All patients will be eligible to apply for financial assistance at any time during the continuum of care, except for those services excluded from this Policy. Each patient’s situation will be evaluated according to relevant circumstances, such as income, assets or other resources available to the patient or patient’s family when determining the ability to pay the outstanding patient account balance. Taking this information into consideration, the attached Financial Assistance Eligibility Discount Guidelines (Attachment B) are utilized to determine what amount, if any, of the outstanding patient account balance will be discounted after payment by all third parties.
PLEASE NOTE: The financial assistance offered under this Policy does not apply to some physician services or other professional fees billed separately from the hospital fees, or cosmetic and not medically necessary procedures. GSHS reserves the right to further limit the services covered by this Policy.
METHOD FOR APPLYING OR OBTAINING FINANCIAL ASSISTANCE
2.1 Application Process
Applying for financial assistance can be initiated by a patient requesting assistance in person, over the phone at 1-800-766-4762,through the mail or via the GSHS website (www.gsmc.org). Additionally, GSHS can initiate an Assistance Application on behalf of the patient. It is ultimately the patient’s responsibility to provide the necessary information to qualify for financial assistance. There is no assurance that the patient will qualify for financial assistance.
2.2 Community and Charitable Programs
Patients of certain approved community and charitable organizations and programs qualify for financial assistance under this policy. The Financial Assistance Committee will be responsible for determining the approved organizations and programs.
2.3 Presumptive Eligibility for Financial Assistance
GSHS may review credit reports and other publicly available information to determine, consistent with applicable legal requirements, estimated household size and income amounts for the basis of determining financial assistance eligibility when a patient does not provide an Assistance Application or supporting documentation.
3. LENGTH OF ELIGIBILITY
Once financial assistance has been approved, it is effective for all outstanding patient accounts and for all services provided within six (6) months after the Assistance Application is signed by the patient or their responsible party or the GSHS employee (“Date of Completion”). Financial assistance may be extended for an additional six months with affirmation of the patient’s income or estimated income and household size.
Approval under Section 2.3 above will only apply to the date(s) of service on the patient account balance being evaluated. Eligibility will not apply to accounts for future dates of service.
4. BASIS FOR CALCULATING AMOUNTS CHARGED
The level of financial assistance will be based on a classification as Financially Indigent, Medically Indigent, or Catastrophic Medically Indigent, as defined.
4.1 FINANCIALLY INDIGENT
“Financially Indigent” means a patient whose Yearly Household Income (as defined below in section 5.2.i) is less than or equal to 225% of the Federal Poverty Guidelines (“FPG”). These Financially Indigent patients are eligible for a 100% discount on outstanding patient account balances based on Schedule A of the Financial Assistance Eligibility Discount Guidelines. Example: A patient with a Household Size of 3 (as defined below in section 5.2.ii) and Yearly Household Income of $36,620 is eligible for a financial assistance discount of 100%.
4.2 MEDICALLY INDIGENT
“Medically Indigent” means a patient whose hospital bills from all related or unrelated providers, after payment by all third parties, exceed a specified percentage of their Yearly Household income (ranging from 5%-10%), whose Yearly Household income is greater than 225% but less than or equal to 500% of the FPG and who is unable to pay the outstanding patient account balance. These Medically Indigent patients are eligible for a discount as set forth in Schedule A of the Financial Assistance Eligibility Discount Guidelines.
Example: A patient with a Household Size of 4 and Yearly Household Income of $85,000 (between 350-400% of FPG) is eligible for a financial assistance discount of 60%. If the patient’s total outstanding bills, after the third-party payments, exceeds 10% of the Yearly Household Income. Assuming the patient’s account balance is $10,000 (which is greater than 10% of the Yearly Household Income), the patient is eligible for a 60% discount ($6,000). The patient’s remaining obligation would be 40% ($4,000).
4.3 FINANCIAL ASSISTANCE ELIGIBILITY DISCOUNT GUIDELINES
The Financial Assistance Eligibility Discount Guidelines are attached and are made a part of the policy. The Financial Assistance Eligibility Discount Guidelines will be updated annually in accordance with the FPG as published in the Federal Register by the U.S. Department of Health and Human Services. The discount percentage will be adjusted annually and approved by the Financial Assistance Committee to ensure patient’s outstanding account balances after discount are no more than amounts generally billed to individuals with insurance coverage.
4.4 Uninsured discounts. All uninsured patients who qualify for less than 68% financial assistance and complete necessary application process, will receive the discount under an uninsured adjustment. This amount is based on an average of GSHS managed care contracts deepest discounts. This amount will be reviewed annually by the FAP committee to adjust for changes as appropriate.
5. DETERMINATION OF FINANCIAL ASSISTANCE
5.1 FINANCIAL ASSISTANCE ASSESSMENT
Determination of financial assistance will be in accordance with procedures that may involve:
5.1.i. An application process, in which the patient or the patient’s guarantor is required to supply information and documentation relevant to making a determination of financial need;
5.1.ii. The use of credit reports and other publicly available information that provide information on a patient’s or a patient’s guarantor’s ability to pay;
5.1.iii. A review of the patient’s available assets, and all other financial resources available to the patient. If other assets are available, GSHS reserves the right to not grant financial assistance.
5.2 DEFINITION OF HOUSEHOLD INCOME AND HOUSEHOLD SIZE
Determination of financial assistance will be based on the household income and size provided by the patient and/or by an estimated household income and size obtained from a third party vendor.
5.2.i. HOUSEHOLD INCOME
I. Adults: If the patient is an adult, “Yearly Household Income” means the sum of the total yearly gross income or estimated yearly income of the patient and the patient’s spouse, defined by marriage or common law.
II. Minors: If the patient is a minor, “Yearly Household Income” means the sum of the total yearly gross income or estimated yearly income of the patient, the patient’s mother, father, or guardian.
5.2.ii. HOUSEHOLD SIZE
I. Adults: In calculating the Household Size, include the patient, the patient’s spouse, and any dependents (as defined by the Internal Revenue Code).
II. Minors: In calculating the Household Size, include the patient, the patient’s mother, the patient’s father, dependents of the patient’s mother, and dependents of the patient’s father.
5.3 INCOME VERIFICATION
Household income will be documented through any of the following mechanisms:
5.3.i. Third Party Documentation. By the provision of third party financial documentation including IRS Form W-2 Wages and Tax Statement; pay check remittance; individual tax return; telephone verification by employer; bank statements; Social Security payment remittance; Worker’s Compensation payment remittance; unemployment insurance payment notice; Unemployment Compensation Determination Letters; response from a credit inquiry and other publicly available information; or other appropriate indicators of the patient’s income.
5.3.ii. Participation in a Benefit Program. By the provision of documentation showing current participation in a public benefit program such as Medicaid; County Indigent Health Program; AFDC; Food Stamps; WIC; Tex-Care Partnership; or other similar means tested 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 income on the Assistance Application.
5.3.iii. In cases where third party documentation is unavailable, verification of the patient’s Yearly Household Income can be done in either of the following ways:
I. Obtaining the patient’s or responsible party’s Written Attestation. By obtaining an Assistance Application signed by the patient or responsible party attesting to the veracity of the patient’s income information provided;
II. Obtaining the patient’s or responsible party’s Verbal Attestation. Through the written attestation of the Good Shepherd employee completing the Assistance Application that the patient or responsible party verbally verified the patient’s income information provided.
In both above instances where the patient or responsible party is unable to provide the requested third party verification of the patient’s income, the patient or responsible party is required to provide a reasonable explanation of why the patient or responsible party is unable to provide the required third party verification. Reasonable attempts will be used to verify patient’s attestation and supporting information.
5.3.iv. Expired Patients. Unmarried expired patients may be deemed to have no income for purposes of calculation of Yearly Household Income. Documentation of income is not required for expired patients; however, documentation of estate assets may be required. The surviving spouse of an expired patient may apply for financial assistance.
5.3 v. Charity Care for Gregg and Harrison County Patients. Patients will be eligible for charity coverage from Good Shepherd Medical Center provided they:
1. Reside in Gregg or Harrison County and intend to remain in Gregg or Harrison county
2. Receive services from Good Shepherd Medical Center
3. Otherwise meet the eligibility criteria, including income and asset testing for Gregg or Harrison County Indigent Care Program and/or as further outlined in Good Shepherd Medical Center policies.
5.4 Financial Assistance Disqualification
Disqualification after financial assistance has been granted may be for reasons that include, but are not limited to one of the following:
I. Information Falsification. Financial assistance will be denied to the patient if the patient or responsible party provides false information including information regarding their income, household size, assets or other resources available that might indicate a financial means to pay for care.
II. Third Party Settlement. Financial assistance will be denied if the patient receives a third party financial settlement associated with the care rendered by a GSHS Affiliated Entity. The patient is expected to use the settlement amount to satisfy any patient account balances rendered by a GSHS Affiliated Entity.
6. MEASURES TO PUBLICIZE THE FINANCIAL ASSISTANCE POLICY
The following measures are used to publicize the Policy to the community and Patients. The FAP application form, a plain language summary of the FAP and the FAP are available without charge through the following means:
6.1 COMMUNITY NOTIFICATION
6.1.i. Posting on the GSHS website at the following location: https://www.gsmc.org
6.1.ii. Providing information when a patient calls the 1-800-766-4762 contacting a GSHS Affiliated Entity.
6.1.iv. Posting of a notice in the emergency department of a GSHS Affiliated Entity, admitting areas and business offices and other patient access points as determined by GSHS management.
6.2 Personal Notification
6.2.i. Financial Counselors visit as necessary, with patients in person at GSHS hospital facilites.
6.2.ii. Billing statements will include a phone number for inquiries about financial assistance.
6.2.iii. GSHS staff will discuss when appropriate, in person or during billing and customer service phone contacts with patients.
7. RELATIONSHIP TO COLLECTION POLICIES
7.1 During the verification process, while information to determine a patient’s income is being collected, the patient may be treated as a Private pay patient in accordance with the other GSHS Policies, including the Debt Collection Policies. No extrodinary collection efforts would be pursued until review is being undertaken.
7.2 After the patient’s account is reduced by the discounts based on the Financial Assistance Eligibility Discount Guidelines, the patient is responsible for the remainder of the outstanding patient account balances which shall be no more than amounts generally billed to individuals who have insurance coverage. Once the patient qualifies for financial assistance, GSHS will not pursue collections on the amount qualified for financial assistance. Patients will be invoiced for any remaining amounts in accordance with other GSHS Debt Collection Policies.
7.3 GSHS reserves the right to bill and collect a reasonable copayment for Services rendered from patients who qualify for financial assistance.
7.4 The Policy does not affect any GSHS Affiliated Entity’s obligation under “Emergency Medical Treatment and Active Labor Act (EMTALA)”. The Policy also does not alter or modify other policies concerning efforts to obtain payments from third-party payers.
8. Periodic Audits
Reviews will be done to assure that this policy is being adhered to, and that proper documentation is present. Required levels of monthly review are as follows:
Customer Service/Collection Supervisor — 100% of all claims and accounts
System Business Office Manager — 100% of all Claims and accounts, excluding outlier charity greater than $10,000.
System Director of Revenue Cycle — All Presumptive Charity over $25,000, and all claims over $25,000.
Chief Financial Officer — 1% of all claims and all accounts greater than $100,000.
When used in this policy these terms have the following meaning:
FINANCIAL ASSISTANCE COMMITTEE: A committee comprised of a representative from the following departments: Financial Operations, Tax Management, Revenue Cycle, Legal department, Director of Budget and others appointed by the Chair of the Committee deemed necessary to fulfill the responsibilities of the Committee. The Chair of the Committee shall be appointed by the Chief Financial Officer.
Regulatory Agency Citation Reference
Texas Health and Safety Code Chapter 311
Internal Revenue Code Section 501(r)
RELATED INTERNAL DOCUMENTS
For more information on financial assistance, please call the Business Office at 903-315-5200 or 1-800-766-4762 Monday through Friday, 8am to 5pm, or contact the email@example.com.