Financial Assistance

To describe how Cook Children's Health Care System (CCHCS) will allocate resources for emergency and other medically necessary care provided at Cook Children's Medical Center (CCMC) to patients who need financial assistance, and to manage CCHCS's limited resources to appropriately provide medically necessary care to:

1. The residents of the communities in CCHCS's primary service area;
2. Those patients residing outside of the primary service area, including out of state, who come to CCMC through established physician relationships; and
3. Recognize that reasonable limits must be established for the amount of financial assistance that can be furnished to the intended recipients to ensure the continued financial viability of CCMC and its affiliated entities.

The CCHCS primary service area is comprised of Tarrant, Johnson, Parker, Denton, Hood, and Wise counties.

This policy is supported by the requirements of CCMC policies MC 171 - Admissions, MC 011 – Emergency Medical Screening and Transfer of Patients, MC 484 - Emergency Department Services and Coordination of Care, and CCHCS policies FN 175 Collection Requirements at Time of Service, FN 300 – Financial Assistance, AD 550 - Undocumented Immigrants, and FN 480 - Prompt Pay Discounts for the Uninsured.

In connection with CCMC's exemption from certain federal and state taxes, and in support of CCMC's mission to serve the health care needs of the community, CCMC will provide financial assistance to eligible patients in accordance with this Financial Assistance Policy (FAP).

Information about financial assistance will be widely publicized and made available to guarantors whose children have received care from CCMC.

Financial assistance may be granted to United States (U.S.) citizens or lawful permanent residents who are not residents of the CCHCS primary service area within the limitations of this policy. Applications for financial assistance will be approved in accordance with the levels of authority indicated in this policy. The approving individual(s) will review and document that all applicable policies were followed.

Financial assistance will be available to all individuals who receive services at CCMC on an emergency basis and do not have the resources to pay for the services, regardless of residency or citizenship status.

CCMC will, through the Case Management Department, on a case-by-case basis, provide prescription medications to a patient whose family has no resources with which to fill physician prescribed medications. These medications will be dispensed in accordance with applicable state and federal statutes and will be done only for inpatients at CCMC, and/or outpatients in the hospital-based specialty clinics, and emergency room.

Financial assistance will be granted, if qualified, without regard to age, sex, gender identity or expression, sexual orientation, physical or mental disability, race, creed, ethnicity, religion, language, or national origin.

CCMC is required to make a reasonable effort to determine whether an individual is eligible for financial assistance in accordance with the terms of this policy. Eligibility will be determined no later than 240 days after CCMC provides the individual with the first post-discharge billing statement. It is the goal of CCMC to make an eligibility determination as soon as possible after all information is collected in the application process.

A person who is eligible for financial assistance will never be charged more for emergency or other medically necessary care than the amounts generally billed to individuals with insurance.

There may be unique situations when a guarantor may have a financial hardship, but not meet the requirements of this policy to receive financial assistance.

This FAP applies to emergency and other medically necessary care provided by CCMC. Services provided by all other CCHCS affiliated entities are covered by CCHCS policy FN 300 – Financial Assistance, which applies eligibility criteria and discounts identical to those set forth in this policy.

This FAP does not apply to, and a patient may be billed separately for, services provided by certain physicians that are not employed by one of CCHCS's affiliated entities and/or other non-hospital providers. Refer to Attachment A for a list of providers and services that are not covered under this FAP. This list will be reviewed quarterly for accuracy and updated as appropriate.

Family - A group of two or more persons related by birth, marriage, or adoption; all such related persons are considered members of one family. For instance, if an older married couple, their daughter and her husband and two children, and the older couple's nephew all lived in the same house or apartment, they would all be considered members of a single family.

Unrelated individual -  A person 15 years old or over (other than an inmate of an institution) who is not living with any relatives. Examples of unrelated individuals residing with others include a lodger, a foster child, a ward, or an employee.

Household - A household consists of all the persons who occupy a housing unit (house or apartment), whether they are related to each other or not. If a family and an unrelated individual, or two unrelated individuals, are living in the same housing unit, they would constitute two family units, but only one household.

Income - Total annual cash receipts before taxes from all sources, with the exceptions noted below. Income includes money wages and salaries before any deductions; net receipts from self-employment; regular payments from social security, railroad retirement, unemployment compensation, strike benefits from union funds, workers' compensation, veterans' payments, public assistance and training stipends; alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household; private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments; college or university scholarships, grants, fellowships, and assistantships; and dividends, interest, net rental income, net royalties, periodic receipts from estates or trusts, and net gambling or lottery winnings.

Exclusions From Income - Income does not include the following types of money received: capital gains, any assets drawn down as withdrawals from a bank, the sale of property, a house, or a car, tax refunds, gifts, loans, lump-sum inheritances, one-time insurance payments or compensation for injury, or non-cash benefits.

Resident - An individual who is either a U.S. citizen or a lawful permanent resident and lives in the CCHCS primary service area. A lawful permanent resident is issued an alien registration card, an I-551 card, which is better known as a "green card." Persons in the U.S. on any valid visa are not considered residents.

Undocumented Immigrant - A non-citizen who enters the U.S. without inspection or who overstays his/her visa. Also referred to as "person not lawfully present," "illegal alien," or "illegal immigrant."

CCMC will widely publicize information in this FAP by:

1. Making paper copies of the policy, a plain language summary of the policy, and the Financial Evaluation Form available, in English and Spanish, upon request and free of charge, both by mail and in the ED and admission areas;
2. Conspicuously displaying signs and flyers with general information about the availability of financial assistance in public areas of the Medical Center, including the ED and admission areas;
3. Notifying members of the community likely to need financial assistance of its availability by providing flyers for distribution at local agencies and nonprofit organizations that address the health needs of the community's low-income populations, along with instructions on how they may obtain more information;
4. Posting this Financial Assistance Policy, a plain language summary of the policy, and the Financial Evaluation Form in an easily accessible location on the Cook Children's website.
5. Including a conspicuous written notice on all billing statements that notifies and informs recipients about the availability of financial assistance under the FAP and includes a telephone number of the department that can provide information about the FAP and the application process, as well as the website address where copies of the FAP, Financial Evaluation Form, and plain language summary of the FAP may be obtained; and
6. Offering a paper copy of the plain language summary of this FAP as part of the intake or discharge process.

Except for individuals that are admitted to CCMC on an emergency basis, to be eligible for financial assistance, the individual must be a resident of either Denton, Hood, Johnson, Parker, Tarrant, or Wise County, or he/she must be a patient of a physician that has an established relationship with CCHCS.

1. Financially Indigent
   1. A financially indigent guarantor is a person who is uninsured or underinsured and is accepted for care with no obligation to pay for the services rendered based on the eligibility criteria set forth in this policy.
   2. To be eligible for financial assistance as a financially indigent guarantor, a person's income must be at or below 400% of the federal poverty guidelines. CCMC may consider other financial assets and liabilities of the person when determining eligibility.
   3. CCMC will use the most current poverty income guidelines issued by the U.S. Department of Health and Human Services to determine an individual's eligibility for financial assistance as a financially indigent guarantor. The poverty income guidelines are published in the Federal Register each year, and for purposes of this policy, become effective the first day of the month following the month of publication.
   4. In no event will CCMC establish eligibility criteria for financially indigent guarantors that set the income level for financial assistance lower than that required for counties under the Texas Indigent Health Care and Treatment Act, or higher than 400% of the federal poverty guidelines. CCMC may, however, adjust the eligibility criteria from time to time based on the financial resources of CCMC and as necessary to meet the needs of the community.
2. Medically Indigent
   1. A medically indigent guarantor is a person whose medical or hospital bills exceed 5% of the guarantor's annual gross income, who has no third party insurance coverage, whose family income exceeds 400% of the federal poverty guidelines, and who is unable to pay. CCMC may consider other financial assets and liabilities of the person when determining ability to pay.
   2. Write-off of a portion of the guarantor's balance in cases of medical indigency will be based upon the sliding scale found in Attachment B of this policy.
   3. If a determination is made that a guarantor has the ability to pay the remainder of the bill, such a determination does not prevent a re-assessment of the guarantor's ability to pay at a later date.
3. Catastrophically Indigent
   1. A catastrophically indigent guarantor is a person:
      1. Whose medical bills after payment by third-party payers exceed 35% of the guarantor's annual gross income, or
      2. Whose medical bills exceed 35% of the guarantor's annual gross income, and that income exceeds 500% of Federal Poverty Guidelines, and who is unable to pay the remaining bill.
   2. Write-off of a portion of the guarantor's balance in cases of catastrophic indigency will be based upon the sliding scale found in Attachment A of this policy.
   3. If a determination is made that a guarantor has the ability to pay the remainder of the bill, such a determination does not prevent a re-assessment of the guarantor's ability to pay at a later date.
4. Automatic Qualifications
   1. Charges for services not covered by Medicaid/CSHCN will be automatically written off to charity if the patient was a Medicaid/CSHCN beneficiary at the time of the uncovered service.
   2. When a patient has been approved for CHIP, but services are received prior to the effective date, the patient will automatically be deemed eligible for financial assistance for those services that are within 60 days of the effective date.
   3. Following a patient's death, any amounts remaining due on the patient's account after payment by third-party payers will be automatically written off to charity, to the extent permitted by applicable state and federal law, including payment rules and regulations promulgated by the Centers for Medicare & Medicaid Services and the Texas Health & Human Services Commission.

Patients may not be covered under this financial assistance policy if they are covered by a commercial insurance company that:

1. Does not have a contract with CCMC and will not pay out-of-network benefits to CCMC; and
2. Does not authorize services to be rendered at CCMC.

Patients are also ineligible if they do not provide all required information to CCMC or to their insurance company. If the family chooses to receive non-emergency care for their child(ren) at CCMC, even though they know the services will not be covered, the family will be responsible for payment of the estimated amount of the claim in full prior to service.

If it is determined that a patient may qualify for a government-sponsored program such as Medicaid, Children's Health Insurance Program (CHIP), Children with Special Health Care Needs (CSHCN), or Supplemental Security Income (SSI), but the family refuses to apply for assistance, the bill will not be considered for financial assistance. The family will be responsible for the entire balance and payment of the estimated amount at the time of the services.

Elective cosmetic procedures may not qualify for financial assistance. Elective cosmetic procedures must be approved in advance by the President of CCMC or his/her designee.

1. Applying for Financial Assistance
   1. Patient Registration will refer those guarantors who may qualify for financial assistance from a governmental program to the appropriate program, such as Medicaid, CHIP, CSHCN, or SSI.
   2. For patients with no insurance coverage, upon denial from a government program, a Financial Evaluation form (refer to Attachment C) will be completed by the guarantor and forwarded to the Patient Accounting Department for financial assistance screening. If it is apparent the patient will not qualify for governmental assistance because income exceeds thresholds, the requirement for a denial will be waived.
   3. For patients with insurance coverage, the Financial Evaluation form will be completed by the guarantor and forwarded to the Patient Accounting Department for financial assistance screening without the need for the guarantor to apply for assistance from a governmental program when it is apparent that the guarantor's income exceeds the threshold for government programs. If it is not apparent that the guarantor's income exceeds the income threshold, then the guarantor should be screened for eligibility under governmental assistance programs.
   4. The following documentation must be received in order to process the request for financial assistance (only copies of documentation should be submitted; originals will not be returned to the guarantor):
      1. Signed, completed Financial Evaluation form.
      2. One of the following types of proof of income must be provided for both the guarantor and his/her spouse. For any type of check stub or letter, proof must be provided for the three most recent pay periods:
         • W-2;
         • Prior year's tax return (this is required for all self-employed guarantors/spouses);
         • Pay check stubs;
         • Retirement check stubs;
         • Social Security letters or deposit slips showing the amount of the Social Security deposits;
         • U.S. unemployment check stubs;
         • Other governmental program check stubs;
         • Letter from employer, on employer letterhead, indicating the payment amount; and
         • In exceptional cases, verbal or written attestation may be used as proof of income. The Director of Patient Accounting or Vice President of Finance has final approval authority regarding verbal or written attestation.
   5. Medicaid denial for the period including the dates of service for all accounts. This requirement will be waived if it is apparent the patient will not qualify for governmental assistance. If the patient has governmental coverage for only a portion of the treatment days, an application/denial may be required for the date span not covered by Medicaid/CSHCN.
2. Factors To Be Considered For Eligibility Determination
   1. The following factors are to be considered in determining the eligibility of the guarantor for financial assistance:
      1. Household gross income;
      2. Family size; and
      3. The federal poverty income guidelines, as updated annually by the Department of Health and Human Services (DHHS).
3. Incomplete Applications – If all required documentation is not received (i.e., the application is incomplete), the applicant will be provided with information relevant to completing the application along with a summary of this financial assistance policy. No collection efforts will be pursued until reasonable efforts have been made to determine financial assistance eligibility.
4. Time Frame For Eligibility Determination - It is the goal of CCMC to make a determination concerning the guarantor's eligibility for financial assistance as soon as sufficient information is available concerning the guarantor's financial resources and eligibility for governmental assistance.
   1. A determination of eligibility will be made by Patient Accounting Supervisor/ Director or Vice President of Finance within 30 days from the time all information necessary to make a determination is received, but in no event more than 240 days from the date CCHCS provided the individual with the first billing statement post-discharge.
   2. The determination of eligibility may be valid for a period of up to one year.
   3. At least 30 days before the deadline for determining eligibility, at least one written notice will be provided advising that the hospital or collection agency may initiate or resume collection efforts if the individual does not pay the amount due or complete the application by the specified deadline.
5. Documentation of Eligibility Determination - Once an eligibility determination has been made, the following will be documented in the account message area for each account affected by the determination:
   1. The individual was determined eligible for financial assistance;
   2. The individual was notified of his/her eligibility for financial assistance in writing;
   3. No collection efforts were made while financial assistance eligibility was reasonably being determined;
   The determination only has to be made once by any CCHCS entity. The information can be shared between entities so that the process is not duplicated. All documentation provided for the determination will be kept in Patient Accounting records for a period of at least seven years.
6. Approval authorities for total write-off of a guarantor's accounts will be as follows:
   1. Guarantor balance less than $10,000 requires approval by the Patient Accounts or Billing Supervisor.
   2. Guarantor balance from $10,000 to $50,000 also requires approval of the Manager/Director of Patient Accounting.
   3. Guarantor balances greater than $50,000 also require approval of the Vice President, Revenue Cycle.
   For automatic qualifications, approval is not required.
7. If payment arrangements are made, the payout period must not exceed 24 months from the date the payment schedule is arranged. Exceptions must be approved by the Patient Accounts Supervisor/Director of Patient Accounting or the Vice President-Revenue Cycle.
8. Any exceptions to this policy require the written approval of the President.

1. Following a determination of financial assistance eligibility, a billing statement will be provided to the individual that indicates the amount the individual owes as a result of being eligible for financial assistance.
   1. The billing statement will indicate the amount the individual owes and how that amount was calculated. The billing statement may reflect gross charges that were used as the starting point before allowances, discounts or deductions were applied, provided that the amount that the individual is personally responsible for paying is less than the gross charges for such care.
   2. A FAP-eligible individual may not be charged more for emergency or other medically necessary care than the amounts generally billed (AGB) to individuals with insurance.
2. The billing statement will provide the website address (www.cookchildrens.org/financial-assistance) where the individual can go for information about the amounts generally billed (AGB) for the care provided, and how the AGB is calculated.
   1. Cook Children's Medical Center uses the "Look-Back Method" to calculate AGB by dividing the sum of Medicare fee-for-service, Medicaid, and private health insurer claims by the associated gross charges for those claims.
   2. Claims during the prior fiscal year (12 months) are included in the calculation.
   3. The AGB is calculated annually and applied on a calendar year basis.
3. If any excess payments were made by the individual prior to being determined eligible for financial assistance, those payments, if over $5.00, must be refunded.
4. At least 30 days before initiating one or more extraordinary collection activities (ECAs) to obtain payment for care, CCMC will notify patients about its FAP by:
   1. Including a plain language summary of the FAP along with a notice of the ECA(s) that the hospital intends to initiate to obtain payment for the care, and a deadline after which such ECA(s) may be initiated (the deadline may be no earlier than 30 days after the date that the written notice is provided).
   2. Making a reasonable effort to orally notify the individual about the FAP and how the individual may obtain assistance with the FAP application process.
5. No collection efforts will be pursued until reasonable efforts have been made to determine financial assistance eligibility based on a complete FAP application, or in the case of an incomplete FAP application, the individual has failed to respond to the request for additional information and/or documentation within a reasonable period of time.
6. Agreements with collection agencies must state that they will not begin collection efforts until CCMC has made reasonable efforts as indicated in this policy to determine whether the individual is eligible for financial assistance. If the individual is determined to be eligible, the collection agency must take all reasonably available measures to reverse any collection efforts (with the exception of the sale of debt) taken against the individual to collect the debt at issue.
7. Accounts worked by contracted collection agencies that have been screened for financial ability to pay, and are determined not to be able to pay account balances, will automatically be deemed eligible for financial assistance. Collection agencies will provide separate reports for accounts returned to CCHCS indicating the accounts where the guarantor does not have the ability to pay and those where the guarantor has been determined to have the ability to pay but refuses.
8. If the CCMC does not know whether a person is eligible, it can bill the person its usual charges provided that it makes timely attempts to determine the person's eligibility and refunds excess payments of more than $5.00 if eligibility is found.

Information regarding the amount of financial assistance provided by CCMC each fiscal year is aggregated and reported to the Texas Department of Health in the America Hospital Association (AHA)/Department of Health and Human Services (DHHS)/Texas Hospital Association (THA) Annual Survey of Hospitals (cooperative annual survey). It is broken down into two sections: The American Hospital Association Annual Survey and the Texas Department of Health Survey Supplement.

U.S. Department of Treasury proposed regulations See [4830-01-p] DEPARTMENT OF THE TREASURY Internal Revenue Service, 26 CFR Part 1, [REG-130266-11], RIN 1545-BK57, Additional Requirements for Charitable Hospitals, AGENCY: Internal Revenue Service (IRS), Treasury, page 52, released June 26, 2012.

CCHCS policy Prompt Pay Discounts for the Uninsured (FN 480)
CCHCS policy Undocumented Immigrants (AD 550)
CCHCS policy Financial Assistance (FN 300)
CCMC policy Admissions (MC171)
CCMC policy Emergency Department Services and Coordination of Care (MC 484)
CCMC policy Transfer of Patients: Emergency Medical Screening (MC011)
CCHCS policy Collection Requirement at Time of Service (FN 175)

• Any physician not employed by Cook Children’s Physician Network, which may include:
  • Adult pulmonologists
  • Allergists/Immunologists
  • Dentists
  • Dermatologists
  • Neonatologists
  • Obstetricians/Gynecologists
  • Ophthalmologists
  • Oral maxillofacial surgeons
  • Orthodontists
  • Orthopedic surgeons
  • Otolaryngology
  • Plastic surgeons
  • Radiologists
  • Renal transplant surgeons
  • Urologists
• Transport services provided by any entity other than Cook Children's Teddy Bear Transport
• Outside laboratory services
• Durable medical equipment

	Federal Poverty Guidelines	Financially Indigent	Medical Indigency	Medical Indigency
Number of household	100%	400%	450%	$500%
1	11,880	47,520	$53,460	$59,400
2	16,020	64,080	$72,090	$80,100
3	20,160	80,640	$90,720	$100,800
4	24,300	97,200	$109,350	$121,500
5	28,440	113,760	$127,980	$142,200
6	32,580	130,320	$146,610	$162,900
7	36,730	146,920	$165,285	$183,650
8	40,890	163,560	$184,005	$204,450
Discount		100%	85%	70%

Catastrophic Eligibility - Insured Patients or Patient's Income exceeds 500% of Federal Poverty Guidelines (also applies to Medically indigent).

Balance due must be equal to or greater than 35% of the patient's gross annual household income.

Balance Due	Discount
Balance due is equal to or greater than 90% of the patient's annual income	90%
Balance due is equal to or greater than 80% and less than 90% of the patient's annual income	80%
Balance due is equal to or greater than 70% and less than 80% of the patient's annual income	70%
Balance due is equal to or greater than 60% and less than 70% of the patient's annual income	60%
Balance due is equal to or greater than 50% and less than 60% of the patient's annual income	55%