DANA-FARBER CANCER INSTITUTE PATIENT CARE AND ADMINISTRATIVE POLICY MANUAL PATIENT FINANCIAL ASSISTANCE POLICY

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1 DANA-FARBER CANCER INSTITUTE PATIENT CARE AND ADMINISTRATIVE POLICY MANUAL 1. Purpose PATIENT FINANCIAL ASSISTANCE POLICY This policy establishes Dana-Farber Cancer Institute s (DFCI s) commitment to a Patient Financial Assistance program intended to assist patients who do not have the ability to pay for their health care because they are low-income patients who are uninsured or have limited or exhausted insurance benefits ( underinsured ) or because they have excessive medical expenses. 2. Scope This policy applies to all eligible DFCI Patients. 3. Policy DFCI maintains a Patient Financial Assistance ( PFA ) program intended to assist (i) low-income Patients (family income less than or equal to 300 percent of Federal Poverty Guidelines), who are uninsured or underinsured and do not have the ability to pay for their healthcare services, and (ii) Patients of any family income who have excessive medical expenses and do not have the ability to pay for their healthcare services. For purposes of this Policy, Patient is defined to include the Patient or the guarantor (i.e., the person who is financially responsible for the patient s care). This program waives or partially waives Patient financial obligations for health care services provided by DFCI for (i) qualifying low-income Patients with no commercial health insurance and who are deemed ineligible for federal or any state health insurance programs or federal, state or commercial health insurance who have limited or fully exhausted medical benefits and (ii) Patients of any income whose family medical expenses are deemed excessive in accordance with this Policy. Patient financial obligations include obligations relating to services where the Patient s insurer denied coverage at DFCI due to the insurer s network limitations as well as co-payment, co-insurance and deductible amounts due from the Patient. DFCI will provide financial assistance, by partially or fully waiving Patient financial obligations, for Patients who: (i) complete the Patient Financial Assistance Application ( PFA Application ) and provided necessary supporting documentation, and (ii) are determined eligible for financial assistance in accordance with this Policy ( PFA Eligible Patients ). Patients who qualify for this assistance will not be charged more than amounts generally billed ( AGB ) to insured individuals, as described in Section 4.2 below. Financial assistance under this Policy will not be provided for medically unnecessary services. Uninsured and underinsured Patients ineligible for DFCI s PFA program may be eligible for DFCI s Self- Pay Discount, as described in Section 4.5 below, but may not qualify for both. 4. Financial Assistance to Patients 4.1 Income Limitations This PFA program is limited to Patients with demonstrated financial hardship either due to limited income or in cases where their medical bills are a significant portion of their family income. The most recently Page 1 of 12

2 published Federal Income Poverty Guidelines (FPG) will be used as the primary determinant of a Patient s income. Discounts based on income level are limited to Patients with family incomes of less than 301% of the FPG; discounts based on excessive medical expenses vary based on family income level. Federal Income Poverty Guidelines February 1, % FPG 250% FPG 300% FPG 600% FPG Family Size = 1 $15,521 $29,175 $35,010 $70,020 Family Size = 2 $20,921 $39,325 $47,190 $94,380 Family Size = 3 $26,321 $49,475 $59,370 $118,740 Family Size = 4 $31,721 $59,625 $71,550 $143,100 Family Size = 5 $37,120 $69,775 $83,730 $167,460 Family Size = 6 $42,520 $79,925 $95,910 $191,820 Family Size = 7 $47,920 $90,075 $108,090 $216,180 Family Size = 8 $53,320 $100,225 $120,270 $240,540 Family Size > 8 $5,400 ea add l person $10,150 ea add l person $12,180 ea add l person $24,360 ea add l person 4.2 Limitation on Charges PFA Eligible Patients will not be charged more than the AGB to insured individuals. DFCI determines AGB on an annual basis using the look-back method, described under Treasury Regulation Section 1.501(r)- 5(b)(1). Specifically, DFCI s annual AGB percentage is equal to the sum of all gross charges during the prior fiscal year divided by Claims Paid in connection with those charges. For purposes of the AGB calculation, Claims Paid include claims for emergency and medically necessary care paid by both Medicare fee-forservice and all private health insurers as primary payers, together with any associated portions of these claims paid by Medicare beneficiaries or insured individuals in the form of co-payments, co-insurance or deductibles. Information regarding the current AGB may be obtained by contacting Patient Accounting. DFCI s Finance Department will make these determinations within 45 days of the end of each fiscal year. Page 2 of 12

3 4.3 Financial Assistance Due to Income Limitations Patients who qualify for the PFA program based on their family income level will have their gross charges or applicable Patient balances discounted according to the following schedule: Family Income as a % of FPG 0 to 133% 100% 134 to 250% 85% 251 to 300% 70% Discount Allowed* * The discount allowed to PFA Eligible Patients will be adjusted annually, if and as necessary, to ensure that such individuals are not charged more than the AGB to insured individuals. 4.4 Financial Assistance Due to Excessive Medical Expenses Patients with family income of more than 300 percent of the FPG who can demonstrate that their family s total medical expenses (including, but not limited to DFCI expenses) exceed an established percentage of their family income, will be offered a financial hardship discount. Expenses must have occurred within the prior 12 months and are limited to those expenses that are medically necessary. Patients who qualify for this discount will have their gross charges or applicable Patient balances discounted according to the following schedule. Family Income as a % of FPG With medical bills exceeding this percentage of family income Discount Allowed* 301% - 600% 30% 70% Over 600% 40% 70% * The discount allowed to PFA Eligible Patients will be adjusted annually, if and as necessary, to ensure that such individuals are not charged more than the AGB to insured individuals. 4.5 Self-Pay Discount Uninsured Patients who are not PFA Eligible may be eligible for a self-pay discount of 45 percent against all outpatient uninsured self-pay charges and/or a self-pay discount of 25 percent against all inpatient uninsured self-pay charges. Under no circumstance will multiple discounts be applied. Page 3 of 12

4 5. Applying for DFCI Financial Assistance Upon a request for financial assistance from a Patient, a Financial Counselor will help a Patient complete the PFA Application and will determine if the Patient is eligible for DFCI and/ or other assistance. Customer Service Representatives may refer Patients to Financial Counselors for assistance in completing the PFA Application. 5.1 Patient Financial Assistance Application The PFA Application shall request information regarding the Patient s family, insurance status, and family income. Disclosure of assets is not required. Proof of family income must be provided by means of Forms W-2, year-to-date pay information from an employer, federal or state assistance award letters, an income statement from an accountant, or other third-party documentation. A Financial Counselor will begin processing a Patient s application when it is complete. Applications not completed within 14 days will be closed by the Financial Counselor and the Patient may be required to reapply at a later date. 5.2 Applying for State, Federal or Employer Programs Upon receipt of a completed PFA Application, Financial Counselors will: A. Determine if the Patient has applied for and been denied eligibility in applicable state or federal health insurance programs within the prior 12 months; B. Determine if the Patient has or is eligible for commercial insurance through their employer or the employer of a person who can claim the Patient as a dependent; and C. Determine that the Patient has or will exhaust healthcare benefits; including COBRA benefits and that no other healthcare benefits are available. 5.3 Financial Assistance Determination Once a Patient has submitted a complete PFA Application, the Financial Counselor will determine if the Patient (i) has family income less than or equal to 300 percent of FPG, or (ii) has excessive medical expenses as described in Section 4.4 above. If the Financial Counselor makes an initial determination that a Patient is PFA Eligible, he or she will notify the Access Management Supervisor responsible for financial counseling services, who will make a final determination as to PFA eligibility. Financial Counselors will communicate to a Patient who has submitted a PFA Application: (1) any deficiencies in his or her application; and (2) whether the Patient is or is not PFA eligible. Upon final determination that a Patient is PFA Eligible, the Financial Counselor will document the Patient s account and if approval occurs after an episode of care, on affected visits. 5.4 Semi-Annual Review Determination that a Patient is PFA Eligible will be valid for 6 months. Patients requiring financial assistance after 6 months must reapply. Patients whose insurance coverage resumes on January 1 of the next calendar year (due to annual benefit limits) will need to reapply for assistance when benefits are exhausted again. Page 4 of 12

5 5.5 Patient Responsibility to Report Updates and Changes Patients are required to report to DFCI any changes to their insurance or financial situation that may affect their eligibility for financial assistance. Patients whose insurance coverage resumes on January 1 of the next calendar year (due to annual benefit limits) need to inform DFCI of resumption of insurance coverage. 6. Patients Requesting or Requiring Emergency Medical Care The Emergency Medical Treatment and Active Labor Act (EMTALA) requires DFCI to provide a medical screening examination and treatment for emergency medical conditions without regard to the Patient s insurance status, ability to pay or eligibility under this Policy. No financial information will be requested of Patients with emergency medical conditions until after the Patient s emergency medical condition has been stabilized. 7. Collection Efforts DFCI reserves the right to pursue generally accepted healthcare collection practices to recover balances owed, including by taking extraordinary collection activities (i.e., referring unpaid Patient balances to a collection agency, filing legal claims, placing liens on residences, and seeking body attachments in order to obtain payment). DFCI will not engage in extraordinary collection activities before making a reasonable effort to determine if a Patient is PFA Eligible. DFCI s efforts to determine if a Patient is PFA Eligible will include: (i) Financial Counselors and Customer Service Representatives notifying Patients of this Policy, (ii) Financial Counselors providing Patients with information regarding deficiencies in their PFA Applications, and (iii) Financial Counselors making and documenting decisions on complete PFA Applications. With respect to each balance due for care provided, DFCI Customer Service Representative will notify Patients of this Policy between the date of care and 120 days after the first billing statement for such care. If no PFA application is submitted by the end of the period just described, DFCI may take extraordinary collection activities. DFCI will accept PFA Applications for 240 days after the first billing statement for care and will cease any extraordinary collection activities during the review of any submitted PFA Application. Decisions regarding PFA Applications, including whether reasonable efforts have been made to determine if a Patient is PFA Eligible and whether extraordinary collection activities may be taken, shall be made by the Senior Director of Patient Financial Services subject to the final authority of the Senior Vice President and Chief Financial Officer. 8. Efforts to Publicize DFCI s PFA Policy DFCI is committed to offering financial assistance to eligible Patients who do not have the ability to pay for their medical services in whole or in part. In order to accomplish this charitable goal, DFCI will widely publicize this Policy within its facilities, in direct communications with Patients and in the communities that it services, particularly in the communities with the greatest unmet health needs. Patients who are undergoing a course of treatment or who have outstanding financial obligations (either open account receivable or bad debt) for treatment provided at DFCI who indicate a need for financial assistance should be referred to: A DFCI Financial Counselor Page 5 of 12

6 The Dana-Farber website ( where the patient may access the Patient Financial Assistance Application. This Policy, a plain language summary of this Policy (attached hereto) and the PFA Application (attached hereto) shall be posted on DFCI s website at Paper copies of this Policy, a plain language summary of this Policy and the PFA Application shall be included in the patient handbook and available upon request, without charge, through a DFCI Financial Counselor, Customer Service Representative, or by mail. During the period between the date of care and 120 days after the first billing statement for such care, a plain language summary of this Policy shall be included with all billing statements and other written communications regarding a bill. In collaboration with DFCI s community partners, information about this Policy will be shared with residents of DFCI s priority neighborhoods in a manner reasonably calculated to reach those members of the community who are most likely to require financial assistance. Efforts to notify these community members may include distributing plain language summaries of this Policy to local public agencies and non-profit organizations. Information regarding this Policy shall be posted in conspicuous public displays in Central Registration (Yawkey 268), Registration Offices on D3, and the Registration Offices at each DFCI licensed satellites. Posted signs shall be clearly visible and legible to patients visiting these areas. The posted signs shall be poster size 12 by 18, 34 point font size, in English and Spanish (and any other language that 10 percent or more of DFCI patients speak as their primary language) and shall include language substantially in the form below. Signs required in other languages shall be determined in conjunction with the annual Interpreter Services submission to the state. References English: Financial counseling is available to assist patients in applying for DFCI Financial Assistance, Massachusetts Medicaid and Health Safety Net. If you think you may be eligible for these programs or would like more information about these programs, please call our Financial Counselors Office at Spanish: Ofrecemos Consejeria Financiera para asistir a nuestros pacientes a obtener Massachusetts Medicaid y Health Safety Net. Si usted cree que puede ser elegible para estos programas o desea tener mas informacion acerca de los mismos, comuniquese con nuestra Oficina de Consejeria Financiera al Letter from U.S. Department of Health and Human Services Secretary Tommy Thompson to Richard Davidson, President, American Hospital Association (Feb. 19, 2004). U.S. Department of Health and Human Services, Office of Inspector General, guidance document: Hospital Discounts Offered to Patients who Cannot Afford to Pay their Hospital Bills (Feb. 2, 2004). U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Questions on Charges for the Uninsured (Feb. 17, 2004). 26 U.S.C. 501(r) as added by Section 9007 of the Patient Protection and Affordable Care Act, Public Law (124 Stat. 119 (2010). Page 6 of 12

7 Internal Revenue Service, Proposed Treasury Regulation Section 1.501(r), Additional Requirements for Charitable Hospitals; Proposed Rule (June 26, 2012). Policy Name: Patient Financial Assistance Policy Policy Number: 9.10 Contact Dept/Title: Sponsor: Effective Date: Approved By: Finance, V.P. John Stewart, V.P. Approved: Finance, 7/2014 Revised Reviewed: Policy Review Team, 7/2014 Page 7 of 12

8 Financial Assistance Application Dana-Farber Cancer Institute Patient and family information (please use the back of this form if you need more space to complete) Today s date: Patient name: Date of birth: Address: City, state, ZIP: Phone number: Alternate phone number: Financially responsible party or parties: Relationship of Financially Responsible Party or Parties to Patient: Self Parent Spouse Adult Child Sibling Other Did the patient have health insurance at the time of services: Yes No If yes, please attach a copy of the insurance card (front and back) and complete the following: Name of insurance company: Policy number: Group number: Subscriber s name: Have you applied for Federal or state program assistance in the past 12 months? Yes No If Yes, were you approved or denied? (provide reason for denial): Page 8 of 12

9 Please list all family members, including patient, spouse, parents, children, and siblings, living at the patient s home: Family members Age Relationship to patient Income: Please list all income for responsible parties including gross (pretax) wages, rental income, unemployment, Social Security benefits, pension income, child support, alimony, etc.: Family member Source of income or employer Income amount and frequency Other responsible parties: Please indicate if there is any other person not listed above who is legally responsible for the payment of the patient s medical expenses, such as a guardian. Yes, there is another person who is legally responsible for the patient s medical expenses. No, there isn t another person who is legally responsible for the patient s medical expenses. If yes, please complete the following section: Name Address Role or relationship Page 9 of 12

10 Health Expenses: To be eligible for financial assistance due to excessive medical expenses your family income must be more than 300% of the U.S. Federal Poverty Guidelines and you must provide copies of medical bills from hospitals, physicians, and other allied health professionals other than from DFCI showing the amount you are responsible to pay. DFCI charges will be included in the calculation of your total medical expenses, but you do not need to list those expenses. Only include medical expenses incurred in the last 12 months. Medical Expenses Cost Frequency weekly, monthly, annually Health Insurance Premium Hospital Bills Physician Bills Other Other Other Certification: By my signature below, I certify that I have carefully read this application and everything I have stated and any documentation attached is true and correct to the best of my knowledge and belief. The responsible party acknowledges that he or she is required to report to Dana-Farber Cancer Institute any insurance changes. Printed name of responsible party or parties Signature of responsible party or parties Date Page 10 of 12

11 INTERNAL USE ONLY DO NOT WRITE BELOW THIS LINE. Patient MRN#: Check all that apply: Meets low income guidelines Uninsured Underinsured Actively insured Total Annual Family Income # of Family Members Eligible Discount Excessive Medical Expenses Financial Assistance Application approved? Yes No Date application reviewed: Reason denied: Reviewer/Signature of Financial Counselor Date: Approval/Signature of Access Management Supervisor/Patient Access Supervisor Date: Page 11 of 12

12 Plain Language Summary NOTICE TO DANA-FARBER CANCER INSTITUTE PATIENTS OF AVAILABILITY OF FINANCIAL COUNSELING, PAYMENT PLANS, AND FINANCIAL ASSISTANCE Consistent with its mission, Dana-Farber Cancer Institute (DFCI) takes its obligations seriously to provide highquality cancer care to all patients, including low-income and indigent patients and when needed, provide financial counseling, payment plans and financial assistance to our patients. Some DFCI programs that you may qualify for include: Discounts for low-income patients with no insurance or for medically necessary services not covered by insurance. Medical hardship discounts for patients with excessive medical expenses. Payments plans for patients who need to pay their bills in installments. Financial counseling services, including trying to help patients find a federal, state or private program that may be able to help you with your medical bills. Under DFCI s Patient Financial Assistance program, patients whose household income is between 134% and 300% of the Federal Poverty Level (FPL) may be eligible to have 70-85% of their patient financial obligations waived. Patients whose household income is less than 133% of the FPL may be eligible to have their patient financial obligations waived entirely. Patients whose household income is greater than 300% of the FPL, but whose total medical expenses exceed at least 30% of their household income may be eligible to have 70% of their patient financial obligations waived. In no case will a patient who is eligible under DFCI s Patient Financial Assistance program be charged more for medically necessary care than the amounts generally billed to other patients and their insurers. You should call our Financial Counselors as soon as feasible if you think you will have difficulty paying your medical bills. Our financial counselors can help determine if you are eligible for one of the above-listed programs. Financial Counselors can be reached at , between the hours of 8 a.m. and 6 p.m., Monday through Friday. Copies of this summary, DFCI s Patient Financial Assistance Policy and the Patient Financial Assistance Application, are available in both English and Spanish at or by calling a DFCI Financial Counselor. Page 12 of 12