FINANCIAL ASSISTANCE/CHARITY CARE FOR UNINSURED & UNDERINSURED PATIENTS

PURPOSE:

This policy identifies the circumstances under which South Shore Hospital will extend medical care free of charge or at a discount commensurate with the patient’s ability to pay. The necessity for medical treatment of all patients will be based upon clinical judgment without regard to the financial status of the patient.

DEFINITIONS:

AGB – amounts generally billed for emergency or medically necessary care to individuals who have insurance coverage.

 Bad Debt Expense – health care services provided that are expected to result in the generation of payment of services, but due to the patients’ unwillingness to meet their financial obligation, resulted in non-collection of those services.

Charity (Free) or Discounted Care – health care services provided that are not expected to result in the generation of payment in full, in accordance with procedures established in this policy.  This does not include contractual allowance amounts between hospital gross charges and contracted third party reimbursement rates.

ECAs – extraordinary collection actions are actions taken by South Shore Hospital against an individual related to obtaining payment of a bill for care covered under South Shore Hospital’s FAP that require a legal or judicial process or involve selling an individual’s debt to another party, or reporting adverse information about the individual to consumer credit reporting agencies or credit bureaus.

 FAP – financial assistance policy.

FAP-Eligible Individual – an individual eligible for financial assistance under South Shore Hospital’s FAP (without regard to whether the individual has applied for assistance under the FAP).

Insurance Payments – health care services that were expected to result in the generation of payment of services from Medicare, Medicaid, Blue Cross, HMO’s, PPO’s and any other valid and qualifying insurance that the patient possesses.  This includes any valid supplemental insurance to meet deductible and co-insurance payments required by insurance providers described above.

Patients without Insurance (Uninsured Patients) – patients requiring medically necessary services who are not covered by or eligible for Medicare, Medicaid HMO’s, PPO’s or other third party payers at the time healthcare services are provided.

Presumptive Charity Care – health care services to uninsured patients that are not expected to result in payment and no Financial Assistance Application is completed.

POLICY:

It is the policy of South Shore Hospital to provide quality medical health care to all persons regardless of race, creed, sex, national origin, handicap, age or the ability to pay. South Shore Hospital recognizes that not all individuals possess the ability or means to purchase essential medical services, and, further, that our mission is to serve the community with respect to providing healthcare services and healthcare education. Therefore, in keeping with the South Shore Hospital’s commitment to serve all members of the community, charity and/or subsidized care will be considered where the need and/or an inability to pay are identified.

Charity and/or subsidized care includes medical services provided to uninsured non-governmental patients, indigent government program patients and/or other low income, underinsured patients.  South Shore Hospital will also consider cases of medical need in catastrophic cases where income or assets would otherwise be considered too high to qualify for assistance.  Each patient will be reviewed based upon the standards set forth within this policy. Charity and/or subsidized care will be granted solely for the benefit of the patient and his/her family and is not intended to relieve the patient of liability for payment to other third parties.

PROCEDURES

Determination of Eligibility for Charity, Presumptive Charity or Discounted Care:

  1. Charity or discounted care is available for medically necessary services as defined by Medicare to patients who meet the financial and documentation criteria defined below. Each situation is reviewed on an individual case by case basis.  While not absolutely essential, the need for potential charity or discounted care should be established in advance of admission or rendering of service or shortly thereafter.
  2. Based on Federal Poverty Guidelines (FPG), financial assistance discounts are determined by a sliding scale of total household income. See attached Federal Poverty Guidelines Sliding Scale (Attachment A).  To determine the write off applicable to the patient’s bill, his/her total annual household income will be compared to the most current Federal Poverty Guidelines.

Income Level                                     Discount from Gross Charges

200% FPG or below                                                     100% Discount
Above 200%; at or below 300% FPG                            80% Discount
Above 300%; at or below 400% FPG                           65% Discount
Above 400% FPG                                                        Patient to pay balance
(unless patient qualifies under
the Illinois Hospital Uninsured
Patient Discount Act)

  1. In order to be eligible for charity or discounted care, the patient must be willing to provide verification of income, assets, etc., by filling out the Financial Assistance Application (Attachment B). It is the responsibility of the patient to voluntarily submit any and all documentation in order to be eligible to receive the discount.
  2. During the registration and information gathering process, the Financial Counselors will first determine if the patient qualified for medical assistance from other existing financial resources such as Medicare, Medicaid, Kid Care, Family Care or other state or federal programs. If the patient refuses to apply for existing financial resources or to provide information necessary to the application process, charity or discounted care cannot be granted.  If the application for existing financial resources is denied or has been previously denied, consideration for charity or discounted care will then be given.
  3. Patients will qualify for Presumptive Charity Care assistance based on their individual life circumstances, homeowner status, living address and other measurable socio-economics factors. Assistance provided under Presumptive Charity Care will be the most generous assistance available under the FAP (including free care).  Presumptive eligibility may be determined on the basis of individual life circumstances, including, but not limited to, state-funded prescription programs; homeless or received care from a homeless clinic; participation in Women, Infants and Children (WIC) programs; food stamp eligibility; subsidized school lunch program eligibility; eligibility for other state or local assistance programs that are unfunded (e.g., Medicaid spend-down); low income/subsidized housing is provided as a valid address; or patient is deceased with no known estate.
  4. Once the information on the Financial Assistance Application form is received, the Financial Counselor and the Director of Patient Financial Services (PFS) will determine the eligibility for charity or discount care. South Shore Hospital will suspend any ECA’s while the Financial Assistance Application is being reviewed.  The only criteria to be considered for financial assistance will be income and family size.  Income will be evaluated against the matrix of Federal Poverty Guidelines to determine whether full or partial discount can be approved.  Documentation of income can be submitted in the form of paycheck stubs, income tax return, Social Security checks, and other documents that are indicative of income.  If the information submitted is not perceived to be accurate or reliable, South Shore Hospital reserves the right to request additional documentation to substantiate income or family size.
  5. The insured patient with a large balance due to deductible and/or co-payments may be eligible for charity or discounted care. In order to qualify, the patient must complete the Financial Assistance Application and return it to the Financial Counselor for evaluation and recommendation.
  6. Patients requesting to speak with a Financial Counselor or to obtain an application or itemized bill may contact the Financial Counselor at 773-356-5212, or, if coming in person, the address of South Shore Hospital is Patient Account Department, 8012 S. Crandon Ave., Chicago, Illinois

Determination of Eligibility under the Illinois Uninsured Patient Discount Act:

  1. Illinois residents who have a family income that is no more than 600% of the Federal Poverty Guidelines (as determined each year), and who do not have any health insurance (or coverage under workers’ compensation, accident liability insurance, or other third party liability) as documented through South Shore Hospital’s insurance verification procedures, will receive a discount in accordance with the Illinois Hospital Uninsured Patient Discount Act (Act).  Uninsured patients who own assets with a value of more than 600% of the Federal Poverty Guidelines (excluding the patient’s primary residence, personal property exempt from judgment under Illinois law, and amounts held in a pension or retirement plan) are excluded from the discount required under the Act.
  1. For medically necessary services, charges will be discounted to 135% Medicare cost with the discount applicable to charges greater than $300.00. The maximum amount collectible in a 12-month period from a patient without insurance will be 25% of the family’s annual gross income.
  2. For services excluded by the Act, i.e., elective cosmetic surgery, South Shore Hospital may provide a discount from billed charges based on the patient’s ability to pay, as verified through South Shore Hospital’s procedures.
  3. Requests for the Hospital Uninsured Patient Discount under the Act need to be made within 60 days of the date of discharge or date of service. South Shore Hospital’s obligation under the Act shall cease if the patient fails to provide the hospital with the Financial Assistance Application and required documents or to apply for coverage under public programs when requested within 30 days of the hospital’s request.

 

Approval of Charity or Discounted Care:

To insure that the determination of charity or discounted care receives appropriate levels of considerations the following approval guidelines and levels will be followed:

Charity or Discounted Care
Appropriate Personnel
$1 – $30,000                                                    Director, PFS
$30,000 – and above                                        CFO

Basis for Calculating Amounts Charged to Patients:

Following the determination of FAP-eligibility, a FAP-eligible individual will not be charged more for emergency or other medically necessary care than the amounts generally billed (AGB) to individuals who have insurance covering such care.  The methodology used by South Shore Hospital to calculate AGB is the Look-back Method.  Members of the public may readily obtain the current AGB percentage and a description of how the percentage was calculated by contacting the South Shore Hospital Patient Account Department at 773-356-5219.

Actions That May Be Taken in the Event of Nonpayment:

 

The actions that South Shore Hospital may take in the event of nonpayment are described in a separate Billing and Collection Policy.  Members of the public may readily obtain a free copy of that policy by contacting the South Shore Hospital Patient Account Department at 773-356-5217.

 

Measures to Widely Publicize the Financial Assistance Policy:

  1. Every patient will, upon admission as an inpatient or outpatient, receive a written notice that shall contain information about the availability of financial assistance, including information about this policy as well as contact information for a hospital employee or office from which the person may obtain further information about the policy.
  2. Signs will be posted conspicuously in the admission and registration areas to notify patients and visitors about the availability of financial assistance. The signage will contain the following language, in accordance with the Illinois Hospital Fair Patient Billing Act:

“You may be eligible for financial assistance under the terms and conditions the hospital offers to qualified patients.  For more information contact South Shore Hospital Financial Counselors at 773-356-5212.”

  1. Each hospital bill, invoice, or other summary of charges to an uninsured patient shall include with it, or on it, a prominent statement, in accordance with the Illinois Hospital Uninsured Patient Discount Act, to the effect that an uninsured patient who meets certain income requirements may qualify for an uninsured discount and information regarding how an uninsured patient may apply for consideration under South Shore Hospital’s FAP.
  2. The FAP, Financial Assistance Application and plain language summary of the FAP will be available on South Shore Hospital’s website at southshorehospital.com. The documents will be posted in a format that will allow any individual with access to the Internet to access, download, view, and print a hard copy of the documents without requiring special computer equipment and without the payment of a fee.  South Shore Hospital will provide any individual who asks how to obtain online access to a copy of the FAP, Financial Assistance Application form, or plain language summary of the FAP with the direct website address, or URL, of the web page on which these documents are posted.
  3. Paper copies of the FAP, Financial Assistance Application and plain language summary of the FAP will be readily available in the admitting department and waiting areas. Patients may also call to obtain a copy and it will be mailed it to them at no cost.
  4. The Patient Access Department will also notify those patients with no insurance of the availability of financial assistance and will give a copy of the Financial Assistance Application and plain language summary of the FAP to patients.

Documentation and Recording of Charity or Discounted Care:

In order to quantify the level of charity care, a general ledger report will be available to document the total value of all charity or discounted care.  This report will be available for inspection by any government agency requiring levels of charity or discounted care as part of South Shore Hospital maintaining the exemption from federal, state, or local taxes.