2.2. Residents of other counties are eligible for financial assistance

Revenue Cycle

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Financial Assistance Program

Origination

Date:

02/04/2009

Last

Revision

Date:

06/14/2018

1. POLICY STATEMENT

1.1. Grady Health System and Children’s Healthcare of Atlanta at Hughes Spalding maintains a

Financial Assistance Program (FAP) related to emergency and medically necessary

healthcare services provided to eligible individuals. The Program assures that the amount

billed to eligible individuals is not more than the amount generally billed to individuals who

have insurance covering such services.

1.2. Grady Health System and Children’s Healthcare of Atlanta at Hughes Spalding (CHOA) does

not discriminate in the provision of emergency or medically necessary care on ability to pay

or source of payment.

1.3. Grady Health System and Children’s Healthcare of Atlanta (CHOA) at Hughes Spalding

complies with applicable Federal civil rights laws and does not discriminate on the basis of

race, color, national origin, age, disability, or sex. Grady does not exclude individuals or treat

them differently because of race, color, national origin, age, disability, or sex.

2. FINANCIAL ASSISTANCE PROGRAM

2.1. Who is eligible?

Residents of Fulton and DeKalb Counties with incomes less than 400% of the Federal

Poverty Level (FPL) are eligible for financial assistance.

2.2. Residents of other counties are eligible for financial assistance for emergency

services, related inpatient admissions and related post-discharge care.

2.3. All Medicaid eligible individuals.

2.4. Who is not eligible?

A resident living outside of Fulton and DeKalb Counties receiving care that is not associated

with an Emergency Admission.

3. AUTOMATED FINANCIAL ASSISTANCE

3.1. At the time of registration (during address verification), every patient is electronically

assessed for a Federal Poverty Level ranking through (presumptive) automated third-party

software.

3.2. If the automated system determines a FPL level between 0 and 400%, the FPL value is

returned and placed in the “FPL%” field on the patient’s account. The patient is then auto-

qualified for the corresponding discount level.

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3.3. If the automated system determines a FPL level greater than 400%, “999” is placed in the

“FPL%” field on the patient’s account to indicate the patient is over-income for FAP.

3.4. If the automated system is unable to determine a FPL level (no SSN, insufficient data,

date/determination mismatch), and no value is returned leaving the “FPL%” field blank, the

patient may request that the automated process be repeated or may apply for financial

assistance using the manual process.

3.5. At the time of billing, the automated financial assistance determination will repeat for any

patient with no entry in the FPL field.

4. REQUESTING A GREATER DISCOUNT LEVEL

4.1. Patients who qualify for automated/presumptive financial assistance with a discount below

the greatest discount level will receive a notice on Statement One (1). This notice indicates

that the patient did not qualify for the highest discount level and advising how to apply for a

greater discount level.

4.2. The patient may request that the automated process be repeated or may apply for financial

assistance using the manual process.

5. MANUAL FINANCIAL ASSISTANCE POLICY DETERMINATION

5.1. During the Application Period, a patient may apply for financial assistance at any time using

the manual process.

Application Period: Individuals may apply for financial assistance prior to healthcare

being provided and up to the 240

day after the first billing statement is provided.

During this “Application Period”, the patient or the patient’s representative may apply for

financial assistance.

5.2. A patient may obtain the Financial Assistance Program Application and renewal information

as follows:

Grady

a. Financial Counseling Office, Clinic Registration at Grady Memorial Hospital, a

Neighborhood Health Center, or the Infectious Disease Center at Ponce.

b. Request an application by calling 404.616.6920.

c. Request an application by mail at the following address:

Grady Memorial Hospital

80 Jesse Hill Jr. Dr. SE

PO Box 26071

Atlanta, Georgia 30303

Attn: Financial Assistance Program

d. Download the Financial Assistance Program Application from Grady’s website as follows:

gradyhealth.org/fap/application

CHOA

e. Financial Counseling Office

f. Request an application by calling 404.785.5589

g. Request an application by mail at the following address:

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Children’s Healthcare of Atlanta at Hughes Spalding

35 Jesse Hill Jr. Dr. SE

Atlanta, Georgia 30303

Attn: Financial Assistance Program

h. Download the Financial Assistance Program Application from Grady’s website as follows:

gradyhealth.org/fap/application

Download the Financial Assistance Program Application from Children’s Healthcare of

Atlanta at Hughes Spalding’s website as follows:

https://www.choa.org/~/media/files/Childrens/patients/fap-application-grady-choa-2018.pdf?la=en

5.3. How to apply:

Complete, sign and submit the Financial Assistance Program Application and required

documents as outlined in this policy to determine eligibility for financial assistance.

5.4. What is required?

When applying for financial assistance, individuals must provide the following documents:

a. Proof of Identity: Provide the original or certified copies of acceptable identification and

documentation to verify proof of identity, which includes, but is not limited to the following:

1. Driver’s License (Georgia), State of Georgia ID Card, Any Consular, Credit Card with

Picture or School Picture ID

2. Visa or Resident Alien Card or other immigration documents issued by the U.S.

Government

b. Proof of Residency: One to three of the following showing your current street address

is required to prove residency for at least 30 days from the application date (a PO Box

address and junk mail does not demonstrate residency):

1. One to three utility bills such as power bill, gas bill, water bill and/or telephone bill

2. Lease Contract

3. Rent Receipt (showing current address)

4. Food Stamps Letter

5. Current Issued Voter’s Registration Card

6. Other business documents that verify your place of residency, such as, credit card

statements, IRS, Medicaid letters, student letter from school, cable bill, cell telephone

bills, bank statement, mortgage statement, check stubs showing your address, etc.

c. Proof of income: Provide all proof documents that apply:

1. One to three current paycheck stubs (patient and spouse)

2. Social Security Administration Letter Current Year

3. Unemployment Claim, Department of Labor Wage Inquiry, if applicable or recent bank

statements, if patient is living off savings

4. A letter from employer on company letterhead stating the rate of hourly pay, the total

amount paid each pay period and how often the employee is paid

5. Any decision letters indicating the patient is receiving unemployment compensation,

Medicaid, Social Security disability, General Assistance, workers compensation or

retirement plan

6. Food Stamps Letter and paycheck stubs (if applicable)

7. Verification of homelessness or a letter from a shelter on company letterhead

8. Other business documents showing how the patient is being supported

9. Last year’s tax return statement

d. Proof of number of dependents: One of the following is required as proof of the number

of dependents:

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1. Previous year’s Income Tax Return (most recent)

2. Any decision letters indicating that the patient has legal responsibility for the child,

such as, court ordered guardianship papers or custody papers

3. Birth Certificate for each child age 18 and younger

5.5. WHERE TO RETURN COMPLETED APPLICATIONS AND REQUIRED DOCUMENTS:

A patient may deliver the completed Financial Assistance Program Application and required

documents to one of the following locations, mail the application and documents or email the

application and documents:

Grady

a. Financial Counseling Department

b. Mail to:

Grady Memorial Hospital

80 Jesse Hill Jr. Dr. SE

PO Box 26071

Atlanta, Georgia 30303

Attn: Financial Assistance Program

c. Email:

fapappdocFNC@gmh.edu

CHOA

d. Financial Counseling Department

e. Mail to:

Children’s Healthcare of Atlanta at Hughes Spalding

35 Jesse Hill Jr. Dr. SE

Atlanta, Georgia 30303

Attn: Financial Assistance Program

5.6. AVAILABLE HELP TO COMPLETE AND/OR SUBMIT THE APPLICATION

Grady and CHOA at Hughes Spalding will provide help to individuals with obtaining,

completing, and/or submitting the Financial Assistance Program Application by contacting

the address above or by presenting to a Financial Counseling Office.

For telephone assistance regarding the Financial Assistance Program, please contact the

Grady’s Financial Counseling Department at 404.616.6920 or 404.616.6923, or CHOA’s

Financial Counseling Department at 404.785.5589.

6. NOTIFICATION FOR MANUAL FINANCIAL ASSISTANCE ELIGIBILITY APPROVAL

6.1. Under the manual process, written notification for financial assistance eligibility is provided

to patients. If eligibility cannot be determined due to missing information and/or documents,

the individual will receive a written document indicating required information and/or

documents.

7. FINANCIAL ASSISTANCE ELIGIBILITY

7.1. Eligibility for financial assistance is based on county of residence, family size, gross income

and the Federal Poverty Level.

7.2. If a patient has potential payment resources such as, commercial insurance or third party

liability, the individual must exhaust these payment sources prior to utilizing Grady’s

Financial Assistance Program.

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7.3. If the patient meets criteria for any Federal or State Assistance Program, e.g., Medicaid,

Medicare, Cancer State Aid, Georgia Crime Victims Compensation Program, etc., for some

or all of the costs for healthcare services, the individual is expected to apply for such

programs prior to utilizing Grady’s Financial Assistance Program. Grady and CHOA at

Hughes Spalding will assist patients when applying for such programs.

8. FINANCIAL ASSISTANCE DOES NOT COVER THE FOLLOWING:

a. Cosmetic/Plastic Elective Surgery

b. Elective Services

c. Fetal Anomalies

d. International Patients - - Care provided to an out-of-country patient with a Visitor Visa

e. Accounts with unresolved third party coverage or third party liability coverage

Grady will determine if a service is eligible for financial assistance.

9. MEDICARE PATIENTS WHO QUALIFY FOR MEDICAID OR OTHER THIRD PARTY PAYER

COVERAGE

9.1. Patients who have Medicare as a primary payer and Medicaid as a secondary payer will

have responsibility for the Medicaid copayment only.

9.2. Patients with Medicare coverage as a primary and other third party payer coverage as a

secondary will have responsibility for the third party payer copayment or the financial

assistance copayment whichever is the lesser amount.

10. FINANCIAL ASSISTANCE DISCOUNT

1. Charity FAP Discounts

2. Uninsured Discounts

11. FINANCIAL ASSISTANCE PATIENT ACCOUNT CATEGORIES

The “determination type” and “discount level” are contained on the patient’s account as

follows:

Automated Charity Determination

A-Fulton (Fulton County Resident)

A-DeKalb (DeKalb County Resident)

A-Other (Eligible residents living outside of Fulton and DeKalb Counties.)

A-Title X Family Planning

Manual Determination

Approved-Fulton (Fulton County Resident)

Approved-DeKalb (DeKalb County Resident)

Approved-Other (Eligible residents living outside of Fulton and DeKalb

Counties.)

Approved-Homeless Fulton

Approved-Homeless DeKalb

Approved-Ryan White

Approved-Title X Family Planning

Approved-Children’s Healthcare of Atlanta at Hughes Spalding

12. INCOME GUIDELINES USED TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE

& SUBSEQUENT CHARITY CARE DISCOUNTS

12.1. Discount Levels with Copayments:

Tier 1: Patients with Annual Gross Family Incomes up to 250% of the current

Federal Poverty Income Level will be eligible for discounts assuming they meet

criteria for financial assistance.

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Tier 2: Patients with Annual Gross Family Incomes 251% to 400% of the Federal

Poverty Income Level will be eligible for discounts assuming they meet criteria for

financial assistance.

12.2. Homeless Level without Copayment:

Homelessness – U.S. Department of Housing and Urban Development (HUD)

Definition of Homeless:

The term “homeless, homeless individual or homeless person” includes:

a. An individual who lacks a fixed, regular, and adequate nighttime residence; and

b. An individual who has primary nighttime residence that is:

1. A supervised publicly or privately operated shelter designed to provide

temporary living accommodations (including welfare hotels, congregate

shelters, car, and transitional housing for the mentally ill);

2. An institution that provides a temporary residence for individuals intended to

be institutionalized; or

3. A public or private place not designed for, or ordinarily used as, a regular

sleeping accommodation for human beings.

Reference: Federal Register

Homeless Emergency Assistance and Rapid Transition to Housing: Defining

“Homeless”

Agency: Housing and Urban Development Department

federalregister.gov/documents/2011/12/05/2011-30942/homeless-emergency-

assistance-and-rapid-transition-to-housing-defining-homeless

13. Who participates?

All of the following physician groups and advance practice providers comply with the

Financial Assistance Program policy:

1. Grady

2. Emory School of Medicine

3. Morehouse School of Medicine

4. Grady EMS

5. Children’s Healthcare of Atlanta at Hughes Spalding

Patients may receive a separate bill from each of these providers.

Who does not participate?

When delivering medically necessary care, all of the above physician groups and advance

practice providers adhere to this policy. There are no non-participating providers.

All medically necessary care is covered under the Financial Assistance Program. The

exceptions are outlined under guideline #8.

14. AMOUNT GENERALLY BILLED (AGB)

Financial assistance discounts reduce outstanding balances to nominal copayments

ensuring balances are less than the Amount Generally Billed (AGB).

To comply with Section 501(r), the Financial Assistance Program assures that patients pay

less than the Amount Generally Billed to insured patients for emergency and medically

necessary care.

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“Medicare plus insurance paid” look-back-methodology is used to calculate AGB. The AGB

will be updated at least every three years.

Children’s Healthcare of Atlanta at Hughes Spalding

Basis for Determining Amounts Charged to Patients

“Amounts charged for emergency and medically necessary hospital-based medical services

to patients eligible for Financial Assistance will not be more than the amounts generally billed

to individuals with insurance covering such services.”

To comply with Section 501(r), the Financial Assistance Program assures that patients pay

less than the Amount Generally Billed to insured patients for emergency and medically

necessary care.

AGB Calculation Request

To request a copy of the AGB calculation free of charge, individuals may submit in writing to

one of the following addresses:

Grady Memorial Hospital

80 Jesse Hill Jr. Dr. SE

PO Box 26071

Atlanta, Georgia 30303

Attn: Amount Generally Billed Inquiry - Financial Assistance Program

Children’s Healthcare of Atlanta at Hughes Spalding

35 Jesse Hill Jr. Dr. SE

Atlanta, Georgia 30303

Attn: Amount Generally Billed Inquiry - Financial Assistance Program

15. EXTRAORDINARY COLLECTION ACTIONS (ECA)

An ECA is an action taken by Grady against an individual related to obtaining payment of a

bill for care, service or treatment. This may include:

Reporting adverse information about an individual to consumer credit reporting

agencies or credit bureaus (collectively, credit agencies).

Children’s Healthcare of Atlanta at Hughes Spalding

Children’s is governed by the Fair Debt Collection Practices Act. “Children’s does not implore

any extraordinary collection action as defined by the IRS”. At no time does Children’s or

vendors acting on Children’s behalf, report to any credit bureau (e.g., Equifax, Transunion,

Experian) or use legal or judicial processes to collect self- pay debt. This policy applies to all

self-pay balances for hospital and professional billing for all Children’s entities. Additionally,

Children’s does not “sell” its accounts receivables to outside vendors.

16. BILLING NOTIFICATIONS

The following billing notifications are related to the Financial Assistance Program:

16.1. Plain Language Summary (PLS)

The Plain Language Summary will appear on the back of all billing statements issued

by Grady.

Reference to the PLS will be noted on the first billing statement.

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16.2. Notice of Automated Charity

If a patient qualifies for FAP through the automated/presumptive process and the

discount level is less than the highest discount level, a notice will appear on the first

patient billing statement:

-advising them of the approval that is less than the highest level

-advising them how to manually apply for a higher discount level

16.3. Patients will receive three (3) billing statements:

Self-Pay Billing Statement 1 - Day 1

1. Advising the patient of the account balance due

2. Notice of FAP information on the reverse side of the billing statement

3. The Plain Language Summary appears on the reverse side of the statement

4. Notice of automated charity, if applicable

Self-Pay Billing Statement 2 - Day 15

1. Statement reminder that the account balance is due

2. Notice of FAP information on the reverse side of the billing statement

3. The Plain Language Summary appears on the reverse side of the statement

Self-Pay Billing Statement 3 - Day 30

1. Advising the patient that the account balance is Past Due

2. Advising that balances unpaid at 120 days will be reported to Credit Bureaus

(Extraordinary Collection Actions-ECA)

Self-Pay Day 45

1. Account Transferred to Early Out Pre-Collection Service (no ECA)

Self-Pay Day 120

1. Account Transferred to Bad Debt

2. Account reported to Credit Bureaus (ECA)

Children’s Healthcare of Atlanta at Hughes Spalding

Billing and Collection Practices for Patients with Financial Assistance

Guarantors receive 2 statements and 4 letters. True self-pay accounts/those with

financial assistance are not sent to an early out vendor.

The statements cycle is as follows:

statement when the full balance reaches the self-pay liability bucket

statement at day 30

past due collection letter at day 60

past due collection letter at day 90

past due collection letter at day 120

and final collection letter at day 180

Charity/true self-pay accounts are not sent to an early out vendor and are adjusted to

“Indigent” on day 180 of the billing cycle.

17. FINANCIAL ASSISTANCE TIME PERIOD

17.1. Application Period: Individuals may apply for financial assistance prior to healthcare

being provided and up to the 240

day after the first billing statement is provided.

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During this “Application Period”, the patient or the patient’s representative may apply for

financial assistance.

17.2. Applications will be accepted and processed even when an account has incurred one or

more Extraordinary Collection Actions (ECA) as described in this policy during this period.

If ECAs have been taken against a patient and the patient is later determined to be eligible

for financial assistance, as described in this policy, steps will be taken to reverse the ECA

even if the actions were appropriate and permissible.

18. MEDICARE & MEDICAID NON-COVERED SERVICES:

18.1 Medicare: Charges for non-covered services will be written off to charity for a financial

assistance eligible Medicare beneficiary.

18.2 Medicaid: Charges for non-covered services for a Medicaid recipient will be written off to

charity.

19. RIGHT TO REASSESS FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA AND ELIGIBILITY

STATUS

19.1. In the event of changes in financial circumstances and/or upon receiving new or different

eligibility information, Grady reserves the right to reassess an individual’s eligibility.

19.2. Grady may adjust the eligibility criteria for the Financial Assistance Program periodically

based upon:

1) the Community Health Needs Assessment (CHNA) conducted for the hospital;

2) as necessary to comply with applicable laws, regulations, and/or county agreements.

20. THE FINANCIAL ASSISTANCE PROGRAM POLICY (FAP) BROADLY PUBLICIZED

20.1. The Financial Assistance Program Policy (FAP), Application, and Plain Language

Summary and appropriate translations are made available free of charge to the public.

Grady will make concerted efforts to promote the Financial Assistance Program through

the Plain Language Summary provided to all patients upon registration, on the hospital’s

website, and through the display of signs throughout the Health System. This information

may be obtained as follows:

a. All patients receive the Financial Assistance Program Plain Language Summary at the

time of registration.

b. The Plain Language Summary is available at community healthcare partners.

c. The Financial Assistance Program policy, Plain Language Summary, and application are

displayed for review and available electronically for printing and downloading from the

Grady’s website as follows:

Billing/Insurance -

gradyhealth.org/billing-and-insurance

Policy (includes summary) - gradyhealth.org/fap/policy

Financial Assistance Program Application - gradyhealth.org/fap/application

Plain Summary - gradyhealth.org/fap/summary

Children’s Healthcare of Atlanta’s website as follows:

Financial Assistance Program – choa.org

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20.2. Upon request, free paper copies of the FAP policy and Plain Language Summary are

available from the following:

Grady Memorial Hospital

Financial Counseling Office

Emergency Department

Children’s Health of Atlanta at Hughes Spalding

Financial Counseling Office

Emergency Department

21. POLICY APPROVAL FOR ADOPTION

Grady Board of Directors – Finance Committee

Monday, March 12, 2018

Grady Board of Directors – Finance Committee

Monday, July 9, 2018

22. FINANCIAL ASSISTANCE POLICY Dates:

EFFECTIVE DATE: February 4, 2009

REVISION DATES: April 15, 2009

August 3, 2009

February 15, 2011

March 19, 2014,

January 11, 2016

November 11, 2016

November 1, 2017

December 20, 2017

March 1, 2018

April 23, 2018

June 14, 2018