Policies & Procedures: RW CARE Act Eligibility Determination, Sliding Fee Scale & Caps on Charges
Effective Date: 04/01/2015
Revised Date:
Policy Number: ADM-001
Approved:
I.POLICY:
To comply with the Ryan White CARE Act, Title XXVI, Health Care Services Program, Part C-Care Grant Program, Subpart 1 – General Grant Provisions, Section 2617 (c) Requirement Regarding Imposition of Charges for Services, (1) – (4), in Part C – Care Grant Program, Subpart 1 – General Grant Provisions, Section 2617 (c) Requirement Regarding Imposition of Charges for Services, (1) – (4) – as updated by the Ryan White HIV/AIDS Treatment Extension Act of 2009.
Ryan White HIV/AIDS Treatment Extension Act of 2009
(1) IN GENERAL – The Secretary may not make a grant under this part unless, subject to paragraph (5), the applicant for the grant agrees that –
(A) In the case of individuals with an income less than or equal to 100 percent of the official poverty line, the applicant will not impose a charge on any such individual for the provision of early intervention services under the grant;
(B) In the case of individuals with an income greater than 100 percent of the official poverty line, the applicant-
(i) Will impose a charge on each such individuals for the provision of such services; and
(ii) Will impose the charge according to a schedule of charges that is made available to the public.
(2)LIMITATION ON CHARGES REGARDING INDIVIDUALS SUBJECT TO CHARGES –With
Respect to the imposition of a charge for purposes of paragraph (1) (B) (ii), the Secretary may not make a grant under this part unless, subject to paragraph (5), the applicant for the grant agrees that-
(A) In the case of individuals with an income greater than 100 percent of the official poverty line and not exceeding 200 percent of such poverty line, the applicant will not, for the calendar year, impose charges in an amount exceeding 5 percent of the annual gross income of the individual involved;
(B) In the case of individuals with an income greater than 200 percent of the official poverty line and not exceeding 300 percent of such poverty line, the applicant will not, for thecalendar year, impose charges in an amount exceeding 7 percent of the annual gross income of the individual involved;
(C) In the case of individuals with an income greater than 300 percent of the official poverty line, the applicant will not, for any calendar year, impose charges in an amount exceeding 10 percent of the annual gross income of the individual involved.
(3)ASSESSMENT OF CHARGE – With respect to compliance with the agreement made under paragraph (1), a grantee under this part may, in the case of individuals subject to a charge for purposes of such paragraph –
(A) assess the amount of the charge in the discretion of the grantee, including imposing only a nominal charge for the provision of services, subject to the provisions of such paragraph regarding public schedules and of paragraph (2) regarding limitations on the maximum amount charges; and
(B) Take into consideration the medical expenses of individualsin assessing the amount of the charge, subject to such provisions.
II.PURPOSE
A. To create and maintain a Schedule of Charges/Sliding Fee Scale based on annual
Federal Poverty Guidelines.
B. To assess the patient’s financial responsibility for services provided in GO CARE’s
Clinic treating HIV patients for primary care.
C. To implement limits, or annual caps, placed on the maximum financial responsibility
That a HIV patient would be responsible for during a 12 month period (calendar year) based upon eligible medical expenses – These medical expenses can be incurred from the clinic, private hospitals, or private doctors. It can be any health insurance premium, any insurance deductibles, co-payments for clinic visits or prescriptions, any enrollment fees, or any coinsurance.
D. To designate a responsible employee to liaison for HIV services and for ensuring that
Patients are assessed sliding fee scale charges and caps on charges in compliance
With the reporting requirements of the Ryan White CARE Act.
III.PROCEDURES:
A. A notice announcing the schedule of patient financial responsibility and cap on
Charges will be made available to all patients receiving services in the HIV
Outpatient clinic via either signage and/or brochure in orientation packet. A copy of
The sliding fee scale and cap on charges will be displayed predominately in the
Patient lobby of the HIV clinic.
B. Upon new patient registration individual income will be documented by the intake
Staffmember. A summary form of sliding fee scale and
Annual caps on charges will be calculated by the intake worker and signed/dated by
Patient and staff member as documentation that the patient has been fully advised
Of their responsibility. A copy of this form will be scanned and entered into the
Patient’s electronic health record under insurance information and will be named
“Year/mth/day PT INCOME – SLIDING FEE”.
C. If patient is an established patient, case manager will be responsible for bringing
To the HIV Coordinator, any income statements that are received during the year
In order for them to be scanned into the electronic health record as in B above,
To assess a sliding fee scale for individual patients.
D. Income will be checked on a six (6) month basis, in keeping with uninsured
Patient’s Louisiana HAP application assessments. If no income documents
Can be obtained, patient will be designated as self pay and be billed for the
Full amount of the service provided until requested income information is
Received.
E. The HIV Program Coordinator will be the designated employee for ensuring that
Sliding fee scales and caps on charges are complete and current.
F. Income documentation can consist of the following items:
a.Most recent W-2 and/or 1099
b.Most recent tax return if within 6 months of filing it
c.Most recent check stubs for two pay periods (whether it be monthly,
Weekly or biweekly).
d.Letter from employer stating cash earnings that is signed by employer
Or supervisor
e.Letter from the Social Security Administration documenting SSI or
SSDI benefits
f.Letter and/or computer printout detailing unemployment benefits
g.Military leave and earnings statement
h.Notarized statement of no income.
G. After a sliding fee scale is assigned to patient, the fee will be updated in the insurance
Portion of the electronic health record patient management system and payment will
Be requested before patient is seen by provider.
H. Impact Healthcare billing department will be responsible for backing out all but the
Assigned sliding fee scale from eligible patient’s charges for each visit while patient
Remains eligible.
I. If patient does not have the amount requested at the time of visit, it will be billed by
Impact Healthcare and patient will be seen by the provider. No one will be denied services
Due to inability to pay.
J. A sliding fee scaleand annual cap will be utilized for all uninsured patients of the clinic.
Payment scheduled for Sliding Fee Scale and Annual Caps will consist of the following:
Individual Income / Annual Cap / Sliding Fee Per Visit< than 100% of FPL / None / None
101% to 200% of FPL / 5% of annual gross income / $5.00
201% to 300% of FPL / 7% of annual gross income / $10.00
301% or > of FPL / 10% of annual gross income / $20.00
K. The documentation of gross income will be performed by the Intake worker. Patient’s documented income will be used to determine the patient’s annual cap responsibility. Intake worker will inform patients of their annual financial responsibility and annual caps based on their income reported.
L. Patients who have an annual cap are responsible for providing documentation to the HIV Coordinator of any incurred expenses which could potentially be applied to their annual cap.
M. The Federal Poverty Level guidelines shall be revised each year to the changes published
Annually in the “Federal Register”. The effective date of the annual update will be the first
Day of the month following the notification of the changes published in the Federal
Register.
Policies and Procedures: RW CARE Act Eligibility Determination, Sliding Fee Scale and Cap on Charges