Great River Medical Center Financial Assistance Policy

Great River Medical Center is committed to providing financial assistance, also known as charity care, to people who have health care needs and are:
  • Uninsured
  • Underinsured
  • Ineligible for a government program
  • Otherwise unable to pay for medically necessary care based on their financial situations

Consistent with our mission to deliver high-quality care, world-class customer service and uncompromising value to our patients and their families, Great River Medical Center strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care.

Great River Medical Center will provide, without discrimination, care of emergency medical conditions to people regardless of their eligibility for financial assistance or for government assistance. Accordingly, this written policy:
  • Describes services and service locations eligible under this policy
  • Includes eligibility criteria for financial assistance – free and discounted care
  • Includes criteria that could disqualify a patient from assistance
  • Describes the basis for calculating amounts charged to patients eligible for financial assistance under this policy
  • Describes where the financial assistance applications are located and the method by which patients may apply for financial assistance
  • Describes the relationship of this policy to our facility’s billing and collections policy

Definitions

Amounts generally billed –An amount equivalent to the average amount billed to patients with insurance coverage after insurance pays. The “Look Back” methodology was used in the determination of the amount generally billed percentage of 40 percent of total charges. This calculation was based on Medicare fee for service, Blue Cross Blue Shield and commercial insurances’ actual fiscal year 2014 historical claims. This calculation is re-evaluated annually and will be provided to people by request at no expense to the requesting party.

Emergency medical conditions – Defined within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd).

Family – 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 patients claim people as dependents on their income tax returns, they may be considered dependents for providing financial assistance.

Family income – Follows theCensus Bureau definition, which uses the following before-tax income when computing federal poverty guidelines:
  • Earned income such as monthly gross wages, salary and self-employment income
  • Income of spouses and all guarantors who are legally responsible for the costs of care
  • Unearned income such as 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 households, and other miscellaneous sources
It doesn’t include:
  • Capital gains or losses
  • Income of family members under age 18 or attending high school
  • Noncash benefits such as food stamps and housing subsidies

Financial assistance (charity care) – Health care services that have been or will be provided but are not expected to result in reimbursement or payment by the patient or other payers. Financial assistance results from a provider’s policy to provide health care services free or discounted to people who meet established criteria.

Gross charges – The total charges at the organization’s full established rates for providing patient care services before the limitation on charges discount or other deductions from revenue are applied

Limitation on charges –Total charges for patients with emergency or medically necessary care who qualify for financial assistance are limited to no more than the amounts generally billed to people with insurance coverage.

Medically necessary –As defined by Medicare services or items reasonable and necessary for the diagnosis or treatment of illness or injury. This could also include elective services that are beneficial to the patient’s long-term health. This is at the discretion of Great River Medical Center.

Underinsured – The patient has some level of insurance or third-party assistance but still has out-of-pocket expenses that exceed his or her financial abilities.

Uninsured The patient has no level of insurance or third-party assistance to help with meeting his or her payment obligations.

Procedures

To manage its resources responsibly and allow Great River Medical Center 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 financial assistance.

Services eligible under this policy

For purposes of this policy, “charity care” and “financial assistance” refer to health care services provided by Great River Medical Center without charge or at a discount to qualifying patients. See Exhibit Afor a listing of hospital services that are included and excluded from this policy.
Please note that services provided for nonmedically necessary care that is considered elective and would not be covered by this policy may require prepayment as determined by Great River Medical Center.
 

Eligibility criteria for financial assistance

1.      Financial assistance eligibility will be determined after a Financial Assistance Application has been completed and supporting documentation has been attached. A completed application will serve as documentation regarding the patient’s eligibility for assistance.
2.      The application MUST include:
  • Family income including earned income, unearned income and spousal income. See family income specifications above for clarification.
  • Monthly expenses
  • Number of dependents under age 18
  • Assets and liabilities may be used in the determination of eligibility in conjunction with family income information.
 3.      Supporting documents such as pay stubs and tax returns MUST be included to support the financial information reported.
 4.      Financial assistance will be considered for people who are uninsured, underinsured, ineligible for government programs or are unable to pay for medically necessary or emergency care based on their individual financial situation. Underinsured people include patients who have insurance or other coverage but their out-of-pocket expenses, such as co-insurance, deductibles and spend-downs, exceed their financial abilities.
 5.      Eligibility will be based on an individual determination of financial need, and will not take in to account age, gender, race, social or immigrant status, sexual orientation or religious affiliation.
 6.      Financial assistance may not be considered for patients who qualify for assistance through government programs but do not complete the necessary actions needed to acquire government assistance. It is the patient’s responsibility to contact the local government agency to pursue assistance with government programs. A Medicaid denial letter (or similar agency document) is required before Great River Medical Center will consider financial assistance for these people. Financial counselors are available to help patients with enrollment in Medicaid and Healthcare Marketplace programs.
 7.      Financial assistance is intended for residents for Great River Medical Center’s primary or secondary market service area. An exception could be made for any patient presenting with an urgent, emergent or life-threatening medical condition.
 8.      It is preferred but not required that a request for charity and a determination of financial need occur before providing nonemergency medically necessary services. But the determination may be done at any point in the collection cycle.
 9.      Recurring financial assistance will be re-evaluated every three months.  
 10.  Financial assistance will be applied to all open balances with patient responsibility dates up to three months before the date of the assistance application approval and will include dates of up to 12 months from the date of the application approval. Exceptions to this could include:
  • Extenuating circumstances that could allow for financial assistance to extend beyond the three months before the application date and 12 months from the date of the application. This is at the discretion of Great River Medical Center.
  • A change in financial circumstances that could cause a change in eligibility
11.  Patient payments in excess of $5 received before financial assistance determination including payments made three months before the date of the financial assistance application will be refunded to the patient up to the amount of the eligibility determination, which can be no more than the amount generally billed.
 12.  Great River Medical Center’s values of human dignity and stewardship shall be reflected in the application process, financial need determination and granting of charity.
 13.  Requests for charity will be processed promptly. Great River Medical Center will notify the patient or applicant of qualification in writing within 30 days of receipt of a completed application.
 

Presumptive financial assistance eligibility

There are instances when a patient/individual may appear to be eligible for charity-care discounts, but there is no completed financial assistance form on file because of a lack of supporting documentation. Often there is adequate information provided by the patient or through other resources that could provide sufficient evidence to determine eligibility.
1.      Information is provided weekly to Avadyne, an outside source. Avadyne returns results to Great River Medical Center about patient qualifications based on our Financial Assistance Policy.
2.      Avadyne uses demographic and household information, and credit-scoring technology to determine the percentage of assistance for which a patient may be eligible.
 3.      Great River Medical Center will attempt to contact patients based on their Presumptive Assistance qualification to allow the patient to apply for financial assistance.
 4.      Patients will NOT be disqualified from financial assistance based on Presumptive Assistance results.
 5.      If the account is past due and there is no completed financial assistance application or supporting documentation, the patient’s account could be considered for financial assistance based on Avadyne’s results.
 6.      Presumptive eligibility also can be determined based on life circumstances including:
  • Eligibility for other state or local assistance programs that are unfunded
  • Food stamp eligibility
  • Homeless or received care from a homeless clinic
  • Low income/subsidized housing provided as a valid address
  • Participation in the Women Infants and Children (WIC) program 
  • Patient is deceased with no known estate
  • State-funded prescription programs
  • Subsidized school lunch program eligibility
7.      It also is acceptable to use proxy information to determine eligibility when income levels cannot be directly determined. Such information could include statements like “stays with friends” or “occasionally works.”
8.      Patients who meet presumptive-care guidelines may qualify for financial assistance discounts. This determination is at the discretion of Great River Medical Center.
9.      In a situation, where presumptive eligibility is given to a patient and a financial assistance application is obtained later, the updated eligibility will be based on the financial assistance application with supporting documentation. In this case, Great River Medical Center could adjust financial assistance up to three months before the application date.
 

Extenuating circumstances for financial assistance eligibility

Occasionally, there are extenuating circumstances that could cause the hospital to grant a charity-care discount to patients who may otherwise not qualify for financial assistance under the above described criteria. An example would be if the patient had more medical debt in relation to income, resulting in an inability to meet their financial obligation. It is at the discretion of the financial assistance committee or the Vice President of Finance to grant charity discounts to patients with these extenuating circumstances.

Reasons for disqualification from financial assistance

  • Failure to complete a financial assistance application
  • Income is beyond qualification guidelines 
  • Lack of supporting documentation
  • No good-faith effort by patient to apply for financial assistance after Great River Medical Center has made an effort to make the policy known
  • Patient fails to follow through with available government programs
  • Patient provides false documentation or information

Calculating amounts charged to patients who qualify for financial assistance

The Patient Protection and Affordable Care Act (PPACA) Sec. 9007(a)(5)(A) limits the amounts charged to patients who qualify for financial assistance for emergency or medically necessary care to no more than the amounts generally billed to people who have insurance coverage. Because of this requirement, uninsured patients who meet eligibility criteria specific to Great River Medical Center will receive an immediate Limitation on Charges discount of 60 percent of their total charges.

The amount generally billed, which is the account balance after the limitation on charges discount, serves as the basis that the charity-care discount will be applied for uninsured patients. All patients eligible for financial assistance will not be charged an amount greater than the amount generally billed.

Example:
A patient account balance is $10,000. The patient has no insurance, and he or she qualifies for 50 percent financial assistance.
$10,000 x 60 percent = $6,000 (Limitation on Charges discount)
$10,000 - $6,000 = $4,000 (balance after Limitation on Charges discount)
$ 4,000 x 50 percent = $2,000 (financial assistance discount)
Account balance and patient’s responsibility = $2,000
 

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. The sliding fee scale will be updated annually as Federal Poverty Levels are updated. Refer to Exhibit B for the financial assistance sliding-fee scale.

  • Underinsured patients – Financial assistance will be based on the patient’s account balance after insurance.
  • Uninsured patients – Financial assistance will be based on the patient’s account balance after the limitation on charges discount.

Where to find financial assistance applications

A patient can apply for financial assistance by filling out the required financial assistance application. Applications or application information is available:  
  • At all Patient Access locations
  • At Registration in the hospital lobby
  • At the Department of Human Services office in Burlington
  • By calling Patient Financial Services-Patient Billing at 319-768-3625, option 2
  • In clinic offices when procedures are set up with Great River Medical Center
  • In the Emergency Department at registration and discharge
  • In the Patient Financial Services-Patient Billing offices in the hospital lobby next to Great River Gift Shop and on the lower level
  • Offered to patients during Pre-access
  • On Great River Health Systems’ website: www.greatrivermedical.org under Bill Payment/Financial Assistance
  • On the back of Great River Medical Center billing statements

Relationship to collection policies

Great River Medical Center has developed policies and procedures for internal and external collection practices (including actions the hospital may take in the event of nonpayment, which includes collection action and reporting to credit agencies) that take into account:
  • Extent to which the patient qualifies for charity
  • Patient’s good-faith effort to apply for governmental programs
  • Patient’s good-faith effort to apply for Great River Medical Center’s Financial Assistance Program
  • Patient’s good-faith effort to comply with payment agreements made with Great River Medical Center
For patients who qualify for financial assistance and are cooperating in good faith to resolve their discounted hospital bills, Great River Medical Center:  
  • May offer extended payment plans
  • Will cease collection efforts with outside collection agencies
  • Won’t send unpaid balances to outside collection agencies
Great River Medical Center and agencies acting on its behalf will not impose extraordinary collection actions without first making reasonable efforts to determine if the patient is eligible for financial assistance under this policy. Reasonable efforts include:
  • Documentation that Great River Medical Center has attempted to offer the patient an opportunity to apply for financial assistance according to this policy and that the patient has not complied with the hospital’s application requirements
  • Documentation that the patient has been offered a payment plan but has not honored the terms of that plan
  • Validating that the patient owes the unpaid bills and that all sources of third-party payments have been identified and billed by the hospital
Great River Medical Center will not send outstanding balances to an outside collection agency until 120 days from the date the balance became the patient’s responsibility have been exhausted. An outside agency acting on the behalf of Great River Medical Center will not take extraordinary collection action until an additional 120 days have been exhausted. Extraordinary Collection action includes but is not limited to:
  • Filing a claim for unpaid debt through the court system
  • Reporting adverse information to a consumer credit reporting agency or credit bureau
  • Selling debt to a third party other than a collection agency

Refer to Great River Medical Center’s Billing and Collection Policy for additional information.

Regulatory requirements

In implementing this policy, Great River Medical Center will comply with all other federal, state and local laws, rules and regulations that may apply to activities conducted according to this policy. The Patient Financial Services-Patient Billing manager is responsible monitoring and evaluating compliance.

References

  • Federal Poverty Guidelines – updated each year in February and published in the Federal Register. Available on the internet at ASPE.HHS.GOV/POVERTY/POVERTY.htm
  • Patient Protection and Affordable Care Act of 2010
  • Social Security Act, section 1867 (42 U.S.C. 1395dd)

EXHIBIT A – Included and excluded services and department listings

Included

The following services are included when in relation to trauma/emergency care, a condition that if not promptly treated would lead to an adverse change in the health status, nonelective services provided in response to life-threatening circumstances in a nonemergency room setting and medically necessary services:
  • All inpatient services
  • Day Hospital services
  • Diagnostic imaging services (CT, MRI, mammography, nuclear medicine, ultrasound)
  • Digestive health services
  • Emergency medical services
  • Heart and vascular services
  • Hematology and medical oncology services
  • Laboratory services
  • Obstetric services
  • Radiation oncology services
  • Surgical services
  • Wound clinic services

May be included

These services could be included or excluded from this policy based on the decision of Great River Medical Center’s Financial Assistance Committee. They will be evaluated individually.
  • Business health
  • Cosmetic services
  • Elective services
  • Home health and hospice services  
  • Occupational therapy
  • Physical therapy
  • Rehabilitation services (Rehabilitation services unrelated to services provided by Great River Health Systems could be excluded.)
  • Skilled nursing facility and residential services (Klein Center)
  • Speech therapy

Departments

These department services are included in Great River Medical Center’s Financial Assistance Policy:
  • Acute Care Center
  • Behavioral Health Unit
  • Cancer Center
  • Cardiovascular Care Unit
  • Day Hospital
  • Diagnostic Imaging
  • Digestive Health Center
  • Emergency Department
  • Heart and Vascular Center
  • Inpatient Dialysis
  • Intensive Care Unit
  • Laboratory
  • Nursery
  • Obstetrics Unit
  • Palliative Care
  • Pediatrics Unit
  • Pharmacy
  • Rehabilitation Unit
  • Respiratory Care Services
  • Sleep Disorders Center
  • Surgical Services
  • Swing Unit
  • Wound and Hyperbaric Clinic

Excluded

These services could be included or excluded from this policy based on the decision of Great River Medical Center’s Financial Assistance Committee. They will be evaluated individually.
  • Business health
  • Cosmetic services
  • Elective services
  • Home health and hospice services
  • Occupational therapy
  • Physical therapy
  • Rehabilitation services (Rehabilitation services unrelated to services provided by Great River Health Systems could be excluded.)
  • Skilled nursing facility and residential services (Klein Center)
  • Speech therapy

2017 Charity Care Matrix