Policy Number 245: Financial Assistance Policy PURPOSE:

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1 Policy Number 245: Financial Assistance Policy PURPOSE: UVA Culpeper Hospital s mission is to help people achieve and maintain optimal health by providing the best possible healthcare services. We always make the needs of our patients our top priority. Financial Assistance policies have been created to facilitate access to care based on county of residence, need and ability to pay. UVA Culpeper Hospital strives to ensure that an individual's financial capacity does not prevent them from seeking or receiving care. UVA Culpeper Hospital will provide, without discrimination, care of emergency medical conditions to individuals regardless of their eligibility for financial or government assistance. POLICY: Emergency Medical Care: UVA Culpeper Hospital will provide treatment services for all emergency medical conditions without regard to ability to pay. Payment is due after the service is rendered and UVA Culpeper Hospital will assist the patient in applying for uncompensated care (charity) and any other funding sources that may be available for which they may qualify. Pre-screening for charity care eligibility may be conducted at pre-admission or point-of-service for all private-pay accounts that cannot meet the deposit requirements. Eligibility Criteria: All patients of UVA Culpeper Hospital receiving inpatient or outpatient services, including freestanding facilities operating under the UVA Culpeper Hospital license, are eligible to apply for financial assistance. This policy does not cover elective services. Patients are expected to cooperate with UVA Culpeper Hospital 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. Individuals with the financial capacity to purchase health insurance shall be encouraged to do so, as a means of assuring access to health care services, for their overall personal health, and for the protection of their individual assets. In order to manage its resources responsibly and to allow UVA Culpeper Hospital to provide the appropriate level of assistance to the greatest number of persons in need, UVA Culpeper Hospital provides charity and/or free care for patients whose annual household income falls at or below two hundred (200 percent) of the poverty level, as defined by the Federal Poverty Guidelines, and have no other sources of payment. Reduced fee services are provided to

2 self-pay patients (having no other insurance) whose resources and income are under 200 percent. Refer to supplemental table for current year rates. UVA Culpeper Hospital Guidelines for Medically Indigent Patients Annual Income Ranges for Fical Year 2016 July 1, 2015 to June 30, 2016 Payscale 1 Payscale 2 Payscale 3 Payscale 4 Payscale 5 Payscale 7 NO.OF 0% CO-PAY 5% CO-PAY 20% CO-PAY 45% CO-PAY 70% CO-PAY 100% CO-PAY DEPENDENTS RANGE RANGE RANGE RANGE RANGE RANGE OVER OVER OVER OVER OVER OVER OVER OVER FOR EACH ADDITIONAL DEPENDENT IN THE 0%, 5%, 20%, 45%, AND 70% COPAY RANGES ADD: 4,160 4,576 5,547 6,933 8,320 THE "MEDICALLY INDIGENT" PATIENT MAY BE RESPONSIBLE FOR A PORTION OF THE CHARGES RELATED TO THE SERVICES RENDERED BASED ON HIS INCOME AND AMOUNT DUE WITH THE FOLLOWING PERCENTAGES AND AMOUNTS: TOWARD BASIC OR ROUTINE MEDICAL EXPENSES 0% 5% 20% 45% 70% 100% THE MEDICALLY INDIGENT PATIENT WILL BE RESPONSIBLE FOR A CO-PAYMENT AMOUNT WHICH IS THE LESSER OF THE BELOW CO-PAYMENT AMOUNT, OR THE AMOUNT REMAINING AFTER APPLICATION OF THEIR RESPECTIVE ADJUSTMENT PERCENTAGE MAXIMUM CO-PAYMENTS DUE FROM MEDICALLY INDIGENT PATIENTS: 2,589 3,139 3,923 4,708 Patients who have no insurance coverage will automatically receive a 20 percent discount at the time of service. This discount is granted prior to any payment arrangements and/or financial assistance you may be qualified to receive. Uninsured patients who pay their account in full within 30 days of the date listed on the initial statement will qualify for an additional 15 percent discount. Financial counselors will make every effort to personally visit uninsured patients upon their admission to determine Federal / State financial assistance. Additional outreach will be made by written and telephone communication to outpatients whose balance meet the minimum threshold. In addition, financial counseling services will be available to all patients Monday through Friday from 8 a.m. to 5 p.m. Financial counseling staff will assist patients and prospective patients in determining whether they qualify for financial assistance from the hospital or from outside sources. Financial counselors are fully trained in hospital financial policies. Periodic audits will be conducted to ensure financial counselors and other authorized hospital management and staff are appropriately administering discounts consistent with this policy.

3 Contract Accounts Patients who cannot afford to pay the entire balance upon receipt of a bill may establish an interest free monthly payment plan. The patient must pay five percent (5%) of the total balance (the balance of all outstanding accounts combined) or twenty-five dollars ($25), whichever is greater. In circumstances where the patient is unable to pay, the Revenue Cycle Director will have the authority to reduce the patient s monthly payment to four percent (4%) of the total account(s) balance. In no circumstances should monthly payment amounts be less than four percent (4%) of the total balance unless approved by the Chief Financial Officer. No interest will be charged the patient, provided the patient continues to meet the minimum monthly payment requirements. If monthly payments are not made consistent with this policy, the account will age consistent with hospital bad debt policy. Method by Which Patients may apply for Financial Assistance 1. 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 publically available 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 UVA Culpeper Hospital 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 all other financial resources available to the patient; and - Include a review of the patient s outstanding accounts receivable for prior services rendered and the patient s payment history. 2. It is preferred but not required that a request for charity and a determination of financial need occur prior to rendering of non-emergent medically necessary services. However, the determination may be done at any point in the collection cycle. The need for financial assistance shall be re-evaluated at each subsequent time of service if the last financial evaluation was completed more than a year prior, or at any time additional information relevant to the eligibility of the patient for charity becomes known. Income Verification Requirements In order to determine a patient s eligibility for charity care and/or the self-pay discount, UVA Culpeper Hospital will need to verify household income for the applicant. Charity care and discounts will not be

4 applied until all applicable income documentation is received from the patient based upon forms required by the hospital. The following information may be required; 1. Most recent pay stub from employer (within one month from date of request) for all members of the household who are employed 2. W-2 or copy of Federal tax filing from most recent tax year for all members of the household 3. Valid phone numbers for all employers for all members of household who are employed 4. Child support documentation 5. Unemployment benefits verification for all members of household who are unemployed 6. Passive income from trust funds, real estate holdings and other income producing assets. To the extent non-reported income is discovered by the Hospital or later disclosed by the patient, previously applied discounts may be revoked by the Hospital. The main criteria used in determining applicable discount levels will be annual household income as of the date services were rendered. However, real estate holdings, trusts and other passive income will also be considered in determining eligibility for discounts. To the extent income levels reported by patients are not consistent with Federal tax filings, employers for all household members will be contacted. Additional information may be required on a case-by-case basis. Collection Practices: UVA Culpeper Hospital management shall develop policies and procedures for internal and external collection practices (including actions the hospital may take in the event of non-payment, including collections action and reporting to credit agencies) that take into account the extent to which the patient qualifies for charity care or discounted care; a patient s good faith efforts to apply for governmental assistance programs or financial assistance from UVA Culpeper Hospital, and a patient s good faith effort to comply with his or her payment agreements with UVA Culpeper Hospital. UVA Culpeper Hospital will not impose extraordinary collections actions such as lawsuits, wage garnishments, arrests, body attachments, liens on residences or other similar legal actions against any patient without first making reasonable efforts to determine whether that patient is eligible for financial assistance under this financial assistance policy. Reasonable efforts include notifications by the hospital of this financial assistance policy upon admission and in written and oral communications with the patient regarding the patient s bill, including invoices and telephone calls before collection action or reporting to credit agencies is initiated. Bad Debt Once an account has been processed through the routine collection channels internally, it may be assigned to an attorney or collection agency for collection. Although the age will vary somewhat from

5 account to account due to the various elements contained in the patient billing file, the average period of time for in-house follow-up is not less than one-hundred twenty (120) days. In accordance with State and Federal Law, UVA Culpeper Hospital reserves the right to bill the customer for interest, late fees, finance fees and collection costs as they apply. Collection Agency Requirements All contracted collection agencies will receive a copy of the hospital s financial assistance policy and will be expected to follow the same guiding principles as the hospital s policy. All collection agencies will be expected to treat UVA Culpeper Hospital patients with courtesy, dignity and respect. UVA Culpeper Hospital management will approve all routine collection agency correspondence (form letters and telephone scripts) utilized by collection agencies to collect debts from hospital patients. Once an account has been sent to the agency and remains unpaid for a 90-day period after initial transfer, the account will be reported to the Credit Bureau. Accessibility of Financial Assistance Policy: UVA Culpeper Hospital will widely publicize this policy within the community served by the hospital. The hospital will notify all patients of this policy upon admission to the hospital. Signs will be posted strategically throughout the hospital (including all outpatient, ancillary and emergency department registration booths), which indicate the availability of financial counseling. Notifications regarding this policy and summary information shall be provided in both English and Spanish, the primary languages spoken by the population serviced by UVA Culpeper Hospital. The policy is published on the hospital s web site: Patients can also visit the UVA Culpeper Hospital Financial Counselor office or call or Confidentiality The staff of UVA Culpeper Hospital will always treat all customers with respect and dignity. All records and information, including knowledge of a debt, will be held in strictest confidence.

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