Tarzana Treatment Centers, Inc.

Tarzana Treatment Centers, Inc. Title: Charity Care INTENT The prpose of this policy is to ensre a consistent and niform method among all Tarzana Treatment Centers, Inc. (TTC) facilities for compliance with the California Volntary Principles and Gidelines on Billing and Collection Practices for Services Provided to Low-income Uninsred Patients. It is the intent of this policy to comply with all federal, state, and local reglations. If any reglation, crrent or ftre, conflicts with this policy, the reglation will spersede this policy. PRINCIPLES This policy reflects a commitment to provide financial assistance to patients who cannot pay for part or all of the care they receive. This policy balances a patient s need for financial assistance with TTC s broader fiscal responsibilities. Financial assistance provided by TTC is not a sbstitte for personal responsibility. All patients are expected to contribte to the cost of their care, based pon their individal ability to pay. TTC contracts with all levels of government to provide large variety of sbstance abse, mental health, HIV/AIDS, primary care and other health and hosing related services to the ninsred, low income and indigent members of or commnities. Consistent with or commitment to reach ot and service those most in need. GUIDELINES TTC s financial assistance policies shall clearly state the eligibility criteria (i.e., income, assets) and the process sed by the TTC to determine whether a patient is eligible for financial assistance. Sch process shall take into accont where and how far a particlar patient falls relative to existing Federal Poverty Levels (FPL). (See Exhibit C for crrent FPL.) Any patient who believes that they are qalified may apply for financial assistance nder TTC s charity care policy or discont payment policy. TTC staff shall se their best efforts to ensre all financial assistance policies are applied consistently. In determining a patient s eligibility for financial assistance, TTC staff shall assist the patient in determining if he/she is eligible for government-sponsored programs. Commnication of Financial Assistance Policies with Patients and the Pblic Each facility shall post notices regarding the availability of financial assistance to lowincome ninsred patients. These notices shall be posted in visible locations sch as admitting/registration and billing office. Every posted notice regarding financial assistance policies shall contain brief instrctions Charity Care_11 written: 01/23/08 rev. 01/30/08 Page 1 of 8

on how to apply for charity care or a disconted payment. Directors shall ensre that appropriate staff members are knowledgeable abot the existence of the Facility s financial assistance policies. When commnicating to patients regarding the financial assistance policy, staff shall do so in the primary langage of the patient, or his/her family, if reasonably possible, and in a manner consistent with all applicable federal and state laws and reglations. TTC shall share the financial assistance policy with appropriate commnity health and hman services agencies and other organizations that assist sch patients. POLICY: COMPLIANCE KEY ELEMENTS CHARITY CARE Any self-pay, ninsred patient who indicates an inability to pay will be screened for charity care. Additionally, any insred patient who indicates an inability to pay their liability after their insrance has paid may be screened for charity care. Screening shall inclde a review of the patient s eligibility for pblicly fnded programs operated by TTC. Screening for charity care will occr only after all other potential resorces have been exhasted. The screening process will optimally occr at the time of service bt may occr anytime dring the collection process inclding post assignment to an otside collection agency. At minimm, screening for charity care will inclde docmentation of family size and gross family income. Charity care will be granted based pon the following income levels. Income Level Less than 200% of the Federal Poverty Level 200% to 300% of the Federal Poverty Level 75% Discont 301% to 350% of the Federal Poverty Level 50% Discont Discont Amont 100% Discont 350% to 400% of the Federal Poverty Level 25% Discont Greater than 400% of Federal Poverty Level Patient Pays Fll charges CATASTROPHIC CHARITY CARE Based pon the patients complete financial sitation, when the patient liability amont exceeds 50% of the total annal family income, amonts greater than 50% of the income may be written off to charity care. CLASSIFICATION AS STATUTORY OR NON STATUTORY Charity care will be classified into two categories: stattory and non-stattory. Stattory Charity Care Stattory charity care will be defined by facility participation in varios federal, state, and/or conty indigent care programs. Criteria mst comply with governmental gidelines and/or state or conty reglations. Each patient who appears eligible for stattory charity care determination and who reqests sch determination mst complete a Confidential Financial Statement (exhibit A in English and Spanish). Additionally, he/she mst provide spporting docmentation to the financial conselor as reqired to verify his/her financial condition. Stattory charity care will generally be identified at the time of admission or while the patient is in-hose by the facility financial conselor, however, it may also be identified after discharge or whenever a patient declares an inability to pay. Non-Stattory Charity Care Charity Care_11 written: 01/23/08 rev. 01/30/08 Page 2 of 8

Non-Stattory Charity Care is defined as charity care for patients known to meet the general charity care criteria. The determination of non-stattory charity care will be made at admission or while the patient is in-hose; however, this determination cold also be made after discharge or whenever patient declares an inability to pay. Unless the patient qalifies for the abbreviated screening procedre, every effort will be made to secre a signed application, bt this may not be possible in all cases. Patients stating that they are homeless and withot income, at the discretion of the PFS Director, do not need to complete a Confidential Financial Statement. Instead, charity care determination may be made by the financial conselor s completion of the eligibility worksheet. Non-stattory charity care shall be sed for homeless patients that have no income or docmentation to report. MEDICAID/MEDI-CAL DENIALS Patients who qalify for Medicaid are also presmed to qalify for fll charity write off. Any charges for services written off (exclding billing timeliness, medical records, missing invoices, or eligibility isses) as a reslt of a Medicaid denial (sch as TAR denial) shall be written off to a specific code and booked as charity. RESTRICTED MEDICAID/MEDI-CAL COVERAGE Some Medicaid plans offer coverage for a limited or restricted list of services. If a patient is eligible for Medicaid, any charges for services not covered by the patient s coverage may be written off to charity withot a completed Confidential Financial Statement. This does not inclde any Share of Cost (SOC) amonts, as SOC s are determined by the state to be an amont that the patient mst pay before the patient is eligible for Medicaid. DOCUMENTATION REQUIREMENTS Application In order to qalify for charity care, a Confidential Financial Statement shall be completed. The Confidential Financial Statement allows for the collection of information. Income and docmentation reqirements are defined below. Pending the completion of sch application, the patient shall be treated as a pending charity care patient in accordance with the TTC s policies and the appropriate financial class recorded to reflect this stats. Family Members: Patients will be reqired to provide the nmber of family members in their hosehold. Adlts: In calclating the nmber of family members in an adlt patient s hosehold, inclde the patient, the patient s spose and/or legal gardian, and all dependents. Minors: In calclating the nmber of family members in a minor patient s hosehold, inclde the patient, the patient s mother and/or father and/or legal gardian and any other dependents. Income Calclation: Patients will be reqired to provide their hosehold s yearly gross income. Adlts: The term yearly income on the Confidential Financial Statement means the sm of the total yearly gross income of the patient and patient s spose. Minors: If the patient is a minor, the term yearly income on the Confidential Financial Statement means income from the patient, the patient s mother and/or father and/or legal gardian and any other dependents. Income Verification Charity Care_11 written: 01/23/08 rev. 01/30/08 Page 3 of 8

Patients will be reqired to verify the income set forth in the Confidential Financial Statement in accordance with the docmentation reqirements identified below in cases where docmentation is available. Any of the following docments is appropriate for verifying income: Income Docmentation: Income docmentation may inclde IRS Form W-2, wage and earnings statement, paycheck stb, tax retrns, telephone verification by employer of the patient s income, bank statements, or other appropriate indicators of income. Participation in a Pblic Benefit Program: Docmentation showing crrent participation in a pblic benefit program inclding Social Secrity, Workers Compensation, Unemployment Insrance, General Relief, CALWORKS, Benefits, Medicaid, Conty Indigent Health, Food Stamps, WIC, or other similar indigence related programs. Docmentation Unavailable In cases where the patient is nable to provide docmentation verifying income, the following procedres shall be followed: Obtain Patient s Written Attestation: Have the patient sign the Financial Assistance Application attesting to the accracy of the income information provided; or Obtain Patient s Verbal Attestation: The Financial Conselor who is completing the Confidential Financial Statement may provide written attestation that the patient verbally verified the income calclation. In all cases, at least two attempts mst be made and docmented to attempt to obtain the appropriate income verification. Expired Patients: Expired patients may be deemed to have no income for prposes of the financial calclation. Althogh no docmentation of income is reqired for expired patients, an asset verification process shall be completed to ensre that a charity care adjstment is appropriate. Uncooperative Patients Uncooperative patients are defined as nwilling to disclose any financial information as reqested for Medicaid and/or charity care determination dring the screening process. In these cases, the accont will not be processed as charity care. The patient will be advised that nless they comply and provide the information, no frther consideration will be given for charity care processing, and standard A/R follow-p will begin. Non-Compliant patients are defined as not meeting all reqired docmentation for Medicaid/Medi-Cal screening, bt qalifying for charity care. In these cases, the Financial Conselor may process the accont for charity care, and the accont will remain in the charity-pending financial class ntil the facility processes a charity write-off adjstment. Abbreviated Application Process TTC may establish an abbreviated application and verification process for those service areas in which they have determined that the typical level of charges are not high sch as clinics, and otpatient areas. In these service areas, admissions staff or the financial conselor mst at minimm docment the family size and the total family gross income in order to determine the level of charity discont if any. TTC may reqire income verification if there are discrepancies in income reported by the client. For example, if the patient reports $1,000 of gross income per month bt is making a large mortgage payment along with several credit card payments TTC may reqire frther income verification sch as a credit report. If a credit report is not available, docment that fact in the patient notes. No frther effort is reqired. Commnication Facilities are reqired to post signs in their admitting and registration areas that inform patients abot their financial assistance policies. Additionally, patient statements shall have standard Charity Care_11 written: 01/23/08 rev. 01/30/08 Page 4 of 8

langage informing patients that they may reqest financial screening to determine eligibility for charity care. To the extent possible, these commnications shall be in the primary langage of the patient. Once a charity determination has been made, the otcome mst be commnicated to the patient. That commnication may be accomplished by sending the patient Exhibit B EXHIBIT A Patient Name Facility: DOS: Patient Nmber Confidential Financial Statement (Application) RESPONSIBLE PARTY Name Marital Stats Social Secrity Nmber Street Address, City, State, Zip How long at this address Home Phone Employers Name and Address (If Unemployed How Long) Bsiness Phone Position / Title Monthly income Gross Monthly income - Net Length of crrent employment SPOUSE Name Social Secrity Nmber Employer Name and Address Bsiness Phone Position / Title Monthly income Gross Monthly income Net Length of crrent employment DEPENDENTS Name & Year of Birth of all dependents in Total Nmber of Do Any Other Persons Contribte? If Yes, hosehold dependents in hosehold Amont: Yes/No Amont INCOME PER MONTH & ASSETS Dividends, Interest $ Child Spport / Alimony $ Pblic Assistance / Food Stamps $ Rental Income $ Social Secrity $ Grants $ Unemployment Compensation $ IRA $ Workers Compensation $ Other $ Savings $ EXPENSES PER MONTH Mortgage / Rent Payment: $ Balance: $ Medical / Dental $ Own Home? (Yes/No) Doctor Name $ Food $ Doctor Name $ Utilities: $ Doctor Name $ Electric $ Credit Cards: $ Gas $ Visa Limit $ Water / Sewer $ Mastercard Limit $ Trash $ Discover Limit $ Phone $ Other Limit $ Cable $ Installment Loans $ Ato Payments $ Child Spport $ Ato Expenses $ Miscellaneos Expenses $ Insrance: Ato Premim $ Life Insrance $ Health Insrance $ OFFICE USE ONLY Gross income Net income Total Expenses Total Net income(loss) PATIENT/GUARANTOR DATE Note: The Financial Statement (Application) is available in Spanish To my knowledge the information provided above is tre. I athorize a Credit Brea Report to be secred by the Tarzana or its agent to verify my financial standing. SIGNATURE Nombre del OFICINA DOS Número del DECLARACION CONFIDENCIAL DE ESTADO FINANCIERO Charity Care_11 written: 01/23/08 rev. 01/30/08 Page 5 of 8

PERSONA RESPONSABLE Nombre Estado Civil Número de Segro Social Dirección, cidad, estado, código postal Cánto tiempo ha vivido en esta Teléfono de s domicilio dirección? Nombre y dirección de s empleador (Si está desempleado, por cánto tiempo?) Teléfono de s trabajo Empleo/Pesto Ingreso mensal-brto Ingreso mensal- Tiempo en s empleo actal Neto ESPOSA/ESPOSO Nombre Número de Segro Social Nombre y dirección del empleador Teléfono de s trabajo Empleo/Cargo Ingreso mensal-brto Ingreso mensal-neto Tiempo en s empleo actal DEPENDIENTES Nombre y año de nacimiento de todos Número total de dependientes Algna otra persona contribye? Si la respesta los dependientes qe viven en s casa qe viven en s casa: es sí, con qé cantidad? : Sí/No Cantidad INGRESO MENSUAL Y ACTIVOS Dividendos, Intereses $ Mantención para hijos menores/esposa $ Ayda pública/cpones de alimentos $ Ingreso por alqileres $ Segro social $ Acciones, bonos $ Compensación por desempleo $ Sbvenciones (grants) $ Compensación por accidente de trabajo $ Centa de jbilación individal (IRA) $ Ahorros $ Otros inmebles, sin inclir a s vivienda $ GASTOS MENSUALES Pagos de hipoteca/alqiler $ Gastos médicos/dentales $ Es propietario de s vivienda? Alimentos $ Doctor-Nombre Servicios públicos: $ Doctor-Nombre Electricidad $ Doctor-Nombre Gas $ Tarjetas de crédito: Aga-Alcantarillado $ Visa $ Límite $ Recolección de basra $ Mastercard $ Límite $ Teléfono $ Discover $ Límite $ Cable $ Otras $ Límite $ Pago de vehíclos $ Préstamos a plazo $ Gasto de vehíclos $ Mantención para hijos menores $ Segro : $ Gastos misceláneos $ Prima de vehíclos $ Segro de vida $ Segro médico $ SOLO PARA USO DE LA OFICINA Ingresos brtos Ingresos netos Total de gastos Ingreso neto total (pérdida) Hasta donde me es posible saber, la información arriba proporcionada es correcta. Atorizo al Tarzana o a s representante, para qe obtengan n reporte de crédito para la verificación de mi sitación financiera. FIRMA DEL PACIENTE/GARANTE FECHA EXHIBIT B Charity Care_11 written: 01/23/08 rev. 01/30/08 Page 6 of 8

RE: Tarzana Name Date Tarzana Address Tarzana Phone Garantor Name Garantor Address Accont Nmber: Patient Name: Dates of Service: Accont Balance: Yor accont has been reviewed for possible charity assistance. After review of all of yor sbmitted financial docmentation it has been determined yo do meet eligibility gidelines for fll charity assistance on this accont. Yor accont has been reviewed for possible charity assistance. After review of all of yor sbmitted financial docmentation it has been determined yo do not meet eligibility gidelines for fll charity assistance on this accont. Yor accont has been reviewed for possible charity assistance. After review of all of yor sbmitted financial docmentation it has been determined yo meet eligibility gidelines for partial charity assistance on this accont. Accont balance is the remaining portion, which is yor responsibility to pay. If yo have any qestions, please feel free to contact s at 818.996.1051 dring normal bsiness hors. Patient Financial Services Department Tarzana Name Tarzana Phone Nmber Tarzana Name Tarzana Address Tarzana Phone Date Garantor Name Garantor Address RE: Número de Centa: Nombre del Paciente: Fechas de Servicio: Balance de la Centa: S centa ha sido revisada para na posible asistencia de caridad. Despés de revisar toda s docmentación financiera se ha determinado qe sted satisface las normas de elegibilidad para la asistencia de caridad por completo en esta centa. S centa ha sido revisada para na posible asistencia de caridad. Despés de revisar toda s docmentación financiera se ha determinado qe sted no satisface las normas de elegibilidad para la asistencia de caridad por completo en esta centa. S centa ha sido revisada para na posible asistencia de caridad. Despés de revisar toda s docmentación financiera se ha determinado qe sted satisface las normas de elegibilidad para la asistencia de caridad parcial en esta centa. $(accont balance) es la porción remanente, lacal es s responsabilidad de pagar. Charity Care_11 written: 01/23/08 rev. 01/30/08 Page 7 of 8

Si tiene algna pregnta, por favor siéntase libre de llamarnos al (Tarzana phone) drante horas normales de oficina. Departamento de Servicios Financieros del Cliente Tarzana Name Tarzana Phone Nmber http://www.aspe.hhs.gov/poverty/07poverty.shtml Charity Care_11 written: 01/23/08 rev. 01/28/08 Page 8 of 8