BronxCare Health System

Determining Patient Eligibility under this Policy for Inpatient and Outpatient Services

1.

When registering or scheduling a patient, responsible Staff should inform all self-pay patients of this Policy, and, assist the self-pay patient in determining eligibility under this Policy. A “self-pay” patient does not have health insurance and does not receive benefits from a governmental assistance program, such as Medicaid, HMO/Managed Care program;

2.

Insured patients may apply for the sliding fee discount as a secondary coverage. Responsible Staff will usually be:

a. The Financial Investigator/Certified Application Counselor for inpatient and elective services

b. The Registrar/Receptionist, Associates, Financial Investigators or Central Registration Associate for outpatient/clinic appointment services.

3.

Self-pay patients who reside in the Institution’s Service Area, as defined above, should complete an application for assistance under this Policy and any applicable governmental program and provide supporting documentation of identity, address, household income and household composition.

4.

Staff will refer patients who may be eligible for governmental assistance, such as Medicaid, HMO/Managed Care program to the Department of Managed Care.

5.

Staff will review the application and determine if the patient qualifies for Charity Care or Financial Aid under this Policy.

6.

Eligibility should be determined prior to elective ordered ambulatory diagnostic and High Cost Outpatient services, such as MRI, CAT Scan, PET Scan, or LINAC.

7.

If the patient is eligible, Staff will determine what level of Charity Care and Financial Aid is applicable, as well as the patient’s financial commitment under this Policy. The patient, legal guardian or financially responsible person, as the case may be, should be advised of the determination, and each of these determinations should be documented in the patient’s file.

8.

The patient will receive a bill for the services provided. This bill should state that amount which is being provided as Charity Care or Financial Aid and that amount which is the patient’s financial obligation. Generally, the patient’s financial obligation will be a fixed amount for outpatient services or a percentage of what Medicaid would have paid for inpatient services.

Example – Determination of Patient’s Financial Obligation

The patient’s application shows annual family income of $35,000 and there are 4 family members. The patient would fall within 150% of the Federal Poverty Guidelines.

Inpatient Services: the patient would be financially responsible for 20% of the Medicaid rate and the balance in charges would be Charity Care and Financial Aid.

For example:

Inpatient Charges:

DRG XXX (Medicaid Rate)

Patient’s Financial Obligation
(20% of $4,000 Medicaid Rate)

Charity Care and Financial Aid Provided

$10,000

$4,000

800
(Includes HCRA Surcharge applicable to Self-Pay Patients)

$9,200

General Outpatient Services: the patient would be financially responsible for the fixed payment of $30 and the balance in charges would be Charity Care and Financial Aid.

High Cost Outpatient Services: the patient would be financially responsible for 20% of the Medicaid rate and the balance in charges would be Charity Care and Financial Aid.

1. Staff should review the patient’s outstanding financial obligations when the patient arrives for outpatient services. If a patient has not made a payment between his/her last and current visit or within 60 days from his/her last visit, the case should be referred to the Practice Administrator or his/her designee, and, if necessary, discussed with the Medical Director, or his designee.

2. The patient is allowed 90 days from the date of discharge or of service to apply for financial assistance and 20 days to submit a completed application (including all required documentation). A written response to all completed applications for Charity Care or Financial Aid approving or denying the application will be sent within 30 days after receipt of a completed application. If an application is not complete, the patient should be requested to provide the necessary information to complete the application. If the patient does not provide the requested information within the allowed timeframes, the application may be denied.

3. Once a completed application, including required documentation or other information needed to make a determination on the request for Charity Care or Financial Aid has been submitted, the patient could disregard any bill that has been sent until the hospital had rendered a decision on the application.

4. Eligible patients may request an extended payment plan. Installment payments will not be greater than 10% of gross monthly income.