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ADMINISTRATIVE/OPERATIONSPOLICY

FINANCIALASSISTANCEPOLICY EffectiveDate:July1,2016 Approval:CHRISTUSHealthPresident PolicyInitiatedby:RevenueCycle Application:SystemWide

SCOPE:Theprovisionsofthispolicyareapplicabletoallnon-profit,tax-exempthospitalsoperatedbyCHRISTUSHealthintheUnitedStates,aslistedinAttachmentA.

PURPOSE:TodescribetheCHRISTUSHealthFinancialAssistanceProgram,includinghowCHRISTUShospitalswilldeterminepatients’eligibilitytoreceivefreeordiscountedemergencyandmedicallynecessaryhealthcare.ThisPolicyconstitutestheFinancialAssistancePolicyandtheEmergencyMedicalCarePolicy(withinthemeaningofSection501(r)oftheInternalRevenueCode)foreachhospitallistedinAttachmentA.

POLICY:CHRISTUSiscommittedtominimizingthefinancialbarrierstohealthcare,especiallytothosewhoareeconomicallypoorandunderservedandtothosewhoarenotcoveredbyhealthinsuranceorgovernmentalhealthcareprograms.ConsistentwithitsMissionandValuesasaministryoftheCatholicChurch,CHRISTUSwillprovidefinancialassistancetopatientswhoqualifypursuanttothisPolicy.CHRISTUShospitalsprovide,withoutdiscrimination,careforemergencymedicalconditionstopatientsregardlessofwhetherthepatientsareeligibleforfinancialassistance.

PROCEDURES:

A. ProgramEligibility

1. TobeeligiblefortheCHRISTUSFinancialAssistanceProgramunderthisPolicy,thepatientmustbeuninsuredorparticipateinagovernment-sponsoredprogramfortheindigent,suchascountyhealthcareassistanceprograms.Commercially-insuredandMedicarepatientsmaybeeligibleforassistanceundertheCHRISTUSHardshipDiscountPolicy.

2. PatientsinterestedinfinancialassistancewillreceivefreefinancialcounselingfromCHRISTUStoidentifypotentialpublicorprivatehealthcoverageprogramstoassistwithlong-termhealthcareneeds.

3. ExceptasotherwisedescribedinthisPolicy,uninsuredorindigentpatientswhoapplyfortheFinancialAssistanceProgramwillqualifyiftheirgrossfamilyincomeisatorbelow400%ofthethen-currentFederalPovertyGuidelines.UninsuredpatientswhoapplyfortheFinancialAssistanceProgrammayalsoqualifyforassistanceunderthisPolicy,regardlessofincomelevel,iftheyhavemedicalorhospitalbillsthatexceed10%ofthetheirgrossfamilyincome.

4. CHRISTUSreservestherighttodenyassistancetopatientswhomeettheincomelevelcriteriaif,inthejudgmentofCHRISTUS,suchpatientshavesufficientnetassetstopayforCovered

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Services(asdefinedinSectionB.1)atusualandcustomarycharges.Inreviewingavailableassets,CHRISTUSwillnotconsiderthevalueofapatient’sprimaryresidence,primaryvehicle,orretirementaccount.PatientswhodisagreewiththedenialmayappealasdescribedbelowinSectionD.8.

5. BeforefindingapatienteligibleforassistanceunderthisPolicy,CHRISTUSmayrequirepatientstoapplyforpublichealthcoverageprogramsforwhichCHRISTUSpresumesthepatientsareeligible,asinstructedbyCHRISTUSfinancialcounselors.CHRISTUSmaydenyeligibilityfortheFinancialAssistanceProgramtopatientswhohavebeenscreenedforapublichealthcoverageprogramandarepresumedtobeeligiblebutarenotcooperatingwiththeprocesstoapplyforthehealthcoverageprogram.AsaconditiontoparticipationintheFinancialAssistanceProgram,CHRISTUSmayalsorequirepatientstoapplyforfuturehealthcarecoveragethroughthefederalhealthcareexchangeiftheindividualiseligibleforsubsidizedpremiums.

6. PatientsarenoteligiblefortheFinancialAssistanceProgramifthepatientreceivesorisexpectedtoreceiveathird-partyfinancialsettlementthatincludespaymentintendedtocompensatethepatientforchargesrelatedtomedicalcarerenderedbyaCHRISTUSfacility.Thepatientisexpectedtousethesettlementamounttosatisfyanypatientaccountbalances.

7. Inmakingeligibilitydeterminations,CHRISTUSmayconsiderfactorssuchas:thepatient’sandfamily’searningstatus,sourcesofincomeandassets,natureandextentofliabilities,abilitytoobtainadditionalcredit,amountofmedicalbills,andfamilysize.

8. CHRISTUSwillevaluatepatientstodetermineiftheymeetpresumptiveeligibilitycriteriafortheFinancialAssistanceProgramwithoutthepatientscompletinganapplication.Uninsuredpatientsareordinarilypresumedtobeeligibleforfinancialassistanceinthefollowingcircumstances:

a. Thepatientishomeless;

b. ThepatientwasnotrequiredtofileaFederaltaxreturnforthemostrecentlyconcludedcalendaryear;or

c. Electroniceligibilitytoolsthatusepatientdemographicdata,creditreports,andotherpubliclyavailableinformationindicatethatthefamily’sincomeislessthan200%oftheFederalPovertyGuidelines.

d. RecentMedicaidcoverage(i.e.,coveragewithin3monthsofdischargeoradmission)

Apatientpresumptivelyfoundtobeeligiblemaybeaskedtoverifybasicfinancialinformationbeforereceivingfinancialassistance.

B. CoveredServices

1. BenefitsundertheFinancialAssistanceProgrammaybeappliedtoanyemergencyandmedicallynecessaryhealthcareservicesprovidedatthehospitalslistedinExhibitA(“CoveredServices”).ThisPolicyusestheMedicaredefinitionof“medicallynecessary,”whichis“healthcareservicesorsuppliesneededtodiagnoseortreatanillness,injury,condition,disease,oritssymptomsandthatmeetacceptedstandardsofmedicine.”

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2. CertainservicesarenoteligibleforbenefitsandarenotconsideredCoveredServicesundertheCHRISTUSFinancialAssistanceProgram.Theseinclude,butarenotlimitedto,thefollowing:

a. ElectiveorlifestyleservicesthatarenotconsideredemergentormedicallynecessaryasdeterminedbyaphysicianataCHRISTUSfacility;

b. Servicesprovidedforworkers’compensationcareorwhenathirdpartyisliablefortheinjuriesorillnessrequiringmedicalservices;and

c. Servicesprovidedoutsideofthehospitalsetting,includingaturgentcarecenters,ambulatorysurgerycenters,physicianofficeclinics,homehealthandhospice.

3. CHRISTUSprovides,withoutdiscrimination,careforemergencymedicalconditionstoindividualsregardlessofwhethertheyareeligibleforassistanceunderthisPolicy.CHRISTUSwillnotengageinactionsthatdiscourageindividualsfromseekingemergencymedicalcare,suchasdemandingthatpatientspaybeforereceivingtreatmentforemergencymedicalconditions.EmergencymedicalservicesareprovidedtoallCHRISTUSpatientsinanon-discriminatorymanner,pursuanttoeachhospital’sEmergencyMedicalTreatmentandActiveLaborAct(EMTALA)policy.

C. HowtoApplyforFinancialAssistance

1. Thepatientorpatient’sguarantorshouldcompleteandsubmitaFinancialAssistanceProgramapplicationtoapplyforfinancialassistance.

a. Patientsandguarantorsmayrequestapplicationsby:

i. AskingwithintheAdmittingDepartmentatanyCHRISTUShospitalii. CallingCustomerServiceat903-531-5518,MondaythroughFriday,8a.m.to5

p.m.(centraltime)iii. Mailingawrittenrequestto CustomerService,P.O.Box6997,Tyler,TX75711iv. Downloadinganapplicationatwww.tmfhc.org/patients-visitors/financial-

assistance

b. Theapplicationdescribesallthepersonal,financial,andotherinformationordocumentationthatanindividualmustsubmittobeconsideredforeligibilityintheCHRISTUSFinancialAssistanceProgram.

c. CHRISTUSmaypresumptivelyqualifysomepatientsforthemostgenerousdiscountofferedundertheFinancialAssistanceProgrambasedonexternaldatasourcesandelectroniceligibilitytoolsthatusepatientdemographicdata,creditreportsandotherpubliclyavailableinformation.PatientswhodonotpresumptivelyqualifymayapplyfortheFinancialAssistanceProgramusingtheapplication.

2. TheapplicationfortheFinancialAssistanceProgrammustbesubmittedtoCHRISTUSwithin8monthsofthedateofthefirstpost-dischargebillingstatementthatpertainstothecareforwhichthepatientorguarantorisseekingfinancialassistance.

3. Completedapplications,includingallrequiredinformationanddocumentation,shouldbesubmittedtoCHRISTUSforeligibilitydetermination.Completedapplicationsmaybe:

a. SubmittedbymailtoCustomerServiceusingtheaddressontheapplication;or

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b. Deliveredinpersontothehospitaladmittingdepartmentorbusinessoffice.

4. Applicantsarenotifiedbymailwhentheirapplicationisincompleteandaregivenanopportunitytoprovidethemissingdocumentationorinformationwithin60daysofthedateofnotification.Writtennoticestopersonswithincompleteapplicationswillinclude:

a. Instructionsforhowtosubmittherequesteddocumentationorinformation;

b. Aplainlanguagesummaryofthispolicy;

c. InformationaboutExtraordinaryCollectionActions(ECAs)thatthehospitalmighttakeifitdoesnotreceivetheinformationrequestedwithinthe60-dayperiod;and

d. ContactinformationforaCHRISTUSdepartmentthatcanprovideassistancewiththeapplicationprocess.

Inadditiontothewrittennotice,applicantsmayalsoreceiveaphonecalliftheirapplicationisincomplete.

D. EligibilityDeterminations

1. Forcompletedapplications,CHRISTUSwillmakeadeterminationregardingtheapplicant’seligibilityinatimelymannerandconsistentwiththisPolicy.

a. IfCHRISTUSbelievesanindividualwhohassubmittedacompletedapplicationmayqualifyforMedicaid,CHRISTUSmaypostponemakingafinancialassistanceeligibilitydeterminationuntilafteraMedicaidapplicationhasbeensubmittedandtheMedicaideligibilitydeterminationhasbeenmade.

b. Uponreceiptofacompletedapplication,CHRISTUSmaynotinitiateorresumeanyECAstoobtainpaymentforthecareatissueuntiltheeligibilitydeterminationhasbeenmade.

2. IfCHRISTUSfindstheapplicantiseligibleforfreecare(100%discount),CHRISTUSwill:

a. Providetheapplicantwithawrittennoticethatindicatestheindividualwasdeterminedtobeeligibleforfreecare;

b. Refundtotheindividualanyamountthatheorshehaspreviouslypaidforthecare,unlessthatamountislessthan$5;and

c. TakeallreasonablyavailablemeasurestoreverseanyECAtakenagainsttheindividual,includingremovinganyadverseinformationfromacreditreportthataroseasaresultofaCHRISTUScreditdisclosuremadefortherelevantepisodeofcare.

3. IfCHRISTUSfindstheapplicantiseligibleforassistanceotherthanfreecare,CHRISTUSwill:

a. Providetheapplicantwithabillingstatementandwrittennoticethatindicatestheamounttheindividualowesbasedonthefinancialassistancegiven,howthatamount

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wasdetermined,andhowtheindividualmayobtaininformationregardingtheamountsgenerallybilled(AGB)forthecare;

b. Refundtotheindividualanyamountthatheorshehaspreviouslypaidforthecarethatexceedstheamountheorsheispersonallyresponsibleforasapersoneligibleforfinancialassistance,unlessthatamountislessthan$5;and

c. TakeallreasonablyavailablemeasurestoreverseanyECAtakenagainsttheindividual,includingremovinganyadverseinformationfromacreditreportthataroseasaresultofaCHRISTUScreditdisclosuremadefortherelevantepisodeofcare.

4. IfCHRISTUSfindstheapplicantisnoteligibleforassistance,CHRISTUSwillprovidetheapplicantwithabillingstatementandwrittennoticethatindicatestheamounttheapplicantowesandthebasisforthedeterminationthattheapplicantwasineligibleforfinancialassistance.Thedenialletterwillalsoincludeinformationonhowtheapplicantmayappealthedecision,asdescribedinSectionD.10below.

5. Underthefollowingcircumstances,CHRISTUSmayrevoke,rescind,oramendthefinancialassistanceprovided:

a. Fraud,theft,ormisrepresentationbythepatientorguarantor,orothercircumstancesthatunderminetheintegrityoftheFinancialAssistanceProgram;

b. Identificationofathird-partypayor,includingapublicorprivatehealthcoverageprogram,workers’compensation,orthird-partyliabilityinsurance.

6. Ifadeniedapplicantbelievesthathisorherapplicationwasnotproperlyconsidered,heorshemaysubmitawrittenrequestforreconsiderationwithin60daysofthedateofdetermination.Therequestshouldincludeinformationthatwasnotsubmittedwiththeoriginalapplicationthatsupportstheapplicant’sreasonforappealing.Thedenialletterprovidesadditionalinformationabouttheappealprocess.Appealsarereviewedbydesignatedhospitalstaff,andappealdecisionsarefinal.

7. EligibilitydeterminationswillnotbebasedoninformationthatCHRISTUShasreasontobelieveisunreliableorincorrectoroninformationobtainedfromtheapplicantunderduressorthroughtheuseofcoercivepractices.CoercivepracticesincludedelayingordenyingemergencymedicalcaretoanindividualuntiltheindividualhasprovidedinformationrequestedtodeterminewhethertheindividualiseligibleforassistanceunderthisPolicy.

E. LengthofEligibilityDetermination

AtthediscretionofCHRISTUS,FinancialAssistanceProgrameligibilitywillapply:

a. Toaparticularepisodeofcareordatesofservice;or

b. Foruptoa12-monthperiodfromtheinitialeligibilitydetermination.

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Iftheeligibilitydeterminationisexpectedtolastforaperiodoftimefollowingthedateoftheeligibilitydetermination,CHRISTUS,atitsdiscretion,mayaskforanupdatedapplicationoradjustthefinancialassistanceforfutureepisodesofcarebasedonchangestothepatient’sorguarantor’sdemonstratedfinancialneed.

F. DiscountsAvailableUndertheFinancialAssistanceProgram

1. FollowingadeterminationofeligibilityunderthisFinancialAssistancePolicy,apatientdeemedtobeeligibleforfinancialassistance(“EligiblePatient”)willnotbechargedmoreforemergencyorothermedicallynecessarycarethantheamountsgenerallybilledtoindividualswhohaveinsurancecoveringsuchcare(“AGB”).

2. Ingeneral,EligiblePatientswithagrossfamilyincomeatorbelow200%oftheFederalPovertyLevelwillqualifyfor100%discount(freecare)onallCoveredServices.

3. Ingeneral,EligiblePatientswithagrossfamilyincomebetween200%and400%oftheFederalPovertyLevelwillqualifyforaslidingscalediscountonallCoveredServices,rangingfrom50%to100%discountoneligibleservices.

4. TheremaybecircumstancesinwhichCHRISTUShasbilledapatientmorethanAGBbeforethepatienthadsubmittedacompletedapplicationorbeforeCHRISTUSdeterminedthepatientwasanEligiblePatient.IfanEligiblePatienthaspaidchargesinexcessofAGB,thehospitalwillrefundanyamounttheindividualhaspaidforthecarethatexceedstheamountheorsheisdeterminedtobepersonallyresponsibleforpayingasanindividualeligibleforfinancialassistance,unlesssuchexcesspaymentislessthan$5.

5. Eligibilitydeterminationswillbemadeanddiscountswillbeofferedwithoutregardtorace,creed,color,religion,gender,orientation,nationalorigin,orphysicaldisability.

G. AmountsGenerallyBilledCalculation

CHRISTUSusestheProspectiveMedicareMethodtodetermineAGB,byusingthebillingandcodingprocessitwoulduseiftheindividualwereaMedicarefee-for-servicebeneficiaryandsettingAGBforthecareattheamountitdeterminesMedicareandtheMedicarebeneficiarytogetherwouldbeexpectedtopayforthecare.

H. ActionsintheEventofNon-Payment

1. UnpaiddiscountedbalancesofpatientswhoqualifyfortheFinancialAssistanceProgramareconsidereduncollectiblebaddebts.

2. CHRISTUSdoesnotconduct,orpermitcollectionagenciestoconductonitsbehalf,ExtraordinaryCollectionActions(ECAs),asdefinedunderInternalRevenueCodeSection501(r),againstindividualsbeforereasonableeffortshavebeenmadetodeterminewhetherthepatientiseligiblefortheFinancialAssistanceProgram.ReasonableeffortsincludethehospitalmakingadeterminationthatthepatientisineligiblefortheFinancialAssistanceProgrambecausethepatientiscoveredbyMedicareorcommercialinsurance.

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3. TheSystemDirectorofPatientFinancialServicesmaintainsoversightandresponsibilityfordeterminingifCHRISTUShasmadereasonableeffortsandwhetheranECAisappropriate.IfapatientbelievesanECAwasinitiatedimproperly,thepatientshouldcontacttheCHRISTUSIntegrityLineat1-888-728-8383andprovidehis/hercontactinformationforfollowup.

4. UndernocircumstancewillCHRISTUSpursueanECAuntil120daysafterthedateofthefirstpost-dischargebillingstatementforthecareatissue.

5. Atleast30daysbeforeinitiatinganECA,CHRISTUSwill:

a. Providetheindividualwithawrittennoticethat:indicatesfinancialassistanceisavailableforeligibleindividuals,identifiestheECAsthatthehospitalintendstoinitiatetoobtainpaymentforthecare,andstatesthatECAswillbeinitiated30daysafterthedateofthewrittennotice;

b. ProvidetheindividualwithaplainlanguagesummaryofthisPolicy;and

c. MakeareasonableefforttoorallynotifytheindividualaboutthisPolicyandabouthowtheindividualmayobtainassistancewiththeapplicationprocess.

6. Asauthorizedbystateandfederallaw,CHRISTUSmayfileahospitallienontheproceedsofajudgment,settlement,orcompromiseowedtoapatient(orhisorherrepresentative)asaresultofpersonalinjuriesforwhichaCHRISTUShospitalprovidedcare.ThistypeoflienisnotconsideredanECAanddoesnotrequireadvancenoticebegiventothepatient.CHRISTUSwillnotifythepatientofsuchalieninaccordancewithstatelaw.

I. ProvidersWhoParticipateintheFinancialAssistanceProgram

CHRISTUShospitalsmaycontractwithphysiciangroupsandotherindependentcontractorsthatprovidemedicallynecessarycarebutdonotparticipateintheCHRISTUSFinancialAssistanceProgram.Therefore,apatientwhoiseligiblefortheFinancialAssistanceProgramwillnotnecessarilyreceivefinancialassistancefromthosenon-participatingproviders.AttachmentBliststhesecontractedprovidersandindicateswhetherornottheyparticipateinthisPolicy.Patientswhoreceivecarefromoneofthenon-participatingprovidersareadvisedtocontacttheproviderdirectlytodeterminewhethertheproviderhasitsownfinancialassistanceprogram.

J. DistributionofthePolicy

1. EachCHRISTUShospitalwillofferaplainlanguagesummaryofthisPolicytopatientsaspartoftheintakeordischargeprocess.CHRISTUSfinancialcounselorswillalsodistributethesummaryofthisPolicytopatientsasappropriateduringcounselingsessions.

2. EachbillingstatementfromCHRISTUSwillincludeaconspicuouswrittennoticeinformingpatientsabouttheavailabilityoffinancialassistance,includingbothatelephonenumberandwebsiteaddresswherethepatientmayobtainadditionalinformationandcopiesoftheplainlanguagesummaryofthisPolicy.

3. EachhospitalwillhavepublicdisplaysintheemergencydepartmentandadmissionsareasnotifyingpatientsoftheFinancialAssistanceProgram.

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4. ThisPolicy,theplainlanguagesummary,andtheFinancialAssistanceProgramapplicationwillbeavailableathttp://www.tmfhc.org/patients-visitors/financial-assistanceandarealsoavailableuponrequestandwithoutchargeineachhospital’semergencydepartmentandadmissionsareas.

5. ThisPolicy,theplainlanguagesummary,andtheFinancialAssistanceProgramapplicationwillbetranslatedintothelanguagespokenbyeachlimitedEnglishproficiencygroupthatconstitutesthelesserof1,000individualsor5%ofthecommunityservedbythehospitalfacility.

TITLE: Financial Assistance Policy

DEPT: Revenue Cycle Effective Date: 07/01/2016

REVISION: 1.0 Revision Date: 07/01/2016

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AttachmentAParticipatingHospitals

CHRISTUSMotherFrancesHospital…Tyler,TXCHRISTUSMotherFrancesHospital…Jacksonville,TXCHRISTUSMotherFrancesHospital…Winnsboro,TXCHRISTUSMotherFrancesHospital…SulphurSprings,TX

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AttachmentBProviderListing

Medically-necessaryhospitalservicesprovidedbyCHRISTUShospitalemployeesarecoveredundertheCHRISTUSFinancialAssistancePolicy.However,someservicesprovidedatCHRISTUSTrinityMotherFrancesHospitalarenotprovidedbyCHRISTUSemployeesandinsteadareprovidedbyindependentphysicians,groups,orotherentities.YoumayreceiveabillfromCHRISTUSforhospitalfacilityservicesandanotherbillfromyourdoctorforphysicianservices.Paymentarrangementsfortheseservicesmustbemadedirectlywiththosedoctorsandgroups.ThelistbelowidentifiesproviderswhoareauthorizedtoprovidecareinthehospitalbutdonotparticipateintheCHRISTUSFinancialAssistancePolicy.Pleasecontacttheseprovidersdirectlyifyouhavequestionsabouttheirfinancialassistancepolicies.TylerRadiologyAssociatesBrazosValleyPathologyAssociatesSoundPhysicianGroupABEOAnesthesiaCardiologyAssociatesofEastTexasHeatonENTAssociatesAzaleaOrthopedicsSleepyTimeAnesthesiaDeHavenEyeAssociatesTylerInternalMedicineAssociatesSpineandJointHospitalandPhysiciansOBHospitalistGroupSigalandAssociatesCardiovascularAssociatesETMCFirstPhysiciansDermatologyandAssociatesofTylerHematologyandOncologyTexasOncologyTylerCancerCenter