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Financial Assistance Policy

Purpose

To define the policy for providing financial assistance to patients of University of Miami Health System
(UHealth) who have received emergency or other medically necessary care, meet certain income
requirements, do not qualify for state or federal assistance for the date of service, and are unable to establish
partial payments or pay their balance.

Also, to establish protocols for requesting and processing the Financial Assistance Application and defining the
supporting income validation documentation requirements.

Policy Statement

UHealth provides financial assistance for emergency care to individuals whose family income level is up to four times the Federal Poverty Guidelines. UHealth also provides financial assistance for medically necessary care to individuals who are residents of Florida whose family income level is up to four times the Federal Poverty Guidelines. Financial assistance applies to certain hospital and physician services, as described herein.

Definitions

  1. AHCA: Florida Agency for Health Care Administration.
  2. AGB: Amounts generally billed for emergency or other medically necessary care to individuals who have insurance coverage.
  3. Elective Care: Routine care that if not provided is not likely to lead to a deterioration of a patient's health status.
  4. EMTALA: The Emergency Medical Treatment and Labor Act, 42 USC 1395dd.
  5. FAP: Financial Assistance Policy.
  6. FPG: Federal Poverty Guidelines as updated annually in the Federal Register by the United States Department of Health and Human Services.
  7. Medically Necessary: Services that are necessary to evaluate, diagnose or treat an illness, injury or disease.
  8. Uninsured/Self-Pay patients: Patients who are uninsured or have no source of third-party coverage.
  9. UHealth: The University of Miami Health System
  10. Underinsured Patients: Patients who have insurance, but who demonstrate an inability to pay co-pays, co-insurance and deductibles, or whose coverage is insufficient to pay the current bill.
  11. Family: Family members consist of: patient, spouse, biological children, adopted children, and other verifiable dependents. Dependent status will be verified by Federal Income Tax Return for the most recent year or by a current court order. Separated spouses must provide proof of legal separation to be considered as single applicants.
  12. 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.
    • Non-cash benefits (such as food stamps and housing subsidies) do not count.
    • Income will be determined on a before-tax basis.

Commitment to Provide Emergency Medical Care

UHealth provides, without discrimination, care for emergency medical conditions to individuals regardless of whether they are eligible for assistance under this policy. UHealth will not engage in actions that discourage individuals from seeking emergency medical care, such as by demanding that emergency department patients pay before receiving treatment for emergency medical conditions or by permitting debt collection activities that interfere with the provision, without discrimination, of emergency medical care. Emergency medical services, including emergency transfers, pursuant to EMTALA, are provided to all UHealth patients in a nondiscriminatory manner, pursuant to UHealth's EMTALA policy.

Types of Financial Assistance; Eligibility Criteria

  1. Charity care approved for patients meeting eligibility guidelines. AHCA defines charity care as that portion of patient charges which are provided and are never expected to be reimbursed by the recipient of the services or third party payor, that were furnished through a charity care program operated by the provider and that adheres to the principles of the Healthcare Financial Management Association. The services is provided regardless of the recipient's ability to pay. Non-contractual adjustments, including discounts for prepayment, payment at time of service, and single case rate, are not to be treated as financial assistance for budgetary purposes.
  2. Uninsured/Self-Pay – financial assistance will be approved for patients who provide the required documentation and whose family income for the preceding twelve (12) months falls below 300% FPG. For those who qualify, balances will be reduced to zero.
  3. Underinsured – financial assistance will also be approved for patients who are underinsured. For these patients, the balance remaining after third party liability must be $1,000 or more. The family income for the preceding twelve (12) months must be less than or equal to 300% FPG. For those who qualify, balances will be reduced to zero.
  4. Medically indigent (uninsured or underinsured) – patients whose family income is less than 400% FPG with an uncollectable balance that exceeds 25% of their annual family income for the preceding 12 months will also be eligible for financial assistance. In no case shall the balance for a patient whose family income exceeds four (4) times FPG be considered for financial assistance. For those who qualify, balances will be reduced to zero.
  5. A validation must be completed to ensure that if any portion of the patient's medical services can be paid by any federal or state governmental health care program (e.g., Medicare, Medicaid, Tricare, Medicare secondary payer), private insurance company, or other private, non-governmental third-party payer, that the payment has been received and posted to the account. Financial assistance will not be granted until outstanding third-party payer liability has been resolved.
  6. FPG limits will be reviewed annually based upon income levels published in the Federal Register.

How to Apply for Financial Assistance

  1. In order to apply for financial assistance, generally patients must submit a completed Financial Assistance Application (attached to this policy) and provide the required documentation as follows:
  2. For Medicare beneficiaries, in addition to thorough completion of a Financial Assistance Application, the preferred income documentation will be the most current year's Federal Tax Return. Any patient/responsible party unable to provide his/her most recent Federal Tax Return may provide two pieces of supporting documentation from the following list to meet this income verification requirement:
    • State Income Tax Return for the most current year
    • Supporting W-2
    • Supporting 1099's
    • Copies of all bank statements for the last 3 months
    • Most recent bank and broker statements listed in the Federal Tax Return
    • Current credit report
    • Qualified Medicare Benefits (QMB for inpatients only)
  3. For Non-Medicare patients, the following items are the only forms of income verification that AHCA has approved and are required for submission with the Financial Assistance Application (documentation shall include ONE of the following forms at a minimum):
    • Current W-2 withholding statement
    • Current pay stubs
    • Income tax returns from the most recent prior year
    • Forms approving or denying unemployment compensation
    • Written verification of wage from employer
    • Written verification from public welfare agencies or any other governmental agency that can attest to the patient's income status for the past twelve (12) months
    • A witnessed statement signed by the patient or responsible party as provided for in public law 770-725, as amended, known as the Hill Burton Act. This statement must reference Florida Statutes 817.50, providing false information to defraud a hospital for the purposes of obtaining goods or services, is a misdemeanor in the second degree.
    • A Medicaid remittance voucher that reflects that the patient's Medicaid benefits for that Medicaid fiscal year have been exhausted.
  4. UHealth may also obtain a credit report for the purpose of identifying additional expenses, obligations, and income to assist in developing a full understanding of the patient's financial circumstances.
  5. Approved Financial Assistance Applications are valid for any prior dates of service where there is an outstanding patient balance that meets the financial assistance requirements in all other respects.
  6. The pending Medicaid and pending financial assistance processes should not be concurrent processes. Determination of pending Medicaid should be resolved prior to evaluating for potential pending financial assistance

Presumptive Financial Assistance Eligibility

There are instances when a patient may appear eligible for financial assistance 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 financial assistance. In the event there is no evidence to support a patient's eligibility for financial assistance, UHealth may use outside agencies in determining estimate income amounts for the basis of determining financial assistance eligibility and potential discount amounts. If deemed eligible, a charity write off amount will be determined. Presumptive eligibility may be determined on the basis of individual life circumstances that may include:

  1. State-funded prescription programs;
  2. Homeless or received care 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.
  9. Patients receiving charity assistance at JHS.
     

Assurance of Charging No More Than Amounts Generally Billed (AGB)

Following a determination of eligibility under this policy, a patient eligible for financial assistance will not be charged more for emergency or other medically necessary care than the amounts generally billed to individuals who have insurance covering such care (AGB). UHealth uses the Look-Back Method to determine AGB. Under this method, AGB is calculated for each licensed hospital by dividing the sum of all amounts of its claims for emergency and other medically necessary care that have been allowed by Medicare and all private health insurers during a prior 12-month period by the sum of the associated gross charges for those claims. UHealth will begin applying the AGB percentage by the 120th day after the end of the 12-month period used in the calculation, or otherwise to the earliest extent practicable. Members of the public may obtain the current AGB percentage and accompanying description of the calculation for any licensed hospital in writing and free of charge via the hospital contact information set forth below.

UHealth does not bill or expect payment of gross/total charges from individuals who qualify for financial assistance under this policy

Measures to Widely Publicize the Availability of Financial Assistance

UHealth implements various measures to widely publicize this FAP in communities served. Among other things, UHealth will publicize the existence of its financial assistance program to the community served by posting a copy of the FAP, FAP application, and a plain language summary of the FAP on its internet website. Furthermore, patient billing statements will advise patients of the existence of the financial assistance program, and signage will be posted at points of patient registration throughout the hospital (including emergency room and admissions areas) advising patients of the availability of financial assistance.

Actions Taken in the Event of Nonpayment

Information regarding the actions that UHealth may take in the event of nonpayment are described in a separate Billing and Collection Policy. Members of the public may obtain a free copy of this separate policy from UHealth via the contact information listed below.

Scope

This policy applies to UHealth, its employees, and medical staff involved in any aspect of the revenue cycle for patient appointments.

Responsibility

Practitioners and clinic managers are individually responsible for compliance with these parameters, will be held personally accountable for lack of compliance, and will be subject to corrective action for such failures, as outlined above. Chairs and VCAs are responsible for ensuring compliance for their departments. Chairs are ultimately responsible for ensuring compliance within their departments.

Hospital Contact Information

Mailing Address
University of Miami Health System
1320 S. Dixie Highway, Suite 285
Coral Gables, Florida 33146

Phone
UHealth Financial Counselors
305-243-2900


Website
http://uhealthsystem.com/billing/financial-assistance