Introduction

Jefferson Community Health & Life is committed to providing an exceptional healthcare experience for every patient, every time. Jefferson Community Health & Life is dedicated to the view that emergency, other non-elective medically necessary care, and prescription medications should be accessible to all, regardless of age, gender, geographic location, cultural background, physical mobility, or ability to pay. Jefferson Community Health & Life is committed to providing health care services and acknowledges that in some cases an individual will not be financially able to pay for the services received. This policy is intended to comply with Section 501(r) of the Internal Revenue Code and the regulations promulgated thereunder and shall be interpreted and applied in accordance with such regulations. This policy has been adopted by the Jefferson Community Health & Life Board of Directors in accordance with the regulations under Section 501(r). Jefferson Community Health & Life provides emergency, other non-elective medically necessary care and prescription medications to individual patients without discrimination regardless of their ability to pay, ability to qualify for financial assistance, or the availability of third-party coverage. In the event that third-party coverage is not available, an allocation is made each year for funds to be available for financial assistance. Wherever possible, a determination of eligibility for financial assistance will be initiated prior to, or at the time of admission, by a financial counselor. This policy identifies those circumstances when Jefferson Community Health & Life may provide care without charge or at a discount based on the financial need of the individual. The financial assistance policy provides guidelines for financial assistance to individual patients receiving emergency, other non-elective medically necessary services, and prescription medications based on financial need (full write-off and discounted care) and is in addition to other prompt-pay discount processes offered by Jefferson Community Health & Life.

Policy

A. All or a portion of emergency, non-elective medically necessary care, and prescription medications may be considered for financial assistance if a patient presents with any of the following conditions:

1. No third-party coverage is available.

2. Patient is already eligible for assistance (e.g. Medicaid), but the particular services are not covered.

3. Medicare or Medicaid benefits have been exhausted and the patient has no further ability to pay.

B. This policy only applies to JCH&L. Patients at JCH&L are commonly seen by private physician groups or other third party providers. These health care providers are not covered by this policy and do not participate in JCH&L’s Financial Assistance Program. However, these providers may have their own financial assistance program. A list of providers whom are included and excluded from JCH&L’s financial assistance program is maintained in an appendix, which is attached to this policy.

C. Financial Assistance Policies are transparent and available to the individuals served at any point in the care continuum in languages that are appropriate for the Jefferson Community Health & Life service area in compliance with the Language Assistance Services Act and in the primary languages of any populations with limited proficiency in English that constitute more than 5% of the residents of Jefferson County.

1. Website: Jefferson Community Health & Life will prominently and conspicuously post complete and current versions of the following on its website in English and in the primary languages of any populations with limited proficiency in English that constitute more than 5% of the residents of Jefferson County:

a. Financial Assistance Policy (FAP)

b. Financial Assistance Application Form (FAA Form)

c. Plain Language Summary of the Financial Assistance Policy (PLS)

d. Contact information for the Jefferson Community Health & Life Business Office at 402.729.3351

2. Signage (in English and in the primary languages of any populations with limited proficiency in English that constitute more than 5% of the residents of Jefferson County) will be displayed in Jefferson Community Health & Life at all points of admission and registration areas, including the Emergency Department. All signage denoting that financial assistance may be available will contain the following elements:

a. Jefferson Community Health & Life website address where the FAP and the FAA Form can be accessed

b. The telephone number and physical location that individuals can call or visit with any questions about the FAP or the application process

3. Jefferson Community Health & Life will make paper copies of the FAP, FAA Form and the PLS available upon request and without charge, both in public locations in the hospital (i.e. admission and registration areas) and by mail. Paper copies will be available in English and in the primary languages of any populations with limited proficiency in English that constitute more than 5% of the residents of Jefferson County.

4. Financial Counselor Visits: Financial counselors will seek to provide personal financial counseling to all individuals admitted to Jefferson Community Health & Life who are classified as self-pay. Interpreters will be used, as indicated, to allow for meaningful communication with individuals who have limited English proficiency. Financial assistance and discount information will be made available.

5. The PLS should be distributed to residents of Jefferson County in a manner reasonably calculated to reach those members of the community who are most likely to require financial assistance. An example would be the distribution of copies of the PLS to organizations in the community that address the health needs of low-income populations.

D. Jefferson Community Health & Life and the patients served both are accountable for the general processes related to the provision of financial assistance.

1. Jefferson Community Health & Life Responsibilities:

a. Jefferson Community Health & Life has a financial assistance policy to evaluate and determine an individual’s eligibility for financial assistance.

b. Jefferson Community Health & Life has a means of communicating the availability of financial assistance to all individuals in a manner that promotes full participation by the individual.

c. Jefferson Community Health & Life workforce members in the Business Office and Registration areas understand the Jefferson Community Health & Life financial assistance policy and are able to direct questions regarding the policy to the proper hospital representatives.

d. Jefferson Community Health & Life requires all contracts with third party agents who collect bills on behalf of Jefferson Community Health & Life to include provisions that these agents will follow Jefferson Community Health & Life financial assistance policies.

e. The Jefferson Community Health & Life Board of Directors provides organizational oversight for the provision of financial assistance and the policies/processes that govern the financial assistance process.

f. After receiving the individual’s request for financial assistance, Jefferson Community Health & Life notifies the individual of the eligibility determination within a reasonable period of time.

g. Jefferson Community Health & Life provides options for payment arrangements.

h. Jefferson Community Health & Life upholds and honors individuals’ right to appeal decisions and seek reconsideration.

i. Jefferson Community Health & Life maintains (and requires billing contractors to maintain) documentation that supports the offer, application for, and provision of financial assistance for a minimum period of seven years.

j. Jefferson Community Health & Life will periodically review and incorporate federal poverty guidelines for updates published by the United States Department of Health and Human Services.

2. Individual Patient Responsibilities:

a. To be considered for a discount under the financial assistance policy, the individual must cooperate with Jefferson Community Health & Life to provide the information and documentation necessary to apply for other existing financial resources that may be available to pay for healthcare, such as Medicare, Medicaid, third-party liability, etc.

b. To be considered for a discount under the financial assistance policy, the individual must provide Jefferson Community Health & Life with financial and other information needed to determine eligibility (this includes completing the required application forms and cooperating fully with the information gathering and assessment process).

c. An individual who qualifies for a partial discount must cooperate with the hospital to establish a reasonable payment plan.

d. An individual who qualifies for partial discounts must make good faith efforts to honor the payment plans for their discounted hospital bills. The individual is responsible to promptly notify Jefferson Community Health & Life of any change in financial situation so that the impact of this change may be evaluated against financial assistance policies governing the provision of financial assistance, their discounted hospital bills or provisions of payment plans.

E. Financial assistance eligibility determinations and the process of applying for financial assistance will be equitable, consistent, and timely.

1. Identification of Potentially Eligible Individuals. Requests for financial assistance will be honored up to 240 days after the date the first statement is remitted to the individual.

a. Registration and pre-registration processes notify patients of the FAP and promote identification of individuals in need of financial assistance.

b. Financial counselors will make best efforts to contact all self-pay inpatients during the course of their stay or at time of discharge.

c. Each billing statement that is sent to the individual during the 120-day period after the first billing statement will contain language notifying the individual of available financial assistance.

d. Jefferson Community Health & Life will make every reasonable effort to notify individual patients about the Jefferson Community Health & Life FAP in oral communications.

e. The individual will be provided with at least one written notice (notice of actions that may be taken) that informs the individual that the hospital may take action to forward the account to a collection agency if the individual does not submit a FAA Form or pay the amount due by a specified deadline. This deadline cannot be earlier than 120 days after the first billing statement is sent to the individual. The notice must be provided to the individual at least 30 days before the deadline specified in the notice.

2. Requests for Financial Assistance. Requests for financial assistance may be received from multiple sources (including the patient, a family member, a community organization, a church, a collection agency, caregiver, Administration, etc.).

a. Requests received from third parties will be directed to a financial counselor.

b. The financial counselor will work with the third party to provide resources available to assist the individual in the application process.

c. Upon request, an estimated charges letter will be provided to individuals who request a written description of estimated charges.

3. Eligibility Criteria

a. To be eligible for a 100% reduction from gross charges (i.e. full write-off) the individual’s household income must be at or below 150% of the current Federal Poverty Guidelines. Individuals with household income between 150% and 300% of the current Federal Poverty Guidelines will be eligible for a partial discount. See Exhibit A for the 2015 Financial Assistance Guidelines. Please note that the amounts within Exhibit A are updated annually based upon federal poverty guidelines published in the Federal Register.

b. The amount charged to any individual for emergency and all other medically necessary care will be based on amounts generally billed (AGB) to individuals who have insurance covering such care at Jefferson Community Health & Life and a FAP-eligible individual will never be charged more than AGB. An additional discount opportunity for prompt payment is available to self-pay patients. Jefferson Community Health & Life will determine its AGB by determining an AGB percentage and multiplying that percentage by the gross charges for the services provided to the individual. Jefferson Community Health & Life will utilize the look-back method as described in §1.501(r)-5(b) to determine AGB. Jefferson Community Health & Life determines AGB based on all Medicare, Medicaid, and private insurance claims paid in full to Jefferson Community Health & Life over a 12-month period, divided by the associated gross charges for those claims.

c. If a greater minimum discount percentage is required by market-specific conditions (including competition and public relations), or the 300% maximum financial assistance threshold needs to be expanded for similar reasons, the exception must be approved by the Jefferson Community Health & Life Chief Financial Officer.

d. When determining an individual’s income, the following terms apply:

i. Household size and income includes all members of the immediate family and other dependents in the household as follows:

1. An adult and, if married, a spouse.

2. Any natural or adopted minor children of the adult or spouse.

3. Any minor for whom the adult or spouse has been given the legal responsibility by a court.

4. Any student over 18 years old, dependent on the family for over 50% support (current tax return of the responsible adult is required).

5. Any other persons dependent on the family’s income for over 50% support (current tax return of the responsible adult is required).

e. Income can be verified by using a personal financial statement or by obtaining copies of Form W-2, Form 1040, bank statements or any other form of documentation that supports reported income.

f. Documentation supporting income verification and Available Assets is to be maintained in patient files for future reference.

g. A credit report may be generated for the purpose of identifying additional expense, obligations and income to assist in developing a full understanding of the individual’s financial circumstances. A third party scoring tool may be used to justify financial assistance eligibility.

h. Financial assistance application forms will be considered up to 240 days after the first billing statement is remitted to the patient or when a change in patient financial status is determined. A financial assistance application will not need to be repeated for dates of service incurred up to one (1) year after the last date of application approval.

i. Presumptive eligibility: Individuals who are uninsured and are represented by one or more of the following may be considered eligible for the most generous financial assistance in the absence of a completed Financial Assistance Application Form:

i. Individual is homeless;

ii. Individual is deceased and has no known estate able to pay hospital debts;

iii. Individual is incarcerated for a felony;

iv. Individual is currently eligible for Medicaid, but was not at the date of service;

v. Individual is eligible by the State to receive assistance under the Violent Crimes Victims Compensation Act or the Sexual Assault Victims Compensation Act;

vi. Individual meets the financial assistance criteria based on the FasTag application. The FasTag application utilizes publicly available and purchased transaction data to estimate a patient’s financial profile and household size.

vii. For any individual presumed to be eligible for financial assistance in accordance with this policy, the same actions described in this Section D and throughout this policy would apply as if the individual had submitted a completed Financial Assistance Application Form.

4. Method for Applying for Financial Assistance

a. In order to apply for financial assistance, the individual will complete the Jefferson Community Health & Life Financial Assistance Application Form. The individual will provide all supporting data required to verify eligibility, including supporting documentation verifying income.

b. An individual can obtain a copy of the Jefferson Community Health & Life Financial Assistance Application Form by accessing it on the Jefferson Community Health & Life’s website, by requesting a free copy by mail by contacting the Jefferson Community Health & Life Business Office at 402.729.3351 or mailing Business Office, Jefferson Community Health & Life, PO Box 277, Fairbury, NE 68352, or by requesting a copy in person in the Jefferson Community Health & Life Business Office located at 2200 H Street, Fairbury, NE 68352.

c. A completed Jefferson Community Health & Life Financial Assistance Application Form will be submitted to the Business Office for processing. Proof of income and available assets will be required from the individual. In addition, Medicare beneficiaries are subject to an additional asset test in accordance with federal law. A review is completed to determine individual eligibility based on the individual’s total resources (including but not limited to family income level, assets (as required for Medicare patients) and other pertinent information).

5. Actions that May be Taken in the Event of Non-Payment: Jefferson Community Health & Life may forward outstanding debts for care provided to individuals to collection agencies in the following situations:

a. No Financial Assistance Application Form Submitted: An individual has not submitted a Financial Assistance Application Form in the 120-day period following the date after the first billing statement was sent (the notification period) to the individual (or, if later, the specified deadline date given in the written notice of actions that may be taken (see D.1.e. above)).

b. Incomplete Financial Assistance Application Form Submitted: If an individual submits an incomplete Financial Assistance Application Form during the 240-day period following the date on which the first billing statement was sent to the individual (the application period), Jefferson Community Health & Life must take the following actions:

i. Suspend any reporting to consumer credit reporting agencies/credit bureaus;

ii. Provide the individual with a written notice that describes the additional information and/or documentation required under the Financial Assistance Policy or Financial Assistance Application Form that the individual must submit to complete his or her Financial Assistance Application Form and include the hospital’s PLS with the notice;

iii. Provide the individual with at least one written notice that informs the individual that the hospital may forward the account to a collection agency if the individual does not complete the Financial Assistance Application Form or pay the amount due by a specified deadline. The deadline date must not be earlier than the last day of the application period or 30 days after the written notice is provided to the individual. If the Financial Assistance Application Form is not completed by the specified deadline discussed above, the hospital may initiate activities permitted in connection with the collection process.

c. Complete Financial Assistance Application Submitted: If an individual submits a complete Financial Assistance Application Form during the application period (240 days after the first billing statement is sent), Jefferson Community Health & Life must take the following actions:

i. Suspend any adverse reporting to consumer credit agencies/credit bureaus.

ii. Suspend any collection activity during the consideration of a completed Jefferson Community Health & Life Financial Assistance Application Form. A note will be entered into the patient’s account to suspend collection activity until the financial assistance process is complete. If the account has been placed with a collection agency, the agency will be notified to suspend collection efforts until a determination is made. This notification will be documented in the account notes.

iii. Make and document the determination as to an individual’s eligibility for financial assistance.

iv. Notify the individual in writing generally within 60 days after receiving a completed Financial Assistance Application Form of the eligibility determination and the basis for the determination.

v. Provide the individual with a billing statement that indicates the amount owed as a FAP-eligible individual and describes how the individual can get information regarding the AGB for care and how Jefferson Community Health & Life determined the amount the individual owes.

vi. Refund any excess payments to the individual.

vii. Take all reasonably available measures to remove from the individual’s credit report any adverse information that was previously reported to a consumer credit agency/credit bureau.

viii. Provide a written notification of denial to any individual determined to not be FAP-eligible and include both a reason for denial and a process and contact information for filing an appeal. If an individual disagrees with the decision to deny the provision of financial assistance, the individual may request an appeal in writing within 45 days of the denial. The appeal must include any additional relevant information that may assist in the appeal evaluation. Requests for denial appeal will be reviewed on a monthly basis by the Chief Financial Officer. Decisions reached by the Chief Financial Officer will be communicated to the individual within 60 days of the Chief Financial Officer’s review and will reflect the Chief Financial Officer’s final decision.

F. Patient Financial Services Responsibilities

1. A summary of the financial assistance applications and resulting recommendations processed by the Business Office will be reviewed regularly by the hospital’s Chief Financial Officer. The Chief Financial Officer reviews all financial assistance recommendations, with a focused review on borderline or non-routine requests that require case-by-case review.

2. Provision of financial assistance that exceeds $5,000 must be approved by the Jefferson Community Health & Life Chief Financial Officer.

3. Following review and approval by the Chief Financial Officer, the approved financial assistance will be applied to the individual’s account by Patient Financial Services.

4. The Jefferson Community Health & Life Business Office has the responsibility for determining that the hospital has made reasonable efforts to determine whether an individual is FAP-eligible and whether the hospital may take action to report adverse information to consumer credit agencies/credit bureaus.

5. Billing agencies that contract with Jefferson Community Health & Life for collection services will follow this financial assistance policy with respect to all billing and collections matters.

G. Individual Payment Plans

1. Payment plans for partial financial assistance accounts will be individually developed with the individual patient. All collection activities will be conducted in conformance with the federal and state laws governing debt collection practices. No interest will accrue to account balances while payments are being made unless the individual has voluntarily chosen to participate in a long term payment arrangement that bears interest applied by a third-party financing agent.

2. If an individual complies with the terms of his or her individually developed payment plan, no collection action will be taken.

H. Record-Keeping

1. A record, paper or electronic, will be maintained reflecting authorization of financial assistance along with copies of all application and worksheet forms.

2. Summary information regarding applications processed and financial assistance provided will be maintained for a period of seven years. Summary information includes the number of patients who applied for financial assistance at Jefferson Community Health & Life, how many patients received financial assistance, the amount of financial assistance provided to each patient, and the total bill for each patient.

3. The cost of financial assistance will be reported annually in the Community Benefit Report. Financial Assistance (Charity Care) will be reported as the cost of care provided (not charges) using the most recently available operating costs and the associated cost to charge ratio.

I. Subordinate to Law: The provision of financial assistance may now or in the future be subject to federal, state or local law. Such law governs to the extent it imposes more stringent requirements than this policy.

Exhibit A


Jefferson Community Health & Life2017 Financial Assistance Guidelines


Source: Federal Register, Updated 1/31/17
Percent of Federal Poverty Guideline150%187.5%225%262.5%300%
Percent of Discount (If Less Than Guideline)100%80%60%40%20%
Size of Household112,06018,09022,61327,13531,65836,180
216,24024,36030,45036,54042,63048,720
320,42030,63038,28845,94553,60361,260
424,60036,90046,12555,35064,57573,800
528,78043,17053,96364,75575,54886,340
632,96049,44061,80074,16086,52098,990
737,14055,71069,63883,56597,493111,420
841,32061,98077,47592,970108,465123,960
945,50068,25085,313102,375119,438136,500
1049,68074,52093,150111,780130,410149,040
1153,86080,790100,988121,185141,383161,580
1258,04087,060108,825130,590152,355174,120

Exhibit B


2017 Eligible Providers


Richard Blatny Sr., MD
Richard Blatny Jr., MD
Jessica Borrenpohl, PA-C
Doug Ruzicka, PA-C
Craig Shumard, MD
Julie Siefers, PA-C
Ted Tucker, MD