ARIA HEALTH SYSTEMS ADMINISTRATIVE POLICY

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1 ARIA HEALTH SYSTEMS ADMINISTRATIVE POLICY SUBJECT: Charity Care and Financial Assistance DATE: January 2011 Purpose Consistent with its Mission and Values, Aria Health considers each individual s ability to contribute to the cost of his or her care and is committed to treating patients with financial needs with the same dignity and consideration extended to all its patients. It is Aria Health s intention to establish a minimum standard to be applied in a consistent manner for the provision of free care or financial assistance. Only medically necessary health care is covered under these guidelines (e.g., patients receiving elective cosmetic surgery are not eligible for Charity Care or Financial Assistance). Only patients residing in the geographic service area of Aria Health s Frankford, Torresdale and Bucks County campuses are eligible for Charity Care and Financial Assistance (excepting patients presenting with emergent medical conditions and immediately ensuing admissions). Consistent with the Administrative policy on Medical Screening Examinations, Stabilizing Treatment and Appropriate Transfers, Aria Health will provide services to patients presenting with emergency medical conditions regardless of their ability to pay. Definitions Charity Care: Patients who are uninsured for the relevant, medically necessary service, who are ineligible for governmental or other insurance coverage, and who have family incomes not in excess of 200% of the Federal Poverty Level will be eligible to receive Charity (free) care. (See attached Schedule A). Charity Care patients will receive a 100% allowance of the charges (except for personal charges incurred by the patient such as telephone services, etc.) The patient will receive a bill showing the charges, the amount of the allowance (100% of the charges), and a zero balance due (unless there are personal charges). Uninsured: Patient that has no level of insurance or third party assistance. Underinsured: Patient has some level of insurance but has out of pocket expenses. Financial Assistance: Patients who are uninsured for the relevant service, who are ineligible for governmental or other insurance coverage, and who have family incomes in excess of 200%, but not exceeding 500%, of the Federal Poverty Level, will be eligible to receive Financial Assistance in the form of a partial allowance of charges. (See attached Schedule A). Patients extended a partial allowance must sign a written agreement to pay the amount of the charges remaining after deducting the allowance. The patient will receive a bill showing charges, the amount of the allowance and the amount due.

2 Procedures 1. Eligible Service: For purposes of this policy, the following healthcare services are eligible for charity: a. Emergency medical services provided in an emergency room setting. b. Services for conditions requiring immediate attention, or have been deemed emergent by the provider. c. Medically necessary services, evaluated on a case by case basis at Aria Health s discretion 2. Eligible Patient: a. Patients residing in the geographic service area of Aria Health s Frankford, Torresdale and Bucks County campuses. b. Patients that are uninsured, underinsured, ineligible for governmental or other insurance coverage and are unable to pay for their care. c. Charity Care determination will be based on an individual determination of financial need, and shall not take into consideration age, gender, race, social or immigrant status, sexual orientation or religious affiliation. Process 1. Aria Health shall assist its patients in obtaining health insurance coverage from privately and publicly funded (e.g. Medicaid, etc.) sources whenever appropriate. 2. The Patient Financial Services and Patient Access Departments shall implement written procedures and practices consistent with this Administrative Policy to identify uninsured self-pay patients, to assist those patients to obtain government-sponsored or other insurance coverage. 3. Patient Financial Services and/or Patient Access will determine eligibility for Charity Care and Financial Assistance for patients for whom insurance cannot be obtained or for those patients which are underinsured that have out-of-pocket expenses that exceed their financial abilities. 4. Patient Financial Services Representative will complete a review of the patient s outstanding accounts receivable for prior services rendered and the patient s payment history. 5. Patient will complete the Charity Care Application in its entirety and supply all relevant documents. 6. The Charity Care determination 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 one year prior, or at any time additional information relevant to the eligibility of the patient becomes known. 7. Patient will continue to be evaluated for possible coverage through privately and publicly funded sources.

3 8. Patients who do not provide the requested information necessary to completely and accurately assess their financial situation and/or who do not cooperate with efforts to secure governmental health care coverage will not be eligible for Charity care or Financial Assistance. 9. Applications outside of these guidelines may be approved based upon extraordinary circumstances with the documented approval of the Vice President of Finance and/or Chief Financial Officer. 10. Collection of amounts due from patients receiving Financial Assistance shall be handled pursuant to the Aria Health Policy on Collections. 11. Copies of this policy and instructions on how to apply or obtain further information are also available in English, Spanish and Russian and shall be posted on the Aria Health website and available in registration. 12. Aria Health s commitment to treating patients with financial needs with the same dignity and consideration extended to all its patients will be reflected in the application process. Charity Care applications will be processed promptly and Aria Health shall notify the patient or applicant in writing within 30 days of the receipt of a completed application. Presumptive Eligibility: There are instances when a patient may be eligible for charity care, but there is not a completed Charity Care application or supporting documentation. There may be adequate information provided by the patient or other sources. Aria Health could use outside agencies in determining estimate income amounts for the basis of determining charity care eligibility and potential discount amounts. Once determined, due to the inherent nature of the presumptive circumstances, the only discount that can be granted is a 100% write off of the account balances. Presumptive eligibility may be determined on the basis of individual life circumstances that may include: 1. State-funded prescription programs 2. Homeless or received care from a homeless clinic 3. Participation in Women, Infants and Children Programs (WIC) 4. Food stamp eligibility 5. Subsidized school lunch program eligibility 6. Eligibility for other state or local assistance programs that are unfunded (e.g., Medicaid spend-down) 7. Low income/subsidized housing is provided as a valid address 8. Patient is deceased with no known estate Key Contact: Director Business Services.

4 Today s Date ARIA HEALTH CHARITY CARE AND FINANCIAL ASSISTANCE APPLICATION Patient Name: Social Security #: Date of Birth: Address: City: State: Zip Code: Telephone #: Health Insurance Plan: Date(s) of Service: Gross Monthly Income: Self: $ Source(s): Spouse: $ Source(s): Other Household Members: $ Source(s): Other sources of income: $ Description: Number of Dependents in Household: (Including self) Are you currently employed? Yes / No If No what was your last date of employment? Present or Last Employer: Employer Address: Employer Phone #: I understand that by signing this document I am applying for Charity Care or Financial Assistance at Aria Health and agree to pay any balances not covered 100 % by Charity Care. I certify that the above information is true and accurate to the best of my knowledge. I also understand that Aria Health may verify the information I am providing. I will cooperate with this verification and provide all needed evidence to support the information I have declared on this application. Applicant s Signature: Date: Aria Health Representative : CONFIDENTIAL

5 ARIA HEALTH Policy # Charity Care and Financial Assistance February 1, 2012 Schedule A 2012 Federal Poverty Guidelines Aria Health Charity Care and Financial Assistance Household Income Limits All Patients Size of Family Unit 100% 75% 50% 25% 1 $22, $33, $44, $55, $30, $45, $60, $75, $38, $57, $76, $95, $46, $69, $92, $115, $54, $81, $108, $135, $61, $92, $123, $154, $69, $104, $139, $174, $77, $116, $155, $194, ADD $7,920 for each additional person Source: U.S. Department of Health and Human Services Health and Human Services update the poverty guidelines at least annually, adjusting them on the basis of the Consumer Price Index for All Urban Consumers (CPI-U). The poverty guidelines are used as an eligibility criterion for various Community Services and a number of other Federal programs. The poverty guidelines issued here are a simplified version of the poverty thresholds that the Census Bureau uses to prepare its estimates of the number of individuals and families in poverty. Feauthority of 42 U.S.C. 9902

6 Patient Name Social Security # Date of Birth ARIA HEALTH CHARITY CARE / FINANCIAL ASSISTANCE APPLICATION Description of Terms Address / City / State / Zip / Telephone # Health Insurance Plan Date(s) of Service Gross Monthly Income Self and Spouse Gross Month Income - Other Household Members Other sources of Income Number of Dependents in Household: Are you currently employed? Last date of employment? Current or Last Employer Employer Address / Phone number The name of the patient applying for financial assistance. If the patient is under the age of 18, then the name of the parent or guardian. The social security of the person applying for financial assistance. The month, day, and year of birth for the person applying for financial assistance. The address and telephone number of the person applying for financial assistance. If the patient has any type of health care coverage, provide the name of the insurance company. If the patient does not have health coverage, enter None. The date the patient came to the hospital and the date the patient is discharged from the hospital (if different.) Total income in one month before taxes and other deductions. This may include all sources of income such as wages, social security benefits, pensions, etc. This amount may be an average if the income varies month to month. Enter separately on each line the income of the person applying for financial assistance (self) and his/her spouse. If there are other members of the household for whom the person applying for financial assistance provides at least one-half of their annual living expenses, enter their income, if any. If the person applying for financial assistance has any other sources of income that were not included in the lines above, enter it here. (Examples: alimony, child support, and welfare benefits.) Include the person applying for financial assistance and all persons who occupy a housing unit with him/her and for whom he/she provides at least one half of their annual living expenses. Enter Yes if the person applying for financial assistance is currently employed, No if he/she is not. If the person applying for financial assistance is currently not employed, enter the last month and year at which time he/she was employed. The name of the company with whom the person applying for financial assistance is currently employed. Enter Self-employed if he/she owns his/her own business. Address of current or last employer.

II. Definitions: For the purpose of this policy, the terms below are defined as follows:

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