POLICY AND PROCEDURE
SECTION: Patient Accounts/Patient Access
MANUAL
SUBJECT : IRS Regulation #130266-11 501(r) (4) Affordable Care Act/ Financial Assistance Process
PURPOSE:
To ensure that Raritan Bay Medical Center’s hospital facilities (Perth Amboy and Old Bridge) are in compliance with the guidelines outlined in IRS Regulation 130266-11, Internal Revenue Code §501(r)(4) regarding the written Financial Assistance Policy (“FAP”) and Emergency Medical Care Policy, Federal Emergency Medical Treatment and Active Labor Transport Act of 1986 (“EMTALA”). The hospital will be referred to as RBMC throughout this policy.
RBMC adheres to the patient notification criteria with regards to the financial assistance programs that are available, eligibility requirements, calculation of amounts charged to patients and the actions taken in the event of nonpayment. RBMC will apply a self-pay discount rate that is equal to 100% of the Medicare fee schedule, to all uninsured individuals that do not qualify for Charity Care for all emergency and medically necessary healthcare services received as an inpatient or outpatient. This discount will be reflected in the patient’s first billing statement. Uninsured billing limits are in accordance with NJ P.L.2008 c.60
It is the policy of RBMC and all physicians with admitting privileges including ER, Trauma, Radiology, Pathology, Anesthesiology or any provider delivering emergency or other medically necessary care to comply with the standards of EMTALA and the EMTALA regulations. RBMC will provide a medical screening examination and such further treatment as may be necessary to stabilize an emergency medical condition for any individual coming to the emergency department seeking treatment, regardless of the individual’s medical or psychiatric condition, race, religion, age, gender, color, national origin, immigration status, sexual preference, handicap or ability to pay.
Certain physicians providing emergency or other medically necessary services to patients (including Emergency Department, Trauma, Radiology, Pathology, Anesthesiology, or Hospitalists and Intensivists) within the hospital facilities may not be covered under the RBMC FAP. Please refer to Exhibit A for RBMC’s provider listing. This listing specifies, by department, which providers are covered under this FAP and which are not.
New Jersey Hospital Care Payment Assistance Program (“Charity Care”) is available to those that do not qualify for state or federal programs, or are underinsured. Patients earning up to 300% of the Federal Poverty Level (FPL) may be eligible for New Jersey’s Charity Care program according to the regulations established in NJAC 10:52, Subchapters 11, 12, 13. Charity Care accounts are reported to the State of New Jersey at gross charges for subsidy valuation.
POLICY:
Financial Assistance Process:
Uninsured patients are screened by RBMC Financial Assistance Counselors to determine if they qualify for insurance prior to the determination of Charity Care. The screening process will not occur until a patient has been assessed and stabilized by a physician. In addition, RBMC may request a credit report for patients who identify that they have no income or for those who are self-employed. Below summarizes the different programs that individuals will be screened for:
Health Insurance Marketplace: In compliance with the Affordable Care Act, RBMC Certified Application Counselors will screen patients to determine if they are eligible to purchase insurance through the Marketplace and/or receive a subsidy from the Federal Government to assist with the purchasing of insurance.
Medicaid: RBMC Financial Assistance Counselors will assist patients, who meet the eligibility criteria, with the application process. There are several types of Medicaid available through the NJ Department of Health; we will help determine the program best suited for the patient’s circumstances.
o SSI-Medicaid: Supplements Medicaid benefits with a monthly income stipend that can help with basic needs. Assistance is available onsite to assist inpatients and certain outpatients who meet the eligibility criteria with the application process.
o Emergency Medicaid: This program will pay for emergency care provided by a hospital for people who would have been eligible for NJ FamilyCare/Medicaid but do not, due to their immigration status. The care must be for medical conditions that happen suddenly with severe symptoms that will cause a serious health problem if immediate medical attention is not provided. If care is received in a hospital for a condition meeting the above criteria, the hospital, physicians' and other related costs (including ambulance service) may be covered by this program.
o NJ FamilyCare (“NJFC”): Insurance program designed to provide coverage for adults and children up to 138% of the FPL. RBMC’s Financial Assistance Counselors will assist in completing the online application.
o Presumptive Eligibility-Medicaid: Presumptive Eligibility (PE) for NJFC offers temporary medical insurance for services provided by participating providers while NJFC applications are pending an eligibility determination. RBMC’s Financial Assistance Counselors will assist in completing the application.
Charity Care: Provides assistance to cover the costs of hospital services only. Patient must be categorically ineligible or present a NJFC denial letter which identifies that the patient has been denied for NJFC due to being over income or does not meet residency/other requirements as per NJFC regulations. Denial due to non-compliance with NJFC is not sufficient to be granted Charity Care. Patients are asked to document income, family size and asset information based on the regulations established in N.J.A.C. 10:52, Subchapters 11, 12 & 13. Patients requesting financial assistance are referred to an onsite Financial Assistance Counselor for consideration.
Uninsured Discounted Rates – RBMC will apply a self-pay discount rate that is equal to 100% of the Medicare fee schedule, to all uninsured individuals that do not qualify for insurance or Charity Care for all emergency and medically necessary healthcare services received as an inpatient or outpatient. This discount will be taken at the time of billing and will be reflected in the patient’s first billing statement.
Charity Care Eligibility Requirements
Charity Care assistance is free or reduced charge care which is provided to patients who receive inpatient and outpatient services at acute care hospitals throughout the State of New Jersey. Hospital assistance and reduced charge care are available for emergency or other medically necessary hospital care. Some services such as physician fees, anesthesiology fees, radiology interpretation, and outpatient prescriptions are separate from hospital charges and may not be eligible for reduction. Financial need is determined in accordance with NJAC 10:52, Subchapters 11, 12, 13 Charity Care applications, approval, billing and processing.
Hospital care payment assistance is available to New Jersey residents who:
1. Have no health coverage or have coverage that pays only part of the bill;
2. Are ineligible for any private or governmental sponsored coverage (such as Medicaid): and
3. Meet the income and assets criteria listed below.
Hospital assistance is also available to non-New Jersey residents, subject to specific provisions. Income Criteria
Income as a Percentage of Percentage of Medicaid Rate HHS Poverty Income Guidelines Paid by Patient
less than or equal to 200% 0% of Medicaid Rate greater than 200% but less than or equal to
225%
20% of Medicaid Rate greater than 225% but less than or equal to
250%
40% of Medicaid Rate greater than 250% but less than or equal to
275%
60% of Medicaid Rate greater than 275% but less than or equal to
300%
80% of Medicaid Rate
greater than 300% RBMC Uninsured Discount Rate
If patients on the 20% to 80% sliding fee scale are responsible for qualified out-of-pocket paid medical expenses in excess of 30% of their gross annual income (i.e. bills unpaid by other parties), then the amount in excess of 30% is considered hospital care payment assistance.
Assets Criteria
Individual assets cannot exceed $7,500 and family assets cannot exceed $15,000. Should an applicant’s assets exceed these limits, he/she may “spend down” the assets to the eligible limits through payment of the excess toward the hospital bill and other approved out-of-pocket medical expenses.
Methods Used to Determine Amounts Generally Billed (“AGB”) for Emergency or Medically Necessary Care
RBMC hospital outpatient and inpatient Charity Care claims are priced based on the New Jersey Medicaid program’s pricing and program policies for hospital outpatient and inpatient hospital services based on N.J.A.C. 10:52-1.6, Covered Services (inpatient and outpatient services) and NJAC 10:52-4, Basis of Payment.
Under Internal Revenue Code §501(r)(5), in the case of emergency or other medically necessary care, FAP-eligible patients will not be charged more than an individual who has insurance covering such care. Under these regulations RBMC has adopted the Prospective Medicare Method to calculate its AGB.
The Prospective Medicare Method is used for all other uninsured patients to calculate the amount that Medicare would allow (this includes the amount reimbursed by Medicare as well as the amount the beneficiary would be personally responsible for paying in the form of co-payments, co-insurance and deductibles) for emergency or other medically necessary care as if the FAP-eligible individual were a Medicare fee-for-service beneficiary. The billing statement will state the gross charges as a starting point for allowances, discounts, and deductions.
Any FAP-eligible individual will always be charged the lesser of AGB or any discounted rate available under this FAP.
Method of Applying for Charity Care
RBMC will apply a self-pay discount rate that is equal to 100% of the Medicare fee schedule, to all uninsured individuals for all emergency and medically necessary healthcare services received as an inpatient or outpatient. This discount will be taken at the time of billing and will be reflected in the patient’s first statement. Charity Care is available to those individuals who still cannot afford to pay this discounted amount.
A request for Charity Care and a determination of financial need may be done at any point in the revenue cycle. Eligibility is from the date of service and length of eligibility is based on the type of Charity Care received – see below.
• ER Charity Care Only – For Inpatients admitted through Emergency Room, good for that hospital stay only;
• 3 Month Charity Care – For Outpatient/Observation - Patients that will qualify for NJFC. This type of charity care covers the patients for any additional services they need from the hospital for the next 3 months while they are waiting for the NJFC approval;
• Up to One Year Charity Care – Patients who would not qualify for NJFC (i.e.; already have insurance but no secondary, undocumented, Medicare no secondary, individuals who would qualify for Marketplace but can’t apply due to Marketplace being closed). Charity Care applications and department contact information are available at any RBMC facility, by accessing www.rbmc.org/patient-guide/financial-information, and hospital staff have been provided with contact information. Financial Assistance Counselors are available on site for interviews and to answer questions. Applicants must provide RBMC with a completed Charity Care Application (“Application”). A completed Application must include certain required documents. These required documents include identification, proof that he/she has been residing in New Jersey since the time of service and intend to remain in the State, proof of income for one month prior to the date of service, and bank statements that include the balance on the date of service. Additional documents may be required depending on the individual applicant’s circumstance. Completed Applications can be mailed to any RBMC facility.
Upon receipt of a completed Application (and all required documentation), the request will be processed promptly and the applicant will be informed of the status no later than 10 days from receipt. If the application does not include sufficient documentation to make the determination, the application will be considered incomplete and the applicant will be notified in writing within 10 working days what is needed to complete the application. Additionally, RBMC will include a copy of the Plain Language Summary (“PLS”) (defined below). Patients will be given a reasonable period of time to provide the additional requested documentation. During this time RBMC, or any third parties acting on their behalf, will suspend any extraordinary collection actions (“ECAs”) (defined below) to obtain payment until a FAP-eligibility determination is made. An applicant (patient) or guarantor can submit a completed application for determination for Charity Care or reduced charge Charity Care at any time up to 24 months from the date of outpatient service or inpatient discharge or 240 days from the date of the first post-discharge billing statement; whichever is greater.
RBMC may grant Charity Care based on evidence other than what is described in the FAP and may be granted based on attestation even if the Financial Assistance Process or Application does not describe such evidence. Information may be obtained from an individual either in writing or orally (or a combination of both). RBMC may grant assistance based upon information provided by the individual on prior Charity Care Applications if such information is relevant to the current Application. RBMC may utilize information from credit bureaus or other outside sources. Charity Care applicants who are deemed ineligible for Charity Care will be notified in writing of the reasons for the denial and will be informed of the availability of the uninsured discount. Measures to Widely Publicize the FAP, Application & Plain Language Summary
The FAP and Plain language Summary is posted on RBMC’s website (www.rbmc.org/patient-guide/financial-information) and are available free of charge upon request. The guide contains information regarding all NJ Medicaid programs, SSI Medicaid, NJ Family Care, Presumptive Eligibility, and Charity Care. The NJ Charity Care Application and New Jersey Hospital Care Payment Assistance Fact Sheet are also available at each campus.
Notices are posted in emergency rooms, urgent care centers, admitting and registration departments, and patient financial services offices that are located at each campus. Notices are posted in English and in Spanish.
The FAP and PLS (defined below) are available in English and in the primary language of populations with limited proficiency in English (“LEP”) that constitute the lesser of 1,000 individuals or 5% of RBMC’s primary service area. Additionally, RBMC provides language interpreting and translation services, and provides information to patients with vision, speech, hearing or cognitive impairments in a manner that meets the patient’s needs.
The Plain Language Summary (“PLS”) of the FAP is available and will be distributed and posted in Community Centers, Churches, public gathering areas and community events. This is a written statement that notifies an individual that the hospital facility(s) offers financial assistance under the FAP and provides additional information in language that is clear, concise and easy to understand. This will help ensure that the community serviced by RBMC is aware of financial assistance availability. Additionally, Financial Counselors may participate in community outreach programs.
All patients will be offered a copy of the PLS as part of the intake or discharge process.
The availability of financial assistance will appear on billing statements. Each billing statement will also includes the website of where an individual can obtain copies of the FAP and PLS. They also will include the telephone number that patients can call if they have questions regarding the availability of financial assistance and the application process.
DEFINITIONS
Amounts Generally Billed (AGB): The amounts generally billed for emergency or other medically necessary care to individuals who have insurance covering such care.
Charity Care - NJ Hospital Care Payment Assistance Program: is free or reduced charge care which is provided to patients who receive inpatient and outpatient services at acute care hospitals throughout the State of New Jersey. Provides assistance to cover the costs of hospital services only.
Extraordinary Collection Action (ECA): Actions taken by a hospital facility against an individual related to obtaining payment of a bill for care covered under the hospital facility's FAP that requires a legal or judicial process, involves selling an individual's debt to another party, or involves reporting adverse information about an individual to consumer credit reporting agencies or credit bureaus (collectively, "credit agencies").
Financial Assistance Plan (FAP): A written policy that applies to all emergency and other medically necessary care provided by a hospital facility unless excluded in this policy. The policy does not generally apply to physician services.
Guarantor: The individual who is responsible for payment of health care services.
Household Income: Any funds coming into the household from immediate family members. This is not limited to wages, but also includes social security, unemployment compensation, disability benefits, income from investments, rental.
Uninsured: A patient/guarantor who has no level of insurance or third party assistance to provide for meeting payment obligation for health care services.
Underinsured: A patient/guarantor who has some level of insurance or third-party assistance but the remaining out-of-pocket responsibility exceeds their ability to pay without creating an extreme financial hardship
Please refer to our separate, written billing and collections policy for procedures and the actions that may take place in the event of non-payment.
See Patient Accounting IRS Regulation #130266-11 501(r)(6), Extraordinary Collection Actions/ Notification Process date
