I. Qualifying Criteria for Financial Assistance


Assisting Patients Who May Qualify for Coverage



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Assisting Patients Who May Qualify for Coverage




  1. LHS 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. Premium assistance may also be granted on a discretionary basis according to Trinity Health’s “Payment of QHP Premium and Patient Payables" procedure.




  1. LHS will have understandable, written procedures to help patients determine if they qualify for public assistance programs or LHS's FAP.




  1. Effective Communications



  1. LHS will provide financial counseling to patients about their health care bills related to the services they receive from LHS and will make the availability of such counseling known.




  1. LHS will respond promptly and courteously to patients’ questions about their bills and requests for financial assistance.




  1. LHS will utilize a billing process that is clear, concise, correct and patient friendly.




  1. LHS will make available information about charges for services they provide in an understandable format.




  1. LHS will post signs and display brochures that provide basic information about their FAP in public locations (at a minimum, the emergency room (if any) and admission areas) in LHS and list those public locations in LHS’s FAP.




  1. LHS will make available a paper copy of the plain language summary of the FAP to patients as part of the intake or discharge process. LHS will not have failed to widely publicize its FAP because an individual declines a plain language summary that was offered on intake or before discharge or indicates that he or she would prefer to receive a plain language summary electronically.



  1. LHS will make the FAP, a plain language summary of the FAP and the FAP application form available to patients upon request, in public places (at a minimum, the emergency room (if any) and admission areas) in LHS, by mail and on the LHS website. Any individual with access to the Internet must be able to view, download and print a hard copy of these documents. LHS must provide any individual who asks how to access a copy of the FAP, FAP application form, or plain language summary of the FAP online with the direct website address, or URL, where these documents are posted.




  1. LHS will list the names of individual doctors, practice groups, or any other entities that are providing emergency or medically necessary care in the LHS facilities by the name used either to contract with the hospital or to bill patients for care provided. Alternately, a hospital facility may specify providers by reference to a department or a type of service if the reference makes clear which services and providers are covered under LHS’s FAP.




  1. These documents will be made available in English and in the primary language of any population with limited proficiency in English that constitutes the lesser of the 1,000 individuals or 5 percent of the community served by LHS.



  1. LHS will take measures to notify members of the community served by LHS about the FAP. Such measures may include, for example, the distribution of information sheets summarizing the FAP to local public agencies and nonprofit organizations that address the health needs of the community’s low income populations.




  1. LHS will include a conspicuous written notice on billing statements that notifies and informs recipients about the availability of financial assistance under LHS's FAP and includes the telephone number of the LHS department that can provide information about the FAP, the FAP application process and the direct Web site address (or URL) where copies of the FAP, FAP application form, and plain language summary of the FAP may be obtained.




  1. LHS will refrain from initiating ECA(s) until 120 days after providing patients the first post-discharge billing statement for the episode of care, including the most recent episodes of care for outstanding bills that are aggregated for billing to the patient. LHS will also ensure all vendor contracts for business associates performing collection activity will contain a clause or clauses prohibiting ECA(s) until 120 days after providing patients the first post-discharge billing statement for the episode of care, including the most recent episodes of care for outstanding bills that are aggregated for billing to the patient.

  2. LHS will provide patients with a written notice that indicates financial assistance is available for eligible patients, identifies the ECA(s) that LHS (or other authorized party) intends to initiate to obtain payment for the care, and states a deadline after which such ECA(s) may be initiated that is no earlier than 30 days after the date that the written notice is provided. RHMs will include a plain language summary of the FAP with the written notice and make a reasonable effort to orally notify the patient about the LHS FAP and about how the patient may obtain assistance with the FAP application process.




  1. In the case of deferring or denying, or requiring a payment for providing, medically necessary care because of an individual's nonpayment of one or more bills for previously provided care covered under LHS's FAP, LHS may notify the individual about its FAP less than 30 days before initiating the ECA. However, to avail itself of this exception, LHS must satisfy several conditions. LHS must:




      1. Provide the patient with an FAP application form (to ensure the patient may apply immediately, if necessary) and notify the patient in writing about the availability of financial assistance for eligible individuals and the deadline, if any, after which the hospital facility will no longer accept and process an FAP application submitted by the patient for the previously provided care at issue. This deadline must be no earlier than the later of 30 days after the date that the written notice is provided or 240 days after the date that the first post‐discharge billing statement for the previously provided care was provided. Thus, although the ECA involving deferral or denial of care may occur immediately after the requisite written (and oral) notice is provided, the patient must be afforded at least 30 days after the notice to submit an FAP application for the previously provided care.




      1. Notify the patient about the FAP by providing a plain‐language summary of the FAP and by orally notifying the patient about the hospital facility’s FAP and about how the patient may obtain assistance with the FAP application process.




      1. Process the application on an expedited basis, to ensure that medically necessary care is not unnecessarily delayed if an application is submitted.

The modified reasonable efforts discussed above are not needed in the following cases:



  1. If 120 days have passed since the first post‐discharge bill for the previously provided care, and LHS has already notified the patient about intended ECAs

  2. If LHS had already determined whether the patient was FAP‐eligible for the previously provided care at issue based on a complete FAP application or had presumptively determined the patient was FAP‐eligible for the previously provided care




  1. LHS will provide written notification that nothing is owed if a patient is determined to be eligible for Free Care.




  1. LHS will provide patients that are determined to be eligible for assistance other than Free Care, with a billing statement that indicates the amount the patient owes for care as a FAP-eligible patient. The statement will also describe how that amount was determined or how the patient can get information regarding how the amount was determined.




  1. Fair Billing and Collection Practices




  1. LHS will implement billing and collection practices for the patient payment obligations that are fair, consistent and compliant with state and federal regulations.




  1. LHS will 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. LHS will also offer a loan program for patients who qualify.




  1. LHS will have written procedures outlining when and under whose authority a patient debt is advanced for external collection activities that are consistent with this Procedure.



  1. The following collection activities may be pursued by LHS or by a collection agent on their behalf:




  1. Communicate with patients (call, written correspondence, fax, text, email, etc.) and their representatives in compliance with the Fair Debt Collections Act, clearly identifying LHS. The patient communications will also comply with HIPAA privacy regulations.




  1. Solicit payment of the estimated patient payment obligation portion at the time of service in compliance with EMTALA regulations and state laws.




  1. Provide low-interest loan program for payment of outstanding debts for patients who have the ability to pay but cannot meet the short-term payment requirements.

  2. Report outstanding debts to Credit Bureaus only after all aspects of this Procedure have been applied and after reasonable collection efforts have been made in conformance with LHS's FAP.



  1. Pursue legal action for individuals who have the means to pay, but do not pay, or who are unwilling to pay. Legal action also may be pursued for the portion of the unpaid amount after application of LHS’s FAP. An approval by the LHS CEO/CFO must be obtained prior to commencing a legal proceeding or proceeding with a legal action to collect a judgment (i.e. garnishment of wages, debtor’s exam).




  1. Place liens on property of individuals who have the means to pay, but do not pay, or who are unwilling to pay. Liens may be placed for the portion of the unpaid amount after application of LHS’s FAP. Placement of a lien requires approval by the LHS CEO/CFO. Liens on primary residence can only be exercised upon the sale of property and will protect certain asset value in the property as documented in each RHM’s Procedure. Trinity Health recommends protecting 50% of the equity up to $50,000.




  1. LHS (or a collection agent on their behalf) shall not pursue action against the debtor’s person, such as arrest warrants or “body attachments.” LHS recognizes that a court of law may impose an arrest warrant or other similar action against a defendant for failure to comply with a court’s order or for other violations of law related to a collection effort. While in extreme cases of willful avoidance and failure to pay a justly due amount when adequate resources are available to do so, a court order may be issued; in general, LHS will first use its efforts to convince the public authorities not to take such an action and, if not successful, consider the appropriateness of ceasing the collection effort to avoid an action against the person of the debtor.




  1. LHS (or a collection agent on its behalf) will take all reasonably available measures to reverse ECAs related to amounts no longer owed by FAP-eligible patients.




  1. LHS may have a System Office approved arrangement with a collection agency, provided that such agreement meets the following criteria:




  1. The agreement with a collection agency must be in writing;




  1. Neither LHS nor the collection agency may at any time pursue action against the debtor’s person, such as arrest warrants or “body attachments;”




  1. The agreement must define the standards and scope of practices to be used by outside collection agents acting on behalf of LHS, all of which must be in compliance with this Procedure;




  1. No legal action may be undertaken by the collection agency without the prior written permission of LHS;




  1. Trinity Health Legal Services must approve all terms and conditions of the engagement of attorneys to represent LHS in collection of patient accounts;




  1. All decisions as to the manner in which the claim is to be handled by the attorney, whether suit is to be brought, whether the claim is to be compromised or settled, whether the claim is to be returned to LHS, and any other matters related to resolution of the claim by the attorney shall be made by LHS in consultation with Trinity Health Legal Services;




  1. Any request for legal action to collect a judgment (i.e., lien, garnishment, debtor’s exam) must be approved in writing and in advance with respect to each account by the appropriate authorized LHS representative as detailed in section V;




  1. LHS must reserve the right to discontinue collection actions at any time with respect to any specific account; and




  1. The collection agency must agree to indemnify LHS for any violation of the terms of its written agreement with LHS.




  1. Implementation of Accurate and Consistent Policies




  1. Representatives of LHS's Patient Financial Services and Patient Access departments will educate staff members who work closely with patients (including those working in patient registration and admitting, financial assistance, customer service, billing and collections, physician offices) 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.




  1. LHS will honor Financial Support commitments that were approved under previous financial assistance guidelines.




  1. Other Discounts




  1. Prompt Pay Discounts: RHMs may develop a prompt pay discount program which will be limited to balances equal to or greater than $200.00 and will be no more than 20% of the balance due. The prompt pay discount is to be offered at the time of service and recorded as a contractual adjustment and cannot be recorded as charity care on the financial statements.

b. Self-Pay Discounts: LHS will apply a standard self-pay discount off of charges for all registered self-pay patients that do not qualify for financial assistance under New Jersey law. These patients will be charged the highest commercial reimbursement percentage rate. This percentage rate will be updated yearly. 

c. Additional Discounts: Adjustments in excess of the percentage discounts described in this Procedure may be made on a case-by-case basis upon an evaluation of the collectability of the account and authorized by LHS's established approval levels.
Should any provision of this FAP conflict with the requirement of the law of the state of New Jersey, state law shall supersede the conflicting provision and LHS shall act in conformance with applicable state law.
SCOPE/APPLICABILITY

This procedure is based on a Trinity Health "Mirror Policy" and applies to all LHS Subsidiaries that operate licensed tax-exempt hospitals. Questions in this regard should be referred to the Trinity Health Office of General Counsel.


DEFINITIONS
Application Period begins the day that care is provide and ends the later of 240 days after the first post-discharge billing statement is provided to the patient or either --

  1. the end of the 30 day period that patients who qualified for less than the most generous assistance available based upon presumptive support status or prior FAP eligibility are provided to apply for more generous assistance.

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


Amounts Generally Billed ("AGB") means the amounts generally billed for emergency or other medically necessary care to patients who have insurance covering such care, The RHM’s acute and physician AGB will be calculated utilizing the look back methodology of calculating the sum of paid Medicare 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.
Discounted care means a partial discount off the amount owed for patients that qualify under the FAP.
Emergent medical services are those needed for a condition that may be life threatening or the result of a serious injury and requiring immediate medical attention. This medical condition is generally governed by Emergency Medical Treatment and Active Labor Act (EMTALA).
Executive Leadership Team (“ELT”) means the group that is composed of the highest level of management at Trinity Health.
Extraordinary Collection Actions ("ECA") include the following actions taken by a RHM (or a collection agent on their behalf):


  • Deferring or denying, or requiring a payment before providing, medically necessary care because of a patient’s nonpayment of one or more bills for previously provided care covered under the hospital facility’s FAP. If LHS requires payment before providing care to an individual with one or more outstanding bills, such a payment requirement will be presumed to be because of the individual’s nonpayment of the outstanding bill(s) unless LHS can demonstrate that it required the payment from the individual based on factors other than, and without regard to, his or her nonpayment of past bills.

  • Reporting outstanding debts to Credit Bureaus.

  • Pursuing legal action to collect a judgment (i.e. garnishment of wages, debtor's exam).

  • Placing liens on property of individuals.


Family (as defined by the U.S. Census Bureau) is a group of two or more people who reside together and who are related by birth, marriage, or adoption. If a patient claims someone as a dependent on their income tax return, according to the Internal Revenue Service rules, they may be considered a dependent for the purpose of determining eligibility under the RHM’s FAP.
Family Income - A person’s Family Income includes the Income of all adult Family members in the household. For patients under 18 years of age, Family Income includes that of the parents and/or step-parents, or caretaker relatives’ annual Income from the prior 12 month period or the prior tax year as shown by recent pay stubs or income tax returns and other information. Proof of earnings may be determined by annualizing the year-to-date Family Income, taking into consideration the current earnings rate.
Financial assistance policy (FAP) means a written policy and procedure that meets the requirements described in §1.501(r)-4(b).
Financial Assistance Policy ("FAP") application means the information and accompanying documentation that a patient submits to apply for financial assistance under a RHM's FAP. RHMs may obtain information from an individual in writing or orally (or a combination of both).
Financial Support means support (charity, discounts, etc.) provided to patients for whom it would be a hardship to pay for the full cost of medically necessary services provided by Trinity Health who meet the eligibility criteria for such assistance.
Free Care means a full discount off the amount owed for patients that qualify under the FAP.
Income includes wages, salaries, salary and self-employment income, unemployment compensation, worker’s compensation, payments from Social Security, public assistance, veteran's benefits, child support, alimony, educational assistance, survivor's benefits, pensions, retirement income, regular insurance and annuity payments, income from estates and trusts, rents received, interest/dividends, and income from other miscellaneous sources.
Medical Necessity is defined as documented in each RHM’s state’s Medicaid Provider Manual.
Policy means a statement of high-level direction on matters of strategic importance to Trinity Health or a statement that further interprets Trinity Health’s governing documents. System Policies may be either stand alone or Mirror Policies designated by the approving body.
Plain language summary of the FAP means a written statement that notifies a patient that the hospital facility offers financial assistance under a FAP and provides the following additional information in language that is clear, concise, and easy to understand:

  • A brief description of the eligibility requirements and assistance offered under the FAP.

  • A brief summary of how to apply for assistance under the FAP.

  • The direct Web site address (or URL) and physical locations where the patient can obtain copies of the FAP and FAP application form.

  • Instructions on how the patient can obtain a free copy of the FAP and FAP application form by mail

  • The contact information, including telephone number and physical location, of the hospital facility office or department that can provide information about the FAP and provide assistance with the FAP application process

  • A statement of the availability of translations of the FAP, FAP application form, and plain language summary of the FAP in other languages, if applicable.

  • A statement that a FAP-eligible patient may not be charged more than AGB for emergency or other medically necessary care


Procedure means a document designed to implement a Policy or a description of specific required actions or processes.
Regional Health Ministry (“RHM”) means a first tier (direct) subsidiary, affiliate or operating division of Trinity Health that maintains a governing body that has day-to-day management oversight of a designated portion of Trinity Health System operations. RHMs may be based on a geographic market or dedication to a service line or business.


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