Financial Assistance

POLICY

It is the policy of WEH to provide financial assistance in the form of Financial Assistance and Partial Financial Assistance by WEH to patients residing in the Commonwealth of Pennsylvania and does not include non-employed physicians and other services provided by outside vendors.

Patients seeking emergent care at WEH will be treated without regard to their ability to pay for such care.  WEH operates in accordance with all federal and state requirements for the provision of health services under the requirements of the Federal Emergency Medical Treatment and Active Labor Act (EMTLA).

SCOPE/PURPOSE

Consistent with WEH Eye Hospital’s (WEH) mission of providing care to needy and underserved persons in a manner that preserves the dignity of the individual, this Financial Assistance Policy (the Policy) describes the policies and procedures relating to the provision of Financial Assistance to persons who are unable to pay for all or a portion of their bill.  No individual will be denied non-elective medically necessary services based on a demonstrated inability to pay for those services.

RELATED POLICIES

Patient Care Manual                        4.1.3.6                    PATIENT HEALTH RECORDS

Leadership  Manual                          1.7.2.5                    RETENTION AND DESTRUCTION OF RECORDS

PROCEDURE

Financial Assistance: 100% free medical care for Medically Necessary services provided by WEH. Patients who are Uninsured or Underinsured for a medically necessary service, who are ineligible for governmental or other insurance coverage, and who have family incomes not in excess of 200% of the Federal Poverty Guidelines are eligible to receive Financial Assistance. (See Attachment 2).

Medical Necessity: Any diagnostic study, procedure or treatment needed to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, if there is no other equally effective, more conservative or less costly course of treatment available.

Partial Financial Assistance: Care at a discounted rate for Medically Necessary services provided by WEH. Patients who are uninsured or underinsured for a medically necessary service, and who have family incomes in excess of 200%, but not exceeding 500%, of the Federal Poverty Guidelines, are eligible to receive Partial Financial Assistance in the form of a sliding scale discount off charges. (See Attachment 3). However, patients who would otherwise qualify for Partial Financial Assistance but who have sufficient liquid assets available to pay for care without becoming Medically Indigent are not eligible for Partial Financial Assistance.

Uninsured Patient: An individual who does not have any third-party health care coverage from either: (a) a third party insurer, (b) an ERISA plan, (c) a Federal Health Care Program (including without limitation Medicare, Medicaid, HealthChoices, CHIP, adult Basic and TRICARE), (d) Workers’ Compensation, (e) Healthcare Reinsurance or Savings Accounts, or (f) other coverage, for any part of the bill, including claims against third parties covered by insurance to which WEH is subrogated, but only if payment is actually made by such insurance company.

Underinsured Patient: An individual who has medical insurance coverage that is limited in the scope of covered services or policy maximums such that his or her medical bills are not fully covered.

1.     Identifying Patients Eligible for Financial Assistance or Partial Financial Assistance

1.1.  Patients who qualify for Financial Assistance or Partial Financial Assistance shall be identified as soon as possible, either before or after care is provided.

1.2.  If it is difficult to determine a patient’s eligibility prior to the provision of care, such determination shall be made as soon as possible, but no later than 6 months after the provision of care.

1.3.  WEH shall publish and post signage and internet notices to advise patients of the availability of Financial Assistance and Partial Financial Assistance in the English and Spanish languages.

2.     Dissemination of Eligibility Information

2.1.  Patients identified through the registration process who appear to be Uninsured or Underinsured and who indicate their inability to pay for Medically Necessary services shall receive:

2.1.1.     A packet of information that describes this Financial Assistance policy and relevant procedures, including an application for financial assistance and/or,

2.1.2.     Financial counseling, including an application for financial assistance.

2.2.  In order to allow WEH to properly determine Financial Assistance or Partial Financial Assistance eligibility, documents provided to patients by WEH shall be written in English, and translation assistance will be provided as needed.

3.     Eligibility Methodology

3.1.  WEH shall adhere to an established methodology to determine eligibility for Financial Assistance and Partial Financial Assistance. The methodology shall consider whether health care services meet Medical Necessity criteria, as well as income, family size, and resources available to pay for care.

3.2.  All available financial resources shall be evaluated before a determination regarding Financial Assistance or Partial Financial Assistance is made. WEH shall consider the financial resources of the patient, as well as other persons having legal responsibility to provide for the patient (e.g. parent of a minor, spouse).

3.3.  Copies of documents to substantiate income levels and assets shall be provided by the patient/guarantor (e.g.: W-2, Tax Returns, Pay Stubs, Bank Statements)

3.4.  The patient/guarantor shall be required to provide information sufficient for WEH to determine whether he or she is eligible for benefits available from insurance, Medicare, Medicaid, Workers’ Compensation, third party liability, and other federal, state, or local programs.

3.4.1.     If in the course of evaluating the patient’s financial circumstances it is determined by WEH that the patient may qualify for federal, state, or local programs or insurance coverage, information will be provided to assist patients in applying for available coverage. Financial Assistance and Partial Financial Assistance will be denied to patients/guarantors who do not cooperate fully in applying for available coverage.

3.4.2.     Patients with Healthcare Reinsurance or Medical Savings Accounts are insured for purposes of this policy, and the amount on deposit will be considered an available resource toward payment for Medically Necessary services.

3.4.3.     If a patient has a claim (or potential claim) against a third party from which the hospital's bill may be paid, the hospital will defer its Financial Assistance determination pending disposition of the third party claim.

3.5.  Eligibility for Financial Assistance or Partial Financial Assistance shall be determined using a sliding scale based on 200-500% of the Federal Poverty Level Guidelines as published annually in the Federal Register as well as consideration of available assets and any extenuating circumstances. (See Attachment 3)

3.6.  Eligibility for Financial Assistance and Partial Financial Assistance will extend for up to 180 days from the date eligibility is determined.

3.7.  Patients/guarantors shall be notified in writing when WEH makes a determination concerning Financial Assistance or Partial Financial Assistance.

3.8.  This policy covers WEH surgery center, WEH Clinics and the ER. Services provided by physicians and other non-WEH services are not covered by this policy. Patients seeking a discount for such services should contact the physician or other provider directly.

3.9.  All information obtained from patients and guarantors shall be treated as confidential to the extent required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

3.10. This Policy is subject to change without prior notice, is subject to interpretation by WEH at its sole discretion, and is not intended to create any contractual relationship or obligation.

Attachment 1: Proof of income and residency. Click here.

Attachment 2: Federal Poverty Guidelines. Click here.

Attachment 3: Financial Assistance and Partial Financial Assistance. Click here.

Attachment 4: Prompt Pay Discount Information. Click here.

Attachment 5: Patient Billing and Collections. Click here.

Patient Assistance Program Required Documentation

• Government Issued identification
• List of household members
• Proof of residency (utility bill)
• Proof of income, such as:
  • tax return from prior year
  • current pay stub
  • social security statement
  • disability statement
• Bank statements for last 2 months
• Denial for Medical Assistance or proof that the application has been started
• Patient Initial Assessment Questionnaire. Download Here