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CONTRACT NO: C-86-02-073-2-50 HEALTHCARE FOR THE HOMELESS POLICY MARICOPA COUNTY By and Through DEPARTMENT OF PUBLIC HEALTH 4041 N Central Avenue, Suite 1400, Phoenix, Arizona 85012 I. Approve Health Care for the Homeless policies to comply with Conditions 3 and 4 of the Notice of Award (NOA), dated 1/5/2017, approve the policies as the response to the NOA ‘Program Specific Conditions’ and approve its submission to Health Resources Services Administration (HRSA). IN WITNESS WHEREOF, the parties agree to the changes indicated herein: FOR AND ON BEHALF OF MARICOPA COUNTY By: Denny Barney Chairman, Board of Supervisors Date ATTEST: Clerk of the Board Date APPROVED AS TO FORM: Attorney for Maricopa County Date 1 DEPARTMENT OF PUBLIC HEALTH SERVICES HEALTH CARE FOR THE HOMELESS PROGRAM POLICIES, PROCEDURES AND PRACTICES Title: Sliding Fee Scale Effective Date: Applicability: Health Care for the Homeless Next Revision Date: Responsible Party: Program Supervisor Latest Revision Date: APPROVED: DPPN: Page: 1 of I. PURPOSE To provide care to eligible patients through the establishment of a sliding fee scale discount schedule based on federal poverty guidelines. II. POLICY No patient will be denied health care services due to an individual's inability to pay for such services. Fees or payments required for such services will be reduced or waived to meet the needs of the patient. III. PROCEDURE A. Payment for Services 1. The Healthcare for the Homeless (HCH) program supervisor will prepare a schedule of fees or payments for the provision of its services consistent with local prevailing rates or charges and designed to cover its reasonable costs of operation. 2. HCH will make every reasonable effort to secure from patients payment for services in accordance with its fee schedules and to collect appropriate reimbursement for health services from Medicare, Medicaid, other public assistance programs, and other third party payers used by HCH patients. 3. Although HCH cannot require patients to enroll in public or private insurance or related third party coverage, the health center will educate patients on options available to them based on their eligibility for insurance or other third party coverage. During the application process for the entitlement program, the patient will 2 receive the sliding fee discount if they qualify based on the income guidelines. No patient who refuses to apply for any public or private insurance program will be denied access to HCH's sliding fee program. B. Sliding Fee Discount Schedules 1. Sliding fee discount schedules shall: a. Apply to patients with annual incomes at or below 200% of the Federal Poverty Level (FPL). b. Provide a full discount for patients with annual incomes at or below 100% FPL with an allowance for a nominal charge. c. Adjust fees based on household size and income for patients above 100% FPL and at or below 200% FPL. d. Include at least three discount levels between 100% FPL and 200% FPL. e. Not apply to patients with annual incomes above 200% FPL. f. Determine eligibility solely by household size and income. 2. The sliding fee discount schedule for medical services is as follows: a. Plan 1. 0% - 100% FPL: $0 nominal charge which includes office visit, in-house and referral laboratory services, medications, vaccines, and x-ray services. b. Plan 2. >100% - 133% FPL: $10 copay which includes office visit, in-house laboratory services, and vaccines for VFC eligible patients. Medications, vaccines, x-rays, and referral laboratory services are provided at cost. c. Plan 3. >133% - 150% FPL: $15 copay which includes office visit, in-house laboratory services, and vaccines for VFC eligible patients. Medications, vaccines, x-rays, and referral laboratory services are provided at cost. 3 d. Plan 4. >150% - 200% FPL: $20 copay which includes office visit, in-house laboratory services, and vaccines for VFC eligible patients. Medications, vaccines, x-rays, and referral laboratory services are provided at cost. e. >200% FPLL - No discount. C. Notification of Sliding Fee Program 1. The HCH program supervisor will ensure that patients are made aware of the sliding fee program. The program supervisor will accomplish this by using multiple methods of informing patients including, but not limited to signage throughout HCH locations, information on the HCH website, and personally notifying patients during registration or appointment scheduling. 2. Sliding fee program information will be available in appropriate languages and literacy levels for the target population. D. Assessing Household Income 1. Patients will be asked to complete a registration form annually and encouraged to provide their household size and income information to perform a household assessment for the purpose of collecting HRSA/UDS required information. HCH staff will assist the patient in determining their household and income as necessary. A patient has the right to refuse to complete the assessment. A patient who refuses to complete the household size and income assessment will be ineligible for any discounts allowed herein. 2. Registration staff will enter household size and income information into the practice management system and notify the patient if they are likely eligible for the sliding fee program pending proof of income and a completed application. E. Application Process for the Sliding Fee Program 1. A completed proof of income form and a sliding fee program application will be expected from the applicant. 2. Patient bills will be adjusted to the appropriate discount level once the sliding fee program application is completed and proof of income is received. Patients qualifying for the sliding fee program will have 30 days from the date of service to provide 4 documentation. Once 30 days has elapsed, sliding fee discounts cannot be applied to that date of service. 3. If the patient reports no income, they may, in lieu of proof of income, submit a self-attestation of zero income form. 4. Once the household has completed the application process for the sliding fee program, the discount level will be listed in the practice management system. The discount level will be effective for one year. 5. If a patient knowingly provides false or incomplete information, any sliding fee discounts received based upon the false or incomplete information will be removed and the patient will be barred from receiving future discounts. F. Using the Sliding Fee Discount 1. When a patient schedules an appointment, the scheduler will remind patients that their payment will be due at the time of the service. HCH registration staff will ask for the full payment at the time of registration, prior to the patient seeing a provider. With the exception of Plan 1 patients, if the patient is unwilling to pay, HCH staff will offer to reschedule the appointment at a later date. HCH staff will inform Plan 1 patients that a statement will be mailed to them for the nominal fee. No Plan 1 patient shall be denied care because of failure to pay the nominal fee. 2. Patients will be required to pay in full for services not covered by the sliding fee program prior to services being rendered. For services requiring multiple visits, the patient will be required to pay 50% of the fee prior to the first visit. HCH will set the patient up on a financial treatment plan (FTP) where the patient will be required to make equal payments against the balance of the FTP prior to each visit. Payment will be made in full prior to the final visit. If a patient is unable to stay current with the FTP, HCH staff will offer to reschedule the appointment at a later date. 3. Exceptions to the payment at time of service rule will also be made for emergent care as determined by a qualified clinical person authorized to make triage decisions and also for children. In this event, the patient guarantor will be referred to an appropriate member of HCH staff to set up a payment plan. 5 G. Refusal to Pay 1. When all reasonable collection efforts/enforcement steps as established by policy have been exhausted (which may include offering grace periods, meeting with HCH financial or certified application counselors, or establishing payment plans), non- compliant patients will be notified that they are no longer allowed to access services at any HCH facility. 2. Discharged patients frequently will request an appointment with a HCH provider. These patients will be reinstated if they agree to comply with their payment plan and pay the next amount due at the time of service. H. Other Considerations 1. For services the health center provides only via a formal written referral arrangement, the health center will make every attempt to ensure that the referral provider’s discounts for health center patients meet the criteria set forth by HRSA’s PIN 2014-02 “Sliding Fee Discount and Related Billing and Collections Program Requirements.” 2. Although HCH offers all FQHC in-scope services to patients without regard to ability to pay, availability of these services is subject to budget restrictions. HCH reserves the right to control access to discounted services in order to remain sustainable. 3. In addition to the sliding fee discounts, HCH will work with other providers, such as our referral laboratory, to make additional discounts available where possible. IV. BOARD OF SUPERVISORS APPROVAL This policy was approved by the Board of Supervisors on __________________. V. REFERENCES (IF APPLICABLE) VI. DEFINITIONS 1. Applicant – Refers to the individual whose signature appears the Sliding Fee application. 2. Household – Defined to mimic the state and federal definition of household for healthcare programs, household refers to all persons related 6 by birth, marriage, or adoption who reside together, dependents, and others in the same tax household. Unrelated individuals who are not dependents living at the same address are considered separate households. The following compose the household: a. The applicant and their spouse. b. The applicant’s unmarried partner if they are the parent of the applicant’s child. c. Anyone under 19 years of age who lives with and is taken care of by the applicant. d. Anyone claimed as a dependent on the applicant’s federal tax return. e. Anyone who claims the applicant on a federal tax return and their tax dependents. 3. Income – The modified adjusted gross income (MAGI) as defined by the IRS and used by the state and federal agencies for healthcare programs, Income refers to all cash receipts before taxes with certain adjustments. Income does not include non-cash benefits such as SNAP, school lunch programs, clothing vouchers, or food/rent in lieu of wages. For most patients eligible for sliding fee discounts, income calculation is simple. A full definition of MAGI is available from the IRS. a. Common income sources included in MAGI i. Wages, salaries, and tips. ii. Social Security benefits. iii. Unemployment compensation. iv. Net self - employment or business income (generally the amount of money you take in from your business minus your business expenses). v. Alimony. vi. Retirement and pension income. vii. Investment and rental income. 7 b. Common income sources excluded from MAGI i. Child Support. ii. Supplemental Security Income (SSI). iii. Veteran’s disability benefits. iv. Workers’ compensation. c. Common Deductions from MAGI i. Alimony paid. ii. Student loan interest and tuition costs paid. iii. Individual retirement account contributions. 4. Proof of Income – Must be current information and includes, but is not limited to any or all of the following. Where proof of before tax income is not available, income before taxes can be estimated from proof of net income. a. Most recent income tax return or W-2. b. Two most recent pay stubs. c. Most recent unemployment check. d. Proof of other household income (Social Security, pension, etc.). e. Bank statements showing direct deposits. 5. Income Guidelines – Revised annually based on the Federal Poverty Guidelines 6. Household Assessment – The application process and review for consideration of eligibility for the sliding fee program and for reporting of patient demographics to HRSA. 7. Ability to Pay – Defined by this policy and by the results of the Household Assessment process. 8. Refusal to Pay – Defined by consistent non-compliance with this policy and with monthly payment plans. 8 9. Consistent Non-Compliance – Defined by failure to make the assigned monthly payment for three consecutive months. VII. APPENDICES 9 DEPARTMENT OF PUBLIC HEALTH SERVICES HEALTH CARE FOR THE HOMELESS PROGRAM POLICIES, PROCEDURES AND PRACTICES Title: Billing, Credit and Collections Effective Date: Applicability: Health Care for the Homeless Next Revision Date: Responsible Party: Program Supervisor Latest Revision Date: APPROVED: DPPN: A25 Page: 1 of 2 I. PURPOSE To establish policies related to billing, credit and collections for services provided by the Maricopa County Health Care for the Homeless Program (HCH). II. POLICY HCH will maximize its ability to deliver healthcare services to the homeless community by maintaining a thorough record of all services provided to patients and submitting timely and accurate bill for said services to relevant healthcare payers. III. PROCEDURE A. Posting Transactions. 1. The HCH program supervisor will ensure that the posting of services transactions occurs on a timely basis to the appropriate accounting system or to the appropriate vendor selected to perform the billing and collections tasks. 2. The HCH front desk/registration staff are responsible for accurately collecting, verifying and entering into the patient medical record all information necessary to bill for services provided for the health center. 3. Medical providers are responsible for accurately and thoroughly documenting all services delivered to each patient for each encounter, and for reviewing and submitting the necessary diagnostic and treatment data needed to support claims for services. 10 4. The HCH program supervisor is responsible for monitoring the submittal of claims and subsequent payments necessary to satisfy those claims. Claims should typically be submitted within two business days following an encounter being closed by a provider. 5. The HCH program supervisor is responsible for ensuring that all claims that are denied by the health insurer get resolved and resubmitted in a timely manner. The resubmittal process should typically occur within three business days following the receipt of a denied claim. 6. The HCH program supervisor is responsible for monitoring the billing process and may implement process improvements as necessary to ensure maximum collection amounts and timely billing and resubmissions. 7. The HCH program supervisor is responsible for ensuring that timely and accurate cost reports and other requested data are submitted to contracted insurance plans as requested. B. Patient Credit Transactions 1. All services available at HCH will be provided to patients regardless of their ability to pay at the time of service. 2. An account will be established for any patient who is obligated to pay for any portion of his/her care but is unable to do so at the time of service. 3. Patients who have a documented ability to pay for services as defined in the sliding fee discount schedule, but are unable or unwilling to do so, shall be referred to a case manager for financial planning assistance. 4. The HCH program supervisor and medical director have the authority to waive fees for services, including co-pays, deductibles, sliding fees or self-pay charges. In the event that a waiver of fees is indicated, both the HCH program supervisor and the medical director are required to authorize the transaction. Documentation of the waived fees and authorizing administrators should be placed on the patient account. 11 C. Collections 1. Self-pay and/or sliding fee payments are of a nominal amount and, therefore, HCH will not utilize outside collection agencies or employ collection practices in the pursuit of outstanding balances on patient accounts. 2. HCH will make reasonable efforts to educate patients about obligations to pay and periodically remind patients to do so in a manner and frequency that maintains patient engagement with the health center and protects the privacy and dignity of the patient. 3. The HCH program supervisor is responsible for monitoring, on a monthly basis, the amount and aging of outstanding receivables. If the HCH program supervisor determines that the probability of collecting outstanding debts to be unlikely, the program supervisor will initiate the necessary transactions in the general ledger to write off the bad debts. A record of these transactions shall be maintained along with supporting documentation necessary to support the write off. IV. BOARD OF SUPERVISORS APPROVAL This policy was approved by the Board of Supervisors on __________________. V. REFERENCES (IF APPLICABLE) VI. DEFINITIONS VII. APPENDICES 12