Melissa Memorial HospitalManual: Business Office

Holyoke, CO 80734Section: Financial Assistance

Policy#: 1700.4

Page 1 of 3

SUBJECT: FINANCIAL ASSISTANCE PROGRAM FOR INSURED PATIENTS

PURPOSE:

East Phillips County Hospital District dba Melissa Memorial Hospital (MMH) is dedicated to providing quality healthcare to all patients regardless of age, sex, race, religion, disability, veteran status, national origin and/orability to pay. MMH makes every effort to complete a financial evaluation at the earliest possible point in the registration/accounting process for all patients indicating an inability to meet their financial obligation and will provide a Financial Assistance Program application once all other options for reimbursement have been exhausted. MMH’s Financial Assistance Program is intended to address the dual interests of providing access to care to those without the ability to pay (economic indigence) and to offer a discount from billed charges for those who are able to pay a portion of the costs of their care (medical indigence).

POLICY:

A. Definitions:

  1. Medicaid: The use of the term “Medicaid” throughout this document will refer to all State and Federal programs which include (but are not limited to) Medicaid, Medi-Cal, AHCCCS, CICP, FES, etc.
  1. Covered Services: Those inpatient and outpatient services provided by MMH which are Medically Necessary in accordance with the standards of MMH’s Medicare fiscal intermediary.
  1. Medically Necessary: Services required to identify or treat an illness or injury that is either diagnosed orreasonably suspected to be medically necessary. The most appropriate level of care, depending on a patient’s medical condition, may be a home, a physician’s office, an outpatient facility, or a long-term care, rehabilitation or hospital bed. A service must:
  1. Be required to treat an illness or injury or
  2. Be consistent with the diagnosis and treatment of the Patient’s conditions; and
  3. Be in accordance with the standards of good medical practice; and
  4. Be not be for the convenience of the Patient or the Patient’s physician; and
  5. Be performed at the most appropriate and readily available level of care or manner required by the patient’s medical condition; or
  6. Be that level of care most appropriate for the Patient as determined by the Patient’s medical condition and not the patient’s financial or family situation.
  1. Uninsured Patient: A patient without benefit of health insurance or government programs that may be billed for the care provided.
  1. Uninsured patients who are unable to pay for hospital services arepotential Financial Assistance Program patients. The criteria under which a patient will be considered for eligibility will be based upon the following:
  1. Income (using poverty levels established annually by the Department of Health and Human Services);
  1. Household size;
  2. Assets and liabilities;
  3. Estimated medical bill;
  4. Other extenuating circumstances.
  1. Patients eligible for Financial Assistance Program consideration will receive medically necessary services on a reduced or uncompensated basis. Eligibility will be based on the financial evaluation and determination of their ability to meet the financial obligation for the claim in question.
  1. Upon approval for eligibility, write-offs will be processed promptly in accordance with procedures, state statutes and regulations.
  1. Patients who are able, but unwilling, to pay for hospital services are considered uncollectible bad debts and will be referred to outside agencies for collection.
  1. Services will be eligible for write-off if:
  1. A patient qualifies for Medicaid after service has been provided by MMH. This includes any bills for services that predate coverage except those services provided to patients under the Colorado Indigent Care Program (CICP). Services provided to a CICP patient will be eligible for write-off only if they are not excluded services in accordance with the MMH’s contract with the CICP program.
  1. A patient qualifies for Medicaid but funding is not available to pay for services or Medicaid denies coverage for particular Covered Services.
  1. Financial Assistance Program write-offs will be granted subject to the approval of the administrator and CFO.
  1. The CFO/ financial counselorwill be responsible for monitoring the appropriateness of the Financial Assistance Program, the charges, patient days, and allowances.
  1. A patient who fails to fully cooperate with the Medicaid eligibility process will not be eligible for MMH Financial Assistance Program.

PROCEDURE:

  1. Document eligibility for Financial Assistance Program.
  1. Notify Medicaid on inpatients with no insurance or insufficient coverage, who cannot pay in full at time of service.
  1. Request a copy of the patient’s past year’s Federal income tax return, current bank statements, pay stubs and a completed MMH Financial Assistance Application.
  1. Use the Federal Poverty Guidelines as a source to determine eligibility for Financial Assistance Program multiplied by the factors in the attached Sliding Fee Schedule (1700.4A). Net worth (assets less liabilities) will be factored into the income guidelines in cases where guarantor has significant assets, but may not have a steady income.
  1. Provide patient and/or family with guidance through this process.
  1. Write-off the patient account using the appropriate general ledger account number when it is

determined that the write-off is appropriate. A monthly allowance for Financial Assistance

Program is also calculated to properly reserve accounts receivable.

  1. The appropriate Financial Assistance Program funding will be reversed if patient becomes eligible for any third-party funding source.

Additional Information:

Financial Assistance Program matrices outlining the discount from billed charges are listed below:

Percent of discount applied to prevailing wage for services rendered and according to income
$10 Clinic Fee / 90 % Discount / 75% Discount / 50% Discount / 25% Discount / 15% Discount / 11% Discount / 8% Discount
Percent of Poverty Guideline 2015
Size of Family Unit / 100% of Poverty / 110% of Poverty / 125% of Poverty / 150% of Poverty / 175% of Poverty / 185% of Poverty / 200% of Poverty / 250% of Poverty
1 / $11,670.00 / $12,837.00 / $14,588.00 / $17,505.00 / $20,423.00 / $21,590.00 / $23,340.00 / $29,175.00
2 / $15,730.00 / $17,303.00 / $19,663.00 / $23,595.00 / $27,528.00 / $29,101.00 / $31,460.00 / $39,325.00
3 / $19,790.00 / $21,769.00 / $24,738.00 / $29,685.00 / $34,633.00 / $36,612.00 / $39,580.00 / $49,475.00
4 / $23,850.00 / $26,235.00 / $29,813.00 / $35,775.00 / $41,738.00 / $44,123.00 / $47,700.00 / $59,625.00
5 / $27,910.00 / $30,701.00 / $34,888.00 / $41,865.00 / $48,843.00 / $51,634.00 / $55,820.00 / $69,775.00
6 / $31,970.00 / $35,167.00 / $39,963.00 / $47,955.00 / $55,948.00 / $59,145.00 / $63,940.00 / $79,925.00
7 / $36,030.00 / $39,633.00 / $45,038.00 / $54,045.00 / $63,053.00 / $66,656.00 / $72,060.00 / $90,075.00
8 / $40,090.00 / $44,099.00 / $50,113.00 / $60,135.00 / $70,158.00 / $74,167.00 / $80,180.00 / $100,225.00

DEPARTMENT / AREA: Business Office, Admissions DATE ORIGINATED: 11/04

APPROVED: Administration Last date revised: 12/10; 8/12, 2/15