Curry Health Network Financial Assistance Policy
PLAIN LANGUAGE SUMMARYThe financial assistance policy, in a brief, plain language summary version is available in brochure format, or as a single page download.
PURPOSE:Curry Health Network is committed to providing charity care to persons who have healthcare needs and are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay, for medically necessary care based on their individual financial situation.
Although charity care is important, it is only one component of the community benefit that Curry Health Network (CHN) provides. Other components of community benefit include, but are not limited to:
Unpaid public health, wellness, and educational programs
Unpaid cost of Medicaid and other public programs
Provision of essential healthcare services such as emergency rooms and low-income and Rural Health clinics
Cash and in-kind donations on behalf of the poor and needy to community agencies
Unreimbursed cost of training health professionals and clinical and community health research.
Consistent with the importance of delivering compassionate, high quality, affordable health care services and to advocate for those who are poor and disenfranchised, CHN strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care.
POLICY:Consistent with the importance of delivering compassionate, high quality, affordable healthcare services and to advocate for those who are poor and disenfranchised, CHN strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. CHN will provide, without discrimination, care of emergency medical conditions to individuals regardless of their eligibility for financial assistance or for government assistance.
Accordingly, this written policy:
Includes eligibility criteria for financial assistance -- free and discounted (partial charity) care
Describes the basis for calculating amounts charged to patients eligible for financial assistance under this policy
Describes the method by which patients may apply for financial assistance
Describes how the policy will be widely publicized within the community served by CHN
Provides an explanation of Amounts Generally Billed
Following a determination of financial-assistance eligibility, an individual will not be charged (billed) more than the Amounts Generally Billed (AGB) for emergency or other medically necessary care provided to individuals with insurance covering that care. At CHN, the AGB is determined by the "look-back" method, which is calculated as follows:
1. The AGB is calculated by reviewing all past claims that have been paid in full to CHN for medically necessary care by Medicare fee-for-service together with all private health insurers paying claims to CHN in a prior 12-month period. This amount can include co-insurance, copayments and deductibles.
2. The AGB for emergency or medically necessary care provided to a financial assistance-eligible individual is determined by multiplying gross charges for that care by one or more percentages of gross charges (called "AGB percentages").
a. The percentages are calculated at least annually by dividing the sum of certain claims paid to CHN by the sum of the associated gross charges for those claims.
b. Multiple AGB percentages may be calculated for separate categories of care (for example, in-patient vs out-patient care; or care provided by different departments) or for separate items or services.
3. The percentages are applied by the 45th day after the end of the 12-month period CHN used in calculating the AGB percentage(s).
Charity is not considered to be a substitute for personal responsibility. Patients are expected to cooperate with CHN'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 responsibility and to allow CHN to provide the appropriate level of assistance to the greatest number of persons in need, the following guidelines for the provision of patient charity are established.
II. DefinitionsFor the purpose of this policy, the terms below are defined as follows:
Charity Care: Healthcare services that have been or will be provided but are never expected to result in cash inflows. Charity care results from a provider's policy to provide healthcare services free or at a discount to individuals who meet the established criteria.
Family: Using the Census Bureau definition, a group of two or more people who reside together and who are related by birth, marriage, or adoption. According to Internal Revenue Service rules, if the patient claims someone as a dependent on their income tax return, they may be considered a dependent for purposes of the provision of financial assistance. Family includes unmarried parents.
Family Income: Family Income is determined using the Census Bureau definition, which uses the following income when computing federal poverty guidelines:
Includes earnings, unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources;
Noncash benefits (such as food stamps and housing subsidies) do not count;
Determined on a before-tax basis;
Excludes capital gains or losses; and
If a person lives with a family, includes the income of all family members, including unmarried parents (Non-relatives, such as housemates, do not count).
Uninsured: The patient has no level of insurance or third party assistance to assist with meeting his/her payment obligations.
Underinsured: The patient has some level of insurance or third-party assistance but still has out-of-pocket expenses that exceed his/her financial abilities.
Gross Charges: The total charges at the organization's full established rates for the provision of patient care services before deductions from revenue are applied.
Emergency medical conditions: Defined within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd).
Medically necessary: As defined by Medicare (services or items reasonable and necessary for the diagnosis or treatment of illness or injury).
III. ProcedureA. Services Eligible Under this Policy. For purposes of this policy, "charity" or "financial assistance" refers to healthcare services provided by Curry Health Network without charge or at a discount to qualifying patients. The following healthcare services offered at Curry General Hospital, Curry Medical Center, Curry Family Medical, Curry Medical Practice and Rush Surgery Center are eligible for charity:
1. Emergency medical services provided in an emergency room setting;
2. Services for a condition which, if not promptly treated, would lead to an adverse change in the health status of an individual;
3. Non-elective services provided in response to life-threatening circumstances in a non-emergency room setting; and
4. Medically necessary services, evaluated on a case-by-case basis at CHN's discretion.
B. Eligibility for Charity. Eligibility for charity will be considered for those individuals who are uninsured, underinsured, ineligible for any government health care benefit program, and who are unable to pay for their care, based upon a determination of financial need in accordance with this policy. The granting of charity shall be based on an individualized determination of financial need, and shall not take into account age, gender, race, social or immigrant status, sexual orientation or religious affiliation. Charity approval covers current accounts with a balance due. Future care will be reviewed on a case-by-case basis. Charity applications will be kept on file for one year. CHN reserves the right to request a new charity application at any time. CHN shall determine whether patients are eligible to receive charity for deductibles, co-insurance, or co-payment responsibilities.
C. Exclusion of Services Provided by Outside Contracted Agencies. This policy does not apply to services provided by outside agencies contracted by CHN, including but not limited to those provided by Rural Physicians Group, Wild Rivers Emergency Physicians, Medford Radiological Group, Aris Radiology, Quest Diagnostics, Peace Health Laboratories, Vista Pathology, and other outside agencies that may be contracted by CHN in the future.
D. Method by Which Patients May Apply for Charity Care.
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; tax returns
the use of external publicly available data sources that provide information on a patient's or a patient's guarantor's ability to pay (such as credit scoring);
reasonable efforts by CHN to explore appropriate alternative sources of payment and coverage from public and private payment programs, and to assist patients to apply for such programs;
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 services 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.
3. CHN's respect for human dignity and stewardship shall be reflected in the application process, financial need determination and granting of charity. Requests for charity shall be processed promptly and CHN shall notify the patient or applicant in writing within 30 days of receipt of a completed application.
E. Presumptive Financial Assistance Eligibility. There are instances when a patient may appear eligible for charity care discounts, but there is no financial assistance form on file due to a lack of supporting documentation. Often there is adequate information provided by the patient or through other sources, which could provide sufficient evidence to provide the patient with charity care assistance. In the event there is no evidence to support a patient's eligibility for charity care, Curry Health Network could use outside agencies in determining estimate income amounts for the basis of determining charity care eligibility and potential discount amounts. Once determined, due to the inherent nature of the presumptive circumstances, the discount can be granted - up to 100% write off of the account balance. Presumptive eligibility may be determined on the basis of individual life circumstances that may include:
1. State-funded prescription programs;
2. Homelessness or care received from a homeless clinic;
3. Participation in Women, Infants and Children programs (WIC);
4. Food stamp eligibility;
5. Subsidized school lunch program eligibility;
6. Eligibility for other state or local assistance programs that are unfunded (e.g., Medicaid spend-down);
7. Low income/subsidized housing is provided as a valid address; and
8. Patient is deceased with no known estate.
F. Eligibility Criteria and Amounts Charged to Patients. Services eligible under this policy will be made available to the patient on a sliding fee scale, in accordance with financial need, as determined in reference to Federal Poverty Levels (FPL) in effect at the time of the determination. Once a patient has been determined by Curry Health Network to be eligible for financial assistance, that patient shall not receive any future bills, for the discounted amount. The basis for the amounts Curry Health Network will charge patients qualifying for financial assistance is as follows:
1. Patients whose family income is at or below 150% of the FPL are eligible to receive free care;
2. Partial financial assistance for patients who have received medically necessary service and whose family income is in excess of 150%, but not exceeding 330%, of the FPL will be eligible for prorated discounts.
3. Patients whose family income exceeds 330% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of CHN.
G. Communication of the Charity Program to Patients and Within the Community. Notification about charity available from CHN, which shall include a contact number, shall be disseminated by CHN by various means, which may include, but are not limited to, the publication of notices in patient bills and by posting notices in emergency rooms, in the Conditions of Admission form, at urgent care centers, admitting and registration departments, business offices, patient financial services offices that are located on facility campuses, and at other public places as CHN may elect. CHN also shall publish and widely publicize a summary of this charity care policy on facility websites, in brochures available in patient access sites and at other places within the community served by the CHN as CHN may elect. Such notices and summary information shall be provided in the primary languages spoken by the population serviced by CHN. Referral of patients for charity may be made by any member of CHN staff or medical staff, including healthcare providers, nurses, financial counselors, social workers, case managers, chaplains, and religious sponsors. A request for charity may be made by the patient or a family member, close friend, or associate of the patient, subject to applicable privacy laws.
H. Relationship to Collection Policies. CHN shall develop policies and procedures for internal and external collection practices (including actions CHN 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, a patient's good faith effort to apply for a governmental program or for charity from CHN, and a patient's good faith effort to comply with his or her payment agreements with CHN. For patients who qualify for charity and who are cooperating in good faith to resolve their discounted bills, CHN may offer extended payment plans, will not send unpaid bills to outside collection agencies, and will cease all collection efforts. CHN will not impose extraordinary collections actions such as wage garnishments; liens on primary residences, or other legal actions for any patient without first making reasonable efforts to determine whether that patient is eligible for charity care under this financial assistance policy. Reasonable efforts shall include:
1. Validating that the patient owes the unpaid bills and that all sources of third-party payments have been identified and billed by CHN;
2. Documentation that CHN has, or has attempted to, offer the patient the opportunity to apply for charity care pursuant to this policy and that the patient has not complied with the application requirements;
3. Documentation that the patient has been offered a payment plan but has not honored the terms of that plan.
I. Regulatory Requirements. In implementing this policy, CHN management and facilities shall comply with all other federal, state, and local laws, rules, and regulations that may apply to activities conducted pursuant to this Policy.