March 2009 1
Sliding Fee Scales, Patients Sliding Fee Scales, Patients Cap on ChargesCap on Charges
Sliding Fee Scales, Patients Sliding Fee Scales, Patients Cap on ChargesCap on Charges
Eli Camhi, MSSW – [email protected] Camhi, MSSW – [email protected] Hickey - [email protected] Hickey - [email protected]
March 2009 2
Session Focus• the definition of program income• the definition of sliding fee scale and patient caps on
charges and their legislative and program requirements
• the legislative and regulatory requirements for program income
March 2009 3
Special Attentionprogram income, sliding fee scale and patient caps on charges in complex healthcare settings– university hospitals– subcontractors– 330 health centers
March 2009 4
Outcome• understand the Part C D legislative and regulatory
requirements for program income• understand sliding fee and caps on charges• understand how to bill for program income effectively• understand how program income must be reported
March 2009 5
Sources:
• Program Guidance (Part C)– Sliding Fee Scale– Caps on Charges
March 2009 6
Screening & Reports• New Patient Intake - captures only patient
income (not family)• Group Patients by Poverty Level• Generate monthly reports of patient charges• Monitor YTD charges• Flag patients who are near cap• Stop charges when appropriate
March 2009 7
Self-Pay & Sliding Fee Scales
• Patient Registration
• Accounts Payables• Collections - expected but not aggressively
• Caps – Part C
• Never deny service regardless of ability to pay
March 2009 8
U.S. Poverty Guidelines• Published Annually in the
Federal Register• Health and Human
Services Posts them on the Web
http://aspe.hhs.gov/poverty/index.shtml#latest
March 2009 9
Sliding Fees & CapsIncome Max Charge
At or below100% of Poverty
0
100% to 200%of Poverty
No more than5% of grossannual income
200% to 300%of Poverty
No more than7% of grossannual income
> 300%No more than10% if grossannual income
2009 HHS Poverty GuidelinesPoverty Level 48 States & D.C Charge
100% or less 0 - 10,830 0> 100% <=200% >10,830 <= 21660 5%>200% <=300% >21,660 <= 32,490 7%>300% >32,490 10%
Alaska Charge100% or less 0 - 13,530 0> 100% <=200% >13,530 <= 27,060 5%>200% <=300% >27,060 <= 40,590 7%>300% >40,590 10%
Hawaii Charge100% or less 0 - 12,460 0> 100% <=200% >12,460 <= 24,920 5%>200% <=300% >24,920 <= 37,380 7%>300% >37,380 10%
Based only on patient (not family) income.
March 2009 10
Cap CalculatorCap Calculator - Ryan White Part C
User Entry Annual Income 35,000
Results % 10%Annual Cap 3,500
Base AssumptionsFederal Poverty Selection Other States Alaska Hawaii
Rates 2009 10,830 10,830 13,530 12,460
Percent Breaks0% 10,8305% 21,6607% 32,490
10% 32,490
Provided by Eli [email protected] demonstration purposes only. Please verify all calculations.
2/1/09
Instructions1. Update the Federal Poverty Rates below (Cells C18-D18-E18)2. Enter the Cap Percent Breaks (B21-B24)3. Copy to the Selected Column the appropriate rate for your State from C,D or E to (B18,B19)4. Annual Cap and % is calculated. D13, D14)
March 2009 11
Registration FormDiscount Eligibility
• Grants require this information to determine eligibility for sliding fee scale and caps on charges
• Need to know annual income– wages, salary, public assistance or social
security, other income
• Updated every year• Signature of patient that the information is
true and subject to verification
March 2009 12
Patient Cap on Charges• Determine cap based on patient (not
family) income
• Limit annual patient charges to cap
• Include patient other patient charges related to medical care
• Repeat each year
March 2009 13
Program Eligibility
• HIV Positive
• Primary Care
• Labs - Viral Load / CD4 / HIV Testing
• HIV Medication
March 2009 14
Pharmacy• Participation in 340B Program
• Retail Pharmacy
• Point of Care Medication
• Prescription Refills
• Adherence Expertise
• Filled Prescription Data
March 2009 15
Guidance• Programs are required to maximize the service reimbursement
available from private insurance, Medicaid, Medicare, and other third-party sources (ie. Managed Care).
• Programs are required to track and report all sources of service reimbursement as program income on the annual Financial Status Report and in annual data reports and report on application submitted. Program income is reported on Line R on the Financial Status Report.
• All program income earned must be used to further your HIV program objectives
March 2009 16
What is Program Income?• Program income is any income that is
generated for a grantee or subcontractor by the grant or earned as a result of the grant.
• This includes charges to beneficiaries under the sliding scale, as well as reimbursements from Medicaid, Medicare, and private insurance for services provided.
Grants Policy Directive 1.02: 45 CFR 92.25http://edocket.access.gpo.gov/cfr_2003/octqtr/45cfr92.25.htm
March 2009 17
Maximizing Medicaid Income
• Medicaid certification• Grantees and their contractors are expected to
vigorously pursue Medicaid enrollment for individuals likely eligible for Medicaid coverage
• Seek payment from Medicaid when they provide Medicaid covered services for Medicaid beneficiaries
• Back bill Medicaid for Ryan White Program-funded services provided for all Medicaid eligible clients upon determination.
March 2009 18
Payer of Last Resort• Ryan White Program grant funds cannot be used to make
payments for any item or service if payment has been made, or can reasonably be expected to be made with respect to that item or service under any State compensation program, under any insurance policy, or under any Federal or State health benefits program; or by an entity that provides prepaid health care.*
• In summary; the grantee should not bill the Ryan White program or use federal funds to make up for the balance of the services billed. If you charge Medicaid $120 for the visit and you only get reimbursed $90, you can't bill Ryan White for the $30 balance.
* http://hab.hrsa.gov/law/compile.htm
Section 2617
March 2009 19
No Fear of Income• HRSA discourages grantees from reducing grant funding for
sub-grantees or contractors that collect third party reimbursement revenues.
• Grantees are required to work closely with and encourage and assist sub-grantees and contractors to effectively utilize their Ryan White Program funds and collect third party reimbursement, by maintaining the same level of Ryan White Program funding and using the funding to expand and/or enhance HIV/AIDS services to current eligible clients and/or identifying and enrolling into care new eligible clients in the sub-grantee or contractor service area(s).
March 2009 20
TACT:Technical Assistance Cost Tool
– for use by clinics and individual providers who want to identify the costs of delivering health care services to patients living with HIV and AIDS.
– TACT reports provide cost analyses for internal clinic financial management for third-party reimbursement.
– will assist providers in contract negotiations with managed care organizations that offer the opportunity to participate in their provider network.
– providers will know the cost of the care they provide and can therefore determine the financial adequacy of payment rates in both a fee-for-service and managed-care context.
http://www.hrsa.gov/tact/
March 2009 21
Beyond the Grant• Covering Administrative Costs
• Advocacy within the Organization
• Knowing the Programs Impact
• Growing Program
• Sustain Funding through all funding streams
March 2009 22
Sliding Fee Scales, Patients Sliding Fee Scales, Patients Cap on ChargesCap on Charges
Sliding Fee Scales, Patients Sliding Fee Scales, Patients Cap on ChargesCap on Charges
Eli Camhi, MSSW – [email protected] Camhi, MSSW – [email protected] Hickey - [email protected] Hickey - [email protected]
