|To download the financial assistance policy and application in Spanish, click here.|
|Para descargar la política de asistencia financiera y la aplicación en español, haga clic aquí.|
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 SHS.
Financial Assistance is not considered to be a substitute for personal responsibility. Patients are expected to cooperate with SHS’ procedures for obtaining other forms of payment or financial assistance, and to contribute to the cost of their care based on their individual ability to pay.
All patients of Southwest Health System, Inc.
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).
Application Period: The application period is the period during which a facility must accept and process Financial Assistance Program applications submitted by an individual. This application period ends on the 240th day after the hospital facility provides the individual with the first billing statement for care.
Charges: SHS uses the “Prospective Medicare Method” to determine the Average Gross Billing (AGB). This method takes into account what Medicare together with what a 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. Individuals in the Financial Assistance Program will not be charged more than Medicare pays which are lower than any private health plan pays to SHS.
Community Notification: The Financial Assistance Program (FAP) policy will be available on the SHS website (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 SHS facilities at no charge.
Extraordinary Collection Actions (ECA): ECA’s include any actions that require legal or judicial process taken by a facility against an individual related to obtaining payment of a bill for care covered under the facility’s FAP. ECA’s that require a legal or judicial process include, but are not limited to, the following:
- Placing a lien on an individual’s property;
- Foreclosing on an individual’s real property;
- Attaching or seizing an individual’s bank account or any other personal property;
- Commencing a civil action against an individual;
- Causing an individual’s arrest;
- Causing an individual to be subject to a writ of body attachment; and
- Garnishing an individual’s wages.
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.
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.
Income: Gross wages, salaries, Social Security benefits, unemployment compensation, workers compensation, regular support from family members not living in the household, government pensions, private pensions.
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.
Medically Necessary Service: Any inpatient or outpatient clinics 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
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
Notification Period: The notification period is the period during which the facility must notify an individual of the Financial Assistance Program. This period begins on the date that care is provided to the individual and ends on the 120th day after the facility provides the individual with the first billing statement for care rendered. If the facility has met all notification requirements and the individual has failed to submit an application by the end of the notification period, the facility may engage extraordinary collection actions (ECA).
Patient eligibility for the 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:
- An individual who is uninsured
- Gross income (before taxes) and allowable expenses at or below 250% of federal poverty guidelines. Noncash benefits (food stamps and housing subsidies) do not count. Detailed income and expenses are outlined in Worksheet B page 2 and Worksheet B page 3.
- Not eligible for any other federal or state programs, or other Financial Assistance Program or funding sources.
- Those eligible for the Colorado Indigent Care Program (CICP) are still eligible to apply for additional financial assistance.
- The Financial Assistance Program is only open to active residents of 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.
The 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:
- Medically necessary services
- Services provided by any entity of Southwest Health System, Inc.
- At time of registration, all patients will be given information regarding financial policies, including the Financial Assistance Program, CICP and Prompt Pay Program, including discounts. The information provided to the patients will include how to contact a financial counselor for more information, be in plain language and offer a form upon request.
- DISCOUNTS AND PROMPT PAY ADJUSTMENTS: Prior to being approved for any financial assistance, any patient who is uninsured, or for whom SHS receives zero payment from any insurance company or other financial assistance program, will receive a 25% discount from any charges if payment is received, in full, within 30 days from the date of service or discharge or insurance denial notification.
- Financial Counselors will serve as intake technicians for all patient inquiries and requests for financial assistance.
- Patients requesting financial assistance will be evaluated for residency and citizenship compliance.
- Patients will be screened for medically necessary services in accordance with the Medicare definition stated in the Title XVIII Program.
- Patients will be screened for state or federal programs including alternative funding sources per policy.
- 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.
- 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.
- 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. A written confirmation of the missing documents will be provided to the individual, with a copy filed in the individual’s FAP file.
- Incomplete FAP Applications: If an individual submits an incomplete FAP application during the application period, the facility will suspend all ECA against the individual, provide the individual with written notice describing the additional information and/or documentation needed. The facility will provide at least one written notice that informs the individual the ECA will resume or initiate, if the individual does not complete the application or pay the amount due by a deadline that is no later than 30 days before the specified deadline.
- 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.
- 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 listing of all account balances due must be provided to the individual. A refund must be provided to the individual for any excess payments received after the account adjustments have been made. 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.) All reasonably available measures should be implemented to reverse any ECA (except a sale of debt) taken against the individual to collect the debt at issue.
- The Financial Assistance Program adjustments will then be processed based on the policy and procedure for “Patient Account Adjustments – Authorized Parties and Levels.”
- 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 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.
- 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:
- 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.
- 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.
- If more than one year time has elapsed, it will be necessary for the applicant to complete a new application.
RELATIONSHIP TO COLLECTION POLICIES: SHS has developed policies and procedures for internal and external collection practices (including actions the hospital may take in the event of non-payment, including collections action and reporting to credit agencies) that take into account the extent to which the patient qualifies for financial assistance, a patient’s good faith effort to apply for a governmental program or for financial assistance from SHS and a patient’s good faith effort to comply with his or her payment agreements with SHS. For patients who qualify for financial assistance and who are cooperating in good faith to resolve their discounted hospital bills, SHS may offer extended payment plans, will not send unpaid bills to outside collection agencies, and will cease all collection efforts. SHS will not impose extraordinary collections actions such as wage garnishments; liens on primary residences, or other legal actions for any patient without first making reasonable efforts to determine whether that patient is eligible for financial assistance under this policy. Reasonable efforts shall include:
- Validating that the patient owes the unpaid bills and that all sources of third-party payments have been identified and billed by the hospital;
- Documentation that SHS has or has attempted to offer the patient the opportunity to apply for financial assistance pursuant to this policy and that the patient has not complied with the hospital's application requirements;
- Documentation that the patient has been offered a payment plan but has not honored the terms of that plan;
- Documentation that the patient has received two (2) monthly statements, two (2) letters and a final notice before any outside collection action is taken.
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.
|SOUTHWEST MEMORIAL HOSPITAL|
|Federal Poverty Level||Inpatient, Observation, Outpatient Surgery and Emergency Room||All other Outpatient||Discount Percentage after Co-pay||Patient Percentage Due after Co-pay|
|0 - 150%||$10.00||$10.00||100%||0%|
|Federal Poverty Level||Clinic Visit||Discount Percentage after Co-pay||Patient Percentage Due after Co-pay|
|0 - 150%||$10.00||100%||0%|
|FEDERAL POVERTY GUIDELINES - 2013|
|<------------------PLAN 1--------------->||PLAN 2||PLAN 3|
|* For families with more than 8 per add $4,020 per member (for 100% FPL)|