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PURPOSE
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| This policy establishes a framework within which the Mission Hospital, Inc. (“Hospital”) will identify patients that may qualify for charity care, provide charity care, and account for charity care in accordance with the requirements set forth for Medicaid Disproportionate Share Hospitals. |
CHARITY CARE ELIGIBILITY SYSTEM
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| A. | | Application. To qualify for charity care, the Hospital requires the completion of the Mission Hospital, Inc. Financial Assistance Application. The Financial Assistance Application allows for the collection of information in accordance with State law and the income and documentation requirements set forth below.
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| 1. | | Calculation of Family Members. Hospital will request that patients requesting financial assistance verify the number of family members in their household.
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| | (i) | |
Adults. In calculating the number of family members in an adult patient’s household, include the patient, the patient’s spouse, and any dependents.
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| | (ii) | |
Minors. In calculating the number of family members in a minor patient’s household, include the patient, the patient’s mother, dependents of the patient’s mother, the patient’s father, and dependents of the patient’s father.
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| 2. | |
Income Calculation. Patients must provide their household’s Yearly Income.
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| | (i) | | Adults. For adults, the term “Yearly Income” for purposes of classification as Financially Indigent or Medically Indigent in accordance with this Policy means the sum of the total yearly gross income of the patient and the patient’s spouse.
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| | (i) | |
Minors. If the patient is a minor, the term “Yearly Income” means total yearly gross income from the patient, the patient’s mother, and the patient’s father.
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| B. | |
Income Verification. Patients or the responsible party must verify the income reported on the Financial Assistance Application in accordance with the Documentation Requirements set forth below.
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| 1. | | Documentation Requirements.
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| | (i) | | Documentation Available. The income reported on the Financial Assistance Application may be verified through any of the following mechanisms:
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| | | (a) | | Income Indicators. By the provision of third-party financial documentation, including IRS Form W-2, wage and earnings statement; pay check remittance, individual tax returns; Unemployment insurance, telephone verification by employer of the patient’s income, bank statements, or other appropriate indicators of yearly, monthly, weekly, or hourly income.
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| | | (b) | | Participation in a Public Benefit Program. By the provision of documentation showing current participation in a public benefit program such as Workers’ Compensation, Medicaid, County Indigent Health Program, TANF, WIC, Texas Healthy Kids, Children’s Health Insurance Program, also known as Tex-Care Partnership; Unemployment Compensation Determination letter, Unemployment Insurance, or other similar indigency-related programs. Proof of participation in any of the above programs indicates that the patient has been deemed Financially Indigent and therefore, is not required to provide his or her “Yearly Income” on the Financial Assistance Application.
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| | (ii) | | Documentation Unavailable. In cases where a patient is unable to provide documentation verifying income, Hospital may verify the patient’s income by providing an explanation of why the patient is unable to provide documentation verifying income and:
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| | | (a) | | Obtaining the Patient’s Written Attestation. By having the patient or the responsible party sign the Financial Assistance Application attesting to the veracity of the income information provided; or
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| | | (b) | | Obtaining the Patient’s Verbal Attestation. Through the written attestation of hospital personnel completing the Financial Assistance Application that the patient verbally verified Hospital’s calculation of the income reported on the Financial Assistance Application.
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| | (iii) | | De minimis Accounts. If the patient’s account is of de minimis value, not to exceed $500.00, Hospital may verify the patient’s income reported by the patient on the Financial Assistance Application by:
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| | | (a) | | Obtaining the Patient’s Written Attestation. Obtaining a Financial Assistance Application signed by the patient attesting to the veracity of the income information provided; and
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| | | (b) | | Documenting Efforts to Obtain Documentation. Documenting two attempts by Hospital to obtain documentation from the patient verifying income.
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| | (iv) | | Expired Patients. Expired patients may be deemed to have no Yearly Income. Documentation of patient-reported income on the Financial Assistance Application is not required for expired patients.
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| 2. | | Verification Procedure.
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| | | In determining a patient’s total income, Hospital may consider other financial assets and liabilities of the patient, as well as the patient’s family income and the ability of the patient’s family to pay. If a determination is made that a patient has the ability to pay the remainder of the bill, that determination does not preclude a re-assessment of the patient’s ability to pay upon presentation of additional documentation.
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| 3. | | Classification Pending Income Verification.
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| | | During the verification process, while the hospital is collecting the information necessary to determine a patient’s income, the patient may be treated as a private-pay patient in accordance with Hospital’s policies.
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| 4. | | Information Falsification.
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| | | Falsification of information may result in denial of the Financial Assistance Application. If, after a patient is granted financial assistance, Hospital finds material provision(s) of the Financial Assistance Application to be untrue, charity care status may be revoked and financial assistance may be withdrawn.
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| C. | | Classification as Financially Indigent “Financially Indigent” means an uninsured or underinsured person who is accepted for care with no obligation or with a discounted obligation to pay for the services rendered, based on the Charity Care Eligibility System.
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| | | Patients may be granted classification as Financially Indigent if their Yearly Income is less than or equal to 200% of the poverty guidelines updated annually in the Federal Register by the U.S. Department of Health and Human Services (“Federal Poverty Guidelines”).
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| | | If Hospital accepts a patient as Financially Indigent, the patient may be granted financial assistance in accordance with Schedule A of Hospital’s Financial Assistance Eligibility Discount Guidelines.
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| D. | | Classification as Medically Indigent “Medically Indigent” means a patient whose medical or hospital bills, after payment by third-party payers, exceed a specified percentage of the person’s income and who is unable to pay the remaining bill.
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| | | To be considered for classification as a Medically Indigent patient, the amount owed by the patient after payment by all third-party payers must exceed ten percent (10%) of the patient's Yearly Income, and the patient must be unable to pay the remaining amount owed. If the patient does not meet this initial threshold criteria, the patient cannot be classified as Medically Indigent.
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| | | Hospital may accept a patient who meets the Initial Threshold criteria for Medically Indigent and who meets either of the two acceptance criteria set forth below:
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| | (i) | | Yearly Income Must be Between 200% and 500% of the Federal Poverty Guidelines. The patient’s income must be greater than 200% but less than or equal to 500% of the Federal Poverty Guidelines. In these instances, Hospital will determine the amount of financial assistance granted to these patients in accordance with Schedule B of Hospital’s Financial Assistance Eligibility Discount Guidelines.
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| | (ii) | | Catastrophic Medical Indigence. The patient’s remaining bill must be greater than 50% of the patient’s Yearly Income, and the patient’s income must be greater than 500% of the Federal Poverty Guidelines. In these instances, Hospital may determine the amount of financial assistance granted to these patients in accordance Schedule C of Hospital’s Financial Assistance Eligibility Discount Guidelines.
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| E. | | Approval Procedures. Hospital will complete a Financial Assistance Approval Worksheet for each patient granted status as Financially Indigent or Medically Indigent. The Financial Assistance Approval Worksheet allows for the documentation of the administrative review and approval process utilized by the hospital to grant financial assistance.
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| F. |
| Document Retention Procedures. Hospital will maintain documentation sufficient to identify each patient granted status as Financially Indigent or Medically Indigent, the patient’s income, the method used to verify the patient’s income, the amount owed by the patient, and the person who approved granting the patient status as Financially Indigent or Medically Indigent.
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| | | Hospital reserves the right to limit or deny financial assistance at its sole discretion.
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Hospital reserves the right to designate certain services that are not subject to this Charity Care Policy.
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| NO EFFECT ON OTHER HOSPITAL POLICIES |
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This Policy shall not alter or modify other Hospital policies regarding efforts to obtain payments from third-party payers, patient transfers, or emergency care.
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