Financial Assistance Policy
FINANCIAL ASSISTANCE POLICY
Policy Number: 1.30
Objective: Covenant Medical Center (Covenant) is committed to providing Financial Assistance to patients who have healthcare needs and are uninsured, underinsured, ineligible for government programs, and are otherwise unable to pay for medical care based on their individual financial situation. Consistent with its charitable mission, Covenant strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. Covenant will provide, without discrimination, emergency and other medically necessary care to individuals regardless of their eligibility for Financial Assistance or for government assistance. Covenant will work proactively to grant Financial Assistance to patients who are unable to pay for services rendered, who are not eligible for outside financial aid or government health care programs and who otherwise meet the requirements of this Policy.
Scope: All Covenant facilities and wholly owned entities.
Policy: Financial Assistance will be offered to patients who qualify, based upon their inability to pay, in accordance with U.S. Federal Poverty Guidelines and who meet the criteria outlined in this Policy. Financial Assistance is not considered to be a substitute for personal responsibility. Accordingly, patients seeking Financial Assistance shall be expected to cooperate with Covenant’s procedures for obtaining Financial Assistance, including completing applications for qualifying alternative coverage options, completing the Financial Assistance Application Form appended to this Policy and, where appropriate, to contribute to the cost of their care based on their individual ability to pay. This policy serves to establish and ensure a fair and consistent method for the review and completion of requests for charitable medical care to our patients in need.
- 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.
- Household Income: Household 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 who live together as part of a single family unit. A roomer or boarder is not included.
- 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.
- Emergency medical conditions: Defined within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd).
- Self-Pay Patient: individual receiving medical services that does not subscribe to any health insurance program and with no other third-party payer to accept financial responsibility for payment of medical services.
- Elective Services: Scheduled admissions, surgeries or procedures. Canceling or postponing of the scheduled admission, surgery or procedure would not be life threatening.
- Amount Generally Billed: The Amount Generally Billed (AGB) for emergency and other medically necessary services shall be calculated on an annual basis based upon a methodology approved by the Internal Revenue Service in final regulations. A written explanation of the method utilized by Covenant to calculate the AGB may be obtained from Covenant free of charge upon request.
Limitations: Covenant financial assistance does not include all costs that may be associated with medical services. The following is a non-exhaustive list of items or services that are not included in our financial assistance program:
- Transportation and Lodging: the patient is responsible for transportation to and from Covenant.
- Elective medical procedures, i.e., procedures which are not emergent or medically necessary.
- Food (other than inpatient meals).
- Durable Medical Equipment: Social Services may have limited vouchers available to help cover costs associated with durable medical equipment.
- Pharmacy Supplies: Covenant has a charity program to provide supplies at reduced costs for patients requiring financial assistance.
- Prescriptions filled at a non-Covenant pharmacy.
- Home Health Care or services provided at a non-Covenant entity are not covered under this Policy. Follow up care may be coordinated through Social Services, but approval for financial assistance is limited to services provided on-site and billed by a Covenant entity.
Procedure: Eligibility for financial assistance will be considered for those individuals who are uninsured or underinsured, 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. 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. Referral of patients for Financial Assistance may be made by any member of the Covenant staff or medical staff, including physicians, nurses, financial counselors, registrars, social workers or case managers. A request for Financial Assistance may be made by the patient or a family member, close friend, or associate of the patient, subject to applicable privacy laws. Requests can be made prior to, during or after service is rendered.
Financial Assistance will be calculated based on the sliding scale attached to, and incorporated into this Policy once the following criterion is met:
1. Medicaid denial based on excess income, denial by the Medicaid Medical Review Team, denial by an alternative program with linkage, or not disabled and not a denial due to failure of patient to complete Medicaid application process. Exceptions to this process may be granted through administrative approval by the Director or Patient Administration (or in the case of the VNA, its Director or designee).
i. If a patient has Medicaid coverage and is responsible for non-covered services, Covenant will consider those charges as a hardship and the patient will qualify for a Financial Assistance adjustment.
2. Received completed Patient Financial Profile validated by supporting documentation or internal verification.
3. Patient/Household must meet Covenant's Financial Assistance guidelines.
i. Financial need will be determined in accordance with procedures that involve an individual assessment of financial need and may:
1) Include an application process, in which the patient or the patient’s guarantor may be required to cooperate and supply personal, financial and other information and documentation relevant to making a determination of financial need;
2) Include the use of external publically available data sources that provide information on a patient’s or a patient’s guarantor’s ability to pay (such as credit scoring and propensity to pay evaluations);
3) Include reasonable efforts by Covenant to explore appropriate alternative sources of payment and coverage from public and private payment programs and to assist patients to apply for such programs;
4) Take into account the patient’s available assets, and all other financial resources available to the patient; and
5) Include a review of the patient’s outstanding accounts receivable for prior services rendered and the patient’s payment history.
4. Unusual medical expenses or catastrophic events, identified on the Patient Financial Profile, may also be considered.
i. For the purpose of non-discriminatory assessment, Covenant will consider the household income.
5. When patient services are medically necessary, as determined by referring/attending physician.
- Upon receipt of the requested information from the patient/responsible party, a final determination will be made within seven (7) calendar days.
- The Financial Assistance determination will be valid for three (3) months after approval.
- Presumed Financial Assistance will be determined based on best available information after all efforts to contact the patient and obtain financial information have been exhausted. Determination may be made during the collections process if efforts to collect information are exhausted at that time.
- 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. The need for Financial Assistance shall be re-evaluated at each subsequent time of service or at any time additional information relevant to the eligibility of the patient for Financial Assistance becomes known.
- It shall be the responsibility of the designated program/department to give all necessary information and paperwork for Financial Assistance to all eligible patients. The program designee is responsible to ensure all necessary criteria are met, the allowance is given and the adjustment is processed. Adjustments at or above the stipulated threshold must be approved by the department manager. All documents pertaining to Financial Assistance are maintained by the program designee within the program/department. A financial assistance classification will be recommended by Covenant’s Central Business Office Coordinator and approved by a properly authorized administrator, agreed upon by the Director of Revenue Cycle.
- For all elective admissions/hospital procedures if a patient cannot make a substantial payment or commit to a payment plan, services may be deferred.
- Falsification of information or incomplete documentation from the patient’s guarantor/responsible party would be considered grounds for a denial of Financial Assistance.
- Notwithstanding anything to the contrary stated above, the amounts charged for emergency and medically necessary medical services to patients eligible for Financial Assistance under this Policy will not be more than the amount generally billed to individuals with insurance covering such care.
Reasons for Denial: Covenant may deny a request for financial assistance for a variety of reasons including, but not limited to:
- Sufficient income.
- Sufficient asset levels.
- Patient is uncooperative or unresponsive to reasonable efforts to work with the patient.
- Requests for care when there is no identifiable means of obtaining long-term support (e.g., medication or implantable devices) needed to sustain the initial successful outcomes of care.
- Incomplete Financial Assistance application despite reasonable efforts to work with the patient.
- Pending insurance or liability claim.
- Withholding insurance payment and/or insurance settlement funds, including insurance payments sent to the patient to cover services provided by Covenant, and personal injury and/or accident related claims.
Relationship to Collection Policies: Covenant management has developed policies and procedures for internal and external collection practices (including actions the hospital 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 Financial Assistance, a patient’s good faith effort to apply for a governmental program or for Financial Assistance from Covenant, and a patient’s good faith effort to comply with his or her payment agreements with Covenant. For patients who qualify for Financial Assistance and who are cooperating in good faith to resolve their discounted hospital bills, Covenant may offer extended payment plans, will not send unpaid bills to outside collection agencies, and will cease all collection efforts. Covenant 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 Financial Assistance under this Financial Assistance policy. Reasonable efforts shall include:
- • Validating that the patient owes the unpaid bills and that all sources of third-party payment have been identified and billed by the hospital;
- • Documentation that Covenant 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 hospital’s application requirements;
- • Documentation that the patient has been offered a payment plan but has not honored the terms of that plan.
Nothing in this policy shall preclude Covenant from pursuing reimbursement from third party payers, third party liability settlements or other legally responsible third parties.
Covenant will not engage in extraordinary collection actions before it makes a reasonable effort to determine whether a patient is eligible for financial assistance under this Policy. If a patient fails to submit a financial assistance application during the notification period (120 days after the first billing statement) Covenant may engage in collection activity against the patient. Collection activity will proceed based on a separate Collection Policy (Covenant Policy Number PTAG025, In-House Collections and Bad Debt Referral Policy), which may be obtained from Covenant free of charge, upon request.
If a collection agency identifies a patient as meeting Covenant’s financial assistance eligibility criteria, the patient’s account may be considered for financial assistance up to 120 days after the account has been referred for collection activity (a total of 240 days after providing the first billing statement to the patient). Collection activity will be suspended on these accounts and Covenant will provide the patient notice that describes the additional information or documentation required to complete the financial assistance process (including a plain language summary of the process). If the entire account balance is adjusted, the account will be returned to Covenant. If a partial adjustment occurs, the patient fails to cooperate with the financial assistance process, or if the patient is not eligible for financial assistance, collection activity will resume.
Communication of the Financial Assistance Policy to Patients and Within the Community:
Covenant is committed to offering financial assistance to eligible patients who do not have the ability to pay for their medical services in whole or in part. In order to accomplish this charitable goal, Covenant Medical Center and Covenant HealthCare System sites will widely publicize this Policy in the communities that the individual Covenant affiliated sites serve.
Among other things, a bilingual plain language summary will be posted at main registration points to the hospital which will include instructions on how to obtain a printed version of the policy and an application for financial assistance. Affiliated sites will post a plain language summary of this Policy on its webpage, and shall make a copy of this Policy available by posting it on their webpage including the ability to download a copy of the Policy free of charge. Individuals in the community served will be able to obtain a copy of the Policy in locations throughout each Covenant affiliated site or upon request. Covenant shall also include plain language summaries of this Policy in patient statements.
Equal Opportunity: Covenant is committed to upholding the multiple federal and state laws that preclude discrimination on the basis of race, sex, age, religion, national origin, marital status, sexual orientation, disabilities, military service, or any other classification protected by federal, state or local laws.
Covenant will not consider: bad debt, contractual allowances, perceived underpayments for operations, public programs, cases paid through a charitable contribution, professional courtesy discounts, community service or outreach programs, or employment status as a means to determine financial assistance.
Regulatory Requirements: In implementing this Policy, Covenant 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.
Confidentiality: Covenant staff will uphold the confidentiality and individual dignity of each patient. Covenant will meet all HIPAA requirements for handling personal health information.
Board Approval and Review: This Policy has been adopted by the Board of Directors of Covenant Medical Center, Inc. and shall be reviewed by the Board of Directors on an annual Basis.
Related Policies/Procedures: Discounting Patient Charges Policy
Effective Date: 07/01/01, 03/2004, 01/2007, 12/2008, 04/2009, 8/2013
Revise Date: 06/2013
Approval: _______________________ _________________
Edward Bruff, Executive Vice President/COO Date