THE METHODIST HOSPITAL

Houston Methodist

Policy FI49

Subject: Effective Date:

Financial Assistance January 1, 2016

Applies to: Date Revised/Reviewed

Houston Methodist Hospitals January 1, 2020

Originating Area: Target Review Date:

Revenue Cycle Council January 1, 2023

I. POLICY

Houston Methodist (HM) is committed to providing financial assistance to persons who have healthcare

needs and are otherwise unable to pay for medically necessary care, including emergency care as

defined herein, based on their individual financial situation. Consistent with HM’s objective to deliver

high quality, cost effective healthcare, HM strives to ensure that those in need are not prevented from

receiving necessary health care services. HM will provide, without discrimination, care for emergency

medical conditions regardless of a patient’s ability to pay.

This policy covers how to apply for financial assistance; eligible services; eligibility criteria; the approval

process; the basis for calculating amounts billed; notification and posting requirements; collection

procedures for unpaid amounts; a list of providers that are/are not covered by this policy (Appendix C),

and also provides a plain language summary of this policy (Appendix A).

Financial assistance is not considered to be a substitute for personal responsibility. Patients are

expected to contribute to the cost of their care, based on ability to pay, and comply with HM’s procedures

for obtaining financial assistance. Individuals with the financial capacity to purchase health insurance

will be encouraged to do so, as a means of providing access to health care services. Patients that would

qualify as a Houston Methodist Global patient are excluded from this policy.

Consistent with good financial stewardship and to enable HM to provide healthcare services to the

greatest number of persons in need, HM’s Board of Directors has established the following guidelines for

the provision of patient charity.

II. DEFINITIONS

 Financial Assistance: Healthcare services provided by HM hospitals without charge or at a

discount to patients approved for Financial Assistance.

 Financially Indigent: A patient whose Family Income is less than or equal to 200% of the Federal

Poverty Level (FPL).

 Medically Indigent:

o Threshold #1 - A patient whose Family Income is between 201% and 500% of the FPL.

o Threshold #2 - A patient whose Family Income is greater than 500% of the FPL and

whose Account Balance is greater than 10% of their Family Income.

 Presumptive Charity: In instances where the Financial Assistance Application (FAA) is not

complete, HM will routinely screen uninsured patients using independent third-party sources for

financial assistance eligibility (i.e., electronic scoring model). Information provided in this

screening will include estimated income and number of family members.

 Federal Poverty Level (FPL): Level of income at which an individual is deemed to be at the

threshold of poverty. This income level varies by the size of the family unit. The poverty level is

updated annually by the United States Department of Health and Human Services and published

in the Federal Register. The poverty level indicated in these published guidelines represents

gross income.

 Account Balance: The amount owed after the application of any third-party assistance.

 Family: Using the Census Bureau definition, a group of two or more people who reside together

and who are related by birth, marriage, or adoption. According to Internal Revenue Service rules,

if a patient claims someone as a dependent on their income tax return, they may be considered a

dependent for financial assistance determination purposes.

 Family Income: Family Income, on a before tax basis, is determined using the Census Bureau

definition, which uses the following income when computing federal poverty levels (FPL):

o Earnings, unemployment compensation, workers’ compensation, Social Security,

Supplemental Security Income, public assistance, veterans’ payments, survivor benefits,

pension or retirement income, interest and dividends (excluding capital gains or losses),

rents, royalties, income from estates, trusts, educational assistance, alimony, child

support, assistance from outside the household, and other miscellaneous sources;

o Noncash benefits (such as food stamps and housing subsidies) do not count;

o If a person lives with a family, includes the income of all family members. Non-relatives,

such as a housemate, do not count.

 Houston Methodist Global: A corporation of Houston Methodist that serves the following patients:

o Citizenship in a foreign country;

o Possess valid passports;

o United States retirees that permanently reside abroad; or

o United States citizens that work abroad greater than six months in the year.

 Gross Charges: Charges for services before the application of payments, contractual

adjustments or discounts.

 Amounts Generally Billed (AGB) Percentage: The average payment percentage that a HM

hospital receives for medically necessary or emergency services from Medicare and private

insurance companies (see Appendix B). The AGB percentage is calculated annually for each HM

hospital, within 120 days of December 31

, utilizing a look back method which includes claims

processed for the previous calendar year.

 Emergency medical conditions: Defined within the meaning of Section 1867 of the Social

Security Act (42 U.S.C. 1395dd).

 Medically necessary: As defined by Medicare (services or items reasonable and necessary for

the diagnosis or treatment of illness or injury).

III. PROCEDURE

A. Eligibility Criteria: Individuals who seek financial assistance based on Family Income

shall complete a Financial Assistance Application (FAA). Eligibility for financial assistance

will be considered for patients who qualify as:

1. Financially Indigent as determined by the criteria in this policy;

2. Medically Indigent as determined by the criteria in this policy; or

3. Those who meet presumptive eligibility based upon the criteria in this policy.

B. Eligible Services: The following healthcare services are eligible for financial assistance:

1. Emergency medical services provided in an emergency room setting;

2. Services for a condition which, if not promptly treated, would lead to an adverse

change in the health status of an individual;

3. Non-elective services provided in response to life-threatening circumstances in a

non-emergency room setting; and

4. Medically necessary services, evaluated on a case-by-case basis at HM’s

discretion.

C. Eligibility Process: Financial need will be determined in accordance with an individual

assessment process that may include the following:

1. Presumptive Eligibility: In certain cases, there may be adequate information to

make a financial assistance determination without a completed FAA. Presumptive

financial assistance will be evaluated and/or reevaluated for each date of service.

Some examples of sources HM may use to determine presumptive financial

assistance include:

a) Homeless or received care from a homeless clinic;

b) Participation in Women, Infants, and Children programs (WIC);

c) Food stamp eligibility;

d) Low income/subsidized housing is provided as a valid address;

e) Patient is deceased with no known estate;

f) Acceptance in the Community Scholars Program or other approved

programs of third-party providers (e.g., patients would be presumed eligible

from community referrals under their existing financial assistance

programs) and the patient will qualify for the financial indigency discount;

g) Patients that are dual eligible for primary insurance coverage through

Medicare and secondary insurance coverage through Medicaid;

h) Patients that are Medicaid eligible whose claim is denied by Medicaid due

to spell of illness or exhausted benefits; and

i) Third-party electronic scoring model (i.e., Experian).

 Electronic Scoring Model (ESM). Where the patient does not

complete the FAA or does not provide the necessary

documentation to determine financial assistance eligibility, the

account may be screened using an ESM that derives scores based

on Family Income and the number of family members in the

household. Where the ESM score indicates the account qualifies

for financial assistance, discounts will be applied.

2. An application process culminating in the completion of a FAA (FAA – Appendix

D).

D. How to Apply for Financial Assistance:

1. To apply for Financial Assistance, a patient can obtain a Financial Assistance

Application (FAA), free of charge, as follows:

a. Speak with a Financial Counselor prior to or at time of service;

b. Download from HM’s website at www.HoustonMethodist.org/Billing;

c. Call HM’s Centralized Business Office, Monday through Friday, 7:00 a.m.

through 7:00 p.m., Saturday 8:00 a.m. through 12:00 p.m. at 832-667-5900

or toll free at 877-493-3228; or

d. By Mail:

Houston Methodist

Centralized Business Office

Attn: Financial Assistance Unit

701 S. Fry Road

Katy, TX 77450

2. Once the patient has obtained the FAA, the form should be filled out completely,

required supporting documents should be gathered and attached, all documents

should be submitted by way of the following:

a. By Mail:

Houston Methodist

Centralized Business Office

Attn: Financial Assistance Unit

701 S. Fry Road

Katy, TX 77450

b. Walk up and/or drop off to a Patient Access team member; or

c. Fax to 832-667-5995.

3. It is preferred but not required that a request for financial assistance and a

determination of financial need occur prior to rendering of non-emergent medically

necessary services. However, the determination may be done at any time. The

need for financial assistance is updated for each subsequent service if the last

financial evaluation was completed more than a year prior, or at any time

additional information relevant to the eligibility of the patient for financial assistance

becomes known.

4. HM’s values of human dignity and stewardship will be reflected in the application

and approval process. Requests for financial assistance will be processed

promptly and HM will notify the patient or applicant in writing within 30 days of

receipt of a FAA. Financial Assistance will be approved or denied based on the

completed FAA and other provisions of this policy (e.g., see below). In instances

of presumptive screening, no written notice is provided to the patient whether

approved or denied.

a. Denied decisions: Appeals will be considered by providing additional or

clarifying information for the specific denial reason listed in the letter.

Appeals will be accepted by phone, fax and mail.

E. Amounts Billed: Once care is confirmed for eligibility under this policy, any remaining

Account Balance will be billed to the patient as listed below.

1. Financially Indigent will receive a discount of 100% off gross charges, the patient

will not be billed, and the discount will be classified as financial assistance.

2. Medically Indigent Threshold #1 will be billed the lesser of 5% of gross annual

family income or a percentage of AGB.

3. Medically Indigent Threshold #2 will be billed the lesser of 10% of gross annual

family income or a percentage of the Account Balance.

F. Collection Steps in Case of Non-payment: In cases where a patient does not pay the

amount billed (Section III, E. above), HM management will follow its established collection

policies, which will include extended payment options. At no time will HM impose

extraordinary collection actions, such as wage garnishments, personal liens on primary

residences, credit bureau notification or other legal actions. A copy of HM’s collection

policies can be obtained for free by following one of the steps listed in Section III, D.1.

G. Financial Assistance Notification and Posting Requirements: Notification about

financial assistance will be made available by various means, which may include, but not

be limited to: the publication of notices in patient bills; notices in emergency rooms and

urgent care centers; the Conditions of Admission form; Admitting and Registration

departments, and at other public places as HM may elect. HM may also publish and

widely publicize a summary of this Financial Assistance policy on its hospital websites, in

brochures available in patient access sites and at other places within the community

served by HM. Such notices and summary information will be provided in various primary

languages spoken by the population served by HM. Referral of patients for financial

assistance can be made by any member of HM’s staff or medical staff. A request for

financial assistance may be made by the patient or a family member, close friend, or

associate of the patient, subject to applicable privacy laws.

H. Regulatory Requirements: In implementing this Policy, HM will comply with federal,

state, and local laws, rules, and regulations that apply to activities conducted pursuant to

this Policy.

I. Authoritative References:

1. Patient Protection and Affordable Care Act of 2010;

2. Internal Revenue Code Section 501(r)(4)-(r)(6);

3. Extended Payment Options Policy (FI86); and

4. Collections Policy (FI85).

IV. COUNCILS OR COMMITTEES REVIEWING OR APPROVING PROCEDURE AND REVIEW OF

APPROPRIATE DATES

Recommended by Revenue Cycle Council

Approved by Houston Methodist Board of Directors

V. NAME OF APPROVING EXECUTIVE: Marc L. Boom, M.D.

TITLE: President and Chief Executive Officer

Authorized by Chief Administrative Officer:

(Signed Original on File)

______________________________ _______________

M. Boom Date

President

Chief Executive Officer

Houston Methodist

Appendix A

Plain Language Summary

Houston Methodist’s Financial Assistance Policy

Houston Methodist is committed to providing charity care to persons who are uninsured, underinsured,

ineligible for a government program, or otherwise unable to pay for emergency and medically necessary

care based on their individual financial situation.

Patients whose family income is at or below 200% of the Federal Poverty Level (FPL) are eligible to

receive free services; and patients whose family income is above 200% but not more than 500% of the

FPL are eligible to receive services at a discounted amount. This discounted rate is not to exceed the

average amount Houston Methodist would get paid by private insurance, and Medicare, including any

patient payments in the form of deductibles, co-payments, and co-insurance. Patients whose family

income is above 500% of the FPL may be eligible for discounted services.

You will not be required to make advanced payments or payment arrangements for emergency and

medically necessary services prior to the rendering of services. However, if you are required to pay a

discounted amount, and you cannot pay the discounted amount in full after the services are provided,

Houston Methodist will attempt to collect this discounted amount. Houston Methodist will provide

monthly billing statements requesting payment from you. If you cannot pay the discounted amount in a

single payment, Houston Methodist offers interest free extended payment options. Any discounted

amounts remaining unpaid will be turned over to a third-party collection agency for further collection

attempts. Third party collection activity will not include personal liens, legal actions or credit bureau

notification.

A free copy of Houston Methodist’s Financial Assistance Policy, the Financial Assistance Application and

Collection Policies are available on Houston Methodist’s website at www.houstonmethodist.org/billing,

are available in the Hospitals’ Admitting and Registration areas, can be obtained by contacting the

Centralized Business Office at (local) 832-667-5900, (toll free) 877-493-3228, and can be requested by

mail:

Houston Methodist

Centralized Business Office

Attn: Financial Assistance Unit

701 S. Fry Road

Katy, TX 77450

This Plain Language Summary, Financial Assistance Policy, Financial Assistance Application and

Collection Policies are available in various languages at the contacts listed above.

Houston Methodist’s Financial Assistance Unit is available to answer questions and provide information

about the Financial Assistance Policy and to help you with the application process. You can reach a

member of the Financial Assistance Unit Monday through Friday between the hours of 7:00 a.m. through

7:00 p.m. and Saturday between the hours of 8:00 a.m. – 12:00 p.m. at 877-493-3228.

Once you have completed the Financial Assistance Application, please attach all required supporting

documents and mail to the Financial Assistance Unit, see address listed above, or fax to the attention of

the Financial Assistance Unit at 832-667-5995.

Appendix B

SAMPLE

AMOUNT GENERALLY BILLED (AGB) CALCULATION WORKSHEET

Annual Calculation of Amounts Generally Billed Percentage

Houston Methodist Hospitals

Relevant Measurement Period: January 1, 2019 – December 31, 2019

Medicare Fee-for-Service allowed amounts on claims paid during

relevant period

Private Insurance allowed amounts on claims paid during

relevant period

Co-pays, co-insurance, and deductibles paid by patients on

claims listed in A and B during relevant period

Total insurance allowed amounts and patient payments (A+B+C

above)

Hospital gross charges for services provided in D above $

Hospital-specific Amount Generally Billed (AGB) Percentage

(D/E) %

For a list of current AGB percentages for each HM hospital, please contact any of the individuals listed in

Section III, D.1. This information will be provided to you free of charge.

While it is required to calculate the AGB for each entity, HM will uniformly apply the lowest entity-

calculated AGB, rounded.

Appendix C

List of Providers that are/are not covered by this Policy

Covered

Organization/Group/Practice Yes/No

Houston Methodist Hospital Yes

Houston Methodist Sugar Land Hospital Yes

Houston Methodist Willowbrook Hospital Yes

Houston Methodist West Hospital Yes

Houston Methodist Baytown Hospital Yes

Houston Methodist Clear Lake Hospital Yes

Houston Methodist Continuing Care Hospital Yes

Houston Methodist The Woodlands Hospital Yes

Houston Methodist Imaging Center: Cinco Ranch Yes

Houston Methodist Imaging Center: Cypress Yes

Houston Methodist Imaging Center: Kirby Yes

Houston Methodist Imaging Center: Pearland Yes

Houston Methodist Imaging Center: Sienna Plantation Yes

Houston Methodist Imaging Center: Spring Yes

Houston Methodist Imaging Center: Spring Branch Yes

Houston Methodist Imaging Center: The Woodlands Yes

Houston Methodist Imaging Center: Voss Yes

Houston Methodist Emergency Center: Cinco Ranch Yes

Houston Methodist Emergency Center: Cypress Yes

Houston Methodist Emergency Center: Kirby Yes

Houston Methodist Emergency Center: Pearland Yes

Houston Methodist Emergency Center: Sienna Plantation Yes

Houston Methodist Emergency Center: Spring Yes

Houston Methodist Emergency Center: The Woodlands Yes

Houston Methodist Emergency Center: Voss Yes

Houston Methodist Primary Care Group No

Houston Methodist Specialty Physician Group No

Non-Houston Methodist Physician Groups (Private MDs) No

Anesthesiology: US Anesthesia Partners No

Anesthesiology: Space City Anesthesia No

Emergency Physicians: EmergiGroup Physician Associates No

Emergency Physicians: Kirby Emergency Physicians No

Emergency Physicians: San Jacinto Emergency Physicians No

Emergency Physicians: West Houston Emergency Physicians No

Emergency Physicians: Woodlands Emergency Physicians No

Hospitalist: Medical Clinic of Houston, LLP No

Hospitalist: Houston Hospitalist Joint Venture No

Hospitalist: Houston InPatient Physician Associates No

Hospitalist: Medical Center of Houston Physician Consultants, PLLC No

Hospitalist: Medical Center Hospitalist Associates, PLLC No

Hospitalist: Houston Methodist Academic Hospitalist Group No

Hospitalist: UTS No

Hospitalist: XpertMD No

Hospitalist: TeamHealth No

Hospitalist: OB Hospitalist Group No

Hospitalist: Questcare Obstetrics, PLLC No

Hospitalist: Envision OB/Gyn Hospitalist No

Hospitalist: Vanguard No

Imaging: MASTOS Imaging Associates No

Newborns: Texas Children's Physician Services No

Pathology: Methodist Pathology Associates, PLLC No

Radiology: Houston Radiology Associated No

Appendix D

Financial Assistance Application

Instructions: Please fill in all the blanks below. If an item is not applicable, please write N/A. Attach photocopies of the following that apply to your current

situation: 1. Most recent paycheck stub(s) that reflects YTD income information; 2. Most recent income tax return, including all attachments; 3.

Social Security check or entitlement letter or bank statement, if direct deposit; 4. Unemployment award letter; 5. Harris Health System gold

card. If unemployed and dependent on others for income and/or living expenses, please attach a letter of support and a copy of the tax return, if listed as

a dependent on the tax return. If you have questions or need additional assistance in filling out this application, please contact the Centralized

Business Office at 877-493-3228 M-F 7am – 7pm, Saturday 8am-12pm.

Please return completed application and supporting documents to any Patient Access team member, or fax to (832) 667-5995 or by mail to:

Houston Methodist, Centralized Business Office; Attn: Financial Assistance Unit; 701 S. Fry Road; Katy, TX 77450.

_________________________________________________ __________________________________________________________

PATIENT NAME (PLEASE PRINT) PATIENT SOCIAL SECURITY NUMBER

_________________________________________________ __________________________________________________________

PATIENT’S SPOUSE/GUARDIAN NAME (PLEASE PRINT) PATIENT’S SPOUSE/GUARDIAN SOCIAL SECURITY NUMBER

HOME ADDRESS ________________________________________________________________________________________________________

PHONE NUMBER _____________________ DATE OF BIRTH ________________ MARITAL STATUS ____________________________

CLINICAL SERVICE(S) REQUESTED: ________________________________________________________________________________________

ACCOUNT NUMBER: __________________________________ SERVICE DATES:____________________________________________________

No. of children under 18 years living at home: _______________ Names of Dependents

Directly related ________________ ___________________________________________________________________________

Step-children ________________ ___________________________________________________________________________

Not related ________________ ___________________________________________________________________________

Guardian of ________________ ___________________________________________________________________________

Patient

Spouse/Other

Employer ________________________________________

Employed Full-time

Employed Part Time

Unemployed/retired/disabled

Unable to return to work

Housewife

Employed Full-time

Employed Part Time

Unemployed/retired/disabled

Unable to return to work

Housewife

TOTAL FAMILY INCOME* $_____________________/month (SEND PROOF(S) OF INCOME WITH APPLICATION)

* Includes all wages, farm or self-employment, public assistance, Social Security, unemployment/worker’s compensation, retirement,

strike benefits, alimony, child support, military allotments, pensions, incomes from dividends, interest, rental property and other

miscellaneous income sources.

I certify that the above information is true and accurate to the best of my knowledge. It is understood that failure to provide all

of the information requested above may be considered as a disqualification from any financial relief under the Program.

Further, if applicable, I will make application for governmental assistance, take appropriate action to obtain such assistance

and advise HM of the outcome of my application. I (we) give HM consent to obtain information from any source to verify the

statement(s) that I (we) have made.

________________________________________________________ _____________________________________________________________________