Purpose:
To provide relief for medical expenses incurred by patients who reside within our primary service area who do not have the financial resources to pay for their Roper St. Francis Healthcare services.
Policy:
Roper St Francis Healthcare (“RSFH”) will offer financial assistance and Medical Indigency Adjustments to patients who meet the established Financial Assistance guidelines. Family size and the Federal Poverty Guidelines (www.dhhs.state.nh.us) published annually by the Department of Health and Human Services will be the primary factors used to determine Financial Assistance eligibility. The patient and/or guarantor’s gross income, assets and expenses, and the dollar amount of the hospital bill may be taken into consideration. Patients with an annual income of 400% or less of the Federal Poverty Guidelines may be eligible for Charity Adjustments. Medical Indigency Adjustments may be available for patients whose RSFH medical expenses outweigh the ability to pay, constituting a financial hardship. This is based on medical expenses that exceed 20% of the guarantor’s annual gross income per calendar year.
The hospital shall send to anyone who requests information on the hospital’s Financial Assistance Program a letter outlining required information and a financial assistance application form. Requests for financial assistance may be proposed by sources other than the patient, such as the patient’s physician, family members, social service organizations, community or religious groups, or hospital personnel. Applications for Financial Assistance must be complete and accurate to qualify for financial assistance.
Non-discrimination
RSFH shall render services to all members of the community who are in need of medical care regardless of the ability of the patient, insured or uninsured, to pay for services. The determination of full or partial financial Assistance will be based on the patient’s ability to pay and will not be abridged on the basis of age, sex, race, creed, religion, disability, sexual orientation or national origin. Non U.S. residents must provide necessary documentation proving legal visitation rights, for example, a tourist, work or student visa.
Financial Assistance Services
Financial Assistance applications will be accepted for consideration for all services. Cosmetic services, sterilization reversals, and erectile dysfunction are not eligible. Birth defects are not considered cosmetic. Accounts indicating possible third party involvement (i.e., worker’s compensation, auto accident coverage) will be reviewed in detail and may require proof of no third party liability.
Determination of Eligibility
Verifiable proof of total household income and/or assets may be required to approve financial assistance.
Examples of verifiable proof include, but are not limited to:
- Federal Income Tax Return,
- W-2 forms,
- Social Security Benefits,
- Alimony,
- Family/Outside Contributions,
- Trusts,
- Annuities,
- Pensions,
- Retirement Benefits,
- Disability Income,
- Unemployment Benefits,
- Student Loan Disbursements,
- Unreported income,
- Payroll check stubs,
- Tax records.
All other avenues of payment must be exhausted prior to granting Hospital Financial Assistance (i.e., government and commercial insurance payments, third party payments, MIAP, etc.).
Total Household Income is defined as all available income to the dependent patient, which is indicated on the Federal Income Tax Return, and/or all other income sources listed above. If a current Federal Income Tax Return and/or the above income sources are unavailable, the income information and/or the monthly expenses listed on the application may be considered for charity calculations.
Bankruptcies
Guarantors who have filed for bankruptcy under chapter 7 and 13 (discharged and voluntary) are considered destitute and will be approved for 100% Charity adjustment. Upon determination that a patient has filed for bankruptcy, we will obtain the Bankruptcy Letter to determine the timeframe and entities for relief of debt. If we are listed as a debtor, the balance will be adjusted.
Confidentiality
The need for Financial Assistance may be a sensitive and deeply personal issue for the recipients.
Confidentiality of information and preservation of individual dignity shall be maintained for all who seek charitable services. Orientation of staff and the selection of personnel who will implement this policy and procedure should be guided by these standards. No information obtained in the patient’s Financial Assistance Application will be released without expressed permission for such release. Applications will be scanned in the imaging system and only accessible to select personnel. Hard copy documentation will be shredded.
Retention Policy
The Charity applications and case files will be retained and/or archived for seven (7) years.
- Upon review of the patient’s financial and employment information provided with the application, the hospital will determine if the patient will qualify for charity and/or medical indigency adjustments. Applications should be reviewed within 30 days of receipt. Assets and tax records may be reviewed to assist in determining eligibility for financial assistance.
If additional informatioFinancial Application Review Processn is necessary, the patient is notified by letter and must respond within 30 days from the date of the letter. Patients that do not respond within 30 days of the request will be classified as non-responsive and the charity request will be closed.
Applicants that falsify or alter any portion of the Financial Assistance Application or income information (i.e. tax forms, W-2 forms, etc.) may result in a denial of financial assistance.
Notifications
Patients/Guarantors that apply for Financial Assistance will be notified by letter regarding the outcome of their Financial Assistance request.
Patients approved for financial assistance within a calendar year and assuming their financial circumstances have not changed, will be deemed eligible for financial assistance without re-qualifying. Patients will have to re-qualify for financial assistance each calendar year.
Patients that are denied Financial Assistance and/or Medical Indigency Assistance may request reconsideration within 30 calendar days. The patient will be asked to provide documentation and a full explanation of extenuating and/or special circumstances regarding their financial hardship. Extenuating and/or special circumstances will not include patients that have over extended themselves financially.