A.        Patient Eligibility

To be considered for a discount under the Charity Care Policy, the patient must meet at lease one of the following criteria:

1. No third-party coverage is available.

2. Third-party coverage is available, but with limited benefits.

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. Medicaid or other government healthcare program benefits have been exhausted and the patient has no further ability to pay. Welfare assistance is denied due to resources and/or income, but the patient is deemed by UCH to be in circumstances in which an illness will make it impossible to meet financial obligations.

6. Patient is below four times the most recently available federal poverty threshold requirements.

B.        Application Process and Eligibility

1. When determining patient eligibility for charity care, UCH agrees to be equitable, consistent and timely. Requests for financial assistance will be accepted up to four (4) weeks from the date the first statement is remitted to the patient.

2. Requests may be received from the patient, legal guardian, parent of a minor or incompetent dependent, or spouse.

3. Liens attached to insurance (auto, liability, life and health) are permitted.

4. Patients requesting financial assistance will be required to complete the Financial Assistance Application Form in order to establish eligibility. Patients may be eligible for charity care if they are uninsured and meet other specific criteria.

5. Criteria for which a patient may be eligible for financial assistance are:

(i) Patient is homeless.

(ii) Patient is deceased and has no known estate able to pay hospital debts.

(iii) Patient is incarcerated for a felony.

(iv) Patient is currently eligible for Medicaid, but was not at the date of service.

(v)  Patient is eligible by the State to receive assistance under the Violent Crime Victims Compensation Act or Sexual Assault Victims Compensation Act.

(vi) Patient is eligible for Medicaid or other government healthcare program funding for certain emergency health services provided to undocumented aliens in accordance with the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Section 1011, regardless of whether Section 1011 funds for the applicable state are exhausted.

(vii) Patient is deemed to have minimal financial resources based on analysis of the Financial Assistance Application by UCH.

6.  The completed Financial Assistance Application Form will be submitted to UCH’s Corporate Office for processing.  UCH requires proof of income including employer pay stubs, employer verification and/or IRS tax return summary. If the patient is currently unemployed, they can submit a letter from their former employer indicating that their employment ended on ________  date. In addition, Medicaid or other government healthcare program beneficiaries are subject to an additional asset test in accordance with federal law. This review is completed to determine patient eligibility based on the patient’s total resources (including but not limited to family income level, assets, as required for Medicaid patients and other pertinent information).

C.       Outcomes Process and Notification

1. Financial Assistance approvals will be made according to these Charity Care Guidelines.

2. The minimum discount for private-pay payments of non-elective services will be 30%.

3. An asset test is mandatory for Medicaid patients. The Medicaid patient is responsible for the greater of: a) Seven percent (7%) of Available Assets (defined as cash, cash equivalent and non-retirement investments) or b) Required payment per the Charity and private-pay Discount Worksheet for Non-Elective services.

4. When determining the patient’s 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% support, and any other persons dependent on the family income for over 50% support. (A current tax return of the responsible adult is required.)

5. Proof of Income. Please provide proof of income. Examples accepted are: Prior year 1040 tax return, Social Security Administration statement of benefits, award letter for disability and/or retirement, food stamp approval letter, approval for unemployment benefits , or other proof of government assistance.

6. Financial Assistance applications are reviewed by Revenue Services.

7. The patient will be notified of eligibility for charity care generally within thirty (30) days of receiving a completed application and all requested documentation.

8. If the patient disagrees with the decision, he or she may request an appeal in writing within thirty (30) days of the denial and include any additional relevant information that may assist in the appeal evaluation.

9. For those patients who have applied for Medicaid, collection activity will be suspended during the consideration of a completed application.

10. This process is a courtesy and does not alleviate the financial obligation.