Download a copy of the Financial Assistance Policy (Charity Policy)
SCL Health System (SCLHS ) is committed to providing financial assistance to persons who have health care needs and are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay for medically-necessary care based on their household financial situation. Consistent with its mission to deliver compassionate, high-quality, affordable health care services and to advocate for those who are poor and vulnerable, SCLHS strives to ensure that the financial ability of people who need health care services does not prevent them from seeking or receiving care.
SCLHS will provide, without discrimination, care of emergency medical conditions to individuals regardless of their ability to pay or their eligibility for financial assistance or for government assistance.
Financial assistance shall be provided to patients who meet program qualifications and reside within the SCLHS service areas. Financial assistance shall be provided, without discrimination, to patients from outside the SCLHS service areas, who otherwise qualify for the program, and who present with an urgent, emergent or life-threatening condition.
SCLHS will use the most current Federal Poverty Guidelines to determine eligibility under its financial assistance policy. Patients qualifying for financial assistance may receive fully discounted care or pay a discounted fee under this policy. A medical hardship provision extends financial assistance to patients with incomes above the financial assistance eligibility threshold and medical bills that exceed a threshold percentage of the patient’s household income.
This financial assistance policy complies with applicable federal, state, and local laws. Financial assistance is extended with the expectation that patients will cooperate with SCLHS procedures for applying for such financial assistance or other forms of payment. They will also contribute to the cost of their care according to their ability to pay. Individuals with the financial capacity to purchase health insurance shall be encouraged to do so, as a means of assuring access to health care services, for their overall personal health, and for the protection of their individual assets.
Access to insurance or Medicaid coverage will expand significantly in January 2014 through the federal and state Health Exchanges. It is expected that any uninsured patient cooperate with SCLHS in determining the availability of Medicaid or insurance coverage.
Accordingly, this written policy:
- Includes eligibility criteria for financial assistance – fully or partially discounted care.
- Describes the basis for calculating amounts charged to patients eligible for financial assistance under this policy.
- Describes the method by which patients may apply for financial assistance.
- Describes the methods to be used to widely publicize the policy within the communities served by SCLHS care sites.
- Limits the amounts that SCLHS will charge for emergency or other medically-necessary care provided to individuals eligible for financial assistance. The limit will be based upon the average rate generally approved of by Medicare.
This policy applies to all SCLHS hospital facilities including but not limited to:
- Exempla Good Samaritan Medical Center – Lafayette, CO
- Exempla Lutheran Medical Center – Wheat Ridge, CO
- Exempla Saint Joseph Hospital – Denver, CO
- St. Mary’s Hospital & Regional Medical Center – Grand Junction, CO
- St. Vincent Healthcare – Billings, MT
- Holy Rosary Healthcare – Miles City, MT
- St. James Healthcare – Butte, MT
- St. Francis Health Center – Topeka, KS
- St. John’s Health Center – Santa Monica, CA
In order to manage its resources responsibility and to allow SCLHS to provide the appropriate level of assistance to persons in need, the SCLHS Board of Directors establishes the following financial aid guidelines.
For the purpose of this policy, the following terms are defined:
Discounted Care: Financial assistance that provides care at a discounted fee to eligible patients with annualized family incomes between amounts equal to or greater than 200% but less than or equal to 400% of the Federal Poverty Guidelines. This type of financial assistance waives the patient financial obligation, with the exception of a flat fee copayment, for medical services provided by SCLHS. Eligible patients will receive discounted care with a flat fee copayment. The Discounted Care flat fee copayment charge is outlined in Attachment B.
Eligibility Determination Period: For purposes of determining financial assistance eligibility, SCLHS will review annual family income from the prior six-month period and/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.
Eligibility Qualification Period: Patients determined to be eligible shall be granted financial assistance for a period of six months. Financial assistance will also be applied to eligible accounts incurred for services received six months prior to the financial assistance application date.
Emergency medical conditions: As defined within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd), SCLHS treats persons from outside of an SCLHS service area if there is an emergent, urgent, or life-threatening condition. Effective Date: October 1, 2013
Family: As defined by the U.S. Census Bureau, a group of two or more people who reside together and who are related by birth, marriage or adoption. If a patient claims a dependent on their income tax return, according to the Internal Revenue Service rules, that individual may be considered a dependent for the purposes of determining eligibility. Any and all resources of the household are considered together to determine eligibility under the SCLHS financial assistance policy.
Family Income: Family Income is determined using the U.S. Census Bureau definition when determining eligibility based on the Federal Poverty Guidelines.
- Includes earnings, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, disability payments, pension or retirement income, interest, dividends, rents, royalties, income from estates and trusts, educational assistance, alimony, child support, financial assistance from outside the household, and other miscellaneous sources;
- Non-cash benefits (i.e. Medicare, Medicaid, and Supplemental Nutrition Assistance Program (SNAP) benefits, heat assistance, school lunches, housing assistance, need-based assistance from non-profit organizations, foster care payments, or disaster relief assistance) are not counted as income for making an eligibility determination for financial assistance;
- Capital gains or losses;
- Determined on a before-tax basis;
A person’s family income includes the income of all adult family members. For patients under 18 years of age, family income includes that of the parents and/or step-parents, unmarried or domestic partners, or caretaker relatives.
Federal Poverty Guidelines: Federal Poverty Guidelines are updated annually in the Federal Register by the United States Department of Health and Human Services under authority of subsection (2) of Section 9902 of Title 42 of the United States Code. Current guidelines can be referenced at http://aspe.hhs.gov/POVERTY/
Financial Assistance: Assistance provided to patients for whom it would be a financial hardship to fully pay the expected out-of-pocket expenses for medically-necessary services provided by SCLHS and who meet the eligibility criteria for such assistance.
Fully Discounted (No Charge) Care: A 100% waiver of patient financial obligation resulting from medical services provided by SCLHS. Uninsured and underinsured patients with annualized family incomes not in excess of 200% of the Federal Poverty Guidelines will be eligible for fully discounted care.
Guarantor: An individual other than the patient who is responsible for payment of the patient’s bill.
Gross Charges: The total charges at the organization's full established rates for the provision of patient care services before deductions from revenue are applied.
Medical Hardship: Financial assistance that provides a discount based on a sliding scale, to eligible patients with annualized family income in excess of 400% of the Federal Poverty Guidelines, but not exceeding $200,000, and financial obligations resulting from medical services provided by any SCLHS entity or provider that exceed 20% of annualized family income.
Medically Necessary: As defined by Medicare as services or items reasonable and necessary for the diagnosis or treatment of illness or injury.
Presumptive Charity: Determination of eligibility for financial assistance based upon socio-economic information specific to the patient that is gathered from market sources.
Reasonable Payment Plan: An extended payment plan that is negotiated between SCLHS and patient for any patient out-of-pocket fees. The payment plan shall take into account the patient's income and assets, the amount owed and any prior payments.
Uninsured Patient: An individual having no third-party coverage by a commercial third-party insurer, an ERISA plan, a Federal Health Care Program (including without limitation Medicare, Medicaid, SCHIP and CHAMPUS), Worker’s Compensation, or other third party assistance to assist with meeting his/her payment obligations.
Underinsured Patient: An individual, with private or public insurance coverage, for whom it would be a financial hardship to fully pay the expected out-of-pocket expenses for medical services provided by SCLHS.
Services and goods eligible under this financial assistance policy include the following:
- Trauma and emergency medical services provided in an emergency setting. Care will continue until the patient’s condition has been stabilized prior to any determination of payment arrangements;
- Services for a condition that, if not treated promptly, would lead to an adverse change in the health status of a patient;
- Non-elective services provided in response to life-threatening circumstances in a non-emergency room setting; and/or
- Other medically necessary services scheduled in advance and assessed and approved at the discretion of SCLHS.
Services not eligible for financial support include the following:
- Elective procedures not medically necessary including, and not limited to, cosmetic services.
- Other care providers not billed through SCLHS (e.g. independent physician services, private-duty nursing, ambulance transport, etc.). Patients must contact the service providers directly to inquire about assistance and negotiate payment arrangements with these practices.
Eligibility and Assistance Criteria
Financial assistance shall be extended to patients, or a patient’s guarantor, in accordance with the SCLHS mission and values. Eligibility for financial assistance shall be considered for those individuals who are uninsured, underinsured and unable to pay for their care, based upon a determination of financial need in accordance with this Policy. When determining patient eligibility, SLCHS does not take into account race, gender, age, sexual orientation, religious affiliation, social or immigrant status, or age of the patient’s account.
SCLHS shall provide financial assistance to patients, or a patient’s guarantor, in compliance with federal, state and local laws. Financial assistance shall be based on financial need and shall not take into account race, ethnicity, religion, creed, gender, age, social or immigration status, sexual orientation or insurance status.
Applicants for financial assistance are responsible for applying to public programs for available coverage. They are also expected to pursue public or private health insurance payment options for care provided by SCLHS. The patient’s, or a patient’s guarantor’s, cooperation in applying for applicable programs and identifiable funding sources, including COBRA coverage (a federal law allowing for a time-limited extension of health care benefits), shall be required. If SCLHS determines that COBRA coverage is possible, and the patient is not a Medicare or Medicaid beneficiary, the patient or patient’s guarantor, shall provide SCLHS with information necessary to determine the monthly COBRA premium. They will be expected to cooperate with SCLHS staff to determine whether they qualify for SCLHS COBRA premium assistance, which may be offered for a limited time to assist in securing insurance coverage.
Patients, or patients’ guarantors, who do not cooperate in applying for programs that may pay for their health care services, may be denied financial assistance. SCLHS shall make affirmative efforts to help a patient or patient’s guarantor, apply for public and private programs.
In accordance with FEDERAL EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) regulations, no patients shall be screened for financial assistance or payment information prior to the rendering of services in emergency situations.
The Federal Poverty Guidelines shall be used for determining a patient’s eligibility for financial assistance. Eligibility for financial assistance will be based on a combination of family income and assets.
Fully Discounted (No Charge) Care: For eligible services, fully discounted care will be provided to a patient, or patient’s guarantor, meeting the following criteria:
- Uninsured and underinsured patients meeting other eligibility criteria and with annual family incomes not in excess of 200% of the Federal Poverty Guidelines, and
- All other payment options have been exhausted for the patient including private coverage, federal, state and local medical assistance programs, and other forms of assistance provided by third-parties.
Discounted Care with Flat Fee Copayment: For eligible services, care will be discounted and a patient, or patient’s guarantor, charged a flat fee, providing that they meet the following criteria:
- Uninsured and underinsured patients meeting other eligibility criteria and whose annualized family incomes fall between amounts in excess of 200% but less than or equal to 400% of the Federal Poverty Guidelines, and
- All other payment options have been exhausted for the patient including private coverage, federal, state and local medical assistance programs, and other forms of assistance provided by third-parties.
The flat fee co-payment charge on the fees outlined in Attachment B shall not exceed the average Medicare rate for any eligible service provided.
Medical Hardship: While financial assistance is typically provided in accordance with the established criteria, it is recognized that there may occasionally be a need for granting additional support based on extenuating circumstances.
For eligible services, discounted care will be provided to a patient, or patient’s guarantor, meeting the following criteria:
- Patient, or patient’s guarantor, has annual family income in excess of 400% of the Federal Poverty Guidelines, but less than $200,000, and
- Patient, or patient’s guarantor, has exhausted all other payment options including private coverage, federal, state and local medical assistance programs, and other forms of assistance provided by third-parties; and
- The out-of-pocket, patient obligations resulting from medical services provided by SCLHS providers exceed 20% of annual family income.
Patient, or patient’s guarantor, meeting eligibility criteria for medical hardship shall have their SCLHS charges adjusted to the lower of 1) the average Medicare rate or 2) 20% of their annual family income. This charge adjustment will apply for all medical services qualified under this provision during a calendar year.
Uninsured Discount: Patients ineligible for financial assistance and having no third-party coverage for medically-necessary services provided by SCLHS will be considered for a discount as covered by the SCLHS Uninsured Discount Policy.
Payment Plans: A reasonable, no-interest, short-term payment plan will be established between SCLHS and the patient, or patient’s guarantor, for any balance remaining after the cost of care has been discounted under the financial assistance policy. The term of the payment plan shall not exceed 24 months.
Emergency Medical Services
SCLHS care sites shall provide individuals requesting emergency care, or those for whom a representative has made a request if the patient is unable, a medical screening examination to determine whether an emergency medical condition exists. SCLHS care sites will not delay examination and treatment to inquire about methods of payment or insurance coverage, or a patient's citizenship or legal status.
SCLHS care sites shall treat an individual with an emergency medical condition until the condition is resolved or stabilized and the patient is able to provide self-care following discharge, or if unable, can receive needed continual care. Inpatient care will be provided at an equal level for all patients, regardless of ability to pay. SCLHS care sites will not discharge a patient with an emergency medical condition prior to stabilization if the patient's insurance is canceled or otherwise discontinues payment during course of stay.
If a SCLHS hospital does not have the capability to treat the emergency medical condition, it will make an appropriate transfer of the patient to another hospital with such capability.
Amounts Billed to Patients Eligible for Discounted Care
The amounts to be collected from uninsured patients eligible for discounted care shall not exceed the average Medicare rate. No patients found eligible for financial assistance will be billed gross charges for eligible services while covered under the SCLHS financial assistance policy.
Applying for Financial Assistance
Financial assistance eligibility determinations will be made based on the SCLHS policy and an assessment of financial need. Uninsured and underinsured patients will be informed of the financial assistance policy and the process for submitting an application. Patients, or patients’ guarantors, have a responsibility to cooperate in applying for financial assistance by providing information and documentation on family size, income and assets.
SCHLS will first make reasonable efforts to explain the benefits of Medicaid and other available public and private programs to patients, or patients’ guarantors, and make available to them information on those programs that may provide coverage for services. SCHLS will make affirmative efforts to help patients, or a patients’ guarantors, apply for public programs, private programs and COBRA coverage, for which they may qualify and that may assist them in obtaining and paying for health care services. Patients identified as potentially eligible will be expected to apply for such programs.
Information on external coverage and the financial assistance policy of SCLHS will be communicated to patients in a manner that is easy to understand, culturally appropriate and in the most prevalent languages used in their communities.
Application and Documentation: All applicants must complete the SCLHS Financial Assistance application form and provide requested documents when applying for financial assistance (see #3 below). Documentation may include:
- Income information such as recent pay stubs, supporting documentation for self-employment income, the most recent income tax return and bank statements;
- Monthly expense details (as outlined on the financial assistance application form.); and/or
- 3. Asset information as required in the SCLHS policy and on the financial assistance application form.
This SCLHS policy provides for the protection of a minimum of $10,000 in cash and investments, equity in a primary residence up to a level of value consistent with homestead exemption under the bankruptcy law protections of the state in which the care site operates, one automobile per family, retirement plan accounts, irrevocable trusts for burial purposes, and/or Federal and State administered college savings plans.
All other assets will be considered available for payment of health care expenditures. The SCLHS financial assistance application form must be completed and documentation provided in order for a request to be considered. Financial assistance applications are to be submitted to the following offices:
Reference Attachment A for a listing of all SCLHS hospital locations.
Requests for financial assistance shall be processed promptly, and SCLHS shall notify the patient or applicant in writing within 30 days of receipt of a completed application. If denied eligibility for any of the financial assistance offered by SCLHS, the patient may re-apply whenever there has been a change of income or status. A financial assistance application may also be re-submitted at subsequent times of service if the most recent financial assistance determination was made more than one year prior.
SCLHS recognizes that not all patients, or patients’ guarantors, are able to complete the financial assistance application or provide requisite documentation. Financial counselors are available at each care site to assist any individual seeking application assistance. For patients, or patients’ guarantors, who are unable to provide required documentation but meet certain financial need criteria, SCLHS may grant financial assistance. In particular, presumptive eligibility may be determined on the basis of individual life circumstances that may include:
State-funded prescription programs;
Homeless or one who received care from a homeless clinic;
Participation in Women, Infants and Children programs (WIC);
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; and/or
Patient is deceased with no known estate.
For patients, or their guarantors, who are non-responsive to the SCLHS application process, other sources of information may be used to make an individual assessment of financial need. This information will enable SCHLS to make an informed decision on the financial need of non-responsive patients.
For the purpose of helping financially needy patients, SCLHS may utilize a third-party to review a patient’s, or the patient’s guarantor, information to assess financial need. This review utilizes a health care industry-recognized, predictive model that is based on public record databases. The model incorporates public record data to calculate a socio-economic and financial capacity score. The model’s rule set is designed to assess each patient to the same standards and is calibrated against historical financial assistance approvals for the SCLHS. The predictive model enables SCLHS to assess whether a patient is characteristic of other patients who have historically qualified for financial assistance under the traditional application process.
Information from the predictive model may be used by SCLHS to grant presumptive eligibility to, or relax some of, the documentation requirements for patients or their guarantors. In cases where there is an absence of information provided directly by the patient, and after efforts to confirm coverage availability, the predictive model provides a systematic method to grant presumptive eligibility to financially needy patients.
In the event a patient does not qualify under the presumptive rule set, the patient may still provide requisite information and be considered under the traditional financial assistance application process.
Patient accounts granted presumptive eligibility status will be adjusted accordingly. These accounts will be reclassified under the financial assistance policy. The discount provided will not be sent to collection and will not be included in SCLHS bad debt expense.
Presumptive screening provides a community benefit by enabling SCLHS to systematically identify financially needy patients, reduce administrative burdens and provide financial assistance to patients and the guarantors, some of whom not have been responsive to the financial assistance application process.
Financial Assistance Approvals
Financial assistance determinations will be made according to the approved policy and in a manner that reflects financial stewardship and social responsibility. Adjustments will follow the levels as established in the SCLHS policy.
Timeline for Establishing Financial Eligibility
Every effort will be made to determine a patient, or patient’s guarantor, eligibility prior to, or at the time of, admission or service. However, determination for financial support can be made during any stage of the patient’s stay after stabilization of medical condition or during the collection cycle.
Determination for SCLHS financial assistance will be made after all efforts to qualify the patient for other public or private programs have been exhausted. If other avenues of financial support are being pursued, SCLHS will communicate with the patient, or patient’s guarantor, regarding the process and expected timeline for determination and shall not attempt collection efforts while such determination is being made.
Requests for financial assistance shall be processed promptly, and SCLHS shall notify the patient or applicant in writing within 30 days of receipt of a completed application. If eligibility is approved, the patient will be granted financial assistance for a period of six months. Financial assistance will also be applied to all eligible accounts incurred for services received six months prior to application date.
If denied eligibility for any of the financial assistance offered by SCLHS, a patient, or patient’s guarantor, may re-apply whenever there has been a change of income or status. A financial assistance application may also be re-submitted at subsequent times of service if the most recent financial assistance determination was made more than one year prior.
Notification about Financial Assistance
SCLHS will make information readily available on its financial assistance polices or programs. Such information will be posted on the SCLHS and care site websites. Notices on the availability of financial assistance will be posted in emergency departments, urgent care centers, admitting and registration departments and patient financial services offices that are located on facility campuses, and at other locations that SCLHS deems appropriate. The notices in the care sites will be posted conspicuously. The signs and other information on financial assistance will be in English and in any other language that is the primary language of at least (a certain 20%) of the patients served annually by the specific care site.
In addition to the methods noted above, SCLHS will make financial assistance policies or program summaries available to appropriate community health and human services agencies and other organizations that assist people in need. Financial assistance information, including a contact number, shall be included in patient bills and through oral communication with uninsured and potentially underinsured patients. Notification about financial assistance will also be included in the SCLHS Conditions of Admission form. SCLHS will provide financial counseling to patients about their SCLHS bills and will make the availability of such counseling known. It is the responsibility of the patient or the patient's guarantor to schedule assistance with a financial counselor.
Information on the SCLHS financial assistance policy will be made available to care site staff. SCLHS will educate associates who work closely with patients (including those working in patient registration and admitting, financial assistance, customer service, billing and collections) about financial assistance and collection policies and practices. Referral of patients for financial assistance may be made by any SCLHS associate or medical staff, including physicians, nurses, financial counselors, social workers, case managers, chaplains and religious sponsors.
A request for financial assistance may be made by a patient, a patient’s guarantor, a family member, close friend or associate of the patient, subject to applicable privacy laws. SCLHS will also respond to any oral or written requests for more information on the financial assistance policy made by a patient or any interested party.
Appeals and Dispute Resolution
Patients may seek a review from SCLHS in the event of a dispute over the application of this financial assistance policy. Patients denied financial assistance may also appeal their eligibility determination.
Disputes and appeals may be filed by contacting the care site’s Chief Financial Officer. The basis for the dispute or appeal should be in writing and submitted within six months of the patient’s experience giving rise to the dispute or notification of the decision on financial assistance eligibility.
Refer to Attachment A for a listing of SCLHS hospital locations for the submission of any disputes or appeals.
SCLHS will document any and all financial assistance, whether fully discounted (no charge) care, discounted care or medical hardship in order to maintain proper controls and meet all internal and external compliance requirements.
Actions in the Event of Non-Payment
SCLHS will make certain efforts to provide uninsured patients with information about our financial assistance policy, such as including a summary of it with billing statements, before SCLHS or our collection vendors take certain actions to collect payment. SCLHS collection policies shall comply with federal and state regulations and laws governing health care billing and collections. No documentation information obtained through the application process will be used for collection actions.
No extraordinary collection actions will be pursued against any patient within 150 days of issuing the initial bill or without first making reasonable efforts to determine whether that patient is eligible for financial assistance. Reasonable efforts shall include, but not be limited to, validating that the patient owes the unpaid bills and that all sources of third-party payments have been identified and billed SCLHS. Reasonable efforts also include a prohibition on collection actions pursued against an uninsured patient (or one likely to be underinsured) until the patient has been made aware of the care site’s financial assistance policy and has had the opportunity to apply for it or has availed themselves of a reasonable payment plan. The care sites will refrain from extraordinary collection actions against a patient if s/he provides documentation that s/he has applied for health care coverage under Medicaid, or other publicly-sponsored health care programs.
The SCLHS policy regarding care for emergency medical conditions prohibits demanding payment prior to receiving services or permitting collection activities that could interfere with provision of emergency medical care.
The SCLHS policy requires that information on financial assistance be included in all statements sent to patients informing them of any outstanding balance due. Additionally, the care sites and/or care sites business associates shall contact non-responsive patients, using oral and written means of communication, to inform them of outstanding balances owed and to discuss eligibility for financial assistance or reasonable payment options.
As outlined in separate billing and collection policy, SCLHS may pursue collection actions against patients found ineligible for financial assistance, patients who received discounted care or medical hardship discounts but are no longer cooperating in good faith to pay the remaining balance, or patients who have established payment plans but are not in accordance with the payment plan. All collection practices of SCLHS follow the Fair Debt Collection Practice Act as amended by Public Law 104-208, 110 Stat. 3009.
In implementing this policy, SCLHS management and facilities shall comply with all other federal, state and local laws, rules and regulations that may apply to activities conducted pursuant to this policy.
The following care sites are not covered by this policy:
The SCLHS financial assistance policy is subject to periodic review. Any changes to the policy must be approved by the SCLHS Board of Directors.