Financial Assistance

Southwest Health System Inc. (SHS) is dedicated to providing medically necessary healthcare services. These services are accessible to all without regard to age, race, color, disability, sex, sexual orientation, national origin, religion, marital status, political affiliation, veteran status, ability to pay, or genetic information. To assist in meeting those needs, we have established a policy to provide financial relief to those patients in need of medically necessary services and who are unable to meet their financial obligation due to being low-income uninsured, underinsured or medically indigent. Access to the Financial Assistance Program will be granted after all other payment options have been exhausted.

The Financial Assistance Program will be updated annually in accordance with the Federal Poverty Guidelines as established by the Department of Health and Human Services. Under the rules and regulations, SHS is permitted to charge interest to any outstanding balance owed, however, it has been decided not to charge interest at this time.

The basis of these programs is the truthful and accurate provision and submission of financial information from the patient and/or responsible party(s). Patients and/or responsible party(s) that intentionally misrepresent their household financial information will be automatically disqualified from any consideration whatsoever with regard to this program.  Intentional misrepresentation determination is the sole right of Southwest Health System Inc.

SCOPE
All patients of Southwest Health System, Inc.

DEFINITIONS
Medically Indigent: Any patient whose health insurance coverage, if any, does not provide full coverage for all of their medical expenses, and their medical expenses relative to their income would make them indigent if they were forced to pay full charges for their medical expenses.

Family: The patient, his/her spouse (including a legal common law spouse) and his/her legal dependents according to the Internal Revenue Service rules. Therefore, if the patient claims someone as a dependent on their income tax return they may be considered a dependent for purposes of the provision of Financial Assistance Program.

Income: Gross wages, salaries, Social Security benefits, workers compensation, regular support from family members not living in the household, government pensions, private pensions.

Allowable Expenses: Allowable expenses will include actual payments made for day care, elderly care, child support payments, alimony payments, health insurance premiums and medical expenses (including physician, hospital and prescription expenses).

Charges: Southwest Health System, Inc. uses the “Prospective Medicare Method” to determine the (AGB) Average Gross Billing. This method takes into account what Medicare together with what the Medicare beneficiary would be expected to pay. For purposes of determining AGB, amounts paid under “Medicare” only include amounts paid under “Medicare fee for service” and exclude claims paid under Medicare Advantage.  Claims for Medicare Advantage are treated as claims paid by a private health insurer.

Community Notification: The Financial Assistance Program (FAP) will be available on the website for Southwest Health System, Inc. (www.swhealth.org). Communication regarding the FAP and how to obtain more information is also included in billing statements and registration paperwork. Paper applications and information are available, in plain language, upon request, at the time of registration, and in public locations at no charge. A community newsletter is sent out which includes the information for any community member to call to obtain Financial Assistance Program information.

Method of Application: A person may request information for Financial Assistance Program or Prompt Pay Program by mail, telephone or in person. The contact information is:

Southwest Health System, Inc.
1311 North Mildred Road
Cortez, CO  81321
Attn: Financial Counselor, PFS Department
Telephone:  970-564-2131 or  970-564-2143

Financial Assistance Program Amounts Awarded: The Financial Assistance Program amount awarded will be calculated in accordance with the Federal Poverty Guidelines up to 250% of the Federal Poverty Guidelines.

Medically Necessary Service: Any inpatient or outpatient hospital service that is covered by and considered to be medically necessary under Title XVIII of the Federal Social Security Act and based on the clinical judgment of the provider. Medically necessary services do not include any of the following:

a. Non-medical services such as social and vocational services.

b. Cosmetic surgery

c. Dental procedures

POLICY

Patient eligibility for Financial Assistance Program will be determined based upon demographical and financial information.  Medically indigent cases will be reviewed on a case by case basis, with consideration given to total medical debts as related to gross income and allowable expenses.

Patient Eligibility - Demographical and Financial Requirements:

• Not eligible for any other federal or state programs (excluding CICP), or other Financial Assistance Program or funding sources.
• Party of suit pending for services rendered.
• The Financial Assistance Program is only open to active residents of Montezuma, La Plata and Dolores Counties in Colorado. Any other residency must be approved by the Chief Financial Officer (CFO) for individual consideration.
• Proof of residency is mandatory. 
• Valid Social Security number is required.
• Financial eligibility will be based on family size, gross annual income and allowable expenses. (Detailed income and expenses are outlined in Worksheet B page 2 and Worksheet B page 3.)
• Gross income and allowable expenses at or below 250% of federal poverty guidelines.

Financial Assistance Program will be provided for covered services once the patient has met the demographical and financial requirements. To be a covered service, the service must meet all requirements as follows:

Covered Services:

• Medically necessary services
• Must be patient requested
• Services provided by any entity of Southwest Health System, Inc.

PROCEDURE

1. At time of registration, all patients will be given information regarding financial policies, including the Financial Assistance Program, CICP and Prompt Pay Program. The information provided to the patients will include how to contact a financial counselor for more information.
2. Financial Counselors will serve as intake technicians for all patient inquiries and request for financial assistance.
3. Patients requesting financial assistance will be evaluated for residency and citizenship compliance.
4. Patients will be screened for medically necessary services in accordance with the Medicare definition stated in the Title XV111 Program.
5. Patients will be screened for state or federal programs including alternative funding sources per policy.
6. If patient appears to qualify for a state or federal program they will be referred to such agency. We will make every effort to assist the applicant in this process. If the patient does not qualify for the state or federally funded program, he/she must provide proof of denial.
7. If the patient does not appear to qualify for any state or federal program he/she will be given a Financial Assistance Program packet (Worksheet A, pages 1, 2, 3, and 4) to complete and gather appropriate documentation. 
8. When the applicant arrives for the appointment the Financial Counselor will process the application (Worksheet B, pages 1, 2, 3 and 4). If all appropriate documentation is not provided the Financial Counselor will go over with the applicant what is still needed to complete the application process and re-schedule the applicant for the next appointment.
9. All completed applications will be submitted by the Financial Counselor, within five (5) business days of completion date, for compliance and recommendation for approval or denial by the Director of PFS.
10. If the applicant is recommended for approval the Financial Counselor will coordinate efforts and obtain a list of outstanding accounts at all covered entities (regardless of billing system used) for all applicants listed within the household and complete an “Adjustment Request Form,” attaching Worksheet B, page 1 and Worksheet D as supporting documentation. A separate Adjustment Request Form and Worksheet B will be completed for each entity location and billing system. (NOTE: Amounts eligible for Financial Assistance Program are balances remaining after all other third party payments and adjustments have been posted.  Therefore, all expected payments must be received or denied before any Financial Assistance Program adjustments can be processed. In the event there are accounts with pending third party payer transactions, the Financial Counselor will include the accounts on Worksheet D and indicate third party payments pending.)
11. The Financial Assistance Program adjustments will then be processed based on the policy and procedure for “Patient Account Adjustments – Authorized Parties and Levels.” 
12. Once the Financial Assistance Program adjustments have received the necessary approvals, the applicant will be informed of the accounts and amounts approved for Financial Assistance Program and that any future services will require the applicant to re-apply for the Financial Assistance Program if the date of service is past the date of expiration for the Financial Assistance Program.
13. In the event the patient has encounters after the original application has been processed, and the patient has requested the additional accounts to be considered for Financial Assistance Program, it will be the responsibility of the Financial Counselor to re-verify the patient’s eligibility. The Financial Counselor will review the original application and will follow the following steps:


1. If fewer than 180 days have elapsed since the original application, the Financial Counselor will review the application and apply reasonableness as to whether the applicants would have experienced a change in meeting eligibility requirements. If there is low risk (i.e. income is from fixed income sources, allowable expenses are fixed in nature), the Financial Counselor can recommend the additional services be covered under the original application.
2. In cases where there is more than low risk or more than 180 days have elapsed, the Financial Counselor will work with the applicant in completion of Worksheet C – Declaration Statement. If the applicant discloses there has been a change, the Financial Counselor will interview the applicant to identify the changes and based on findings, will update the application to reflect the changes. The Financial Counselor will request supporting documentation from the applicant as necessary to validate the applicant’s statements.
3. If more than one year time has elapsed, it will be necessary for the applicant to complete a new application.

The Financial Assistance Program will be updated annually in accordance with the Federal Poverty Guidelines as established by the Department of Health and Human Services. Download the full policy here.