Curry Health Network Financial Assistance Policy
PLAIN LANGUAGE SUMMARYThe financial assistance policy, in a brief, plain language summary version is available as a single page download.
PURPOSE:Curry Health Network (CHN) is committed to providing financial assistance 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 financial assistance is important, it is only one component of the community benefit that 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 maximize that the financial capacity of people who need health care services does not prevent them from seeking or receiving care.
DEFINITIONSFor the purpose of this policy, the terms below are defined as follows:
1. Financial Assistance: Healthcare services that have been or shall be provided but are never expected to result in cash inflows. Financial Assistance results from a provider's policy to provide healthcare services free or at a reduced rate.
2. 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.
3. 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).
4. Uninsured: The patient has no level of insurance or third-party assistance to assist with meeting his/her payment obligations.
5. 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.
6. 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.
7. Emergency medical conditions: Defined within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd).
8. Medically necessary: As defined by Medicare (services or items reasonable and necessary for the diagnosis or treatment of illness or injury).
POLICY:Accordingly, this written policy:
• Includes eligibility criteria for financial assistance -- free and discounted 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 shall 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 shall 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 the prior fiscal year period. This amount includes payments by insurance/government payors, and patient co-insurance, copayments and deductibles (collectively, "Payments").
2. The AGB Percentage:
a. The AGB Percentage for emergency or medically necessary care provided to a financial assistance-eligible individual is calculated annually, after the close of the fiscal year, by dividing payments for claims paid to CHN by the sum of the associated Gross Charges for those claims.
b. The AGB Percentage is applied to all types of services received by individuals who qualify for financial assistance under this Policy.
c. The AGB Percentage is calculated not later than the 120th day after the end of the fiscal year. The AGB Percentage will be applied to all applicable Gross Charges accrued for services to patients who qualify for financial assistance under this policy, for the next 12-month period, or until a new AGB Percentage is calculated, whichever is sooner.
d. The latest AGB Percentage in use by CHN is as follows:
Fiscal Year 2019: 60% of Amounts Generally Billed, Effective 7/1/2018
Fiscal Year 2020: 61% of Amounts Generally Billed, Effective 12/1/2019
3. For uninsured patients, the amount generally billed for emergency or medically necessary care provided to a financial assistance-eligible individual is determined by multiplying Gross Charges for that care by the AGB Percentage (the "AGB Payment").
4. For underinsured patients, the amount generally billed for emergency or medically necessary care provided to a financial assistance-eligible individual is determined by multiplying the AGB Percentage by the patient's out-of-pocket portion of the bill.
5. The percentages are applied by the 45th day after the end of the 12-month period CHN used in calculating the AGB percentage(s).
6. Financial assistance is not considered 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.
Guidelines for Implementation
In order to manage its resources responsibly 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 financial assistance are established.
A. Services Eligible under this Policy: For purposes of this policy, financial assistance refers to healthcare services provided by CHN without charge or at a discount to qualifying patients. The following healthcare services provided by CHN and offered at Curry General Hospital, Curry Medical Center, Curry Family Medical, Curry Medical Practice and Curry Medical West, and Curry Medical Center Emergency Care are eligible for financial assistance:
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 Financial Assistance: Eligibility for financial assistance shall 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 financial assistance 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. Financial assistance approval covers current accounts with a balance due. The financial assistance discount approval also applies to services covered under this policy for twelve months from the date of approval. Future care shall be reviewed on a case by case basis. Financial assistance applications shall be kept on file for one year. CHN reserves the right to request a new financial application at any time. Eligibility for the discount will be determined by evaluating family income, family size and the current calendar year federal poverty level. Patients in families whose applicable family income is at or below 450% of the federal poverty level for the size of the family, will be considered eligible for the discount.
The current calendar year federal poverty levels are as follows:
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, Radiology Associates or any other Radiological Groups with whom CHN contracts, 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 Financial Assistance:
1. Financial need shall be determined in accordance with procedures that involve an individual assessment of financial need; and may include:
a. 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;
b. tax returns of the patient or patient's guarantor;
c. 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);
d. 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;
e. review of the patient's (or guarantor's) available assets, and all other financial resources available to the patient; and
f. 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 financial assistance 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 up to two hundred forty (240) days following the first statement mail date. 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 financial assistance becomes known.
3. CHN's respect for human dignity and stewardship shall be reflected in the application process, financial need determination and granting of financial assistance. Requests for financial assistance 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 financial 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 that could provide sufficient evidence to provide the patient with financial assistance. In the event there is no evidence to support a patient's eligibility for financial assistance, CHN could use outside agencies in determining estimated income amounts for the basis of determining financial assistance 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. Payments Expected from Patients: AGB Payments for services eligible under this Policy will be further adjusted using a sliding fee scale, in accordance with Eligibility Criteria, as determined in reference to Federal Poverty Levels (FPL) in effect at the time of the determination. The sliding scale based on family size and income is as follows:
1. 100% waiver of AGB Payments for Family income at or below 200% of FPL.
2. 75% waiver of AGB Payments for Family income between 201% and 300% of FPL.
3. 50% waiver of AGB Payments for Family income between 301% and 350% of FPL.
4. 25% waiver of AGB Payments for Family income between 351% and 400% of FPL.
5. Patients with Family Income not exceeding 450% of FPL are eligible for the ABG Discount.
G. Communication of the Financial Assistance Program to Patients and Within the Community: Notification about financial assistance 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,
1. the publication of notices/information on financial assistance in patient bills and statements, including contact information for the Business Office and the website address of the FAP;
2. a Plain Language Summary with the Financial Assistance application,
3. posting notices in Emergency Department waiting areas,
4. Posting notices at CHN outpatient clinics,
5. Posting notices in CHN Admitting and Registration Departments,
6. Posting notices in CHN business offices, and
7. Posting notices at various locations throughout CHN facilities such as lobbies and patient waiting areas.
CHN also shall publish and widely publicize a summary of this financial assistance policy on facility websites, in brochures available at 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 language(s) spoken by the population serviced by CHN. Referral of patients for financial assistance may be made by any member of the CHN staff or medical staff, including healthcare providers, nurses, financial counselors, social workers, case managers, chaplains, and religious sponsors. A request for assistance may be made by the patient or a family member, close friend, or associate of the patient, subject to applicable privacy laws.
A free copy of the Full Financial Assistance Policy is available to the public at http://www.curryhealthnetwork.com/getpage.php?name=Charity_Policy&sub=Bill+Pay, or upon request, in person or in writing, by contacting Financial Counselors at (541) 247-3855 (Gold Beach, OR) or (541) 412-2017 (Brookings, OR).
CHN will not charge interest on any medical debt owed by a patient who qualifies for financial assistance under this policy.
H. Relationship to Collection Policies:
1. CHN's 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) take into account:
a. the extent to which the patient qualifies for financial assistance,
b. a patient's good faith effort to apply for a governmental program or for financial assistance from CHN, and
c. a patient's good faith effort to comply with his or her payment agreements with CHN.
2. For patients who qualify for financial assistance and who are cooperating in good faith to resolve their discounted bills, CHN may offer extended payment plans, shall not send unpaid bills to outside collection agencies, and shall cease all collection efforts, including extraordinary collection actions (ECAs).
3. CHN shall 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 care under this financial assistance policy or is eligible for coverage under the Oregon Health Plan. Reasonable efforts shall include:
a. Validating that the patient owes the unpaid bills and that all sources of third-party payments have been identified and billed by CHN;
b. Documentation that CHN has, or has attempted to, offer the patient the opportunity to apply for financial assistance pursuant to this policy and that the patient has not complied with the CHN's application requirements;
c. Documentation that the patient has been offered a payment plan but has not honored the terms of that plan.
4. Further, CHN will:
a. Refrain from initiating any Extraordinary Collection Activities (ECA) for at least 240 days from the date of the first post-discharge billing statement for the patient's care;
b. Provide a written notice about this Financial Assistance policy at least 30 days prior to initiating any ECAs. The written notice shall include a copy of the Plain Language Statement regarding any ECAs Curry Health Network or an authorized party intends to initiate, and reasonable efforts to notify the patient or patient guarantor orally about this Financial Assistance policy;
c. Accept Financial Assistance Applications for at least 240 days from the date of the first post-discharge billing statement.
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.