPLOYMENT STATUS (please check the appropriate box) Employed Full Time Employed Part Time Retire Disabled Not Employed 8. SPOUSE S EMPLOYER: YEARS EMP: (If less than 1 year, please list previous employer and employment dates below) PREVIOUS EMPLOYER: DATES: 9. INSURANCE COMPANY NAME: 10. ARE ANY ACCOUNTS THE RESULT OF AN ACCIDENT THAT MAY BE COVERED BY AUTO INSURANCE, WORKER S COMPENSATION, OR LIABILITY? (If the answer is YES, you must contact our office so we can file the insurance before those accounts can be considered for Financial Assistance.) 11. ARE YOU A US CITIZEN OR LEGAL IMMIGRANT? YES NO (Documentation required to show proof of Legal Immigrant Status) 12. FAMILY INFORMATION: List all dependents including yourself that live in your household. NAME DATE OF BIRTH RELATION AGE A) B)

6 C) D) E) F) 13. INCOME: Check all that apply and include the monthly amount. PROOF OF INCOME IS REQUIRED see attached page for acceptable proof of income. Source Amount Source Amount Wage SocialSecurity $ Unemployment $ Pension $ $ Alimony/ChildSupport$ Food Stamps $ Rental Income $ Other (please explain) $ 14. ASSETS: Please list all that apply for the entire household. Liquid Assets Checking Account Balance(s) $ Savings Savings Account Balance(s) $ CD s/bonds/stocks/ira s, etc (total balances) $ Auto/Truck Assets Make/Model/Year Make/Model/Year Home (residence) Fair Market Value $ Other Property: (vacation, rental, etc) Fair Market Value$ Estimated Value$ Estimated Value$ Property Assets Loan Balance$ Loan Balance$ Mortgage Balance $ MortgageBalance$ Other Assets Other (ATV s, Boats, Motorcycles, etc) (list approximate value) $ 15. EXPENSES: Please list the monthly amounts below. Please also list, on the back of the application, any other household or medical expenses. You may use a separate sheet of paper if necessary. Rent/Mortgage $ Phone/Cable $ Credit Cards $ Utilities (gas, electric, water, etc) $ Insurance(auto, home, life, medical, etc) $ Other (please explain) $ Auto Loan Payments $ Other Loan Payments $ Alimony/Child Support $_ If all information requested is not accurate or included, your application will be denied. I hereby do affirm that the information contained in this application is accurate and I authorize Williamson Medical Center to use information on my credit report in their process of determining my eligibility for their Financial Assistance Program. SIGNATURE DATE

7 Proof of Residency Requirements: Please provide proof of your address (a copy of your Driver s License, other form of ID, check stub, bank statement, utility bill, etc) Proof of Income Requirements: MAKE SURE THE FOLLOWING PROOF OF INCOME/ASSETS THAT APPLY TO YOU AND SPOUSE (IF APPLICABLE) IS PROVIDED OR YOUR APPLICATION WILL BE DENIED. *IF YOU ARE LEGALLY SEPARATED PLEASE SEND A COPY OF THE COURT DOCUMENTS AS PROOF OF LEGAL SEPARATION. For those who draw Social Security: A copy of SS check or a copy of your 2 most recent and consecutive bank statements that show name of the bank, you and/or spouse s name and amount of check(s) that is/are direct deposited. The 1099 form from the Social Security department, or the letter from Social Security showing how much you will be drawing for this year. If you draw retirement, a copy of your retirement check or your 2 most recent and consecutive bank statements if direct deposited. If you are employed, a copy of your W2, or a copy of the previous year s tax return. If you are applying in the month of June or after, a copy of your 2 most recent and consecutive check stubs showing Year to Date income. If you receive child support or alimony, a copy of the court order showing how much you receive and if it is weekly, monthly, etc., or a copy of the check you receive, also stating if you receive weekly, monthly, etc. If you have no income, a Notarized letter from whomever is helping you with food and or shelter and which also states that you are unemployed and proof of food stamps or any other government support if applicable. (If you have had any income for the year, you must also provide proof of that income.) If you have been laid off from work, you must show date laid off and when you started receiving unemployment checks and a copy of how much you receive. You may also provide a copy of a If you are on Worker s Compensation, you must provide proof of approval or denial of worker s compensation benefits (a copy of the approval/denial forms, a copy of the check, etc) If you are self employed, you must submit a copy of your tax return for the previous year. If you receive Food Stamps or other governmental support, you must provide proof of the amount (a copy from the Dept of Human Services, a copy of your approval letter, etc) Proof of Assets Requirements: A copy of the 2 most recent bank statements are required for all applicants. Please attach copies of any bank statements, certificates of deposit, IRAs, stocks, bonds or other form of liquid assets listed on your application. If you do not send in proof of all income listed and all other requested information, you will be denied financial assistance. If you have any questions please call (615) and ask to speak with a Financial Counselor.