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FINANCIAL ASSISTANCE PROGRAM
Oaklawn will treat all patients with respect, dignity and compassion regardless of their ability to pay. Oaklawn’s expectation for payment is based on the patient’s ability to meet payment obligations.
Oaklawn is pleased to offer patients financial assistance in the form of discounts up to 100% of the amount owed. Eligibility is based on income as well as other criteria set forth in this policy. This policy describes the eligibility and application process to determine discounts patients may qualify for. This policy gives consideration to and complies with IRS regulations pertaining to charitable hospitals as defined under section 130266-11. This policy also complies with the process for determining discounts under Public Act 107 of the Healthy Michigan law, section 105d, which indicates that hospitals cannot charge uninsured individuals at 250% of poverty level or below more than 115% of the Medicare reimbursement rate. Throughout this procedure this law will be referred to as the Uninsured Mandated Cap. It is the hospital’s responsibility to communicate its financial assistance policies to patients and it is the patient’s responsibility to provide information necessary to determine eligibility in a timely and complete fashion.
This policy applies to the insured and the uninsured. All patient balances including coinsurance, deductible or other non-covered services may be considered for discounts as explained in the procedure below.
Providers Covered/Not Covered by FAP Policy
This policy covers services provided by Oaklawn Hospital and Oaklawn Medical Group except for services provided by Oaklawn DME. Oaklawn DME patients may be eligible for assistance based on the policy specific to that area.
Communication of FAP/Obtaining An Application
The hospital communicates its FAP to patients in the following ways:
An application for assistance and a copy of this policy can be obtained by calling PFS (269-789-7000) to request a mailing, downloading or viewing a copy from the hospital web-site (www.oaklawnhospital.org) or in person at the cashier’s office in the main hospital, the Emergency Department or any area that registers patients.
Eligibility Determination and Timeframe to Apply for Assistance
Eligibility for FAP is primarily based on annualized household income. The determination of eligibility is based on the patient’s financial situation at or near the time service is rendered. (This is consistent with HFMA Principals and Practices Board Statement No.15).
Patients on a fixed income need to apply once a year. All other patients must apply every six months or more frequently if their income changes significantly. The hospital will accept FAP applications up to 240 days from the date of the first billing statement. However, accounts may be referred to collections after 120 days from the date of the first billing statement and if it has been more than 30 days since an application was requested by and sent to the patient. It is in the patient’s best interest to apply for financial assistance as early as possible.
If an account has been placed with a collection agency and the patient requests financial assistance, collection efforts will cease for at least 30 days to allow the patient time to complete the application. If it is determined that the patient is eligible for financial assistance, the account will be withdrawn from collections and the agency will reverse any credit reporting that may have occurred. If there is a balance remaining after the discount is applied, the agency may resume collections if that balance is not paid within 30 days or acceptable payment arrangements are not made with the agency. Accounts that are 240 days past the date of the first billing statement are no longer eligible for assistance.
The Affordable Care Act makes insurance available to all individuals; therefore, the only discount available to the uninsured is the uninsured mandated cap and if applicable the Oaklawn 50/50 (explained below). In Michigan most low-income patients are eligible for Healthy Michigan (Medicaid) through the Marketplace.
Method of Applying for Financial Assistance
The following information is required in order to be considered for an FAP discount.
The completed Application for Assistance and supporting documentation can be submitted in one of the following ways:
The following are exceptions and exclusions, and these persons are not eligible for assistance unless otherwise indicated below.
Actions Taken in the Event of Non-Payment
The actions that are taken by the hospital in the event of non-payment of any balance due from the responsible party are described in the hospital’s Collection Policy. Collection action taken could include placement with third party collection agency, a blemish on the responsible party credit report, garnishment of wages or other litigation. A copy of the Collection Policy is available to the public and can be obtained by calling PFS (269-789-7000), viewed on or downloaded from the hospital’s web-site (www.oaklawnhospital.org), or in person at the cashier office in the main hospital lobby.
Balances in cash accounts such as checking or savings are not considered in determining eligibility if the balance is under $2,000.00. Cash balances that exceed this amount must be used to discount the balance of the outstanding account before assistance will be considered.
Balances in IRA
Income drawn from a retirement account is included as income for determining eligibility.
Balances in IRA are considered cash for determining eligibility unless the patient is on permanent disability or age 55 or older. All other patients who have balances exceeding $2,000 in a retirement account and who would otherwise qualify for assistance will be limited to a 75% discount. If the balance in their retirement together with their income is at or below the income guidelines patients will be eligible for assistance based on adding these together. If the amount owed exceeds the IRA balance, the amount of the bill in excess of their retirement balance should be considered for the discount the patient would otherwise qualify for.
Expenses are typically not considered in determining eligibility for assistance. In unusual circumstances when the patient or their family has experienced a catastrophic event, expenses may be considered and can be documented on the back of the Financial Assistance Application.
Family Size Definition
The family size will be the same as filed on the person’s latest income tax return plus any other person’s whose income is considered in determining eligibility and adjusted for any applicable changes since the income tax return was filed. Parental income for adult children is considered in determining eligibility if the adult child is claimed by their parent(s) on their parent’s income tax return. In the case of divorce, children who are supported by child support can be included even if they are unable to be claimed on the family’s income tax return.
In the case of cohabitation without marriage both parties’ income is considered when determining income and both parties’ dependents are considered in the family size. (Patients can, however, be eligible for the mandated cap without providing their significant other income).
For patients that are enrolled in an out-of-state Medicaid program, presumptive assistance can be granted if the patient was unable to get the service in their home state (i.e., emergency) and the patient can provide proof of active coverage. Otherwise, these patients are only eligible for the mandated cap.
Persons who submit a complete application and meet all other requirement explained in the policy are eligible for assistance based on federal poverty level (FPL). These guidelines are taken from the Department of Health and Human Services “Table of Poverty Guidelines” and are updated annually (see Attachment II). Patients at 175% of FPL or below will receive a full write-off of the amount owed. Patients at 176% to 250% of FPL will have the amount owed reduced by 75%. As explained previously, patients that choose not to have insurance are only eligible for the mandated cap (115% of Medicare reimbursement applied to gross charges).
In order to be eligible for the maximum discount based on income (100% or 75%), services must be medically necessary and urgent or emergent (versus elective). The hospital works with the patient’s physician to determine if the services meet these criteria. When possible determination for eligibility should be made in advance of the service being rendered however emergency medical services are always provided regardless of the patient’s ability to pay and regardless of past payment history or unpaid balances.
If a patient is FAP eligible as described in this policy, all medical care received will be discounted to no less than the mandated cap. This may be applicable for services not eligible for a higher discount because service was not urgent/emergent as explained above. (Per IRS regulations all medical services for FAP eligible patients are limited to something less than gross charges.)
If the patient qualifies for partial assistance, the discount is applied regardless of the payment of the balance, which will follow the normal billing cycle. (See previous section, Actions Taken in the Event of Non-Payment.)
The AGB (Amounts Generally Billed) is calculated annually by the Finance Department and represents an overall average that the hospital is reimbursed by all payers, excluding Medicaid. The hospital calculates two AGB percentage rates: inpatient and outpatient. The AGB is updated annually following the hospital’s fiscal year end. The current AGB is shown on Attachment II. This amount is used to ensure that patients that are FAP eligible are not charged more than the AGB per IRS regulations. The hospital uses the look back method to calculate the AGB.
Oaklawn 50/50 Plan
The Oaklawn 50/50 Plan is an assistance/discount plan that helps people pay large balances. The plan provides a discount on large balances, matching patient payments up to 50% of the bill. Depending on the amount owed, any patient regardless of income may potentially qualify. This discount is in addition to any discounts the patient may qualify for as described previously.
To qualify for the 50/50 program, patients must meet the account balance and income criteria described in Attachment II.
For every dollar the patient pays, the hospital provides a matching discount up to 50% of the bill.
Balances apply to single accounts only with the exception of mom and newborns. These can be combined for the purpose of 50/50. Exceptions for catastrophic or episodes of care that result in multiple account balances may be considered on a case-by-case basis if approved by the Director of Patient Financial Services. Balances can be self-pay, copay/deductible, or even balance after a partial assistance discount.
Patient must enroll in the program and provide proof of income. Enrollment is done as part of the Application for Assistance process, however, if patients do not want to be considered for other discounts they only need to provide proof of income and family size.
Once the patient enrolls, any payments they make within 60 days will be matched up to 50% of the bill. Any payments the patient made prior to the enrollment date are also matched. Payments after the expiration date are not matched. Only self-pay payments are matched. Insurance payments are not matched.
The 60-day time frame can be extended if authorized by the Director of Patient Financial Services. This may be appropriate at times to allow patients more time to secure funds if they are applying for a loan or disposing of assets. The write-off is unconditional and applies regardless of what happens with any balance remaining. Patients can still make payment arrangements for any balances remaining at the end of 60 days.
When the financial application is incomplete or missing information, PFS staff will send the patient a notification in the mail advising the patient what information is needed to complete the application. Patients have 30 days to provide this information. If the information is not provided within 30 days, normal collections will proceed.
Patients can reapply or submit missing information at any time during the 240-day window to apply for assistance since the first statement was sent.
Notification of Determination
Every effort is made to process all applications within 30 days of receipt. While patients remain in the statement cycle while their application is being processed, once an application is received all collection activity (referral to collection agency) will cease until a determination of eligibility has been made. Patients are notified in writing of the determination. If patients do not qualify, they are given the reason that they did not qualify and can reapply if additional information or correction is applicable. When a partial discount is taken, the patient will have at least 30 days to pay the balance or make payment arrangements prior to any collection activity being taken or resumed.
The PFS Director will review all applications and authorize assistance up to $10,000 per individual account. For assistance exceeding $10,000 but less than $25,000, the authorization of the Controller or Reimbursement Director is also required. For assistance exceeding $25,000, the authorization of the Chief Financial Officer is required.
If a patient is determined to be FAP eligible and has made payments in excess of the discount, they will be refunded the overpayment amount.
Emergency Medical Care Policy
The hospital does not allow actions that discourage individuals from seeking medical care and has insured that its FAP policy is in compliance with EMTALA. A copy of the hospital’s EMTALA policy can be obtained by calling PFS at 269-789-7000.
Help is Available
IRS regulation 501(r)-4(5)(ii) indicate that the FAP documents should be translated to other languages if the population of the community served constitutes the lesser of 1,000 individuals or 5%. Oaklawn does not meet this threshold but is happy to assist any individuals that may need help with interpretation or help of any kind completing the application.
If patients have questions regarding this policy, need help submitting a financial application, or for any other inquires related to the financial assistance program or the patient’s outstanding accounts, contact PFS at 269.789.7000.
AUTHOR: Deborah Bowers
REVISED: 3/1989, 5/1990,4/1991, 8/1993, 6/1994, 3/1995, 6/1996, 5/1997, 9/1999, 3/2000, 10/2001,5/2004, 7/2005, 2/2006, 4/2007, 4/2008, 5/2012, 3/2014, 10/2015, 6/2016, 2/2017, 4/2018, 5/2019, 2/2020