PATIENTS & VISITORS

Charity Assistance Program Policy

I. PURPOSE:

To establish charity assistance guidelines for patients receiving hospital licensed services.

II. SCOPE:

This policy applies to all employees of SwedishAmerican Health System (SAHS) who communicate with patients regarding charity assistance.

III. RESPONSIBILITY:

It is the responsibility of the Patient Accounting department to administer this policy.

IV. PRACTICE:

This policy describes the financial assistance practices of SwedishAmerican Hospital and SwedishAmerican Medical Center/Belvidere (collectively referred to as the “Hospital”). The Hospital provides medically necessary health care regardless of the patient’s ability to pay. Hospital will provide, without discrimination, care for emergency medical conditions (within the meaning of section 1867 of the Social Security Act) to individuals regardless of their eligibility under this policy. Patients residing in the State of Illinois may receive financial assistance for hospital licensed services if they meet the criteria outlined below. Exceptions may be made at the sole discretion of the Hospital. Patients unable to pay for services should consult Hospital financial counselors for assistance with identifying available resources to meet financial obligations.

1. Self-pay Patient Qualifications – This policy provides guidelines for the Hospital’s offering of financial assistance to self-pay patients who qualify for such assistance based on financial need. A qualifying self-pay patient is a patient to whom any of the following may apply:
   1. No third-party coverage is available.
      
   2. Third-party coverage is available, but with limited benefits (i.e., patient has an outstanding balance after insurance) and excluding any usual and customary reductions made by insurance.
      
   3. Third-party coverage is denied due to pre-existing conditions.
   4. Patient is already eligible for assistance (e.g., Medicaid), but the particular services are not covered.
   5. Medicare or Medicaid benefits have been exhausted, and the patient has no further ability to pay.
   6. Welfare assistance is denied due to resources and/or income, but the patient is found to be in circumstances where an illness will make it impossible to meet their financial obligations.
   The Hospital generally requires self-pay patients to submit an application to determine if they qualify for financial assistance based on financial need, as described in sections IV. E through H of this policy. The amount of financial assistance provided to a qualifying self-pay patient ranges from full write-off to discounts, and is in addition to other discounts offered by the Hospital.
   
   Qualifying self-pay patients may receive financial assistance for qualifying services as described below:
   
   An “uninsured patient” is eligible for financial assistance for “medically necessary services” received at the Hospital. An “uninsured patient” is an individual who is a patient of the Hospital and is not covered under a policy of health insurance and is not a beneficiary under a public or private health insurance, health benefits, or other health coverage program, including high deductible health insurance plans, workers’ compensation, accident liability insurance, or other third-party liability insurance. “Medically necessary services,” as used in this policy, means any inpatient or outpatient hospital service, including pharmaceuticals or supplies, provided by Hospital to a patient covered under Title XVIII of the federal Social Security Act (“Medicare”) for beneficiaries with the same clinical presentation as the uninsured patient. A “medically necessary service” does not include: 1) non-medical services such as social and vocational services; and 2) elective cosmetic surgery, but not plastic surgery designed to correct disfigurement caused by injury, illness, or congenital defect or deformity.
   
   All other qualifying self-pay patients are eligible for financial assistance for emergency and other non-elective Hospital services that, without immediate attention: 1) places the health of the individual in serious jeopardy; or 2) causes serious impairment to bodily functions or serious dysfunction to a bodily organ.
   
   
2. Publication of the Financial Assistance Policy:
   1. The Hospital’s Financial Assistance policy is transparent and available to all, at all points in the continuum, in languages appropriate for Hospital’s service area. The Hospital’s Financial Assistance policy, application form, signage, and financial counselor contact information are available in English and Spanish. Signage is posted prominently at all points of admission and registration (including the Emergency department). Written information about the Hospital’s financial Assistance policy and copies of the Financial Assistance form are available in admission and registration areas. The Hospital’s Financial Assistance policy, application form, and financial counselor contact information are also posted on the Hospital’s website. The Hospital will make efforts to publicize its policy in print and television media, wherever practicable.
      
   2. Patient billing communications also inform patients of the availability of financial assistance. Each bill, invoice, or other summary of charges to an uninsured patient includes with it, or on it, a prominent statement than an uninsured patient who meets certain income requirements may qualify for financial assistance and information on how to apply for consideration under the Hospital’s financial Assistance policy. All third-party agents to submit or collect bills on behalf of Hospital are required to follow this policy.
      
3. Identification of Potentially Eligible Patients:
   1. Registration and pre-registration processes promote the identification of patients who are potentially eligible for financial assistance. The Hospital’s financial counselors try to contact all registered, self-pay inpatients during their Hospital stay to assess financial needs. Interpreters will be used, as indicated, to allow for meaningful communication with individuals who have limited English proficiency.
   2. Requests for financial assistance may be received from multiple sources, including the patient, a family member, a community organization, a church, a collection agency, caregiver, Hospital administration, and others. Requests received from a third party will be sent to the Hospital’s Business Office, which will secure proper clearance from the patient and then work with the third party on the patient’s behalf. The Business Office will work with the third party to provide resources available to assist the patient in the application process.
   3. The Hospital may use internal staff or third-party agents to assist patients in securing Medicaid or other coverage, if eligible.
   4. Identification of potentially eligible patients is an ongoing process. Eligibility for financial assistance will be re-assessed with each subsequent service.
4. Responsibilities of the Hospital and the Patient Regarding Financial Assistance – Both the Hospital and the patient are accountable for their role in the financial assistance process:
   1. Hospital Responsibilities – The Hospital is responsible for publicizing its Financial Assistance program, for evaluating patient eligibility for financial assistance based on this policy, as well as notifying the patient on payment options. When determining patient eligibility for financial assistance, the Hospital must strive to be fair, consistent, and timely.
   2. Patient Responsibilities:
   1. To cooperate with the Hospital to provide the information and documentation necessary to apply for other existing financial resources that may be available to pay for health care, such as Medicare, Medicaid, third-party liability, etc.
   2. To promptly provide the Hospital with financial and other information needed to determine eligibility. This includes completing the required application forms and cooperating fully with the information gathering and assessment process. Patients are responsible for providing accurate information and all documentation necessary to apply for financial assistance and establish eligibility under this policy.
   3. A patient who qualifies for a partial discount must cooperate with the Hospital in establishing a reasonable payment plan and make good-faith efforts to honor the payment plans for the discounted Hospital bills.
   4. A patient who qualifies for a partial discount is responsible for promptly notifying the Hospital of any change in financial status so that the impact of this change may be evaluated under this Financial Assistance policy, the discounted Hospital bills, or provisions of payment plans. This patient is also responsible for informing the Hospital, in subsequent inpatient admissions or outpatient encounters, that the patient has previously received health care services from the Hospital and was determined to be eligible for discounted care.
5. Financial Assistance Application Form – Patients requesting financial assistance may be required to complete the Hospital’s Financial Assistance Application Form in order to establish eligibility.
   
   The completed Financial Assistance Application Form will be submitted to the Hospital Business Office for processing. The Business Office requires proof of income including employer pay stubs, employer attestation, and/or IRS tax return summary. In addition, Medicare beneficiaries are subject to an additional asset test in accordance with Federal Law.
6. Presumptive Eligibility – Qualifying self-pay patients who are uninsured patients and who fall into one or more of the following categories may be considered eligible for financial assistance in the absence of a completed Financial Assistance Application Form upon confirmation of the circumstance. Once it is established the uninsured patient satisfies one of the following categories, a 100 percent discount should be applied to the uninsured patient’s medically necessary services:
   1. Patient is homeless.
   2. Patient is deceased and has no known estate able to pay Hospital debts.
   3. Patient is in jail for a felony.
   4. Patient is currently eligible for Medicaid but was not at the date of the health care service.
   5. Patient is eligible by the State to receive assistance under the Violent Crime Victims Compensation Act or Sexual Assault Victims Compensation Act.
7. Guidelines for Determining the Amount of Financial Assistance:
   1. 1. Applications for financial assistance will be reviewed according to the guidelines set forth in this policy and the Financial Assistance Discount worksheet. To be eligible for a 100 percent reduction from charges for qualifying services, qualifying self-pay patients must have a family income (as defined below) at or below 200 percent of the current Federal Poverty Guidelines.
   2. Uninsured patients with a family income (as defined below) exceeding 200 percent, but less than or equal to 600 percent of the Federal Poverty Guidelines, will be eligible for a significant discount determined in accordance with the Illinois Hospital Uninsured Patient Discount Act, which states:
      
      “Family income” means the sum of a family’s earnings and cash benefits from all sources before taxes, less payments made for child support. When determining the patient’s family income, the household size and income includes all immediate family members and other dependents in the household. This includes an adult (and spouse, if applicable), natural or adopted minor children of adult or spouse, students over 18 years of age dependent on the family for over 50 percent support, and any other persons dependent on the family income for over 50 percent support. (A current tax return of the responsible adult is required.) Income may be verified by submitting a personal financial statement, copies of W-2/1040 forms, bank statements, or any other form of documentation that supports reported income. A credit report may be obtained for the purpose of identifying additional expense, obligations, and income to assist in developing a full understanding of the patient’s financial circumstances.
   3. The maximum amount that may be collected in a 12-month period from an uninsured patient with family income of less than or equal to 600 percent of the Federal Poverty Guidelines for medically necessary services is 25 percent of that patient’s family income. The Hospital will determine, on a case-by-case basis, whether to extend the same or similar 12-month maximum collectible amount to any other qualifying self-pay patient with family income of less than or equal to 600 percent of the Federal Poverty Guidelines for qualifying services. The Hospital reserves the right to exclude patients having assets with a value in excess of 600 percent of the Federal Poverty Guidelines from the application of this 12-month maximum collectible amount. For purposes of determining the applicability of the 12-month maximum collectible amount, the following assets shall not be counted:
      1. The uninsured patient’s primary residence.
      2. Personal property exempt from judgment under Section 12-1001 of the Code of Civil Procedure.
      3. Any amounts held in a pension or retirement plan, provided, however, that distributions and payments from pension or retirement plan may be included as income.
      To be eligible to have this maximum amount applied to subsequent charges, a patient shall inform the Hospital, in subsequent Hospital inpatient admissions or outpatient encounters, that the patient has previously received medically necessary services from the Hospital and was determined to be entitled to discounted care under this policy.
   4. In no event shall a patient who receives financial assistance under this policy be charged “gross charges” in violation of Internal Revenue Code Section 501(r)(5)(B). For emergency or other medically necessary care provided to patients who receive financial assistance under this policy, Hospital shall not charge amounts in excess of charges allowed under Internal Revenue Code 501(r)(5)(A).
   5. Assets are not considered in determining a self-pay patient’s eligibility for financial assistance under this policy, except for purposes of:
      1. Determining the applicability of the 12-month maximum collectible amount described above; and
      2. In the case of a Medicare beneficiary, applying the mandatory asset test for Medicare beneficiaries described above.
8. Process for Review of Applications and Determinations:
1. Requests for financial assistance will be accepted at any time up to six (6) months from the date the first statement is sent to the patient, except for accounts that have already been referred to a collection agency or for legal action.
2. A representative from the Hospital Business Office will review the completed Financial Assistance Application Form and supporting information and make the determination of eligibility for financial assistance.
3. Following approval, the approved financial assistance amount is applied to the patient account by the Hospital Business Office.
1. The Hospital Business Office will approve or deny applications for financial assistance.
2. The patient will be notified in writing if their application is either denied or results in only a partial discount.
3. Denial notifications will include a reason for the denial.
4. A patient may contact the Hospital Business Office to confirm their account status.
9. Suspension of Collection Activity During Review – For those patients who have applied for financial assistance prior to the expiration of six (6) months, collection agency activity will be suspended while the completed application is being considered.
10. Review of Unusual/Extenuating Circumstances – Hospital is authorized to approve timeframe and documentation exceptions to this policy on a case-by-case basis due to unusual or extenuating circumstances.
11. Payment Plans/Collection Activity:
    1. The provisions of Section IV.K of this policy apply to Hospital’s collection of any self-pay balance owed.
    2. Before pursuing collection against a self-pay patient receiving partial financial assistance under this policy, Hospital will give the patient the opportunity to: 1) review the accuracy of the bill; 2) apply for financial assistance under this policy; and 3) avail him or herself of a reasonable payment plan.
    3. Patients receiving partial financial assistance who are unable to pay the full amount of any self-pay balance in one payment will be offered a reasonable payment plan. Payment plans for partial charity accounts will be individually developed with the patient. No interest will accrue to the account balance on any such account while payments are being made, unless the patient has voluntarily chosen to participate in a long-term payment arrangement that bears interest applied by a third-party financial agent.
    4. The Hospital will not pursue legal action for non-payment of Hospital bills against uninsured patients or patients receiving financial assistance under this policy who clearly demonstrate they have neither sufficient income nor assets to meet their financial obligations, provided the patient has provided the Hospital with all relevant information to determine financial eligibility under this policy and reasonable plan options and reasonable payment plan options, and has notified the Hospital of any material change that may affect such determinations. However, the Hospital may, after a period of one hundred twenty (120) days, send an unresponsive or otherwise inactive patient account to a third-party collections agency. Additionally, if a patient is in violation of the patient’s payment plan, the patient fails to make a monthly payment on any self-pay balance, and after written inquiry to the patient, the Hospital may refer the patient to collection.
    The terms of the Hospital’s collections activity is further described in its ‘Patient Collection’ policy.
12. Recordkeeping:
1. A record, paper or electronic, will be maintained reflecting Hospital’s determinations regarding financial assistance, along with copies of all application and worksheet forms.
2. The cost of financial assistance will be reported annually in the Community Benefit Report in accordance with Illinois law. Financial assistance will be reported as the cost of care provided (not charges) using the most recently available operating cost and the associated cost-to-charge ratio.
3. The provision of financial assistance may now, or in the future, be subject to change in accordance with federal, state, or local law.
For further information, please call the Hospital Business Office at 815-391-7380.

V. AUTHORITY:

Issued and approved by the President and Chief Executive Officer.