Financial Assistance Program (FAP) / Charity Care

Discount Payment and Free Care Summary

HMNH offers financial assistance to patients who are uninsured (self pay) or insured patients with high medical costs. Please visit the Patient Access Services Department in the Main Admitting area or call 661-200-1050 between the hours of 7:00 AM – 7:00 PM, Monday through Friday.

  • This program covers medical necessary services. Medicare defines medically necessary care as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” 
  • All documents related to the FAP are provided in English, Spanish and to “a group that constitutes the lesser of 1,000 individuals or 5% of the community served by the hospital.”
  • Self pay patient means a patient who does not have insurance coverage including but not limited to auto, liability, workers’ compensation, Medicare or Medi-Cal. Self pay charity discounts apply to a patient whose family income is at or below 350% of the Federal Poverty Level (FPL). HMMH allows up to 400% of the (FPL).
  • Patients with high medical costs (a person whose family income is at or below 350% of the (FPL). HMNH allows up to 400% of the FPL), For this purposes high medical costs means any of the following:
    • Annual out of pocket costs incurred by the individual at Henry Mayo Newhall Hospital that exceed 10% of the patient’s family income in the prior 12 months
    • Annual out of pocket expenses that exceed 10% of the patient’s family income, if  the patient provides documentation of payment for the patient’s medical expenses paid by the patient or the patient’s family in the prior 12 months.
    • Underinsured patients whose family income is at or below 400% of the FPL and whose out of  pocket expenses do not exceed 10% of the patient’s family income, may qualify under HMNH’s extended charity or discount policy.
  • FAP application shall be initiated by Patient Access Services (PAS) personnel, or retrospectively, Business Services. In addition, the patient or patient representative may ask for the application in person or by phone or mail.
  • Upon receipt, Henry Mayo Newhall Hospital (HMNH) reviews the application, and approves or denies it based upon the submitted documentation and the discount Payment and Charity Care Programs’ criteria. Denial of the application is based solely upon the criteria submitted by the patient and/or responsible party and is rejected by not meeting the policy guidelines. The patient and/or responsible party will be notified of the application decision, in person, if possible; otherwise through a mailing.
  • Once the application and all requested documentation are received, HMNH will strive to review the application prior to the patient’s discharge, but no later than 30 days of receipt of application. If all requested documentation is not received, the application will be denied. Exceptions to this requirement will be reviewed if the additional supporting documentation is received within 30 days of the initial request.  
  • Patient payment responsibility will be assigned based upon a sliding scale including family size and annual income. Upon approval, the patient will not be charged more for emergency or other medically necessary care than the amounts generally billed (AGB) to individuals who have insurance covering such care. The patient responsibility will be based upon Medicare allowable rates: DRG, APC, Fee schedule. The sliding scale for patient income is directly related to the established Federal Poverty Level (FPL).

Additional Information

Based upon specific qualifications and approved eligibility, you may be eligible to receive health benefits through Medicare, Medi-Cal, CCS, or Healthy Families. Below is information on how you can contact those agencies, if you desire. Upon request, we can provide you with paper applications for Medi-Cal, CCS, and/or Healthy Families.

 

Health Benefit Exchange 

Phone: (800) 300 - 1506

http://www.coveredca.com     

 

Medi-cal

Phone: 1- 877- 597- 4777         

http://www.ladpss.org 

Select :

  • Customer Service Center (left margin under OTHER RESOURCES)
  • Medi-Cal (2nd paragraph)
  • Medi-Cal Application (middle column, 7th option)

 

CCS

Phone: 1- 800- 288- 4584

http://www.dhs.ca.gov

  • Left column – Forms, Laws & Publications
  • Right column – Forms
  • Right column – Applications
  • Near bottom – Applications to Determine GHPP (2 sections to print)

 

Medicare

Phone: 1- 800- 772- 1213

Internet application: https://s044a90.ssa.gov/apps6z/ISBA/main.html

 

California Health Exchange

Phone: 1- 844- 342- 6604

http://www.coveredca.com

 

Applications

Financial Assistance Program (FAP) - Click Here

Charity Care Application - Click Here

Applicacion en espanol - Click Aqui

Billing and Collection Policy - Click Here

 

Policies

HMNH will provide without discrimination, care for emergency medical conditions (EMTALA) to individuals regardless of their eligibility under the Financial Assistance Program (FAP). HMNH will not engage in activities demanding emergency department patients pay before receiving treatment for emergency medical conditions or permit debt collection activities in respective departments where EMTALA applies.  It is the policy of Henry Mayo Newhall Hospital (HMNH) to comply with the State/Federal regulations including but not limited to Assembly Bill 774 and IRS 501(r) related to the discounting of patient bills as reflected in the policy titled: The Financial Assistance Program. This program covers medically necessary services. Medicare defines medically necessary care as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”    Nonprofit credit counseling services may be available in your area or the City of Santa Clarita.

Types of Financial Assistance: 

  • Self-Pay without insurance coverage/benefit – 64% of charges adjusted off
  • Prompt Pay discounts for co-insurance
  • Financial Assistance Program (FAP) Care

Application Methods

  • Eligibility determination may be made through a paper application.
  • Eligibility determination may be made through an oral interview; approval may be granted without formal supporting documentation and may include general FAP.
  • All open patient accounts will be reviewed for consideration. 

A. State Regulation requires hospitals to provide a FAP (free care). 

All services of HMNH will be available for free care, if eligible. Patients whose family income is at or below 200% of the Federal Poverty Level (FPL) may be eligible. These levels are updated as published through the Tobacco Tax Trauma Program and adjusted upon receipt.

B. State Regulation requires hospitals to provide a FAP Discount Payment Process.

  • All services of HMNH will be available for discount payment process, if eligible.
  • Uninsured or underinsured patients whose family income is between 200.1% through 400.0% of the (FPL) may be eligible. Self pay patient means a patient who does not have coverage from a health insurer, health care service plan, Medicare or Medi-Cal, and whose injury is not a compensable injury for purposes of workers’ compensation, automobile insurance, or other insurance as determined and documented by the hospital may be eligible for discounted payments for all medically eligible services.
  • Patients with high medical costs (a person whose family income is between 200.1% through 400.0% of the FPL) who has insurance coverage and whose out-of-pocket medical expenses in the prior twelve (12) months exceeds 10% of the patient’s family income may be eligible for discounted payments for all medically eligible services.
  • Reasonable payment plan means monthly payments that are not more than 10 percent of a patient's family income for a month, excluding deductions for essential living expenses.  Essential living expenses means, expenses for any of the following: The hospital and the patient will negotiate the terms of the payment plan, and take into consideration the patient’s family income and essential living expenses. If the hospital and the patient cannot agree on the payment plan, the hospital will accept a:

"Reasonable payment plan" with monthly payments that are not more than 10 percent of a patient's family income for a month, excluding deductions for essential living expenses. "Essential living expenses" means, for purposes of this subdivision, expenses for any of the following: rent or house payment and maintenance, food and household supplies, utilities and telephone, clothing, medical and dental payments, insurance, school or child care, child or spousal support, transportation and auto expenses, including insurance, gas, and repairs, installment payments, laundry and cleaning, and other extraordinary expenses.” The hospital will agree to an extended payment plan that allows payment of the discounted price over time along with an option for the patient and their family to negotiate the terms of the payment plan.

Out-of-pocket medical expenses are defined as:

  • Annual out of pocket medical expenses incurred by the individual at the hospital that exceed 10% of the patient’s family income in the prior 12 months.
  • Annual out of pocket medical expenses that exceed 10% of the patient’s family income, if the patient provides documentation of the patient’s medical expenses paid by the patient or the patient’s family in the prior 12 months.  

Application Process

  •  The FAP application may be initiated by Patient Access Services (PAS) personnel on admission, or retrospectively by Business Services personnel. FAP approval up to $50,000 may be approved by the Manager of Business Services, $50,001 to $99,999 may be approved by the Director of Business Services, and greater than $99,999 may be approved by the CFO or CEO. 
  • The patient may contact PAS or Business Services for an application, if the patient cannot locate the original. 
  • The patient should complete the  application with supporting documentation and return the application to the hospital.  
  • Incomplete applications may result in the hospital requesting additional information or denying the application. 

Eligibility Requirements 

All reasonable efforts will be made to assist patients to qualify for appropriate County, State, and/or Federal or Health Assistance Programs, and if not qualified, may be eligible for HMNH FAP program. 

  • The hospital may consider income and monetary assets which will not include retirement or deferred compensation plans qualified under the Internal Revenue Code, or non-qualified deferred compensation plans. The first $10,000.00 of a patient’s monetary assets will not be counted, nor will 50% of the patient’s monetary assets over the first $10,000.00. The hospital may require waivers or releases from the patient or patient’s family authorizing the hospital to obtain account information from financial or commercial institutions, or other entities that hold or maintain the monetary assets of the patient or patient’s family to verify their value. Information obtained pursuant to this clause regarding the assets of the patient or patient’s family will not be used for collection activities.  
  • For FAP free care, annual family income (inclusive of applicable monetary assets) at or below 200% of the FPL may qualify for 100% write off of the HMNH account(s). For FAP Discount Payment Program, annual family income between 200.1% and 400% of FPL may qualify HMNH accounts in accordance with the discount sliding scale, based upon Medicare rates (DRG, CMG, APC, fee schedules). 

Patient Requirements 

  • The patient or the patient’s legal representative shall make every reasonable effort to provide the Hospital with documentation of health benefits coverage at time of service or within thirty days of service.
  • The patient or the patient’s legal representative shall provide the hospital with documentation of income within 30 days of receipt of application. Documentation of income will be limited to three recent pay stubs and/or most current income tax return. If a commission or bonus has been received, the hospital may require tax returns. 
  • The information the hospital uses to determine eligibility obtained from sources other than the individual seeking financial assistance may be accepted, including written documentation of person or person’s assisting the patient financially. 
  • Failing to provide information that is reasonable and necessary to make a  determination under this program, may result in the denial of the application.  

Hospital Requirements 

  • The hospital will provide patients with a written notice that contains information about availability of the hospital’s FAP process including information about eligibility as well as contact information for hospital employee or office from which the person may obtain further information about this policy. The notice will be provided to patients who receive emergency or outpatient care, and who may be billed for that care, but who were not admitted. The notice will be provided in English and Spanish.  
  • The hospital will provide uninsured patients upon request, with an estimate of the amount the hospital will require the patient to pay for the healthcare services, procedures, and supplies that are reasonably expected to be provided to the person by the hospital, based upon an average length of stay and services provided for the person’s diagnosis. The hospital may provide this estimate during normal business hours.   
  • A notice of this policy will be clearly and conspicuously posted in locations that are visible to the public, including, but not limited to: the emergency department, billing office, admission’s office, other outpatient settings and hospital web site.  
  • The hospital will make all reasonable efforts to obtain from the patient or his or her representative information about whether private or public health insurance or sponsorship may fully or partially cover the charges for care rendered by the hospital to a patient, including but not limited to: private health insurance, Medicare, Medi-Cal, the California Childrens’ Services Program (CCS), or other state/county funded programs designed to provide health coverage.  
  • If the Hospital bills a patient or the patient’s legal representative who has not provided proof of coverage by a third party at the time the care is provided, or upon discharge, as a part of that billing, the hospital will provide the patient or legal representative with a clear and conspicuous notice that includes all of the following: a statement of charges for services rendered, a request that the patient inform the hospital if the patient has health insurance coverage, Medicare, Medi-Cal, or other coverage; a statement that if the consumer does not have health insurance coverage, the consumer may be eligible for Medicare, Medi-Cal, CCS, Healthcare Exchange or FAP; a statement indicating how the patient may obtain applications for the Medi-Cal program, CCS, Medicare and that the hospital will provide these applications.   
  • If the patient does not indicate coverage by a third party payer and requests a discounted price or FAP, then the hospital will provide an application for Medi-Cal, CCS, Medicare, or other governmental program to the patient, and/or discount or FAP application. This application will be provided prior to discharge if the patient has been admitted or to the patient receiving emergency or outpatient care. Information regarding the financially qualified patient and discount application includes the following: a statement that indicates that if the patient lacks or has insufficient insurance and meets certain low and moderate income requirements, the patient may qualify for discounted payment; the name and telephone number of a hospital employee or office from whom or which the patient may obtain information about the hospital’s FAP care policy and how to apply for that assistance.    

Application Review Process

Upon receipt of completed application, documentation of income, and asset verification, if applicable, the hospital will review and make a determination of the application within 30 days to determine if eligibility requirements are met. 

  • The patient is notified via system-generated letter of acceptance or denial. If the patient is in-house, the letter will be hand delivered; otherwise the letter will be delivered through the U.S. Postal Service.
  • If the patient disagrees with the determination, he/she may follow the dispute process detailed below.
  • If the patient documentation is not received within 30 days, the hospital may consider the patient not eligible
  • Approval is granted for one year unless the patient’s financial situation changes.  

FAP (Free Care) 

Upon approval, HMNH’s approved free care account(s) will be adjusted to patient responsibility of zero. If the patient account reflects a prior payment, a patient refund, if appropriate (inclusive of applicable interest) will be issued to the patient and/or payer.

FAP (Discount Payment)

HMNH will utilize Amounts Generally Billed (AGB) via the Prospective Medicare Method when determining patient liability. Upon approval, the patient will not be charged more for emergency or other medically necessary care than the amounts generally billed (AGB) to individuals who have insurance covering such care. The patient responsibility will be based upon Medicare allowable rates: DRG, APC, Fee Schedule. The sliding scale for patient income is directly related to the established Federal Poverty Level (FPL). The reduced patient liability is a % of the Medicare allowable as noted below:   

  • Up to 200% of FPL,        0% of Medicare allowable
  • 200.01-250% of FPL,     25% of Medicare allowable
  • 250.01-300% of FPL,     50% of Medicare allowable
  • 300.01-350% of FPL,     75% of Medicare allowable
  • 350.01 -400% of FPL,   100% of Medicare allowable 

  
Upon approval, HMNH patient account(s) will be adjusted to the patient responsibility. A reasonable payment plan without interest will be offered. If the patient’s account(s) reflects a prior payment which exceeds the total patient dollar responsibility, a patient refund (inclusive of applicable interest) will be issued to the patient and/or payer based upon HSC 127440 related to reimbursing said patients for excess amounts paid, including interest, as set forth in Section 685.010 of the Code of Civil Procedure.

Dispute Process

  • The patient has the right to appeal the denial to the Business Services Manager. 
  • The patient or legal representative may submit additional supporting documentation within 30 days, to support their financial eligibility.
  • Review of the additional documentation will be completed and patient notified of the outcome no later than 30 - 60 calendar days.  A system-generated letter will be  delivered through the U.S. Postal Service, and if the denial is overturned, the procedures in “Application Review Process” will be followed.        

Hospital Provider List

Emergency physicians who provide emergency medical services in the hospital that provide emergency care is also required by law to provide discounts to uninsured patient or patients with high medical costs who are at or below 350% of the FPL. 

The HMNH FAP does not include professional services provided by our Medical Staff. The listing below is effective immediately and will be updated quarterly beginning 10/1/16. 

For complete provider list please refer to Attachment - FAP Policy Physician List