ELIMINATING BARRIERS TO hospital CHARITY CARE

ELIMINATING BARRIERS TO hospital CHARITY CARE This INFORMATION FOR COMMUNITY HEALTH AND SERVICE NAVIGATORS Was developed originally by Charity care task force,* Tacoma human rights commission September 2018. We appreciate the partnership of CHI and Multicare Health systems in developing this information. *Brad Bates - Chair, Gina Fonesca, Sarah Lee, Al Ratcliffe, Lisa Snyder

Physician/Provider Bills are another matter It depends … We will get to that later in the presentation. Always ask for financial Assistance if you cannot afford to pay.

Tacoma human rights commission • History and Mission: • Tacoma Municipal Code 1.29.010 The City Council creates and empowers a commission to study and investigate problems of prejudice, bigotry, and discrimination, and to encourage and coordinate the implementation of programs consistent with the needs and rights of all residents of the City of Tacoma. • Current protected categories are: • Race Religion Color National origin or ancestry Sex Disability • Gender identity Sexual orientation Marital status Familial status • Honorably discharged veteran or military status Source of Income

Impetus for the task force • 2017 Access Denied report by Columbia Legal Services found that hospitals were not adequately addressing language barriers tor patients with limited English Proficiency. • Access was markedly less for Spanish-speakers than for English speakers: • 80% of hospitals (16 0f 20) hung up at least once on Spanish-speaking telephone testers. • Spanish speakers were told about charity care availability by only 40% of the hospitals tested, while English speakers were informed 100% of the time. • Just 5 of the 20 websites mentioned language assistance for those with LEP. • Our Task Force was formed in November 2017 to look at disparate access to charity care.

Outreach to Information sources • CHI-Franciscan, Columbia Legal Services, Consejo Counseling and Referral Service, • Department of Health, Equal Rights Center, Korean Women’s Association, • Representative Laurie Jinkins Multicare Nativity House • Pierce County Community Healthcare Alliance SEIU 1199 NW • Tacoma Community House

What we learned • Many patients do not realize they may be eligible for medical financial assistance or charity care. • Many do not know how to apply for financial assistance. • English Language Learners may have extra difficulty communicating their needs to hospital staff and understanding the information they are provided about financial assistance • Many English Language Learners fear medical bills and/or running afoul of immigration authorities, so they avoid getting medical care early.

Topics to be covered: • Issues • Washington charity care laws • Language barriers to obtaining charity care • Current efforts to Eliminate Barriers to Charity Care • Multicare • CHI Franciscan

What is Charity Care/Financial Assistance? • Charity care is hospital care provided for free or at reduced cost to low-income patients. Some health care systems choose to offer charity care eligibility to persons seeking primary care. • Hospital charity care laws have existed since 1989 and are meant to ensure that health care is not out of reach for those who cannot afford it. Those laws and regulations have evolved over the years to strengthen access to financial assistance.

Charity care is good policy and promotes health equity • Charity care is good public policy and a fair exchange for the many public benefits conferred on Washington hospitals. • Public funds for hospital construction • Federal income and state property tax exemptions • Certain state business and occupation tax exemptions • The ability to issue levies or public-guarantee bonds • Favorable tax treatment that incentivizes charitable donations to hospitals or their foundations • Substantial public monies as compensation for hospital services • Certificate of Need Program limits the number of beds and concentrates services at certain hospitals, protecting hospitals from competition

NONPROFIT STATUS CARRIES RESPONSIBILITIES • Nonprofit hospitals are exempt from taxation by local, state and federal governments. • In return, they are required to provide charity care (known formally as financial assistance) to people who are “indigent persons”. • WAC 246-453-010(4) defines “Indigent persons” as “those patients who have exhausted third-party sources, including Medicare and Medicaid, and whose income is equal to or below 200% of the federal poverty standards, adjusted for family size or is otherwise not sufficient to enable them to pay for the care or to pay deductibles or coinsurance amounts required by a third-party payor.”

TWO HOSPITAL SYSTEMS HAVE LOCATIONS IN TACOMA • Multicare Health System includes: • Tacoma General Hospital • Mary Bridge Children's Hospital • Allenmore Hospital • Several Primary Care clinics and Urgent Care clinics, often collocated. • CHI Franciscan includes: • St. Joseph Hospital • Rehabilitation Hospital • Several Primary Care clinics and Urgent Care clinics • The new Wellfound Behavioral Health Hospital is a partnership by the two systems.

Washington State Charity Care Laws

THE RELEVANT STATE LAW AND REGULATIONS ARE: Substitute Senate Bill SSB 6273 became effective October 1, 2018. • RCW 70.170.060(6) “Charity Care—Prohibited and required hospital practices and policies—Rules—Department to monitor and report • WAC 246-453-020(1)-(2) Uniform procedures for the identification of indigent persons

Washington LAW ASSIGNS HOSPITALS AN AFFIRMATIVE DUTY TO: • Assess eligibility for charity care, rather than wait for patients to apply. • Perform charity care screening before attempting to collect payment • Provide written notice that free or reduced cost care may be available. • Interpret charity care information for patients with limited English proficiency • Ensure that the charity care application process is not burdensome.

CURRENT EFFORTS TO ELIMINATE LANGUAGE BARRIERS TO CHARITY CARE Multicare Video link: https://spaces.hightail.com/space/LFywo3pSIlhttps://youtu.be/2O0l-byfsNA CHI VIDEO LINK: https://youtu.be/2O0l-byfsNA CHI SPANISH LINK: aqroAku7Db3uUUQnqq9ivJ5EvcnQ_8&m=LEkRwgenxD32f4E5qVKXaMJ7Y1gdR5hpBxlZmgbtFV4&s=WXaVp0Kr3M0lL3pls7WaSykq9eY1PWT3mnfBP_rGPj4&e=>

Language SERVICES CHI Franciscan • Over-the-phone: Cyracom • Video-remote: My Accessible Real-Time Trusted Interpreter (MARTTI) • DSHS/Medicaid: Universal Language MultiCare • Qualified Bilingual Staff Program • InDemand Interpreting

Washington LAW REQUIRES HOSPITALS TO: • Post and prominently display notice of charity care availability in areas where patients are admitted or registered, in emergency departments, and financial service or billing areas accessible to patients. • Make available on the hospital’s website current versions of the hospital’s charity care policy, a plain language summary of the policy, and the application form. • https://www.chifranciscan.org/billing-insurance-and-finances/financial-assistance-discounts-for-patients.html • https://www.multicare.org/financial-assistance/

EXISTING LAW REQUIRES HOSPITALS TO: • Post notice of charity care availability in all languages spoken by more than 10% of the hospital’s service area. • Notice must be interpreted for other non-English speaking or limited-English speaking or other patients who can not read or understand the writing and explanation. • Notice means “posted or prominently displayed within public areas of the hospital, and provided to the individual in writing and explained, at the time the hospital requests information from the responsible party with regard to the availability of any third-party coverage.

Existing law requires hospitals to: • include a statement prominently displayed on the first page of all hospital billing statements/written communications about billing/collection … • In English and the second most spoken language in the hospital’s service area informing people about charity care… • In these or similar words: • “You may qualify for free care or a discount on your hospital bill, whether or not you have insurance. Please contact our financial assistance office at [website} and [phone number].”

Notification posters - multicare

Notification posters - Chi-Franciscan

Notification posters – chi-franciscan

Establishing Financial eligibility for charity care

ELIGIBILITY SCREENING Hospitals gave us these assurances regarding “current” practices: • Patients are affirmatively screened for charity care eligibility as a routine part of admission and registration. • Charity care screening is completed before patients are asked to pay deposits. • Patients who are preliminarily found eligible for charity care are not asked to make any payments until a final determination is made. • Income verification requirements are consistent with Washington law. • Patients are not sent to collections without screening for charity care eligibility. • Interpretive services are available at every step to assist patients.

PATIENTS QUALIFY BASED ON A COMPARISON OF THEIR FINANCIAL RESOURCES AND/OR INCOME TO FEDERAL POVERTY GUIDELINES. CHI Financial Assistance Eligibility Guidelines: “Financial assistance is provided to those with an annual family income of less than 300% of the Federal Poverty Guidelines.” Multicare Financial Assistance Eligibility Guidelines: [Click Ctrl + Link] https://www.multicare.org/file_viewer.php?id=11807&title=Financial+Assistance+Eligibility+Grid Multicare offers four additional levels of discount for income up to 500% of Federal Poverty Guidelines.

Application process cannot be burdensome • Any of these documents is sufficient proof of income: • W-2 • Pay Stub • Income tax return • Forms approving or denying eligibility for Medicaid, state-funded medical assistance, or unemployment compensation. • Written statement from employers or welfare agencies. • For reaching initial determination of Charity Care eligibility hospitals are to rely on information provided orally by the responsible party.

Application process cannot be burdensome • When it is obvious that the responsible party is indigent, the hospital is not obligated to require the person to complete the application process. When the responsible party cannot provide the documentation previously listed, hospitals are required to rely upon a written statement from the responsible party

So, how does one apply for charity care? • Both hospital systems now ask upon entry whether financial assistance is needed. Screening for eligibility takes place immediately or very early in the care process and does not delay medically necessary care. • Application forms are available in several languages and are essentially identical:CHI instructions and form: https://www.chifranciscan.org/content/dam/chi-franciscan/website-files/billing-and-finances/financial-assistance/English2018.07.25.pdf • Multicare instructions and form: https://www.multicareorg/financial-assistance-forms/ NOTE: Click on “language” link in upper right hand corner of screen. • Shortcut: Apply first to Community Health Care, Sea-Mar clinics, or Pierce County Project Access and ask for application assistance.

How often must you reapply? • CHI: Reapply every six months. • Multicare: If on fixed income, reapply annually. If income varies, reapply after six months.

IF you RECEIVED BILLS FOR PAST CARE, YOU MAY APPLY RETROACTIVELY • Hospitals must refund payments if a patient subsequently is found to have met charity care criteria. • Contact hospital financial assistance staff for screening.

REFUNDS If the responsible party pays a portion or all of the charges related to eligible medical services, and is subsequently found to be eligible for charity care, the hospital will issue a refund within 30 days of determining eligibility for charity care [WAC 246-453-020(11)].

Appeal process Hospitals must notify charity care applicants about their eligibility within 14 calendar days of receiving necessary information. Applicants have 30 days to appeal. Collection efforts must cease during an appeal. If approved, notification must include details about the amount for which the patient will be held responsible. If denied, hospitals must notify patients of the basis for denial, and must inform patients that they have 30 days to appeal the decision.

Physician billing • Multicare provides on its website a list of all related providers who accept charity care discounts for services: • https://www.multicare.org/file_viewer.php?id=15101&title=Providers+that+accept+financial+assistance • CHI posts a list of all related physicians, but that list does not indicate whether they accept charity care discounts. ASK about financial assistance at first contact with the provider office. • You must apply separately to the hospital and to provider offices for financial assistance.

Charity care in primary care clinics • Sea-Mar Health Clinics • Community Health Care clinics • or via referral from Pierce County Project Access (Call 253.572.7265) • Multicare family medicine locations, BUT you must be enrolled with a primary care provider located there. You should ask for Financial Assistance • Urgent Care Clinics donot provide financial assistance. • We encourage persons to seek primary care at one of these resources and only go the Emergency Room if it is truly an emergency.

ENCOURAGE YOUR LOW-INCOME CLIENTS TO ASK ABOUT FINANCIAL ASSISTANCE WHEN: • They seek hospital or emergency department care. • They make appointments with health care providers who are employed by the hospital or by contracted provider groups. • They are enrolled in outpatient primary care clinics operated by the hospital systems. • REMEMBER: Urgent Care patients are not eligible for financial assistance

Release of Identifying information? • Neither hospital system releases HIPAA protected consumer information to law enforcement or immigration authorities unless: • The individual consumer has given voluntary informed written consent for release of information. • Or • The hospital is presented with a formal court order, signed by a judge requiring release of information about a specifically named person. In that situation, the hospital can, and probably will, request that the judge review the requested information “in camera” for a final decision about whether and what information should be released.

For a questions or a Copy of this training, • Send an email request to: alratcliffe@gmail.com • Subject: Hospital Financial Assistance Training • I will attach the training and reply to your request. • Thanks!

ELIMINATING BARRIERS TO hospital CHARITY CARE