Financial Assistance Policy
MISSION STATEMENT
Milford Regional Medical Center, Inc. is committed to providing exceptional healthcare services to our community with dignity, compassion and respect.
OPERATING PRINCIPLES
Exceptional Healthcare Services
Our focus is on continually improving the quality of our services in order to provide the best services we can with our resources.
This means a focus on our patients as our customers, in the sense of seeking their satisfaction with us. It means a focus on teamwork by the staff of the various departments that together provide care to our customers. We believe our staff does its best when work is done collaboratively, because so much of what one discipline does relates to the other. We seek to identify our internal customers and meet their expectations as part of this process.
We see teaching and education as part of our mission. Along with our house staff training program in Emergency, Internal and Family Practice Medicine with the University of Massachusetts, our training responsibilities also extend to nurses, to laboratory, radiology personnel and to a variety of other professional groups.
We see the selection, development and continuing education of our staff as central to our mission to assure qualified caregivers.
We seek to provide state-of-the art services and leading technology. We focus on providing a safe environment for our patients and staff.
We collaborate with our communities to assess health needs, including health status indicators as a basis for planning our healthcare services. The Hospital seeks to serve as a catalyst and leader to address these needs with other healthcare providers and community groups in order to improve the health status of the residents of our communities.
We seek to measure in a meaningful way, both internally and by benchmarking to other hospitals, to improve patient outcomes so that our customers can enjoy a healthy life. We also seek to work toward nationally established health status standards to improve the health of the members of our communities.
We seek to continually evaluate and improve our systems and our timeliness for providing care.
We strive to care for our patients ethically, developing and refining our sensitivities to treatment and end-of-life decisions.
When we talk about our "healthcare services", we are talking about inpatient, outpatient and educational services that we provide to our communities at our various locations. We see our services as patient-centered services and strive to make them accessible, convenient and cost-effective to our customers.
We seek to prevent illness and promote the health of the residents of our communities, as well as to treat the illness of our patients.
Community
The Hospital is the community hospital caring for residents of our 20-plus town service area. We strive to be responsive to our various and diverse constituencies – individuals and families of all ages, employees and employers of large and small businesses, physicians and other healthcare providers, our school systems, our local and area officials and safety personnel, churches, community organizations, our insurers and payers and our own employees and volunteers. As a charitable hospital, we acknowledge our special concern for the needs of the underserved, especially the poor and minority populations.
Dignity
We seek to provide our services so that our customers' physical and mental needs are handled with confidentiality and in such a manner to increase, rather than diminish, a sense of personal dignity. This requires facilities in their design and maintenance and staff in their professional demeanor and polite attitude that support this operating principle.
We strive to assure patient autonomy in identifying and responding to our patients.
Compassion
We seek to provide our services in a manner that empathizes with our customers whose symptoms and conditions we diagnose, assess and treat. This also requires facilities in their design and maintenance and staff in their understanding demeanor and caring attitude that can provide comfort and support.
We seek to be sensitive to patients' needs and the value of family involvement in patient care by maintaining open communications and fostering the importance of seeing others' perspectives. We expect ourselves to be attentive and responsive to our patients.
Respect
The concept of respect is similar in meaning to dignity and compassion; we seek to emphasize these qualities as ones that are close to our mission and as a community hospital. We focus on respect as a more active process between staff and customer and also among staff. Respect reflects concern for the individual and for each other. Respect manifests itself in good-natured humor and many other ways. We seek to treat our external customers – our patients, and our internal customers – our staff, with respect.
FINANCIAL ASSISTANCE POLICY
The Hospital is committed to providing you with high-quality care and services. As part of this commitment, The Hospital works with individuals with limited incomes and resources to find financial resources and coverage for their care.
Our financial assistance program helps low-income, uninsured and underinsured individuals determine if they are eligible for public assistance or through other sources, including The Hospital's financial assistance.
I. PURPOSE
Financial assistance is available from The Hospital for uninsured and underinsured individuals who cannot receive public assistance and cannot afford to pay for their medical care.
The premise of the program is that all individuals are expected to contribute to their care, based on their ability to pay. Assistance is given based on the individual's household income, family size, expenses and medical needs.
II. DEFINITION(S)
Amount Generally Billed (AGB): The amount generally billed is calculated using twelve months of Medicare and Commercial claims paid data and by dividing the total payments received from all parties to the covered charges.
The resulting percentage becomes the amount generally billed and is utilized as the maximum net charge (gross charge less discount) to patients qualifying under the Financial Assistance Policy. The AGB will be updated on an annual basis. The AGB percentage is calculated using the "look-back" methodology.
The calculated AGB for services beginning March 1, 2024 is 44%.
Disability: Persons 18 years of age and older who are on disability are considered their own individual. For children under 18 years on disability, both the child and the disability income must be included in the family income.
Emergency and Urgent Services: The Hospital will provide emergent/urgent services without regard to the patient's insurance coverage or ability to pay.
Emergent Services include: Medically necessary services provided after the onset of a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the health of the person or another person in serious jeopardy, serious impairment to body function or serious dysfunction of any body organ or part or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. §1295dd(e)(1)(B).I.
Hospitals follow the federal Emergency Medical Treatment and Active Labor Act (EMTALA) requirements by conducting a medical screening examination to determine whether an emergency medical condition exists. It is important to note that classification of patients' medical condition is for clinical management purposes only, and such classifications are intended for addressing the order in which physicians should see patients based on their presenting clinical symptoms. These classifications do not reflect medical evaluation of the patient's medical condition reflected in final diagnosis.
Urgent Services include: Medically necessary services provided after sudden onset of a medical condition, whether physical or mental, manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson would believe that the absence of medical attention within 24 hours could reasonably expect to result in: placing the patient's health in jeopardy, impairment to bodily function, or dysfunction of any bodily organ or part. Urgent services are provided for conditions that are not life threatening and do not pose a high risk of serious damage to an individual's health.
Family: A family is a group of two or more persons related by birth, marriage or adoption who reside together for support; all such related persons are considered as one family. In the case of divorced/separated/joint custody parental relationships, dependent children may only be considered on one program application. Foster children may be included only if income associated with the care of the foster child is also included. Dependent adult members of the household other than the applicant and co-applicant should apply for Financial Assistance as an unrelated individual. If a household includes more than one family and/or more than one unrelated individual, the income guidelines are applied separately to each family and/or unrelated individual, and not to the household as a whole. Adults living together in a significant-other relationship may qualify as a family.
Federal Poverty Guidelines (FPL): The most current FPL are obtainable at http://aspe.hhs.gov/poverty or by contacting the Massachusetts Department of Health and Human Services office 1-800-841-2900.
Health Safety Net: The payment program established and administered in accordance with M.G.L.e.118E, §§ 8A, and 64 through 69 and regulations promulgated thereunder, and other applicable legislation.
Health Safety Net Trust Fund: The fund established under M.G.L.e.118E, § 66.
Health Safety Net Office (Office): The office within the Office of Medicaid established under M.G.L.e.118E, § 65.
Health Safety Net – Partial: A Low Income Patient eligible for either Health Safety Net – Primary or Health Safety Net – Secondary who documents MassHealth MAGI Household income or Medical Hardship Family Countable Income, as described in 101 CMR 613.04(1), between 200.1% and 400% of the FPL, is considered Health Safety Net – Partial as described in 101 CMR 613.04(4)(b)3.
Health Safety Net – Partial Deductible (Deductible): Annual deductible applied as described in 101 CMR 613.40(6)(c).
Health Safety Net – Primary: A Health Safety Net eligibility category for uninsured Low Income Patients as described in 101 CMR 613.04(4)(a)1.
Health Safety Net – Secondary: A Health Safety Net eligibility category for Low Income Patients with other primary health insurance as described in 101 CMR 613.04(4)(a)2.
MassHealth: The medical assistance and benefit programs administered by the MassHealth Agency pursuance to Title XIX of the Social Security Act (42 U.S.C. 1396), Title XXI of the Social Security Act (42 U.S.C. 1397), M.G.L.e.118E, and other applicable laws and waivers to provide and pay for medical services to eligible members.
MassHealth Agency: The Executive Office of Health and Human Services in accordance with the provisions of M.G.L.e.118E.
MassHealth CarePlus: A program of health care services for eligible adults, age 21 to age 64, administered by the MassHealth Agency pursuant to 130 CMR 505.000: Health Care Reform: MassHealth: Coverage Types.
MassHealth Family Assistance: A program of health care services for eligible children and adults administered by the MassHealth Agency pursuant to 130 CMR 505.000: Health Care Reform: MassHealth: Coverage Types.
MassHealth Family Assistance ‑ Children: Minors enrolled in Family Assistance/Premium Assistance whose MassHealth MAGI Household income, as described in 101 CMR 613.04(1), is between 150% and 300% of the FPL and who reported to MassHealth that they are enrolled in health insurance.
MassHealth Limited: A program of emergency health care services for individuals administered by the MassHealth Agency pursuant to 130 CMR 505.000: Health Care Reform: MassHealth: Coverage Types.
MassHealth MAGI Household: A household as defined in 130 CMR 506.002(B): MassHealth MAGI Household Composition.
MassHealth Standard: A program of health care services for eligible individuals administered by the MassHealth Agency pursuant to 130 CMR 505.000: Health Care Reform: MassHealth: Coverage Types.
Inability to Pay: A person is unable to pay for necessary medical bills when the family income of that person is less than the income guidelines.
Income: Income shall be defined as total annual cash receipts before payment of appropriate social security and income taxes. Income sources shall include, but not be limited to, the following categories:
1. money wages and salaries before any deductions, exclusive of food or rent received in lieu of wages;
2. net receipts (as defined on Schedule C Adjusted Gross Income on Line 37) from self-employment, including farming activities, rental properties;
3. social security, railroad retirement, unemployment compensation, worker's compensation, strike benefits, veteran's benefits;
4. training stipends;
5. public assistance including aid to families with dependent children, supplemental security income and general assistance money payments;
6. alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household;
7. pensions and regular insurance or annuity payments, including IRA's and similar funded accounts;
8. income from dividends, interest, rents, royalties or payments from estates or trusts; and
9. net gambling or lottery winnings.
For eligibility purposes, income does not include the following:
1. capital gains;
2. any liquid assets, including withdrawals from a bank or proceeds from the sale of property;
3. lump-sum inheritances;
4. one-time insurance payment or other one-time compensation for injury, however, one-time insurance payments made for coverage of hospital services would limit the availability of free care to bills not covered by such payments;
5. tax refunds;
6. gifts and loans;
7. non-cash benefits such as the employer-paid or union-paid portion of health insurance or other employee fringe benefits;
8. the value of food and fuel produced and consumed on farms and the imputed value of rent from owner occupied non-farm or farm housing; and
9. federal non-cash benefit programs such as Food Stamps, school lunches, and housing assistance.
Liability/MVA: The terms Liability or Motor Vehicle Accident (MVA) will refer to those claims for which some liability or other non-health insurance is involved. The most common example is motor vehicle accidents in which car insurance is involved, but can include any situation in which a third party or other entity is considered to be responsible or liable. Any situation involving attorney representation would be included. This policy does not cover such claims unless all payments or settlements have been applied against the outstanding claim or until all benefits have been exhausted or denied.
Medically Necessary Services: Medically necessary services are generally defined as services which are ordinarily covered by healthcare insurance. Emergency Care and Urgent Care Services are always considered to be Medically Necessary under this policy. Individual services which are not covered due to an insurance's medical coverage policies and for which other notification of noncoverage was issued are not eligible for coverage under this policy.
Ineligibility for MassHealth: For the purposes of this policy, patients and consumers are considered to fall into the category of being eligible under one of the MassHealth programs when an application has been submitted and approved by Massachusetts Medicaid.
Providers: This policy does not cover the fees for independent providers, surgeons, consultants, anesthesiologists, imaging interpretation services, pathology services and other professionals who may provide services and separately bill for those professional services. A listing of providers is available as Exhibit G of the Financial Assistance Policy and available on the Hospital Website.
Resident of Massachusetts: The term "Resident of Massachusetts" refers to a United States citizen living in the state voluntarily with the intention of making a home in Massachusetts. An individual who is visiting or is in Massachusetts temporarily is not a resident. For individuals who reside in more than one state, residency will be determined by the state of residence identified on their Massachusetts Income Tax Return. Students who are eligible to be considered a family unit of one under the above definition and who are attending a school, exclusive of correspondence courses, in Massachusetts will be considered Massachusetts residents. A copy of a State of Massachusetts issued Driver's License or Photo Identification card, a current and valid school issued ID card or some other proof of residency will be required. Only U.S. citizens who are residents of Massachusetts may qualify for the Category A free care under this policy. U.S. Citizenship is required, but residency is not a requirement for the other categories of free care or cost-sharing.
Milford Regional Medical Center, Inc. Website: All references to the Milford Regional Medical Center Website or Website will refer to www.milfordregional.org. The Financial Assistance and Patient Collections policies, income guidelines and Financial Assistance application are available under the Patient Financial Services tab at this URL milfordregional.org/financialservices.
Urgent Care: Services necessary in order to avoid the onset of illness or injury, disability, death, or serious impairment or dysfunction if treated within 12 to 24 hours. Urgent care will be provided to all presenting persons regardless of ability to pay.
III. PROCEDURE
A. The organization will post a written plain language notice of the policy (Exhibit H) and income guidelines in all registration areas (Exhibit A). In addition, information about the Financial Assistance Program and the income guidelines are posted on the website and on the back side of all self pay billing statements. Staff and representatives will provide information about the programs during appropriate phone calls and follow-up communications with patients.
B. During the registration process, patients may be provided with notice of the guidelines to participate in the Financial Assistance Program as displayed in Exhibit A.
• Telephone pre-registration identifying self-pay patients will be mailed an application.
C. To apply for The Hospital Financial Assistance Program, the patient must request an application for determination of eligibility from the registration representative or billing department or download it from the website and complete the application in its entirety. See Exhibit B for application.
D. The inability to pay shall be determined by one of the following methods and the application's calculated income cannot exceed the guidelines as set forth in subsection E to qualify:
1. Using the person's actual family income for the 12 months preceding the determination of eligibility.
2. Calculate an annualized family income as follows:
a. Applications for working individuals submitted on or prior to March 31 will utilize the filed taxes, W-2 information, etc., from the previous year.
b. Applications for working individuals submitted after March 31 will utilize year-to-date salary information annualized by dividing the amount by the number of periods and multiplying by the total number of periods in a year.
c. Applications for self-employed individuals submitted on or prior to March 31 will utilize the most recent filed Tax Schedule C or the 12 months of ledger information for the previous calendar year -- whichever is most recent.
d. Applications for self-employed individuals submitted after March 31 will utilize year-to-date ledger information annualized by dividing the amount by the number of months and multiplying by 12 months.
E. Upon meeting the following income guidelines for outpatient services, the applicant will qualify for the Program for a period of six months. Income qualification for inpatients must be revalidated with each admission. This revalidation may occur in person or by phone. If the inpatient states that their income has changed from that represented on the most recent application, the account will be held until the proper determination can be made. Should any applicant's financial status change within the following guidelines, it may require a reapplication.
Income eligibility requirements for participation shall be established using guidelines provided by the Department of Human Services and reviewed annually for compliance. See Exhibit A for a breakdown of category by family size.
1. Income up to 200% of the Federal Poverty Guidelines qualifies for a 100% discount – free care.
2. Income up to 350% of the Federal Poverty Guidelines quality for a 56% discount. The remaining 44% is the patient’s responsibility. This category uses the most recent AGB and represents the maximum net charge (gross charge less 56% discount) for persons who quality under the Financial Assistance Policy.
F. Medical Necessity
The Financial Assistance Program only applies to medically necessary services or services not covered under liability or MVA situations. A determination of medical necessity may require documentation from a physician. The program does not apply to elective services which are not deemed to be medically necessary, such as, but not limited to:
1. Cosmetic or aesthetic surgery;
2. Reverse sterilization procedure;
3. Gastric bypass (unless deemed to be medically necessary);
4. Dental procedures;
5. Phase III Cardiac Rehab program;
6. Pre-certification denials for medical necessity;
7. Utilization Review denials for medical necessity and a Notice of Non-Coverage is issued; and
8. Services that the patient elects under the HIPAA Privacy Act to not have billed to his/her health insurance and instead elects to pay for the services in full. These services may be medically necessary, but would not be eligible for this program when another payer source is available, but the patient elects not to utilize it.
In liability or MVA situations, proof of valid insurance denial or exhaustion of benefits must be provided before claims will be considered for this program.
G. Processing of Application:
1. Upon receipt of an application (timely applications can be submitted up to 240 days from the first post-discharge statement) a search of the system will be made for all open accounts, including pre-registration accounts and any open accounts under previous eligibility.
2. Accounts that have already been sent to a Collection Agency will only be eligible for this program if the date of the application for financial assistance is within 240 days of the date of the first statement on each account in question.
3. If no accounts are found, the application will be returned to the patient with a notice of deferral stating that the patient is not eligible for financial assistance until services have been scheduled or provided.
4. The application will be reviewed for completeness of documentation and if found to be incomplete, the application will be returned with a notice itemizing the documents required to complete the application review process (Exhibit C). An application without a signature cannot be processed.
5. The completed application will be reviewed for approval and notice of final approval or disapproval will be sent to the applicant within Fifteen (15) business days of the receipt of the completed application. This notice will indicate all of the accounts in question and their disposition status as a result of the approval or disapproval of the application, see Section I. All accounts will be noted with the approval or disapproval date and placed in either free care or discounted care categories.
6. If the application is not approved, all accounts will be placed into the regular self pay billing cycle.
7. If the application is approved, all of the accounts will be adjusted per the approval category and a single write-off request will be generated. All accounts with remaining balances will be placed into the regular self pay billing cycle.
H. Deferral of Determination:
Each application will be reviewed and based on the information submitted, deferral of approval of the application (Exhibit C) may be made for up to 60 days. The purpose of such delay shall be to require the applicant to obtain and provide evidence of ineligibility for medical assistance programs or to verify that the services in question are not covered by insurance, or other clarification.
If an applicant meets the income guidelines in subsection E and is not covered under any state or federal program for medical assistance, but meets any of the following criteria, qualification shall be deferred pending submission of additional information:
1. Age 65 or over;
2. Blind;
3. Disabled;
4. An individual is a member of a family in which a child is deprived of parental support or care due to one of the following causes, and the individual's income is less than the guidelines in subsection E:
a. Death of a parent;
b. Continued absence of the parent(s) from the home due to incarceration in a penal institute, confinement in a general, chronic or specialized medical institution, deportation to a foreign country, divorce, desertion or mutual separation of parents, or unwed parenthood;
c. Disability of a parent; or
d. Unemployment of a parent who is the principal wage earner;
5. Pregnant woman whose income is less than the guidelines in subsection E.1; or
6. A child up to the age of one year who is born to a woman who meets any of the above criteria.
I. Notification of Applicant:
1. A determination of eligibility (Exhibit D) must be completed on all applications received requesting participation in the Financial Assistance Program.
2. A letter of notification of Approval (Exhibit E) or Denial (Exhibit F) will be forwarded to the applicant within fifteen (15) business days of receiving a completed application. The letter will notify applicant of coverage or the reason for denial.
a. The letter of notification to the patient shall include a list of all accounts being accepted as paid or discounted under the program at the time of acceptance.
b. If a patient has made payments on any of the accounts prior to the date of their application, those will be refunded.
c. The notice must include the name and telephone number of the person who should be contacted should the applicant have questions regarding the notice; and state that the patient has a right to a hearing and how to obtain a hearing.
d. Should the applicant be denied for failure to provide requested information within the timeframe, the applicant will be informed that he/she may reapply if the required information can be furnished before the account goes to a Collection Agency.
IV. REPORTING AND RECORDKEEPING
A. The Patient Financial Services department shall maintain records of the amount of free care and financial assistance provided in accordance with this policy. Records for each category must be kept separately.
V. REFERENCES
A. Department of Health and Human Services Office Free Care Guidelines
B. Federal Poverty Guidelines
C. EMTALA
D. Affordable Care Act
E. IRS Code 501(r)
F. RI.024 Minors Consent Policy
G. RI.029 Patient Collection Policy
