St. Peter’s Hospital is committed to providing financial assistance to persons who have healthcare needs and are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay for medically necessary care based on their individual financial situation.  St. Peter’s strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care.

Patient assistance is not considered to be a substitute for personal responsibility.  Patients are expected to cooperate with St. Peter’s Hospital’s procedures for obtaining charity or other forms of payment or financial assistance, and to contribute to the cost of their care based on their individual 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 health, and for the protection of their individual assets.

In order to manage its resources responsibly and to allow St. Peter’s Hospital to provide the appropriate level of assistance to the greatest number of persons in need, the Board of Directors establishes the following guidelines for the provision of patient assistance.

DEFINITIONS:

For the purposes of this policy, the terms below are defined as follows:

Patient Assistance:  Healthcare services that have or will be provided but are never expected to result in cash inflows.  Patient assistance results from St. Peter’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 patient 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, royalties, 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;
• Excludes capital gains or losses; and
• If a person lives with a family, includes the 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 aid 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.

PROCEDURES:

Services Eligible Under this Policy.  For purposes of this policy, “patient assistance” refers to healthcare services provided without charge or at a discount to qualifying patients.  The following healthcare services are eligible for patient assistance:

1. Emergency medical services provided in an emergency room setting;
2. Services for a condition which, if not promptly treated, would lead to an adverse change in the health status of the individual;
3. Non-elective services provided in response to life-threatening circumstances in a non-emergency room setting;
4. Medically necessary services, evaluated on a case-by-case basis at St. Peter’s Hospital’s discretion.
5. This policy does not apply to the outpatient retail pharmacy.  Patient assistance for this service is covered under policy #110-0073.
6. This policy covers only charges incurred at St. Peter’s Hospital or St. Peter’s Medical Group.

Eligibility for Patient Assistance.  Eligibility for patient assistance will be considered for those individuals who are uninsured, underinsured, ineligible for any government health care benefit program and who are unable to pay for their care, based upon a determination of financial need in accordance with this Policy.  The granting of patient assistance shall be based on an individualized determination of financial need and shall not take into account age, gender, race, social or immigrant status, sexual orientation or religious affiliation.  Patient assistance is secondary to all other financial resources available.  Refusal to access available external funding, such as Medicaid, will disqualify the patient for eligibility under this policy.

Determination of Financial Need. 

1. Financial need will be determined in accordance with procedures that involve an individual assessment of financial need; and may
   • Include an application process, in which the patient or the patient’s guarantor are required to cooperate and supply personal, financial and other information and documentation relevant to making a determination of financial need;
   • Include the use of external publicly available data sources that provide information on a patient’s or a patient’s guarantor’s ability to pay (such as credit scoring);
   • Include reasonable efforts by St. Peter’s Hospital to explore appropriate alternative sources of payment and coverage from public and private payment programs and to assist patients to apply for such programs;
   • Take into account the patient’s available assets and all other financial resources available to the patient; and
   • Include a review of the patient’s outstanding accounts receivable for prior services rendered and the patient’s payment history.
2. It is preferred but not required that a request for patient assistance and a determination of financial need occur prior to rendering of services.  However, the determination may be done at any point in the collection cycle.  The need for payment assistance shall be re-evaluated at each subsequent time of service if the last financial evaluation was completed more than six months prior, or at any time additional information relevant to the eligibility of the patient for assistance becomes known.
3. Requests for patient assistance shall be processed promptly and St. Peter’s shall notify the patient or applicant in writing within 30 days of receipt of a completed application.  Collection activity will be suspended during the consideration of a completed financial assistance application.  A note will be entered into the patient’s account to highlight that a patient assistance application is pending.

Presumptive Financial Assistance Eligibility.  There are instances when a patient may appear eligible for patient assistance discounts, but there is no financial assistance form on file due to a lack of supporting documentation.  Often there is adequate information provided by the patient or through other sources which could provide sufficient evidence to provide the patient with charity care assistance.  Patients that are homeless or deceased with no estate may be presumed to be eligible for patient assistance without the completion of a formal application.  These situations would be eligible for 100% write off of the account balance. 

Patient Assistance Guidelines.  Services eligible under this Policy will be made available to the patient on a sliding fee scale, in accordance with financial need, as determined in reference to Federal Poverty Levels (FPL) in effect at the time of the determination, as follows:

1. Patients whose family income is at or below 150% of the FPL are eligible to receive free care;
2. Patients whose family income is above 150% but not more than 200% of the FPL are eligible to receive a discount of 50% of their account balance.  This discount approximates the percentage that the hospital receives from the Medicare program.
3. Patients whose family income exceeds 200% of the FPL but not more than 250% of the FPL are eligible to receive a discount of 15% of their account balance.  This discount approximates the discount given to the largest commercial insurers. 

Medical Hardship (Medical Indigence).  St. Peter’s Hospital will limit the amount of medical debt that a patient can incur in a 12 month period to 25% of household income.  Medical debt includes all medical costs (excluding copays, deductibles and coinsurance) for which St. Peter’s billing office is responsible to bill.  Patients whose household income exceeds 700% of FPL are ineligible and will be evaluated on a case-by-case basis.  For patients with income between 150% of FPL and 250% FPL, the larger discount between that calculated in (E) and that which is calculated under this provision will apply. 

Household Assets.  Household assets may be included in the calculation of patient eligibility for assistance.  A patient’s primary residence, retirement assets (those assets where the Internal Revenue Service has granted preferential tax treatment as a retirement account) and the patient’s primary automobile are excluded from the calculation of household assets.  In addition, the first $5,000 is excluded.  The balance of net assets will be added to the patient’s household income in section E above.

Communication of the Patient Assistance Program to Patients and the public.  Notification about financial assistance from St. Peter’s Hospital shall be disseminated by various means, which may include the publication of notices in patient bills and by posting notices in the emergency room, physician offices, admitting and registration departments, cashier window and other public places that St. Peter’s may elect.  This Policy will also be posted on the St. Peter’s website.  Referral of patients for financial assistance may be made by any member of the St. Peter’s staff or medical staff.  A request for patient assistance may be made by the patient or a family member, close friend or associate of the patient, subject to applicable privacy laws.

Relationship to Collection Policies.  St. Peter’s Hospital management shall develop policies and procedures for internal and external collection practices that take into account the extent to which the patient qualifies for financial assistance, a patient’s good faith effort to apply for a government program or for assistance from St. Peter’s, and a patient’s good faith effort to comply with his or her payment agreements with St. Peter’s.  For patients who qualify for assistance and who are cooperating in good faith to resolve their hospital bills, St. Peter’s may offer extended payment plans to eligible patients, will not impose wage garnishments or liens on primary residences, will not send unpaid balances to outside collection agencies and will not charge interest on outstanding balances.  Payments made on an account prior to application for assistance will not be refunded. 

Administration.  This policy shall be administered by the Director of Patient Business Services and the Director of Physician Billing.