St. Peter's Hospital ~ Patient Assistance Policy

Patient Assistance Policy

PURPOSE

It is the policy of St. Peter's Hospital to provide care to indigent inpatients and outpatients, regardless of ability to pay. The hospital shall allocate resources to identify charity cases and provide uncompensated care based upon the information submitted at the time of application for patient assistance by the patient or their representative.

In order to assure the funds for uncompensated care are not abused and will be available for those in need, St. Peter's Hospital will make every attempt to assist eligible candidates to become covered under any available assistance programs in the community.
St. Peter's Hospital has limited funds available to cover the cost of health care provided to patients who meet the eligibility standard for patient assistance.

ELIGIBILITY CRITERIA

Patient assistance is secondary to all other financial resources available to the patient.
Determination of eligibility of a patient for patient assistance shall be applied regardless of the source of referral and without discrimination as to race, color, creed, national origin, age, handicap status, or marital status.
Patient care that is cosmetic, experimental, or deemed to be non-reimbursable by traditional insurance carriers and governmental payors shall not be considered eligible for financial assistance under the patient assistance program. The hospital will make an effort to notify the patient in advance of the lack of eligibility of such care under the patient assistance program.
Patient assistance will be provided to patients when net available assets are not sufficient and gross family income is between 0 and 200 percent of the Federal Poverty Guidelines adjusted for family size. Patients who meet this criteria, the unpaid balance on their account, after the application of any third party payments, will be discounted according to the attached sliding scale. The size of the outstanding balance, extraordinary expenses, nondiscretionary expenses, the existence and availability of family assets, the patient’s future earning capacity and the ability to make payments over an extended period of time may all be considered when determining eligibility for patient assistance.
The financial obligations which remain after the application of the sliding fee schedule must be payable in amounts of no less than $25.00 per month
Full or partial patient assistance may be provided to patients with gross family incomes above 200 percent of the Federal Poverty Guidelines adjusted for family size. In circumstances where payment in full will cause financial hardship that will significantly harm the patient or patient’s family, the Vice President of Finance may approve patient assistance.
Once a patient is discharged from a hospital service, such as HomeLink, that patient is no longer eligible for Patient Assistance Program assistance for Durable Medical Equipment or other supplies provided by auxiliary departments of SPH, unless previous payment arrangements have been made with the Patient Business Services, or appropriate billing entity. This includes Pharmacy, DME, or other services provided by APEX.

PATIENT ASSISTANCE GUIDELINES

	Monthly Income	Monthly Income	Monthly Income	Monthly Income	Monthly Income
Family Size at	up to 125%	from 125% to 150%	from 150% to 175%	from 175% to 200%	Over 200%
1	1,083	1,300	1,517	1,733	1,734
2	1,458	1,750	2,042	2,333	2,334
3	1,833	2,200	2,567	2,933	2,934
4	2,203	2,650	3092	3,533	3,534
5	2,583	3,100	3,617	4,133	4,134
6	2,958	3,550	4,142	4,733	4,734
7	3,333	4,000	4,667	5,333	5,334
8	3,708	4,450	5,192	5,933	5,934
over 8 add for each:	375	450	525	600	601
Amount of Assistance	100%	75%	50%	25%	0%

	Annual Income	Annual Income	Annual Income	Annual Income	Annual Income
Family Size at	up to 125%	from 125% to 150%	from 150% to 175%	from 175% to 200%	Over 200%
1	13,000	15,600	18,200	20,800	20,801
2	17,500	21,000	24,500	28,000	28,001
3	22,000	26,400	30,800	35,200	35,201
4	26,500	31,800	37,100	42,400	42,401
5	31,000	37,200	43,400	49,600	49,601
6	35,000	42,600	49,700	56,800	56,801
7	40,000	48,000	56,000	64,000	64,001
8	44,500	53,400	62,300	71,200	71,201
over 8 add for each:	4,500	5,400	6,300	7,200	7,201
Amount of Assistance	100%	75%	50%	25%	0%

ELIGIBILITY DETERMINATION

Cases for consideration may be requested by the patient, the patient’s family, the patient's physician, hospital personnel who have been made aware of the financial need of the patient, or recognized social agencies.
Following the initial request for patient assistance, the hospital may pursue other sources of funding, including Medicaid and/or State Medical. If a patient refuses to pursue any other source of funding, the patient will be ineligible for the Patient Assistance Program.
Forms and instructions will be furnished to the responsible party when patient assistance is requested, when need is indicated, or when financial screening indicates potential needs. Refusal to complete the forms will result in denial of patient assistance.
The responsible party will be given fifteen (15) business days or a reasonable time as required by the person's medical condition to complete the required forms and furnish proof of income and assets.
Designations of patient assistance, while generally determined at the time of application for patient assistance may occur at any time upon learning of facts that would indicate financial need. If a responsible party pays a portion or all of the charges related to medical care, and is subsequently found to have met the patient assistance criteria at the time of reapplication, the amount that will be eligible for patient assistance will be the balance due on the patient account at the time of reapplication.
In connection with Federal guidelines, the following definitions are utilized by St. Peter's Hospital to determine the size of the family unit.
Family: A group of two or more persons related by birth, marriage, or adoption who reside together; all such related persons are considered as members of one family. (If a household includes more than one family and/or more than one unrelated individual, the poverty guidelines are applied separately to each family and/or unrelated individual and not to the household as a whole).
Family unit of size one: An unrelated individual who may be the sole occupant of a housing unit, or may be residing in a housing unit in which one or more persons also reside who are not related to the individual by birth, marriage, or adoption.
Students: To be considered as part of family unit if student qualifies as a dependent on parent's income tax (current year) return.
- Dependent status on income tax return of responsible party(ies) will be used to determine whether that person will be counted as part of family unit.
If it has been more than six months since financial documentation has been supplied to St. Peter's Hospital, a new application must be submitted for consideration of patient assistance.

APPLICATION PROCESS

All patients desiring consideration under the St. Peter's Hospital Patient Assistance Program must apply for assistance in writing disclosing financial information that is considered pertinent to the determination of the patient's eligibility for patient assistance. Persons requesting assistance will be given the following forms:
- Application
- Financial statements
- Program guidelines
The patient will authorize the hospital to make inquiries of employers, banks, credit bureaus, and other institutions for the purpose of verifying statements made by the patient in applying for assistance.
When returned, the financial statement shall be accompanied by one or more of the following types of documentation as needed for purposes of verifying income:
- Payroll check stubs for the last three months
- IRS tax return forms from the most recently completed calendar year
- Forms denying unemployment or worker's compensation benefits
Income shall be annualized, when appropriate, based upon documentation provided and upon verbal information provided by the patient. The annualization process will take into consideration seasonal employment and temporary increases and/or decreases of income.
All applications, supporting documentation, and communications will be treated with the highest regard for patient confidentiality. Copies of documents that support the application will be kept with the application form.
Additional information may be requested to complete the application.

PUBLIC RELATIONS

St. Peter's Hospital will make concerted efforts to promote the patient assistance program. The program will be promoted through educational material provided directly to inpatients upon admission and through the location of signs at principal registration points. Information regarding patient assistance programs will be provided on a periodic basis to physician offices, human service agencies and other community organizations.This policy will be posted on the Hospital’s website.

NOTIFICATION

Financial agreement forms will state that financial responsibility is waived or reduced if the patient is determined eligible for patient assistance.
Signage indicating the hospital's participation in patient assistance shall be conspicuously posted in public areas of the hospital.
The hospital will notify the patient of the final determination within fifteen (15) working days of receipt of financial statement with related documented materials (proof of income, etc.). The notification will include a determination of the amount for which the responsible party will be financially accountable. Denials will be written and include instructions for appeal or reconsideration.

APPEALS PROCESS

The responsible party may appeal a denial of eligibility for patient assistance by providing additional verification of income or family size to the Director of Patient Business Services within 30 calendar days of receipt of notification. The Vice President of Finance will review all appeals for final determination. If the determination affirms the previous denial of patient assistance, written notification will be sent to the patient/guarantor.

POLICY ADMINISTRATION

This policy shall be administered by the Director of Patient Business Services. The Patient Account Representative shall be responsible for reviewing applications for patient assistance, assuring that a determination of eligibility is made, and forwarding the application and accompanying information to the Director of Patient Business Services.
The Patient Account Representative will notify the patient of the final determination decision.

Patient Assistance Program Forms