I. Qualifying Criteria for Financial Assistance



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POLICY

It is the Policy of OUR LADY OF LOURDES HEALTH CARE SERVICES, INC. (the "Corporation") to address the need for financial assistance and support of patients for all eligible services provided under applicable state or federal law. Eligibility for financial assistance and support is determined on an individual basis using specific criteria and evaluated on an assessment of the patient’s and/or family’s health care needs, financial resources and obligations.


Trinity Health has a consistent approach to providing financial assistance to patients approved at the System governance level, which is implemented across all Regional Health Ministries ("RHM"), including the Corporation, through systemwide Procedures and Guidelines followed by each RHM and Subsidiary. Because of the dynamic nature of the environment, the impact will be closely monitored and revisited as necessary.

It is the Policy of the Corporation to follow Trinity Health systemwide Procedures and Guidelines to implement this Policy. Trinity Health has adopted and maintains, and all RHMs will follow, systemwide Procedures and Guidelines that address the following six requirements to ensure a consistent approach:


I. Qualifying Criteria for Financial Assistance
The Corporation will follow systemwide Procedures and Guidelines that specify the patients and services eligible for financial support and not eligible for financial support. The Corporation will establish charges based on amounts generally billed as determined by the Trinity Health System office. The Corporation will follow systemwide Procedures that address residency requirements and documentation required for establishing income. The Corporation will follow systemwide Procedures that describe the consideration required for patient assets, including protected assets. The Corporation will follow systemwide procedures that describe presumptive support and the required timeline for establishing financial eligibility. The Corporation will provide levels of financial support, including at a minimum support for Family Income at or below 200% of Federal Poverty Income Guidelines, and for Family Income between 201% and 400% of Federal Poverty Income as required by systemwide Procedures. The Corporation will follow systemwide Procedures for accounting and reporting for financial support.
II. Assisting Patients Who May Qualify for Coverage
The Corporation will make affirmative efforts to help patients apply for public and private programs for which they may qualify and that may assist them in obtaining and paying for health care services, including adoption of procedures to help patients determine if they qualify as required by systemwide Procedures. The Corporation may adopt procedures to provide patients with premium assistance in accordance with the Trinity Health systemwide Payment of Premiums Assistance Procedure.
III. Effective Communications
The Corporation will follow systemwide Procedures requiring it to provide financial counseling, respond promptly and courteously to patients’ questions, utilize a billing process that is clear, concise, correct and patient friendly, and make available specific information in an understandable format about charges for services. The Corporation will post signs and display brochures that provide basic information about the Corporation's Financial Assistance Policy (“FAP”) in public locations its facilities and list those public locations in the Corporation’s FAP, and make the FAP and a plain language summary and application form available to patients upon request in accordance with systemwide Procedures. The Corporation will post the FAP, a plain language summary, and an application form on the Corporation website.
IV. Implementation of Accurate and Consistent Policies
As required by the systemwide Procedures and Guidelines, the Corporation will provide staff education about billing, financial assistance, collection policies and practices, and treatment of all patients with dignity and respect regardless of their insurance status or their ability to pay for services.
V. Fair Billing and Collection Practices

The Corporation will implement billing and collection practices for the patient payment obligations that are fair, consistent and compliant with state and federal regulations, and make available to all patients who qualify a short term interest free payment plan with defined payment time frames based on the outstanding account balance as required by systemwide Procedures. The Corporation will also offer a loan program for patients who qualify. The Corporation will have written procedures outlining authority for approval of external debt collection activities. The Corporation will follow systemwide Procedures that identify debt collection activities that may be pursued by the Corporation or by a collection agent on their behalf. The Corporation (or a collection agent on its behalf) may NOT pursue action against the debtor’s person, such as arrest warrants or “body attachments.” The Corporation may have a Trinity Health approved arrangement with a collection agency, provided that such agreement meets criteria established by Trinity Health.


VI. Other Discounts
The Corporation will coordinate Financial Assistance to Patients with prompt pay, self-pay and other discounts as provided in systemwide Procedures.
State law shall supersede the systemwide procedures and the Corporation shall act in conformance with applicable state law.
The Policy is intended to fulfill the Corporation's commitment to:


  • Providing access to quality health care services with compassion, dignity and respect for those we serve, particularly the poor and the underserved in our communities;

  • Caring for all persons, regardless of their ability to pay for services; and

  • Assisting patients who cannot pay for part or all of the care that they receive.

The Corporation is a community of persons serving together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities. Aligned with our Core Values, in particular that of “Commitment To Those Who Are Poor”, we provide care for persons who are in need and give special consideration to those who are most vulnerable, including those who are unable to pay and those whose limited means make it extremely difficult to meet the health care expenses incurred.


Appendix A
Trinity Health Revenue Excellence Procedure No. RE-02-12-07

PURPOSE
Our Lady of Lourdes Health Care System, Inc. ("LHS"), an RHM of Trinity Health, is a community of persons serving together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities. Aligned with our Core Values, in particular that of “Commitment To Those Who Are Poor,” we provide care for persons who are in need and give special consideration to those who are most vulnerable, including those who are unable to pay and those whose limited means make it extremely difficult to meet the health care expenses incurred. LHS is committed to:


  • Providing access to quality health care services with compassion, dignity and respect for those we serve, particularly the poor and the underserved in our communities;

  • Caring for all persons, regardless of their ability to pay for services; and

  • Assisting patients who cannot pay for part or all of the care that they receive.

This Procedure, which provides guidance re implementing the accompanying Policy of the same name, balances financial assistance with broader fiscal responsibilities and provides LHS with the Trinity Health requirements for financial assistance for acute care and post-acute care health care services. LHS has adopted the Trinity Mirror Policy “Financial Assistance to Patients” and has developed local operating procedures in compliance with these requirements.



PROCEDURE
LHS will establish and maintain the Financial Assistance to Patients (“FAP”) procedure outlined below. The FAP is designed to address patients' needs for financial assistance and support as they seek services through LHS. It applies to all eligible services as provided under applicable state or federal law. LHS has established additional state-specific financial assistance requirements that will be incorporated into these procedures. Eligibility for financial assistance and support from LHS will be determined on an individual basis using specific criteria and evaluated on an assessment of the patient and/or Family’s health care needs, financial resources and obligations.
I. Qualifying Criteria for Financial Assistance


  1. Services eligible for Financial Support:




  1. All medically necessary services, including medical and support services provided by LHS, will be eligible for Financial Support.




  1. Emergency medical care services will be provided to all patients who present to an LHS hospital's emergency department, regardless of the patient’s ability to pay. Such medical care will continue until the patient’s condition has been stabilized — prior to any determination of payment arrangements.




  1. Services not eligible for Financial Support:




  1. Cosmetic services and other elective procedures and services that are not medically necessary.



  1. Services not provided and billed by LHS (e.g. independent physician services, private duty nursing, ambulance transport, etc.).




  1. As provided in Section II, LHS will proactively help patients apply for public and private programs. LHS may deny Financial Support to those individuals who do not cooperate in applying for programs that may pay for their health care services.




  1. LHS may exclude services that are covered by an insurance program at another provider location but are not covered at LHS hospitals after efforts are made to educate the patients on insurance program coverage limitations and provided that federal Emergency Medical Treatment and Active Labor Act (EMTALA) obligations are satisfied.




  1. Residency requirements




  1. LHS will provide Financial Support only to patients who reside within their service areas in the state of New Jersey and who qualify under LHS's FAP procedure.



  1. LHS may identify Service Areas in their FAP and include Service Area information in procedure design and training with a Service Area residency requirement will start with the list of zip codes provided by System Office Strategic Planning that define LHS's service areas. LHS will verify service areas in consultation with its local Community Benefit department. Eligibility will be determined by LHS using the patient's primary residence zip code.




  1. LHS will provide Financial Support to patients from outside their Service Areas who qualify under the LHS FAP and who present with an Urgent, Emergent or life-threatening condition.




  1. LHS will provide Financial Support to patients identified as needing service by physician foreign mission programs conducted by active medical staff for which prior approval has been obtained from LHS’s President or designee.




  1. Documentation for Establishing Income




    1. Information provided to LHS by the patient and/or Family should include earned income, including monthly gross wages, salary and self-employment income; unearned income including alimony, retirement benefits, dividends, interest and Income from any other source; number of dependents in household; and other information requested on the FAP application.




    1. LHS will list the supporting documentation such as payroll stubs, tax returns, and credit history required to apply for financial assistance in the FAP or FAP application. LHS may not deny Financial Support based on the omission of information or documentation that is not specifically required by the FAP or FAP application form.




    1. LHS will provide patients that submit an incomplete FAP application a written notice that describes the additional information and/or documentation that must be submitted within 30 days from the date of the written notice to complete the FAP application. The notice will provide contact information for questions regarding the missing information. LHS may initiate ECAs if the patient does not submit the missing information and/or documentation within the 30 day resubmission period and it is at least 120 days from the date the RHM provided the first post-discharge billing statement for the care. RHMs must process the FAP application if the patient provides the missing information/or documentation during the 240-day application period (or, if later, within the 30-day resubmission period).




  1. Consideration of Patient Assets




  1. RHMs will also establish a threshold level of assets above which the patient/family's assets will be used for payment of medical expenses and liabilities to be considered in assessing the patient's financial resources.

Protection of certain types of assets and protection of certain levels of assets must be provided in the LHS FAP.

Protected Assets:


  • Equity in primary residence is not considered;

  • Business use vehicles;

  • Tools or equipment used for business; reasonable equipment required to remain in business;

  • Personal use property (clothing, household items, furniture);

  • IRAs, 401K, cash value retirement plans are not protected by the State of New Jersey;

  • Financial awards received from non-medical catastrophic emergencies;

  • Irrevocable trusts for burial purposes, prepaid funeral plans; and/or

  • Federal/State administered college savings plans.

All other assets will be considered available for payment of medical expenses. Available assets above a certain threshold can either be used to pay for medical expenses or, alternatively, LHS may count the excess available assets as current year Income in establishing the level of discount to be offered to the patient. A minimum amount of available assets should be protected. The minimum amount is determined by LHS. LHS adopts the same thresholds that the State of NJ sets: for an Individual, the threshold asset value is $7,500; for a Family the threshold asset value is $15,000. At those threshold amounts, the patient is still eligible for Charity Care ("CC").




  1. Presumptive Support




  1. LHS recognizes that not all patients are able to provide complete financial information. Therefore, approval for Financial Support may be determined based on limited available information. When such approval is granted it is classified as “Presumptive Support”.




  1. The predictive model is one of the reasonable efforts that will be used by LHS to identify patients who may qualify for financial assistance prior to initiating collection actions, i.e. write-off of a patient account to bad debt and referral to collection agency. This predictive model enables LHS to systematically identify financially needy patients.




  1. Examples of presumptive cases include:




  • Deceased patients with no known estate

  • Homeless patients

  • Unemployed patients

  • Non-covered medically necessary services provided to patients qualifying for public assistance programs

  • Patient bankruptcies

  • Members of religious organizations who have taken a vow of poverty and have no resources individually or through the religious order.




  1. For patients who are non-responsive to the FAP application process, other sources of information, if available, should be used to make an individual assessment of financial need. This information will enable LHS to make an informed decision on the financial need of non-responsive patients.

 

  1. For the purpose of helping financially needy patients, a third-party may be utilized to conduct a review of patient information to assess financial need. This review utilizes a health care industry-recognized, predictive model that is based on public record databases. These public records enable LHS to assess whether the patient is characteristic of other patients who have historically qualified for financial assistance under the traditional application process. In cases where there is an absence of information provided directly by the patient, and after efforts to confirm coverage availability are exhausted, the predictive model provides a systematic method to grant presumptive eligibility to financially needy patients.




  1. In the event a patient does not qualify under the predictive model, the patient may still provide supporting information within established timelines and be considered under the traditional financial assistance application process.



  1. Patient accounts granted presumptive support status will be adjusted using Presumptive Financial Support transaction codes at such time the account is deemed uncollectable and prior to referral to collection or write-off to bad debt. The discount granted will be classified as Financial Support; the patient's account will not be sent to collection and will not be included in LHS’s bad debt expense. 




    1. LHS will notify patients determined to be eligible for less than the most generous assistance available under the FAP that he or she may apply for more generous assistance available under the FAP within 30 days of the notice. The determination of a patient being eligible for less than the most generous assistance is based on presumptive support status or a prior FAP eligibility determination. Additionally, LHS may initiate or resume ECAs if the patient does not apply for more generous assistance within 30 days of notification if it is at least 120 days from the date LHS provided the first post-discharge billing statement for the care. LHS will process any new FAP application that the patient submits by the end of the application period or, if later, by the end of the 30-day period given to apply for more generous assistance.




  1. Timeline for Establishing Financial Eligibility




    1. Every effort should be made to determine a patient’s eligibility for Financial Support prior to or at the time of admission or service. FAP Applications must be accepted during the application period. The application period begins the day that care is provided and ends the later of 240 days after the first post-discharge billing statement to the patient or either:

      1. the end of the period of time that a patient that is eligible for less than the most generous assistance available, based upon presumptive support status or a prior FAP eligibility determination, and who has applied for more generous financial assistance; or

      2. the deadline provided in a written notice after which ECAs may be initiated.

LHS may accept and process an individual’s FAP application submitted outside of the application period on a case-by-case basis as authorized by LHS's established approval levels.





    1. LHS (or other authorized party) will refund any amount the patient has paid for care that exceeds the amount he or she is determined to be personally responsible for paying as a FAP-eligible patient, unless such excess amount is less than $5 (or such other amount set by notice or other guidance published in the Internal Revenue Bulletin). The refunds of payments is only required for the episodes of care to which the FAP application applies.



    1. Determinations of Financial Support will be made after all efforts to qualify the patient for governmental financial assistance or other programs have been exhausted.




    1. LHS will make every effort to make a Financial Support determination in a timely fashion. If other avenues of Financial Support are being pursued, LHS will communicate with the patient regarding the process and expected timeline for determination and shall not attempt collection efforts while such determination is being made.



    1. Once qualification for Financial Support has been determined, subsequent reviews for continued eligibility for subsequent services should be made after a reasonable time period as determined by LHS.



  1. Level of Financial Support




    1. LHS will follow the Income guidelines established below in evaluating a patient’s eligibility for Financial Support. A percentage of the Federal Poverty Level (FPL) Guidelines, which are updated on an annual basis, is used for determining a patient’s eligibility for Financial Support. However, other factors should also be considered such as the patient’s financial status and/or ability to pay as determined through the assessment process.






  1. LHS are expected to implement the recommended level of Financial Support set forth in this Procedure. It is recognized that local demographics and the financial assistance policies offered by other providers in the community may expose some RHMs to large financial risks and a financial burden which could threaten LHS’s long-term ability to provide high quality care. RHMs may request approval to implement thresholds that are less than or greater than the recommended amounts from LHS’s Chief Financial Officer.




  1. Family Income at or below 200% of the Federal Poverty Level Guidelines:

Patient will qualify for 100% discount through NJ Hospital Care Assistance Program.










  1. Family Income between 201% and 400% of the Federal Poverty Level Guidelines:




      1. For 201% – 300% of most recent Federal Poverty Level Guidelines patient will qualify for partial discount through NJ Hospital Care Assistance Program as follows:

                                FPL              Patient Pays % of the Medicaid FFS Price

                               >200<=225%                      20%

                        >225<=250%                      40%

                               >250<=275%                      60%

                             >275<=300%                      80%


(Attachment B)
For 300% - 500% of most recent Federal Poverty Level Guidelines patient will receive an uninsured discount and will be charged 100% of the average Medicare percentage rate.
ii. The RHM’s acute and (employed) physician contractual

adjustment amounts for Medicare will be calculated utilizing the look back methodology of calculating the sum of paid claims divided by the total or “gross” charges for those claims by the System Office or RHM annually using twelve months of paid claims with a 30 day lag from report date to the most recent discharge date.




  1. Patients with Family Income up to and including 200% of the Federal Poverty Level Guidelines will be eligible for Financial Support for co-pay, deductible, and co-insurance amounts provided that contractual arrangements with the patient’s insurer do not prohibit providing such assistance.




  1. Medically Indigent Support / Catastrophic: Financial support is also provided for medically indigent patients. Medical indigence occurs when a person is unable to pay some or all of their medical bills because their medical expenses exceed a certain percentage of their Family or household Income (for example, due to catastrophic costs or conditions), regardless of whether they have Income or assets that otherwise exceed the financial eligibility requirements for Free Care or Discounted Care under the RHM’s FAP. Catastrophic costs or conditions occur when there is a loss of employment, death of primary wage earner, excessive medical expenses or other unfortunate events. Medical indigence/catastrophic circumstances will be evaluated on a case-by-case basis that includes a review of the patient’s Income, expenses and assets. If an insured patient claims catastrophic circumstances and applies for financial assistance, medical expenses for an episode of care that exceed 20% of Income will qualify the insured patient's co-pays and deductibles for catastrophic charity care assistance. Discounts for medically indigent care for the uninsured will not be less than LHS’s average contractual adjustment amount for Medicare for the services provided or an amount to bring the patients catastrophic medical expense to Income ratio back to 20%. Medically indigent and catastrophic financial assistance will be approved by LHS's CFO and reported to the System Office Chief Financial Officer.




  1. While Financial Support should be made in accordance with LHS's established written criteria, it is recognized that occasionally there will be a need for granting additional Financial Support to patients based upon individual considerations. Such individual considerations will be approved by LHS's CFO and reported to the System Office Chief Financial Officer.




  1. Accounting and Reporting for Financial Support




  1. In accordance with the Generally Accepted Accounting Principles, Financial Support provided by Trinity Health is recorded systematically and accurately in the financial statements as a deduction from revenue in the category “Charity Care”. For the purposes of Community Benefit reporting, charity care is reported at estimated cost associated with the provision of “Charity Care” services in accordance with the Catholic Health Association.




  1. The following guidelines are provided for the financial statement recording of Financial Support:




  • Financial Support provided to patients under the provisions of “Financial Assistance Program”, including the adjustment for amounts generally accepted as payment for patients with insurance, will be recorded under “Charity Care Allowance.”

  • Write-off of charges for patients who have not qualified for Financial Support under this Procedure and who do not pay for the services received will be recorded as “Bad Debt.”

  • Prompt pay discounts will be recorded under “Contractual Allowance.”

  • Accounts initially written-off to bad debt and subsequently returned from collection agencies where the patient is determined to have met the Financial Support criteria based on information obtained by the collection agency will be reclassified from “Bad Debt” to “Charity Care Allowance”.


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