Title: Financial Assistance (Charity Care/Uncompensated Care) Approver: Kootenai Health Board Date: 09/29/2014 Kootenai Health is committed to excellence in providing high quality health care services while serving the diverse needs of those living within its service area. Kootenai Health provides medically necessary care regardless of ability to pay or insurance coverage status. Whenever possible, a determination of whether a patient qualifies for Charity Care will be initiated prior to or at the time of admission by a Kootenai Health Financial Counselor. Purpose: Kootenai Health believes that medically necessary health care services should be accessible to all, regardless of age, gender, geographic location, cultural background, physical mobility or ability to pay. Kootenai Health is committed to providing health care services and acknowledges that in some cases the patient will not be financially able to pay for the services rendered. This policy describes Charity Care eligibility requirements and approval process. Generally, eligibility for charity care is determined by comparing the patient s income to the Federal Poverty Level Income Guidelines (FPG) as established by the Department of Health and Human Services. These guidelines are published annually and KH will update its policy each year, accordingly. Definitions: Kootenai Health - includes all entities, hospital, clinics, etc. that currently bill under the Kootenai Health Tax ID number. Charity care occurs when it is determined that a patient does not have the ability to pay (either fully or partially) for services. Bad Debt accounts are considered bad debt when the patient has an unwillingness to pay and has not provided documentation to support the fact that they are unable to pay. Eligibility a determination made by Kootenai Health based upon required financial data that can verify, to the extent possible, the inability for a patient to pay for services provided. Catastrophic care a circumstance of extraordinary medical expenses or hardship situations in which a patient or family would not have the ability to pay off the bill in their lifetime, given the income and resources they have without it resulting in severe hardships. Presumptive charity Instance when a person may appear eligible for charity care but there is no supporting documentation to prove the need. In this event, Kootenai Health can use outside agency information in determining income amounts for eligibility of charity. Eligibility requirements: 1. A Charity Care application may be initiated by the patient, a Kootenai Health staff member, a physician or interested party on behalf of the patient. Patients demonstrating and/or communicating a need for assistance will be evaluated according to this policy. Revised: Page 1 of 9
2. Patients who may be eligible for Charity Care shall be identified as early as possible in the patient care cycle. Information regarding eligibility and the Charity Care application process can be obtained from the Financial Counselors located at any KH location, or available on the KH website. 3. During the application process, all requests related to eligibility will be referred to the Financial Counselors or designated personnel. 4. Kootenai Health will generally provide Charity Care only after all other means of financial support are exhausted from available payment sources, including but not limited to Medicaid. 5. Outstanding balances that are owed by the patients as a result of a deductible, coinsurance or where the insurance benefits have been exhausted, may qualify for Charity Care if the patient meets the eligibility requirements. In such cases, the determination of the benefit will be based upon the patient liability and not the total charges. 6. Charity Care determination is based on the patient s financial status at the time of application and presumptive eligibility status as defined by outside agency. The charity committee will examine the patient s account files for any other outstanding obligations. Any obligations prior to the approval date may be considered for charity. 7. All application information, such as financial statements, will be maintained in accordance with the Health Information Portability and Accountability Act and the Kootenai Health retention policy. 8. Patients eligible for Charity Care will be informed of their determination within 30 days of application, along with instructions to contact the Patient Account Representative to arrange for any required payment of the outstanding balance, if any, after the Charity Care discount has been applied. 9. Patients whose applications have been denied will be sent a letter explaining the reason for the denial and a contact number should they wish to discuss the application further. 10. Approval of charity is granted on the individual account basis. Applications may be considered for six (6) months unless the patient ability to pay has changed during the eligible time period. Determination of Eligibility: Some or all of the following qualifying factors may be used to determine eligibility for charity care: 1. In order to be evaluated for Charity Care, it is the responsibility of the patient/guarantor to submit an application, a picture ID, proof of income and assets. The application may include a financial statement that must be completed and signed by the patient. Proof of income and assets includes: a. Yearly income (1) most recent federal income tax return; (2) three months of current paycheck stubs, social security benefits, disability and/or unemployment, worker s compensation benefits (if applicable); (3) W-2 issued by patients employer; (4) three months of bank statements; (4) other evidence of income deemed acceptable by Kootenai Health, or copy of denial from County/Medicaid (if applicable). b. Assets supporting documentation to include the following: value of house, vehicles, land, stocks and bonds, life insurance with cash value, and trusts. 2. To provide a level of control and ensure compliance with the Charity Care policy, attempts will be made to obtain a completed and signed (patient) Charity Care application. 3. Levels of Charity Care a. Full Charity Care A patient who has income falling at or below one hundred seventyfive percent (175%) of Federal Poverty Guidelines as established by the Department of Health and Human Services will qualify for one hundred percent (100%) Charity Care write-off. Revised: Page 2 of 9
b. Partial Charity Care 1) A patient who has income falling at or below two hundred percent (200%) of Federal Poverty Guidelines as established by the Department of Health and Human Services will qualify for fifty percent (50%) Charity Care write-off. 2) A patient who has income falling at or below two hundred twenty-five percent (225%) of Federal Poverty Guidelines as established by the Department of Health and Human Services will qualify for thirty percent (30%) Charity Care write-off. c. Special Circumstances Charity Care (Presumptive Eligibility) A patient who is unable to provide documentation or who is unable to follow the application procedures may receive full/partial charity, with the approval of the Chief Financial Officer, or designee. The hospital must document the decision, including the reasons why the patient did not meet the regular criteria. Circumstances may include, but are not limited to, deceased with no estate, illness, homeless, transient or other domestic issues. d. Catastrophic Charity Care A patient may qualify for a discount or an additional discount when their patient financial responsibility exceeds 30% of the household income and assets. 4. Charity care discounts are not typically applicable to balances represented by: a. Cosmetic surgery b. Bariatric surgery c. Elective services or procedures which do not meet criteria for medical necessity, as determined by a physician or care manager. 5. Services not covered by Medicaid because of patient coverage level may qualify for Charity Care. Charity Care will not be granted for Medicaid accounts where Emergency room visits have exceeded the maximum allowable visits per patient. 6. For patients to remain eligible for Charity Care, patient/guarantor must apply for and/or continue to pursue all benefits for which they are presently entitled to or may become entitled to, including Medicare, Medicaid, Social Security Disability, or any other state or federal programs, until patient/guarantor are approved or denied. If patient/guarantor is denied benefits due to lack of cooperation, Charity Care may not be granted or may be revoked, and discounts will be reversed, resulting in all outstanding debts to Kootenai Health becoming patient/guarantor responsibility. 7. Kootenai Health retains the right to require any patient to reapply if new information pertaining to any change in their income level becomes available that may change the patient s eligibility for Charity Care. Patients may also request to reapply if their income level reduces significantly or their family status changes. 8. All applications will be reviewed weekly by the Charity Committee, comprised of members of the Business Office and Social Services for determination of benefits. 9. Approval authority for Charity Care a. The Social Worker will make determination of eligibility per guidelines for self-pay balances up to $2,000 upon review of completed application and verification of required documentation. b. Supervisor of Business Office or Social Services can approve up to $20,000, based on Charity Committee recommendation. c. Director of Social Services or Revenue Cycle can approve charity up to $50,000 d. Amounts greater than $50,000 require approval from the Chief Financial Officer. e. Catastrophic charity care requires approval from the Chief Financial Officer. Revised: Page 3 of 9
Addendum A: Date Received Financial Assistance Application Patient Birthdate Phone # Address City State Spouse Zip Number of Dependents Ages Monthly Expenses Gross Monthly Income Rent Own Self Power/Water/Sewer Spouse Phone Unemployment Food Pension Car Insurance Food Stamps Home Insurance Child Support Medical Insurance Other Prescriptions Day Care Child Support Gasoline Other Expenses TOTAL Income $ Vehicle Year Make Monthly Payment Vehicle Year Make Monthly Payment Vehicle Year Make Monthly Payment Recreational (Boat, RV, ATV) Monthly Payment TOTAL Expenses $ Additional Assets All Checking Accounts All Savings Accounts Stocks, CD s Trusts, Retirements Life Insurance Cash Value House/Properties Value Purchase Date Amount Owed I authorize Kootenai Health to verify the information that I have supplied on this statement to be true and to access credit information if needed. Signature Date Revised: Page 4 of 9
YOUR MEDICAL BILLS Providers Amount Owed Minimum Payment *To be completed by Financial Assistance Committee Verified Household: Gross Income Net Income Previous year s Income tax Total amount owed to Kootenai Health Monthly Expense Amount Comments Revised: Page 5 of 9
Addendum B: 2014 Annual Poverty Guidelines Family Size 100% 150% 175% 200% 225% 250% 1 11,670.00 17,505.00 20,422.50 23,340.00 26,257.50 29,175.00 2 15,730.00 23,595.00 27,527.50 31,460.00 35,392.50 39,325.00 3 19,790.00 29,685.00 34,632.50 39,580.00 44,527.50 49,475.00 4 23,850.00 35,775.00 41,737.50 47,700.00 53,662.50 59,625.00 5 27,910.00 41,865.00 48,842.50 55,820.00 62,797.50 69,775.00 6 31,970.00 47,955.00 55,947.50 63,940.00 71,932.50 79,925.00 7 36,030.00 54,045.00 63,052.50 72,060.00 81,067.50 90,075.00 8 40,090.00 60,135.00 70,157.50 80,180.00 90,202.50 100,225.00 For family units of more than 8 members, add $4,060.00 for each member. 2014 Monthly Poverty Guidelines Family Size 100% 150% 175% 200% 225% 250% 1 972.50 1,458.75 1,701.88 1,945.00 2,188.13 2,431.25 2 1,310.83 1,966.25 2,293.96 2,621.67 2,949.38 3,277.08 3 1,649.17 2,473.75 2,886.04 3,298.33 3,710.63 4,122.92 4 1,987.50 2,981.25 3,478.13 3,975.00 4,471.88 4,968.75 5 2,325.83 3,488.75 4,070.21 4,651.67 5,233.13 5,814.58 6 2,664.17 3,996.25 4,662.29 5,328.33 5,994.38 6,660.42 7 3,002.50 4,503.75 5,254.38 6,005.00 6,755.63 7,506.25 8 3,340.83 5,011.25 5,846.46 6,681.67 7,516.88 8,352.08 If gross income falls in this range pt may receive charity at 100% If gross income falls in this range pt may receive charity at 50% If gross income falls in this range pt may receive charity at 30% If gross income falls in this range pt may be over income for charity Revised: Page 6 of 9