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This policy applies to all charges for emergency and other medically necessary care provided in the hospital facilities listed in Exhibit A to this Policy, by the hospital facilities themselves and by the other providers identified on such Exhibit A as being subject to this Policy (collectively "Carondelet").
It is the policy of Carondelet to provide emergency and other medically necessary care in its hospital facilities to all patients, and to provide financial assistance to those patients that Carondelet determines require assistance. The determination of financial assistance generally should be made at the time of admission or shortly thereafter, but events after discharge could change the ability of the patient to pay. Eligibility will be considered for those individuals who are uninsured or underinsured and unable to pay for their care. Eligibility will be based on a combination of family income and assets. Designation as financial assistance will only be considered after all payment sources have been exhausted.
A patient may apply for Financial Assistance at any time before the later to occur of (i) one year after discharge or (ii) 240 days after the first post-discharge billing statement to the patient for the care for which the patient desires consideration for Financial Assistance treatment under this Policy.
Amounts Generally Billed (AGB): The amount generally billed for emergency or other medically necessary care to individuals who have insurance covering such care. Carondelet calculates the AGB using the “lookback” method by multiplying the Gross Charges for any eligible services that it provides by AGB percentages which are based upon past claims allowed under Medicare and private insurance as set forth in federal law.
Carondelet’s patients may obtain additional information regarding Carondelet’s AGB percentage and how the AGB percentages were calculated from a financial counselor and at [weblink]. Thus, no individual eligible for assistance under this Policy will be charged in excess of AGB for emergency or other medically necessary care.
Financial Assistance Application: The form adopted by the hospital containing the information which is required under this Policy for the patient to be evaluated for financial assistance, which will be in substantially the form attached to this Policy as Exhibit B.
Extraordinary Collection Actions or ECAs: Certain activities as described in applicable Internal Revenue Service regulations that are undertaken in order to collect amounts owed to the hospital from an individual. Such activities may include, but are not limited to, selling or referring the debt to a third party for collections, reporting adverse information to one or more credit reporting agencies concerning the debt, denying or delaying care due to an individual's nonpayment of a bill for prior care or any activity involving legal action against a patient (such as garnishments, lawsuits, or liens on a patient's real or personal property other than proceeds from a liability claim or settlement).
Gross Charges: Gross Charges (also referred to as “full charges”) means the amount listed on each Carondelet hospital facility’s charge master for each eligible service.
Underinsured: Patients who have public or private health insurance coverage that does not offer complete financial protection, creating a financial hardship for the patient to cover their out-of-pocket expenses.
Uninsured: Patients who do not have any health insurance coverage and are solely liable for payment for treatment.
Plain Language Summary: A brief summary of the financial assistance that is available under this policy, the application process and contact information for the individual or department who can assist the individual with an application, which summary must contain at a minimum the elements described in applicable Internal Revenue Service regulations.
IV. FINANCIAL ASSISTANCE CATEGORIES
Financial Assistance Categories:
Carondelet will not collect Gross Charges from those patients qualifying for financial assistance in the categories below:
Discounted Care is offered to patients meeting the requirements of this Policy. In order to qualify for Discounted Care, a patient's gross family income must not exceed 200% of the applicable Federal Poverty Level ("FPL") in effect at the time of application.
A. Catastrophic Medically Indigent Discounted Care is available for patients meeting the requirements of this Policy. In order to qualify for Catastrophic Medically Indigent Discounted Care, a patient’s gross family income must be greater than 200% FPL, but less than or equal to 300% of the FPL, and the patient must have total hospital charges for the preceding six months that are more than twice the patient’s total gross annual family income.
A. Tenet and Carondelet to reserve the right to designate certain services as elective services that are not subject to this Policy provided those services are not medically necessary.
B. Each hospital must ensure that:
1. It is employees do not at any time indicate or suggest to the patient that he or she will be relieved of the debt by way of a write-off to financial assistance until a determination has been made.
2. Patients and their families must be advised of the hospital’s applicable policies, including the availability of financial assistance, in easily understood terms, as well as in any language commonly used by patients in the community. A Plain Language Summary will be offered to all patients at registration or discharge. Information regarding this Policy must be posted in the admitting and registration areas, including in the Emergency Room.
3. Patients who do not qualify for the financial assistance described above in Section III, may be offered appropriate facility flat rate or prompt-pay discounts that are different than the financial assistance discounts described in this Policy where allowed by state law/regulation.
4. In the event that Carondelet receives a Financial Assistance Application, collection activities with respect to the care covered by the application will be suspended pending determination of eligibility.
A. Financial Assistance Application
In order to qualify for financial assistance, a patient must submit a Financial Assistance Application on or before the deadlines specified in this Policy. In addition, the patient must submit additional supporting documentation verifying the information in the application. The additional supporting documentation that may be required includes, but is not limited to, the following:
1. Credit Bureau Report (including the lack thereof)
2. IRS tax returns
3. Payroll stubs
5. Verbal attestation
6. Other forms used to substantiate the need for financial assistance consideration
B. Factors used in determining eligibility must include comparing the patient's family income to the annually published FPL. This information may be obtained through verbal means from the patient/guarantor and documented by appropriately designated staff. 1. Patients who may be considered for financial assistance without additional supporting documentation include, but are not limited to, the following:
a) Those who are unemployed and do not qualify for government programs
b) Patients who have no credit established and no Bad Debt collection accounts
c) Patients with a lack of revolving credit account(s) information
d) Patients with a lack of revolving bank accounts(s) information and
e) Patients with delinquencies reported on open trade line accounts
f) International patients are considered on a case-by-case basis for ER treatment and/or ER admission only
g) Catastrophic illness
2. Information falsification will result in denial of the Financial Assistance Application. If, after a patient is granted financial assistance, the hospital finds material provision(s) of the application to be untrue, financial assistance eligibility may be revoked and the patient’s account will follow the normal collection processes.
C. Presumptive Charity
1. The following is a listing of types of accounts where financial assistance is considered to be automatic and may be approved for financial assistance without a financial assistance application or documentation of Income: or
A. Medicaid Accounts-Exhausted Days/Benefits
B. Medicaid spend down accounts
C. Medicaid or Medicare Dental denials
D. Medicare Replacement accounts with Medicaid as secondary- where Medicare Replacement plan left patient with responsibility
2. Uninsured and underinsured Patients who do not qualify for a presumptive charity determination must complete an application to document financial need.A. Patients requesting Financial Assistance must verify the number of people in the patient’s household.
i. Adult Patients - In calculating the number of people in an adult patient’s household, include the patient, the patient’s spouse and any dependents of the patient or the patient’s spouse
ii. Minor Patients - In calculating the number of people in a minor patient’s household, include the patient, the patient’s mother, dependents of the patient’s mother, the patient’s father, and dependents of the patient’s father.
B. Patients requesting Financial Assistance must verify their income and provide the documentation requested as set forth in the Assistance Application.
i. Adult Patients. For adult patients, determine the Income of the patient and other adult members of the patient’s household. If and to the extent required by law, the hospital may consider other financial assets of the patient and the patient’s family and the patient’s or the patient’s family’s ability to pay, as reflected in the applicable state-specific job aid, addendum or procedure
ii. Minor Patients. For minor patients, determine the Income from the patient and the patient's legal guardians or other individuals financially responsible for the patient's care. If and to the extent required by law, the facility may consider other financial assets of the patient and the patient’s family and the patient's or the patient’s family’s ability to pay, as reflected in the applicable state-specific job aid, addendum or procedure.
iii. Homeless patients - Homeless (defined as patients who do not have a primary residence or reside with family or friends) are deemed to have no Income for purposes of the hospital’s calculation of income. Documentation of Income is not required for homeless patients. To the extent that family members or others have been identified as financially responsible for the patient’s care, income verification is required for such individuals in accordance with this policy in order to determine that individual’s eligibility for financial assistance.
iv. Incarcerated Patients – Incarcerated patients (Hospital personnel should attempt to verify incarceration) may be deemed to have no income for purpose of the Hospital’s calculation of income, but only if their medical expenses are not covered by the governmental entity incarcerating them (i.e., the Federal Government, the State or a County is a responsible for the care) since in such event they are not uninsured patients. Income verification is still required for any other family members.
v.Expired Patients – Expired patients’ accounts may be reviewed for probate or other responsible parties before being considered for charity. Following such review, expired patients may be deemed to have no income for purposes of income. The Hospital will review the patient’s financial status at the time of death to ensure that a Financial Assistance adjustment is appropriate (e.g., no other guarantor appears on the patient account).
D. Incomplete Applications
In the event that the Financial Assistance Application is incomplete or the patient does not provide additional information that may be required, the Financial Assistance Application will not be denied until written notice has been sent to the patient describing the additional information or documentation that must be submitted to complete the application, which notice will give the patient 30 days to provide such additional information before the application is denied. If the patient fails to provide the missing information or documentation within that time, a written notice will be sent to the patient denying the application for financial assistance and stating the reason for the denial.
E. Complete Applications
Once the Financial Assistance Application is complete and the required supporting documentation has been obtained, the completed financial assistance file will be submitted to appropriate staff. If the information indicates that the patient does not meet criteria to qualify for financial assistance under this Policy, a written notice will be sent to the patient denying the application for financial assistance and stating the reason for the denial. If the information indicates that the patient does meet criteria to qualify for financial assistance under this Policy, the staff reviewing the application will submit a recommendation for approval of the Financial Assistance Application to the person with appropriate approval authority under applicable policies, the approver may approve such Financial Assistance Application by giving affirmative approval, or by not objecting to such recommendation for fourteen days following receipt of the recommendation. Any disagreement by the approver with the recommendation must be reviewed and resolved promptly in accordance with procedures established by Tenet management.
VII. COLLECTION EFFORTS
A. Approved ECAs
Carondelet will not engage in, nor permit any third party debt collector or agency acting on its behalf to engage in, any Extraordinary Collection Actions to collect amounts charged for care, other than reporting of a debt to a credit reporting agency, filing suit, enforcement of liens obtained as a result of any such suit and garnishment of wages when appropriate and approved according to policy (collectively "Approved ECAs"), none of which shall be taken unless or until the other events have occurred as described below.
B. Required Steps Prior to Undertaking Approved ECAs
1. No Approved ECAs will be undertaken or permitted unless and until the following steps have occurred:
a. 120 days have passed since the first billing statement for the most recent episode of care. After this 120-day notification period, written notice (enclosing a Plain Language Summary) has been provided stating the Approved ECAs that the hospital
intends to take if the patient does not make arrangements to pay the bill or apply for financial assistance before a stated deadline, which will be at least 30 days from the date of such notice, and a reasonable effort has been made to orally notify the individual about this policy and how the individual may obtain assistance with the application process.
C. Suspension of Collections Activities.
In the event that Carondelet receives a Financial Assistance Application, and without regard to whether such application is complete or incomplete, at any time within which a patient is permitted to apply for financial assistance under this Policy, collection activities with respect to the care covered by the
application will be suspended pending review and determination of eligibility pursuant to this Policy.
D. Reversal of Collections Activities upon Financial Assistance
If the individual is determined to be eligible for financial assistance under this Policy, the hospital will take, and will cause any third party debt collector or agency acting on its behalf to take, reasonable steps to reverse any ECAs that may have been taken to collect on such account, including, but not limited to, removing any information that has been reported to any credit reporting agency with respect to such account. Further, upon approval for financial assistance, Carondelet will ensure that any amounts that the patient has paid for the care for which financial assistance treatment was approved will be promptly refunded to the patient.