Financial Assistance Policy
Policy Name: Financial Assistance Policy (“FAP”)
Policy Number: ADMIN 0192/ SYS0004
Date this Version Effective: June 2016
Responsible for Content: Financial Assistance Oversight Committee
Policy and procedures for providing financial assistance to patients for services at the University of North Carolina Health Care System (UNCHCS). This policy applies to the following entities: UNC Hospitals (including Wakebrook and Hillsborough campuses), Chatham Hospital, Inc., High Point Regional Health, Regional Physicians, LLC, UNC Faculty Physicians (including Wakebrook and Hillsborough campuses), Rex Hospital, Inc., UNC Physicians Network, LLC, UNC Physicians Network Group Practices, LLC, Henderson County Hospital Corporation, doing business as Margaret R. Pardee Memorial Hospital, Johnston Health Services Corporation doing business as Johnston Health (including Clayton campus), and Caldwell Memorial Hospital, Inc.
As part of its mission, UNCHCS provides care for residents of North Carolina who are uninsured or underinsured and do not have the ability to pay for medically necessary health care services. The purpose of this policy is to use financial assistance resources available to UNCHCS to maximize the availability of health care services to the people of North Carolina in a consistent, equitable and effective manner.
This policy does not affect or limit UNCHCS’s dedication and obligation under EMTALA to treat patients with emergency medical conditions.
UNCHCS shall have an organized patient financial assistance program designed to help provide necessary health care for North Carolina residents to the extent that resources are available. For this purpose, a Financial Assistance Oversight Committee (FAOC) will oversee all aspects of the patient financial assistance program, including pharmacy financial assistance and transplant financial assistance. The policy in effect at the time of the approval/denial will be used to determine eligibility for financial assistance.
A summary of the policy’s baseline criteria, benefits and annual costs will be posted in service areas and on internet sites to include methods and contacts for application. The policy in its entirety may be obtained by contacting the Legal Department or the Office of Revenue Cycle Management.
Patient Financial Assistance consists of the following components:
- Discounts for Uninsured Services
- Charity Care
- Catastrophic Charity Care
- Presumptive Determinations
- Dental Services
- Psychiatry Psychotherapy Resident Clinic
A. Discounts for Uninsured Services
Persons who have no health insurance coverage, no coverage from any other third party (such as third party auto liability coverage), or who obtain services not covered by their health insurance will be eligible for a 40% discount on charges, except for Category 3 and 4 services in the Financial Assistance Exceptions Table (Appendix A). This discount will be given regardless of income or North Carolina residency.
The FAOC will review the discount amount on an interim basis to insure charge amount parity among all patients – those with insurance, those without insurance and those receiving financial assistance. Entities and affiliates not included in this policy may choose to adopt the 40%discount amount or a different amount.
Uninsured patients who ultimately become eligible for Charity Care and have previously received an uninsured discount adjustment will receive a Charity Care adjustment totaling the patient balance at the time of the Charity Careapproval. The uninsured discount will not be reversed. As a result, the sum of the uninsured discount adjustment(s) and Charity Careadjustment(s) posted to the same account equals the total Charity Care adjustment for financial reporting purposes.
B. Charity Care
Charity Care is a benefit where 100% of the current patient’s balance owed after copayment in Appendix C will be written off except for limitations in the Financial Assistance Exceptions Table (Appendix A) and those balances covered by external funding sources. Given the 100%benefit, amounts generally billed (AGB) to determine the benefit does not apply. Charity Care is available for North Carolina residents who meet family income and residency criteria as defined in the Requirement Definitions for Charity Care (Appendix C). Any resident of North Carolina may apply for financial assistance and all applications will be considered without regard to race, color, gender, national origin or religious preference.
- A summary of this policy will be offered to all admitted patients, inpatient and outpatient. An application will be made available to anyone who requests it or is identified with a need AND meets eligibility screening criteria:
– The patient is a NC resident.
– The patient’s household income is at or below 250% of the Federal Poverty Guidelines.
- Patients may submit an application for Charity Care prior to their first visit to UNCHCS.
- UNCHCS will post notices as required by law regarding the availability of financial assistance. Patients requiring financial assistance or thought to require such assistance will be referred to a Financial Counselor or Financial Assistance Specialist.
- UNCHCS will affirmatively provide notices and brochures with contact information and how to obtain an application to community physicians and health centers. Community health centers that perform equivalent evaluations of applicants for financial assistance may be considered as a qualified extraordinary circumstance; whereby, an expedited application and application process is possible. See Section B3 Extraordinary Circumstances/Other Applicant Categories below.
- The provisions of this policy notwithstanding, UNC Physicians Network Group Practices, LLC, and Rex Rehabilitation and Nursing Care Centers of Raleigh and Apex may decline to accept a new patient with no funding source, including a new Charity Care patient.
- UNCHCS shall not refer a patient’s unpaid bill to an outside collection agency during the pendency of a patient’s application for financial assistance, not to exceed a period of 120 days. Patients will continue to receive informational statements during this time period. If the 120 days is reached prior to the final determination of the application or the application is denied, the statement cycle will resume after decrementing one cycle (30 days).
- If a patient is deemed eligible for Charity Care, eligibility is valid at the affiliates of UNCHCS covered by this policy. Patients may only receive Charity Care after all other financial resources available to the patient have been exhausted AND the patient is without sufficient income to cover out-of-pocket expenses as defined by UNCHCS. Other financial resources include, but are not limited to, private health insurance, CHIP, agency funding, Medicare and/or Medicaid.
- If the Charity Care application is approved, Charity Care will apply to balances after all third-party coverage has been collected. Whenever agency funding is available, whether or not the patient has been approved for Charity Care, agency funding must be secured prior to the service being scheduled and covered by Charity Care. If the service is scheduled prior to the completion of the agency funding process, the service must be flagged for exclusion from Charity Care.
- As of January 1, 2015, a determination of eligibility for Charity Care will be effective for 18 months prospectively from the date of approval and retroactively for all patient balances incurred prior to the approved Charity Care application.
- Charity Care covers only services deemed “medically necessary” by Medicare, Medicaid, or industry standards. All medically necessary services will be considered Category 1 unless approved as Category 2, 3 or 4 in the Financial Assistance Exceptions Table (Appendix A).
- For services in Categories 2, 3, and 4 in the Financial Assistance Exceptions Table (Appendix A), medical necessity will be determined by the treating physician. In instances where medical necessity is unclear, the Financial Assistance Oversight Committee will make a final determination.
- Patients actively eligible for Medicaid shall be eligible for Charity Care adjustments of patient balances as defined above except for services rendered in the Rex Rehabilitation and Nursing Care Centers. Confirmation of patient’s eligibility for Medicaid via an electronic Medicaid eligibility verification system is used in lieu of the Charity Care application.
- Medicare patients who are eligible for the Medicaid programs MQB-B and MQB-E qualify for a Charity Care adjustment of the balance remaining after payment by Medicare and any other applicable third-party payer except for balances incurred in the Rex Rehabilitation and Nursing Care Centers. Confirmation of the patient’s eligibility for Medicaid MQB-B or MQB-E on the date of service via an electronic Medicaid eligibility verification system is used in lieu of the Charity Care application.
2. Rights and Responsibilities
- If a patient does not have Medicaid or other private agency funding, but may qualify, the patient must cooperate with any available funding application process to be considered for Charity Care. If a patient does not cooperate, Charity Care will be denied or, if an active approval is on file, revoked, and the patient will be responsible for any balances.
- Only patient balances will be considered for Charity Care write-off. Patient balance is the amount for which there is no third-party coverage or other funding available, or balances after insurance. Accounts in a Liability status are not eligible for Charity Care.
- If the patient’s household income and assets minus a standard allowance for liabilities and expenses is less than or equal to 250% of the current Federal Poverty Guidelines for the patient’s family size, the patient may be eligible for Charity Care.
- Once the final determination has been made regarding Charity Care eligibility, the patient will be notified in writing.
- If a patient’s income or family size changes, a new Charity Care application may be submitted with supporting documentation for re-evaluation of Charity Care status.
- Refunds will be issued where required by Federal guidelines.The patient has the right to appeal a denied application for Charity Care. The appeal will be reviewed by the Financial Assistance Oversight Committee Clinical and/or Administrative Appeals Group. The patient will be notified in writing of the appeal outcome.
- A patient with primary insurance coverage who has been approved for Charity Care shall not be eligible for the Charity Care benefit unless the patient has complied with the terms and requirements of his or her primary insurance coverage to maximize available insurance reimbursements. For example, if the patient’s primary insurance covers services only at designated in-network facilities or with in-network providers, UNCHCS will not provide Charity Care for those services if the patient chooses to use a facility or provider that is not in-network. In those circumstances, the patient will be required to pay in advance for non-emergent/urgent care if the patient choses to use a non-network option.
3. Extraordinary Circumstances/ Other Applicant Categories
Qualification under extraordinary circumstances not outlined below requires approval by the Financial Assistance Oversight Committee.
- Homeless Persons – A homeless person is an individual who has no home or place of residence and depends on charity or public assistance. Such individuals will be eligible, even if they are unable to provide all of the documentation required for the Charity Care application. The Charity Care application needs to indicate in the address field that the patient is homeless, and the application must be signed by the patient.
- TROSA Patients – A TROSA patient is an individual who resides at the TROSA facility and depends on that facility for all of his or her care and does not receive monies when outside of the facility. Written proof from TROSA that the patient is a resident, including date of entry, along with the completed and signed demographic section of the application shall suffice as a complete Charity Care application. TROSA patients are exempt from Charity Care copays.
- Deceased Patients – The charges incurred by a patient who has died may still be considered eligible for Charity Care. For the Charity Care application, the deceased patient will count as a family member, but the deceased patient’s income will be zero. Accounts in an Estate status are not eligible for Charity Care.
- Inmates – Charges incurred by a patient who has subsequently become incarcerated may still be considered eligible for Charity Care. His/her income will be deemed as zero for the purposes of the Charity Care application from the date of entry into the correctional facility until the date of release from the correctional facility. Written proof from the correctional facility that the patient is an inmate, including date of entry and proposed date of release, shall suffice as the Charity Care application. Note: All charges incurred during the incarceration are the responsibility of the correctional facility.
- Transplant Services – are addressed in a separate Solid Organ Transplant Financial Policy.
- Pharmacy Services – are addressed in a separate Pharmacy Assistance Policy.
- International Patients – are not eligible for Traditional Charity Care, and are addressed in a separate International Patient Policy (ADMIN0236 / SYS####). An international patient is defined as one who is a citizen of a foreign country and has entered the United States by virtue of a Visa of any type, effective or expired.
- Eating Disorders – North Carolina residents of Orange, Person, and Chatham counties may apply for traditional Charity Care. Otherwise, eating disorders treatments are addressed in a separate Eating Disorders Treatment Program Policy.
- Project Access – Project Access, which resides in multiple counties throughout North Carolina, is comprised of physician groups that provide free care to the uninsured in their respective counties. A valid Project Access approval letter or card along with the completed and signed demographic section of the application shall suffice as a complete Charity Care application for the counties approved to participate. Current approved counties are Wake, Johnston, and Durham.
- The Community Clinic of High Point, Inc. – The Community Clinic of High Point, Inc., is a physician group that provides free care to the uninsured of High Point. A valid Community Clinic approval letter or card along with the completed and signed demographic section of the application shall suffice as a complete Charity Care application.
- Rex Rehabilitation and Nursing Care Centers – A patient who becomes unable to pay for his/her stay at Rex Rehabilitation and Nursing Care Centers during his/her stay must apply for Medicaid benefits and is not eligible for Charity Care under this policy. A patient who has an outstanding balance for a stay at Rex Rehabilitation and Nursing Care Centers and who is eligible for Charity Care under this policy may, at or after discharge, have Charity Care adjustments applied to the unpaid balance. The discount described above in Section III.A does not apply to services delivered to a patient admitted to Rex Rehabilitation and Nursing Care Centers.
- Helping Hands Clinic – The Helping Hands Clinic in Lenoir is a clinic that provides care for a nominal copayment to the uninsured of Caldwell County. A valid Helping Hands approval letter or card along with the completed and signed demographic section of the application shall suffice as a complete Charity Care application.
- Financial Assistance Application Backlog – When more applications are received than can be processed within 20 business days, adjudication of applications may use one or more of the following expedited methodologies:
– Applicants with a UNC Charity Care approval on file within the prior 18 months from the receipt date of the new application may be approved as long as all pages of the application are complete and the application is signed and dated.
– Applicants that submit a complete, signed, and dated application and either (1) a current tax return or (2) letter of support, if taxes are not filed, may be approved without consideration to bank account balances if the tax return does not indicate the existence of secondary or rental property.
- Once approved or denied, a notification letter will be sent to the patient’s address on file.
- If additional information is required to reach a determination, a request for additional information will be sent to the patient’s address on file.
- Patients approved for Charity Care will be required to pay a copay for each encounter. See Appendix B.
5. Changes to the Policy or Eligibility Criteria
Charity Care eligibility criteria will be reviewed periodically by the Financial Assistance Oversight Committee and is updated to reflect published changes in the Federal Poverty Guidelines. Revisions may be made at any time to the criteria or the policy based on changes in UNCHCS’s financial ability to provide financial assistance or changes in state or federal regulations.
6. Default Criteria Definition
In the absence of specific program description language defined in this policy, the current North Carolina Department of Health and Human Services, Division of Medical Assistance Medicaid Manual will be used as the default.
C. Catastrophic Charity Care
The purpose of this policy is to use financial assistance resources available to UNCHCS to provide health care services needed by people who may incur a catastrophic medical event regardless of their residency status and to do so as consistently, equitably, and effectively as possible.
- UNCHCS shall have a Catastrophic Charity Care Program designed to help provide necessary health care to the extent that resources are available.
- The Financial Assistance Oversight Committee will oversee all aspects of the Catastrophic Charity Care Program.
- The policy in effect at the time of the approval/denial will be used to determine eligibility for Catastrophic Charity Care.
2. Eligibility Criteria
- Patients who are denied Traditional Charity Care based on income exceeding 250% of the Federal Poverty Guidelines or based on residency status will be considered for Catastrophic Charity Care. Any patient or guarantor thereof may be considered without regard to race, color, gender, national origin or religious preference.
- Existing patient balances of UNCHCS, after all other financial resources available to the patient have been exhausted, should produce a medical debt-to-income ratio of greater than or equal to 20%. For example, if a household of two has an annual income of$75,000, the combined balances after all other means of payment must be at least$15,000. Other financial resources include, but are not limited to, private health insurance, agency funding, Medicare and/or Medicaid.
- If Catastrophic Charity Care is approved, Catastrophic Charity Care will apply to balances after all third-party coverage has been ruled out, including Medicaid and any private agency payers.
- For approved Catastrophic Charity Care, the patient’s medical debt after insurance will be reduced to 20% of the patient’s income and assets minus a standard 6% expense and liability allowance. If a patient has no income, the patient’s medical debt after insurance will be reduced by eighty four percent (84%).
- Catastrophic Charity Care may be awarded once every 12 months from the date of last Catastrophic Charity Care approval. If financial and/or family size situations change, a new Charity Care Application must be submitted.
- Balances in bad debt or already with collection agencies and/or the Attorney General’s Office will be considered. Prospective balances will not be considered.
- The calculation of medical debt will include balances that may have been decreased due to the Uninsured Discount.
- For Catastrophic Charity Care, all accounts for which the guarantor is responsible will be considered in the calculation of medical debt. Services otherwise excluded from Charity Care may be included in the Catastrophic calculation.
- When Catastrophic Charity Care is approved, the approval date is recorded. If there are balances pending third-party payment, the adjustment of the balances will be postponed until all third-party coverage has paid. Any patient balances left that were from dates of service on or prior to the approval date will then be adjusted.
- For patients pending Medicaid, Catastrophic Charity Care determination will be postponed until after final Medicaid disposition to allow for full and accurate accumulation of charges.
D. Presumptive Determinations
- To assist patients who may be eligible for financial assistance, but circumstances prevent completion of a full application, a presumptive determination may be utilized.
- Presumptive determinations are performed on individual accounts where no other funding source is available AND after a full 120-day billing cycle having generated three
(3) statements to the patient.
- A scoring methodology that represents a patient’s ability to pay based on criteria such as, but not limited to, asset ownership, debt payment tendencies, and available credit, is used to determine eligibility.
- Scores that qualify for a presumptive adjustment are relative to the scores for patients who would otherwise qualify for Charity Care if a full application were submitted.
- Upon qualification, the individual account will be adjusted to $0 using an adjustment code which identifies the adjustment as a presumptive determination, separate and distinct from Charity Care. Presumptive determinations, because they have been through a full 120-day billing cycle having generated three (3) statements to the patient, may be classified as Medicare Bad Debt, but NOT Medicare Charity for Medicare cost reporting. Only approved applicants who submitted a full paper application with all applicable verifications to determine income, assets, liabilities, and expenses may be classified as Medicare Charity.
E. Dental Services
- This section of the policy is for UNCH and UNCFP balances only. This section of the policy does not apply to any other UNC affiliate.
- In order to be eligible for financial assistance for dental services, the patient must be approved for UNCHCS financial assistance.
- Dental services that are eligible for full charity care coverage are those that would be covered by Medicare. Charity care coverage includes the following:
- When the severity of the underlying illness requires hospitalization
- A secondary service that is integral and necessary to treat a non-dental condition, such as tumor removal, and is provided at the same time as the primary service and by the same physician/dentist
- The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease
- An oral or dental examination performed on an inpatient basis as part of a comprehensive work-up prior to renal transplant surgery or performed in a RHC/FQHC prior to heart valve replacement
F. Psychiatry Psychotherapy Resident Clinic
The UNC Psychiatry Resident Psychotherapy clinics serve a training mission of providing psychiatry residents with the experience of learning to conduct long-term weekly psychotherapy. The patients’ out-of-pocket expense for psychotherapy sessions reflects this training focus and is currently set at $25 per session, regardless of whether the patient has insurance or receives charity care from UNCHCS.
Services appearing in Appendix A as exclusions are not eligible for financial assistance under this policy. Residential and related services at Rex Rehabilitation and Nursing Care Centers of Raleigh and Apex not covered by Medicare, Medicaid or third-party insurance by virtue of coverage limitation, benefit exhaustion and/or medical necessity are not eligible for consideration for the uninsured discount or Charity Care. Consideration may be granted for Rex Rehabilitation and Nursing Care Centers of Raleigh and Apex, residents’ out-of-pocket deductible, co-insurance and/or co-pay amounts up to an individually determined annual maximum which takes into consideration Medicaid spend-down requirements and resource limits.
V. Providers Participating in FAP
For more information regarding which providers who may provide medical services to patients of hospitals owned and/or affiliated with UNCHCS, please see Appendix D in the full pdf of this policy below.