Policy #: 395-102
Current Revision: April 1, 2016
In accordance with Spooner Health’s vision to become a recognized leader in providing quality healthcare in an expanding range of progressive services and Internal Revenue Code Section 501 (r)(4A), Spooner Health will provide uncompensated health care to patient(s) residing in the State of Wisconsin that are determined to be unable to pay for emergency and other medically necessary care provided by the facility. This policy may not cover services provided in the hospital that are billed by contracted providers. (See Attachment A)
Discount levels will be as follows:
Federal Poverty Level of 100% 100% Write Off – Patient will incur no charges.
Federal Poverty Level of 101%-150% 90% discount
Federal Poverty Level of 151%-200% 75% discount
Federal Poverty Level of 201%-250% 50% discount
Federal Poverty Level of 251%-300% AGB discount
This policy serves as Spooner Health’s Financial Assistance Policy (FAP).
Spooner Health’s Financial Assistance Program shall be consistently and equitably administered in accordance with established eligibility requirements. No patient that meets these requirements shall be denied uncompensated health care based upon race, creed, color, sex, national origin, sexual orientation, disability, age, or source of income.
For the purpose of this policy, the terms below are defined as follows:
Charity Care: Healthcare services that have been or will be provided by a provider and are never expected to result in cash inflows. Charity care results from a provider’s policy to provide healthcare services free or at a discount to individuals who meet the established criteria.
Family: Using the Census Bureau definition, a group of two or more people who reside together and who are related by birth, marriage, or adoption. According to Internal Revenue Service rules, if the patient claims someone as a dependent on their income tax return, they may be considered a dependent for purposes of the provision of financial assistance.
Family Income: Family income is determined using the Census Bureau definition, which uses the following income when computing federal poverty guidelines:
- Includes earnings, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources;
- Noncash benefits (such as food stamps and housing subsidies) do not count;
- Determined on a before-tax basis;
- If a person lives with a family, includes income of all family members. (Non-relatives, such as housemates, do not count.)
Uninsured: The patient has no level of insurance or third-party assistance to assist with meeting his/her payment obligations.
Underinsured: The patient has some level of insurance or third-party assistance but still has out-of-pocket expenses that exceed his/her financial abilities.
Gross Charges: The total charges at the organization’s full established rates for the provision of patient care services before deduction from revenue are applied.
Emergency medical conditions: Defined within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd).
Medically Necessary: As defined by Medicare (services or items reasonable and necessary for the diagnosis or treatment of illness or injury).
Poverty Guidelines: The poverty guidelines are a simplified version of the Federal Government’s statistical poverty thresholds used by the Bureau of Census to prepare its statistical estimates of the number of persons and families in poverty. The poverty guidelines are used primarily for statistical purposes. However, the Department of Health and Human Services uses the thresholds for administrative assistance or services under a particular federal program. Other programs, such as our Financial Assistance Program, use the guidelines for the purpose of giving priority to lower income persons or families in the provision of assistance or services. Our poverty guidelines are based on last (calendar) year’s increase in prices as measured by the Consumer Price Index. The poverty guidelines are published in the Federal Register and are revised yearly (Attachment B).
Amounts Generally Billed (AGB): No person eligible for financial assistance under the FAP will be charged more for medically necessary care than amounts generally billed (AGB) to individuals who have insurance covering such care. SHS determines AGB based on all claims paid in full to SHS by Medicare and private health insurers (including payments by Medicare beneficiaries or insured individuals themselves), over a 12-month period, divided by the associated gross charges for those claims.
- Spooner Health’s Financial Assistance Program shall be consistently and equitably administered in accordance with established eligibility requirements.
- All patients with a self-pay balance may be eligible for Financial Assistance which can include free or discounted care as indicated in Attachment C. However, Financial Assistance generally excludes care found not to be medically necessary, or disallowed by government or third party payers including procedures considered elective, experimental or cosmetic in nature.
- The full application process must be completed, preferably by the patient/responsible party. Falsification of the application information, failure to fully disclose all assets and/or income, or refusal to cooperate will result in denial of Financial Assistance benefits.
- All third party resources and non-hospital financial aid programs, including public assistance available through the state Medicaid program must be exhausted before Financial Assistance can be considered. If an individual has applied for and has not yet received a determination, the eligibility for Financial Assistance will be postponed until the Medicaid Eligibility determination has been made.
- Before sending accounts to collection, a search will be made on the Forward Health Portal to determine if the patients become eligible for Wisconsin Medical Assistance (WMA). If they are eligible, any accounts the patient has that are considered Emergent and/or Medically Necessary will qualify to have care provided to them eight months (240 days) prior to date of discovery of WMA eligibility applied to Financial Assistance. The FAP will remain active for six months following discovery of WMA Eligibility.
- In accordance with the joint position of the Wisconsin Hospital Association, The Wisconsin Chapter of Health Care Financial Management Association, and the Wisconsin Medical Credit Association, the following uncollectible accounts will be classified as Financial Assistance:
Spooner Health reserves the right to review eligibility status at any time, and to modify or nullify prior benefit determination if financial circumstances have changed.
- Deceased with no assets, based on the reasoning that the decedent has no ability to pay. If partial payment is received, the remainder of the bill will be classified as Financial Assistance.
- The Financial Counselor will attempt to contact next of kin for six months after the patient has passed to determine if an estate will be filed. When it is determined the deceased has no assets or eligible for Medical Assistance, the Financial Counselor completes the Adjustment Worksheet for NO ESTATE FILING (Attachment D). The Financial Counselor will attach any documentation they are able to obtain as proof of eligibility prior to forwarding to Director of Patient Accounts/Health Information for approval.
- Accounts that have been returned from the collection agency that would have qualified for Financial Assistance.
- Out of state Medicaid when patient is found to be eligible but facility is not credentialed in State of Issuance.
Basis for calculating amounts charged to patients
A. Spooner Health will limit amounts charged for emergency and other medically necessary care provided to Financial Assistance eligible individuals to not more that the amounts generally billed (AGB) to individuals who have insurance covering such care. This discount will be determined annually at the start of the calendar year in accordance with the look-back method outlined in the Federal Register 501(r).5.b.3
B. The charged amount is the amount of Financial Assistance eligible the individual is personally responsible for paying.
Method for applying for Financial Assistance
The Financial Assistance Application (Attachment E) can be completed before or after services are provided. The application must be received within 240 days after the first post-discharge billing statement (herein, the “Application Period”).
The forms may be completed by the applicant at home or onsite with the assistance of Patient Financial Services personnel. All required supporting documentation as listed on Attachment F must be included with the application.
The application can be obtained as described in the section below, Measures to widely publicize this policy within the community served by the facility.
Action the facility may take in the event of non-payment
- See Patient Billing and Collection 395-100 SH Billing and Collection Policy 501r. A copy of this policy can be obtained by contacting a Financial Counselor.
- Telephone: 715-939-1609
- Address: Spooner Health, 1280 Chandler Drive, Spooner, WI 54801
- Website: www.spoonerhealth.com
- A patient will not be deferred or denied medically necessary care based on the non-payment of previously provided care, if financial assistance has not yet been determined.
Measures to widely publicize this policy within the community served by the facility
- Financial Counselors will make paper copies of the Financial Assistance policy, application (Attachment E and F) and plain language summary (Attachment C).
- The paper copies are available upon request and without charge.
- Documents are readily available during normal business hours either directly from the Financial Counselor or by mail.
- Each document is available in English and in the primary language of any populations with limited proficiency in English that constitutes more than either (a) 1,000 individuals or (b) 5% of the residents of the community services by the facility.
- As part of the intake or discharge process, patients are offered a Patient Information Packet that outlines payment plan options and Financial Assistance Policy information including the Plain Language Summary (Attachment C).
- Notify and inform members of the community served by the hospital facility about the Financial Assistance Policy in a reasonable manner to reach those individuals most likely to benefit from assistance.
- Spooner Health Financial Assistance contact information is posted on the home page of the facility website at https://www.spoonerhealth.com. The Financial Assistance documents can be accessed, downloaded, viewed and printed from the Printable Forms tab.
- Include a written notice on each billing statement that notifies the patient about the Financial Assistance Policy that includes how and where to obtain the information.
- Display information that informs and notifies individuals about the Financial Assistance Policy in public areas, including the Emergency Room and Patient Registration areas.
Administration/Guidelines of Financial Assistance Program:
Spooner Health’s (SHS) Financial Assistance Program will be administered according to the following guidelines:
- The application information, along with all the required supporting documentation will be reviewed by the Patient Financial Counselor.
- Patient Financial Counselor will complete the Worksheet for Annual Income, Worksheet for Income and Asset Calculation, and Worksheet for Discount Calculation.
- After reviewing the application, the Director of Patient Accounts will determine if the patient/responsible party qualifies for Financial Assistance based on the supporting documentation and the recommendation of the Patient Financial Counselor who verified the information contained in the application.
- The approval of the Director of Patient Accounts is required for all amounts to be written off to the Financial Assistance Program.
- If the amount to be written off to the Financial Assistance Program exceeds, $5,000, the review and approval of the Chief Financial Officer (CFO) will be required.
- Patient Accounts Data Entry personnel will write off approved amounts from the patient’s account(s) per established procedures.
- The patient/responsible party will be notified in writing within thirty (30) days from applying (when all documentation has been received) if they were approved for Financial Assistance.
- The application will be kept on file for seven (7) years.
- Providing the patient/responsible party’s finances have not changed, an approved application will be good for six (6) months from the date of application and be applicable to all medically necessary services provided by Spooner Health.
- Providing the patient/responsible party’s finances change significantly between tax seasons, current income for the household as defined in procedure I.2 will determine eligibility in lieu of the federal income tax requirements. An approved application will be a one-time grant.
- The patient/responsible party has the right to appeal the Financial Assistance decision.
- The appeal must be received with in thirty (30) days of the determination.
- The appeal must include documented proof justifying why the patient/responsible party is unable to pay.
- The appeal is forwarded to the Director of Patient Accounts and is reviewed with the CFO.
- The patient/responsible party will be notified within sixty (60) days from submission of the appeal if they are approved.