CHARITY CARE: Using WA Charity Care Law to Protect Consumers Northwest Justice Project & Columbia Legal Services May 31, 2017 Access to Justice Advocates’ Training

Washington State Supreme Court Civil Legal Needs Study Update - 2015 -Study available at Office of Civil Legal Aid website. -Legal aid focusing on intersection of healthcare and consumer/finance b/c widened the justice gap for people living in poverty. New consumer issues are constantly emerging due to the echoes of the recession. Unique nature of medical debt b/c bills result from services often involuntary, unplanned, unpredictable, for which price quotes rarely provided. CFPB did study on impact of medical debt on credit score and lowered by 10 points on average. -AG ranked collection agency complaints as the number two issue raised by consumers in 2011. -NJP reports 70% of consumer complaints it received concerned collection agencies, garnishment, and repossession (12 month period over 1,500 cases) in 2013-2014; about the same for 2014-2015. Doubled for medical debt specific cases from 2014-2015. Problems counting numbers due to identifying medical debt from collections. -According to the Consumer Financial Protection Bureau – tens of millions came out of the mortgage and financial crisis with debts that are now in collections as a result of the crisis. Robbing Peter to pay Paul because homeowners decided to continue paying mortgage with decreasing funds while failing to pay other debts. CFPB – Medical Debt Complaints #+14,500. WA # 350. None from Jefferson. http://www.consumerfinance.gov/

Part of the Problem Is Financial Incentives Hospitals have financial incentive to identify third-party payors including private insurers, Medicare, Medicaid, etc. and are very good at doing that (Resource Corporation of America) No financial incentive to identify patients who qualify for charity care – simply asking for income and family size information at or near the time of service

Most Patients Fall Through Charity Care Safety Net Low-income patients don’t get charity care they should be getting under WA law Low-income patients are sued for hospital bills they shouldn’t have gotten in first place (typically when advocates get these cases)

Denial of Charity Care Even Worse Because of “Chargemaster” Rates Uninsured patients charged full, undiscounted hospital rates (“Chargemaster”), double or triple what third-party payors pay for same services

Where Are All the Eligible Charity Care Patients? In WA, there are over 570,000 uninsured patients who are “medically indigent” and eligible for Charity Care. If Medicaid expansion (ACA/Obamacare) is repealed, this number will go even higher, probably to over a million patients. Based on DOH data, it appears that only a small fraction of eligible patients are receiving Charity Care. The Washington legislature enacted the charity care law in 1989 with the explicit purpose of increasing access to health care by requiring all hospitals in the state to provide free or discounted care to patients who qualify based on low income. As the legislature stated, “access to health care is among the state’s goals” and, accordingly, “the legislature intends that charity care requirements . . . for hospitals be explicitly established.” RCW 70.170.010. As a result, the uninsured rate in Washington dropped from 14 percent of the state’s population in 2013 to 8 percent in 2015. Even at the lower uninsured rate of 8 percent, however, that translates to over 570,000 uninsured patients who are “indigent” and should qualify for charity care based on their low income. In addition, because the ACA excludes undocumented immigrants, charity care is the only way most undocumented immigrants can afford hospital care.

Charity Care: What is it and how does it work? By Ariel Speser Northwest Justice Project, Port Angeles

Charity Care Law Revised Code of WA: 70.170.060 WA Administrative Code: WAC 246-453 What is Charity Care? Federal and state law require hospitals to provide certain types of medical care to you for free or at a reduced cost if you cannot afford to pay for the medical treatment. Charity Care covers “medically necessary” treatment, including inpatient hospital stays and emergency room visits. “Appropriate Hospital Based Medical Services” – WAC 246-453-101(7),(8); 050(3)   Some hospitals have a different name for their Charity Care programs, such as Bridge Assistance or Financial Assistance. Charity Care may not cover services by medical workers who are not considered part of the hospital’s medical staff or visits to a hospital’s outpatient clinics. Examples: Charity Care does not cover radiologists or anesthesiologists who work in the emergency room but are not employed by the hospital. How Will I Know About the Hospital’s Charity Care Program? Every hospital that offers Charity Care must provide public notice (WAC 246-453-020(2); 010(16)): Post notice of Charity Care in the Emergency Room Post notice of Charity Care in the Admissions area Provide a patient with Charity Care information at Intake or Discharge Provide a patient with Charity Care information in every Billing Statement NOT ALL HOSPITALS PROVIDE NOTICE OF CHARITY CARE even though the law requires them to do so. Sometimes, notice is provided but you don’t see it. When you are very sick, you may not be focused on notices or forms you are signing. BEST PRACTICE: ALWAYS ASK if there is Charity Care or Financial Assistance and APPLY. Am I Eligible for Charity Care? It depends. If you have Medicaid, Medicare, or other insurance, you must use up those benefits first. WAC 010(4). Hospital must make every effort to determine whether third party sponsorship exits. WAC 020(4). *Special WAC for Medicaid 182-502-0160 – burden on provider to figure out if client has Medicaid coverage and if circumstances allow provider to send bill. Sometimes issues with HCA Form Agreement to Pay. Charity Care benefits depend on your income and household size. If your household income is low enough (below 100% of the Federal Poverty Level), the hospital must cover (forgive or write off) your eligible hospital bill. If your household income is more than 100% of the Federal Poverty Level, you may get some of your hospital bill reduced. WAC 246-453-040. If your income is more than 100% of the Federal Poverty level, the hospital has a right to get information about your assets. WAC 246-453-050(1)(d)(ii). Each hospital has its own Charity Care policy. WAC 246-453-070(1). Sliding fee scale available upon request. WAC 246-453-050. The amount of Charity Care provided to patients with household income above 100% of the Federal Poverty Level can vary, depending on the hospital. To view a particular hospital’s Charity Care policy, go to http://www.doh.wa.gov/DataandStatisticalReports/HealthcareinWashington/HospitalandPatientData/HospitalPolicies or you can call the hospital for a copy of their Charity Care policy. SUMMARY Financial Eligibility Under 100% FPL – full waiver 101% 200% FPL – some discount 201% FPL and up – eligible for discount depending on hospital policy WSHA Pledge Under 100 – not required to pay Under 200 – not required to pay more than cost of care Under 300 – not required to pay more than 130% of cost of care All patients, if otherwise eligible, can receive Charity Care, regardless of your citizenship or alien status. I Have Medical Insurance. Should I Still Apply for Charity Care? YES. Many patients with insurance have high deductibles or insurance coverage that only covers a percentage of a hospital bill. If you are low income, Charity Care may cover these deductibles or co-pays. When Can I Apply for Charity Care? You can apply while you are in the hospital or after you are released. It is best to apply as soon as possible, before the hospital bill is sent to collections or you are sued for the hospital bill. Income at time of service vs. time of bill. Hospitals review for Charity Care “at any time” – WAC 020(1)(d) Always keep a copy of your application and all of the documents you submit to the hospital. Also, get proof of the date you submitted your application and documents to the hospital. If you receive a letter from a collection agency about the hospital bill, you should; Apply for Charity Care immediately, if you have not already done so. Send a letter to the collection agency (keep a copy) demanding it to stop all collection activity while your Charity Care application is being considered. (SEE SAMPLE LETTERS @ WashingtonLawHelp.org) If you are sued for the hospital bill and are served with (handed) court papers, you should: Apply for Charity Care immediately. Respond in writing to the lawsuit (SEE How to Answer a Lawsuit for Debt Collection on WashingtonLawHelp.org, where you can state in the Affirmative Defense section of your Answer that you are eligible for Charity Care). Send a letter to plaintiff’s attorney telling him/her to put the lawsuit on hold while your Charity Care application is being considered. (SEE SAMPLE LETTER on WashingtonLawHelp.org) Collection efforts precluded pending final determination WAC 246-453-020. Where can I get a Charity Care Application Form?  If you are not given an application form when you are admitted or discharged from the hospital, you can get an application form from the hospital’s billing office. You can ask the hospital to mail you the form or you can ask how to apply online. How Does the Hospital Decide If I am Eligible for Charity Care? The hospital first makes an initial determination of eligibility based on the information you verbally give it. WAC 246-453-020(1)(b); 010(19). After an initial determination of eligibility is made, you must provide the hospital with proof of your income (and your assets, depending on your household’s income). Examples of proof of income: Pay stubs Income tax returns from the past year W-2 statements from your employer Social Security or Unemployment income statements DSHS documents, including medical coupons, approval for cash benefits Signed statement of indigent status WAC 030(4) Hospitals may not impose an unreasonable application burden upon the patient, must take into account physical/mental disabilities, language barriers. WAC 020(5) It is very important to provide these documents in the time period stated in the hospital’s letter. If you provide all of the information requested and the hospital needs more, they must request further documentation from you in writing. If you fail to provide all documentation by the deadline, your application may be denied. Once the hospital has received the documentation it asked for from you, it must make a final determination of your eligibility within 14 days. If the hospital approves your Charity Care application, it must send you a letter explaining how much of the bill has been covered and how much, if any, you still owe. If the hospital denies your Charity Care application, it must send you a letter of denial, and tell you how you can file an appeal. The letter must state the reason you were denied Charity Care. The letter must state that you only have 30 days to appeal the denial. Appeal rights and appeal period – 30 days WAC 246-453-020 (no initiating collections within the first 14 days; if appeals on day 15, cease until appeal finalized). If your appeal is denied, they must give you the decision and reason/s for it in writing. The hospital must also send the Department of Health a copy of its decision, and copies of the documents it based the decision on. WAC 020(9)(c). The Department of Health must review Charity Care Denials. If it finds the hospital has inappropriately denied you Charity Care, the Department of Health may seek penalties against the hospital and individual staff members. RCW 70.170.070; WAC 020(9)(d). Department of Health - Responsible for rule making and monitoring related Charity Care enforcement. Gets copy of appeal. Hospitals must report to DOH data about amount of charity care. Reports to Legislature and Governor. What If the Hospital Has Gotten a Judgment Against Me for Hospital Services that Charity Care Should Have Covered? In a few circumstances, you may be able to get the judgment vacated. If neither you nor any member of your household was handed the court papers (the Summons and Complaint), consult with an attorney as soon as possible.

When does CC apply? What is it? Hospitals “Medically necessary” How does someone know if they are financially eligible? Free care if income is below 100% of FPL Discount required between 101% and 200% of FPL Some hospitals provide free care up to 300% FPL Assets not considered below 100% of FPL What is Charity Care? Federal and state law require hospitals to provide certain types of medical care to you for free or at a reduced cost if you cannot afford to pay for the medical treatment. Charity Care covers “medically necessary” treatment, including inpatient hospital stays and emergency room visits. “Appropriate Hospital Based Medical Services” – WAC 246-453-101(7),(8); 050(3)   Some hospitals have a different name for their Charity Care programs, such as Bridge Assistance or Financial Assistance. Charity Care may not cover services by medical workers who are not considered part of the hospital’s medical staff or visits to a hospital’s outpatient clinics. Examples: Charity Care does not cover radiologists or anesthesiologists who work in the emergency room but are not employed by the hospital. How Will I Know About the Hospital’s Charity Care Program? Every hospital that offers Charity Care must provide public notice (WAC 246-453-020(2); 010(16)): Post notice of Charity Care in the Emergency Room Post notice of Charity Care in the Admissions area Provide a patient with Charity Care information at Intake or Discharge Provide a patient with Charity Care information in every Billing Statement NOT ALL HOSPITALS PROVIDE NOTICE OF CHARITY CARE even though the law requires them to do so. Sometimes, notice is provided but you don’t see it. When you are very sick, you may not be focused on notices or forms you are signing. BEST PRACTICE: ALWAYS ASK if there is Charity Care or Financial Assistance and APPLY. Am I Eligible for Charity Care? It depends. If you have Medicaid, Medicare, or other insurance, you must use up those benefits first. WAC 010(4). Hospital must make every effort to determine whether third party sponsorship exits. WAC 020(4). *Special WAC for Medicaid 182-502-0160 – burden on provider to figure out if client has Medicaid coverage and if circumstances allow provider to send bill. Sometimes issues with HCA Form Agreement to Pay. Charity Care benefits depend on your income and household size. If your household income is low enough (below 100% of the Federal Poverty Level), the hospital must cover (forgive or write off) your eligible hospital bill. If your household income is more than 100% of the Federal Poverty Level, you may get some of your hospital bill reduced. WAC 246-453-040. If your income is more than 100% of the Federal Poverty level, the hospital has a right to get information about your assets. WAC 246-453-050(1)(d)(ii). Each hospital has its own Charity Care policy. WAC 246-453-070(1). Sliding fee scale available upon request. WAC 246-453-050. The amount of Charity Care provided to patients with household income above 100% of the Federal Poverty Level can vary, depending on the hospital. To view a particular hospital’s Charity Care policy, go to http://www.doh.wa.gov/DataandStatisticalReports/HealthcareinWashington/HospitalandPatientData/HospitalPolicies or you can call the hospital for a copy of their Charity Care policy. SUMMARY Financial Eligibility Under 100% FPL – full waiver 101% 200% FPL – some discount 201% FPL and up – eligible for discount depending on hospital policy WSHA Pledge Under 100 – not required to pay Under 200 – not required to pay more than cost of care Under 300 – not required to pay more than 130% of cost of care All patients, if otherwise eligible, can receive Charity Care, regardless of your citizenship or alien status. I Have Medical Insurance. Should I Still Apply for Charity Care? YES. Many patients with insurance have high deductibles or insurance coverage that only covers a percentage of a hospital bill. If you are low income, Charity Care may cover these deductibles or co-pays. When Can I Apply for Charity Care? You can apply while you are in the hospital or after you are released. It is best to apply as soon as possible, before the hospital bill is sent to collections or you are sued for the hospital bill. Income at time of service vs. time of bill. Hospitals review for Charity Care “at any time” – WAC 020(1)(d) Always keep a copy of your application and all of the documents you submit to the hospital. Also, get proof of the date you submitted your application and documents to the hospital. If you receive a letter from a collection agency about the hospital bill, you should; Apply for Charity Care immediately, if you have not already done so. Send a letter to the collection agency (keep a copy) demanding it to stop all collection activity while your Charity Care application is being considered. (SEE SAMPLE LETTERS @ WashingtonLawHelp.org) If you are sued for the hospital bill and are served with (handed) court papers, you should: Apply for Charity Care immediately. Respond in writing to the lawsuit (SEE How to Answer a Lawsuit for Debt Collection on WashingtonLawHelp.org, where you can state in the Affirmative Defense section of your Answer that you are eligible for Charity Care). Send a letter to plaintiff’s attorney telling him/her to put the lawsuit on hold while your Charity Care application is being considered. (SEE SAMPLE LETTER on WashingtonLawHelp.org) Collection efforts precluded pending final determination WAC 246-453-020. Where can I get a Charity Care Application Form?  If you are not given an application form when you are admitted or discharged from the hospital, you can get an application form from the hospital’s billing office. You can ask the hospital to mail you the form or you can ask how to apply online. How Does the Hospital Decide If I am Eligible for Charity Care? The hospital first makes an initial determination of eligibility based on the information you verbally give it. WAC 246-453-020(1)(b); 010(19). After an initial determination of eligibility is made, you must provide the hospital with proof of your income (and your assets, depending on your household’s income). Examples of proof of income: Pay stubs Income tax returns from the past year W-2 statements from your employer Social Security or Unemployment income statements DSHS documents, including medical coupons, approval for cash benefits Signed statement of indigent status WAC 030(4) Hospitals may not impose an unreasonable application burden upon the patient, must take into account physical/mental disabilities, language barriers. WAC 020(5) It is very important to provide these documents in the time period stated in the hospital’s letter. If you provide all of the information requested and the hospital needs more, they must request further documentation from you in writing. If you fail to provide all documentation by the deadline, your application may be denied. Once the hospital has received the documentation it asked for from you, it must make a final determination of your eligibility within 14 days. If the hospital approves your Charity Care application, it must send you a letter explaining how much of the bill has been covered and how much, if any, you still owe. If the hospital denies your Charity Care application, it must send you a letter of denial, and tell you how you can file an appeal. The letter must state the reason you were denied Charity Care. The letter must state that you only have 30 days to appeal the denial. Appeal rights and appeal period – 30 days WAC 246-453-020 (no initiating collections within the first 14 days; if appeals on day 15, cease until appeal finalized). If your appeal is denied, they must give you the decision and reason/s for it in writing. The hospital must also send the Department of Health a copy of its decision, and copies of the documents it based the decision on. WAC 020(9)(c). The Department of Health must review Charity Care Denials. If it finds the hospital has inappropriately denied you Charity Care, the Department of Health may seek penalties against the hospital and individual staff members. RCW 70.170.070; WAC 020(9)(d). Department of Health - Responsible for rule making and monitoring related Charity Care enforcement. Gets copy of appeal. Hospitals must report to DOH data about amount of charity care. Reports to Legislature and Governor. What If the Hospital Has Gotten a Judgment Against Me for Hospital Services that Charity Care Should Have Covered? In a few circumstances, you may be able to get the judgment vacated. If neither you nor any member of your household was handed the court papers (the Summons and Complaint), consult with an attorney as soon as possible.

Household/ Family Size Income & Family Size / Eligibility Grid Department of Health and Human Services issues poverty guidelines referred to as the “federal poverty level.” (https://aspe.hhs.gov/poverty-guidelines) Annual 2017 Poverty Guidelines for the 48 Contiguous States Household/ Family Size 100% 200% 300% 400% 1 12,060 24,120 36,180 48,240 2 16,240 32,480 48,720 64,960 3 20,420 40,840 61,260 81,680 4 24,600 49,200 73,800 98,400 5 28,780 57,560 86,340 115,120 Monthly 2017 Poverty Guidelines for the 48 Contiguous States 1,005 2,010 3,015 4,020 1,353 2,707 4,060 5,413 1,702 3,403 5,105 6,807 2,050 4,100 6,150 8,200 2,398 4,797 7,195 9,593

What about insurance? Third-party payers billed first, e.g. private insurance, Medicaid, Medicare. Charity Care covers both uninsured and underinsured (co-pays, deductibles, amounts outside coverage limits, etc.) What is Charity Care? Federal and state law require hospitals to provide certain types of medical care to you for free or at a reduced cost if you cannot afford to pay for the medical treatment. Charity Care covers “medically necessary” treatment, including inpatient hospital stays and emergency room visits. “Appropriate Hospital Based Medical Services” – WAC 246-453-101(7),(8); 050(3)   Some hospitals have a different name for their Charity Care programs, such as Bridge Assistance or Financial Assistance. Charity Care may not cover services by medical workers who are not considered part of the hospital’s medical staff or visits to a hospital’s outpatient clinics. Examples: Charity Care does not cover radiologists or anesthesiologists who work in the emergency room but are not employed by the hospital. How Will I Know About the Hospital’s Charity Care Program? Every hospital that offers Charity Care must provide public notice (WAC 246-453-020(2); 010(16)): Post notice of Charity Care in the Emergency Room Post notice of Charity Care in the Admissions area Provide a patient with Charity Care information at Intake or Discharge Provide a patient with Charity Care information in every Billing Statement NOT ALL HOSPITALS PROVIDE NOTICE OF CHARITY CARE even though the law requires them to do so. Sometimes, notice is provided but you don’t see it. When you are very sick, you may not be focused on notices or forms you are signing. BEST PRACTICE: ALWAYS ASK if there is Charity Care or Financial Assistance and APPLY. Am I Eligible for Charity Care? It depends. If you have Medicaid, Medicare, or other insurance, you must use up those benefits first. WAC 010(4). Hospital must make every effort to determine whether third party sponsorship exits. WAC 020(4). *Special WAC for Medicaid 182-502-0160 – burden on provider to figure out if client has Medicaid coverage and if circumstances allow provider to send bill. Sometimes issues with HCA Form Agreement to Pay. Charity Care benefits depend on your income and household size. If your household income is low enough (below 100% of the Federal Poverty Level), the hospital must cover (forgive or write off) your eligible hospital bill. If your household income is more than 100% of the Federal Poverty Level, you may get some of your hospital bill reduced. WAC 246-453-040. If your income is more than 100% of the Federal Poverty level, the hospital has a right to get information about your assets. WAC 246-453-050(1)(d)(ii). Each hospital has its own Charity Care policy. WAC 246-453-070(1). Sliding fee scale available upon request. WAC 246-453-050. The amount of Charity Care provided to patients with household income above 100% of the Federal Poverty Level can vary, depending on the hospital. To view a particular hospital’s Charity Care policy, go to http://www.doh.wa.gov/DataandStatisticalReports/HealthcareinWashington/HospitalandPatientData/HospitalPolicies or you can call the hospital for a copy of their Charity Care policy. SUMMARY Financial Eligibility Under 100% FPL – full waiver 101% 200% FPL – some discount 201% FPL and up – eligible for discount depending on hospital policy WSHA Pledge Under 100 – not required to pay Under 200 – not required to pay more than cost of care Under 300 – not required to pay more than 130% of cost of care All patients, if otherwise eligible, can receive Charity Care, regardless of your citizenship or alien status. I Have Medical Insurance. Should I Still Apply for Charity Care? YES. Many patients with insurance have high deductibles or insurance coverage that only covers a percentage of a hospital bill. If you are low income, Charity Care may cover these deductibles or co-pays. When Can I Apply for Charity Care? You can apply while you are in the hospital or after you are released. It is best to apply as soon as possible, before the hospital bill is sent to collections or you are sued for the hospital bill. Income at time of service vs. time of bill. Hospitals review for Charity Care “at any time” – WAC 020(1)(d) Always keep a copy of your application and all of the documents you submit to the hospital. Also, get proof of the date you submitted your application and documents to the hospital. If you receive a letter from a collection agency about the hospital bill, you should; Apply for Charity Care immediately, if you have not already done so. Send a letter to the collection agency (keep a copy) demanding it to stop all collection activity while your Charity Care application is being considered. (SEE SAMPLE LETTERS @ WashingtonLawHelp.org) If you are sued for the hospital bill and are served with (handed) court papers, you should: Apply for Charity Care immediately. Respond in writing to the lawsuit (SEE How to Answer a Lawsuit for Debt Collection on WashingtonLawHelp.org, where you can state in the Affirmative Defense section of your Answer that you are eligible for Charity Care). Send a letter to plaintiff’s attorney telling him/her to put the lawsuit on hold while your Charity Care application is being considered. (SEE SAMPLE LETTER on WashingtonLawHelp.org) Collection efforts precluded pending final determination WAC 246-453-020. Where can I get a Charity Care Application Form?  If you are not given an application form when you are admitted or discharged from the hospital, you can get an application form from the hospital’s billing office. You can ask the hospital to mail you the form or you can ask how to apply online. How Does the Hospital Decide If I am Eligible for Charity Care? The hospital first makes an initial determination of eligibility based on the information you verbally give it. WAC 246-453-020(1)(b); 010(19). After an initial determination of eligibility is made, you must provide the hospital with proof of your income (and your assets, depending on your household’s income). Examples of proof of income: Pay stubs Income tax returns from the past year W-2 statements from your employer Social Security or Unemployment income statements DSHS documents, including medical coupons, approval for cash benefits Signed statement of indigent status WAC 030(4) Hospitals may not impose an unreasonable application burden upon the patient, must take into account physical/mental disabilities, language barriers. WAC 020(5) It is very important to provide these documents in the time period stated in the hospital’s letter. If you provide all of the information requested and the hospital needs more, they must request further documentation from you in writing. If you fail to provide all documentation by the deadline, your application may be denied. Once the hospital has received the documentation it asked for from you, it must make a final determination of your eligibility within 14 days. If the hospital approves your Charity Care application, it must send you a letter explaining how much of the bill has been covered and how much, if any, you still owe. If the hospital denies your Charity Care application, it must send you a letter of denial, and tell you how you can file an appeal. The letter must state the reason you were denied Charity Care. The letter must state that you only have 30 days to appeal the denial. Appeal rights and appeal period – 30 days WAC 246-453-020 (no initiating collections within the first 14 days; if appeals on day 15, cease until appeal finalized). If your appeal is denied, they must give you the decision and reason/s for it in writing. The hospital must also send the Department of Health a copy of its decision, and copies of the documents it based the decision on. WAC 020(9)(c). The Department of Health must review Charity Care Denials. If it finds the hospital has inappropriately denied you Charity Care, the Department of Health may seek penalties against the hospital and individual staff members. RCW 70.170.070; WAC 020(9)(d). Department of Health - Responsible for rule making and monitoring related Charity Care enforcement. Gets copy of appeal. Hospitals must report to DOH data about amount of charity care. Reports to Legislature and Governor. What If the Hospital Has Gotten a Judgment Against Me for Hospital Services that Charity Care Should Have Covered? In a few circumstances, you may be able to get the judgment vacated. If neither you nor any member of your household was handed the court papers (the Summons and Complaint), consult with an attorney as soon as possible.

Notice & Initial Determination Hospital’s Duty to Notify Patients About Charity Care Hospital’s Affirmative Duty to Do Initial Screening Hospitals must provide notice of Charity Care Hospitals are required to provide public notice that indigent patients may qualify to have their bill waived or reduced. WAC 246-453-020(2). Notice must be prominently displayed in public areas of the hospital. WAC 246-453-010(16). Notice must be provided to patients, in writing, and explained, at the time hospital asks for third party payment information. Must be provided in any language spoken by more than 10% of the population in the hospital’s service area. Hospitals must make an Initial Determination An initial determination of sponsorship must be completed at the time of admission or as soon as possible following the initiation of services. WAC 246-453-020(1)(b). Initial determination means ANY indication that the services provided may not be covered by third party sponsorship, or an indication that the patient may be indigent. WAC 246-453-010(19). Hospitals shall rely on oral information and may require the patient to sign a statement. WAC 246-453-030(1). If the initial determination of sponsorship status indicates the responsible party MAY be indigent, collection efforts are precluded pending a final determination. WAC 246-453-020(1)(c).

Affirmative DUTY to Screen Before Collection Attempts “Initial determination of sponsorship status shall precede collection efforts directed to the patient.” RCW 70.170.060(6) “Persons who may be eligible for charity care shall be notified by the hospital” and “all persons with family income below one hundred percent of the federal poverty standard shall be deemed charity care patients for the full amount of hospital charges.” RCW 70.170.060(5)

CHARITY CARE: 3 Simple Steps Step One: Is the debt “hospital” debt? Includes outpatient care Step Two: Is the patient eligible? Uninsured or underinsured? Qualifying income based on family size and poverty level “Income” includes “total cash receipts before taxes … salaries, welfare payments, social security” and other benefits such as child support. There are many FPU calculators available of the internet to make the determination easy. Hospitals are required to have a charity care policy filed with the Washington Department of Health, they are all available online. Hospitals can, and many do, provide more generous charity care limits outlined in their charity care policy. They are bound by what is in the policy. So you need to pull the particular policy of the DOH website to determine your client’s eligibility.

CHARITY CARE: Step Three Step Three: Apply To apply, patient/debtor must simply complete hospital’s application (can often print out application from hosp. website) Documentation (pay stubs, tax returns, etc., or letter signed by patient) Collection proceedings are STAYED (stopped) while application is pending Many hospitals do not publish the charity care application, and if it is available online, it can be very difficult to locate. I find it is easier to call the hospital billing department and ask for one. “charity care” doesn’t seem to be hospital billing department lingo, so you might have to ask for a financial assistance form. WAC 246-453-030, provides certain documents, by themselves, are sufficient to support and application: W-2, Pay stubs, recent income tax return, unemployment approval or denial letters, written statements from employers or welfare agencies. Patients are not required to submit to a credit check which can have adverse consequences to their credit rating. Hospital cannot demand more than the statutory minimum. One reported case, pro se submitted a partial tax return. Court found this was insufficient and the whole return had to be disclosed. Undisclosed portion showed substantial income from the sale of real property.

Final Determination & Appeal Process After receiving documents, hospital has 14 days to determine Charity Care eligibility - WAC 246-453-020(7) If hospital denies Charity Care, must explain reason and inform patient of 30 day appeal rights - WAC 246-453-020(8) & (9) Stay of collection action continues during appeal - WAC 246-453-020(9)(a)&(b).

Appeal Process (Cont.) Patient’s internal appeal must be made within 30 days to hospital’s Chief Financial Officer or equivalent - WAC 246-453-020(9) If hospital affirms denial, patient and DOH must be notified and hospital must provide DOH documentation showing basis for decision - WAC 246-453-020(9)(a)

Is There a Time Limit to Apply?

NO: May Apply “at any time” Patient may apply AT ANY TIME, even after litigation is filed, which will stay litigation while application is pending Hospital must allow patient to apply for Charity Care “at any time” even after bill is sent to collections Collection process is STAYED during Charity Care determination if patient applies after collection litigation begins

Charity Care Case Examples & Practical Tips By Julia Kellison Northwest Justice Project, King County

Charity Care: Defending Against a Lawsuit Consumer confusion / complexity of health insurance and medical billing What happens in collections Disproportionate impact on vulnerable communities

Applying for Charity Care Suspending Lawsuit to Allow Patient to Apply for Charity Care Raise Charity Care as an affirmative defense Sample Pro Se Answer Form with Charity Care Affirmative Defense in “How do I Answer a Lawsuit for Debt Collection?” publication: http://www.washingtonlawhelp.org Sample Letters to Debt Collection Agencies or Opposing Attorneys in “Can I Get Charity Care Benefits To Pay for My Hospital Bill?” publication: http://www.washingtonlawhelp.org

Applying for Charity Care (Cont.) Have client apply for Charity Care directly to the hospital immediately Can download application from hospital website or WA Dept of Health website: http://www.doh.wa.gov/DataandStatisticalRe ports/HealthcareinWashington/HospitalandPa tientData/HospitalPolicies Keep copy of application! Add cover letter if necessary

Applying for Charity Care (Cont.) Dealing with variations in income Bird-dog the application! Troubleshooting problems (aka unnecessary barriers) Need more time to submit application Responding to hospital requests for more info Once Charity Care is approved, lawsuit should be dismissed What if there are other non-Charity Care-eligible medical bills in the same lawsuit?

Charity Care and Debt Collection Litigation Scott Kinkley Northwest Justice Project, Spokane Charity care as defense in debt collection litigation, notice of charity care application, potential claims or counterclaims in individual cases under CAA/CPA and/or FDCPA if debt collectors violate charity care law or other laws in collecting medical debts

Other Issues Wont Dismiss? Fee and cost shifting is tied to “prevailing party” judgment. Charity care after judgment?

Charity Care May Apply Even After Judgment & Garnishment Even after garnishment, if patient shows Charity Care eligibility, hospital must refund amounts in excess of amount owed. “In the event that a responsible party pays a portion or all of the charges . . . and is subsequently found to have met the charity care criteria . . . payments in excess of the amount determined to be appropriate . . . shall be refunded” - WAC 246-453-020(11)

New Statute & Regulations for Obamacare and IRC 501(r) – New Statute & Regulations for Non-Profit Hospitals

What Risks Do 501(r) Regs Pose for Hospitals? For Debt Collectors? Only applies to 501(c)(3) non-profit hospitals (excludes private and most public hospital district hospitals) Hospitals can forward accounts for collections before 120 days from first post-discharge bill, but in that case, debt collector has duty to comply Normal collection activities permitted during that time period but not ECAs (litigation, credit reporting) Under 501(r) regulations, hospitals are accountable for actions of debt collectors Debt collector may be directly liable and their violations could also jeopardize hospital’s 501(c)(3) status

Using Charity Care in Affirmative Litigation By Matt Geyman Columbia Legal Services, Seattle

No Private Right of Action Legal Grounds for Claims: Consumer Protection/UDAP Breach of Contract/Duty of Good Faith & Fair Dealing Unjust Enrichment

Affirmative Litigation Claims

Affirmative Litigation Lopez v. Yakima Regional Med. Ctr. Hospital may not demand deposits from indigent patients before providing care. Hospital must affirmatively screen patients for charity care “at or near the time of admission” and before demanding a deposit.

Affirmative Litigation Lopez v. Yakima Regional Med. Ctr.

Affirmative Litigation Lopez v. Yakima Regional Med. Ctr.

Affirmative Litigation Lopez v. Yakima Regional Med. Ctr. Classwide violation of hospitals’ duty to provide charity care to “indigent patients Hospital required to refund amounts collected in excess of amounts, if any, owed under Charity Care law and hospital’s own policy Includes both principal and interest on hospital bills and also collection charges

Affirmative Litigation Amireh v. Northwest Hospital RCW 70.170.060(6): “[H]ospital shall make every reasonable effort to determine . . . eligibility of the patient for charity care . . . [A]n initial determination . . . shall precede collection efforts directed at the patient.” WAC 246-453-020(1): “The initiation of collection efforts shall be precluded pending an initial determination . . .”

Affirmative Litigation Amireh v. Northwest Hospital “Hospitals should make every reasonable effort to reach initial and final determinations of charity care designation in a timely manner; however, hospitals shall make those designations at any time upon learning of facts or receiving documentation . . .”

Affirmative Litigation Roberson v. Ray Klein, Inc. et al. Core issue is unlawful charging of prejudgment interest from the date of hospital service, but most class members were also denied charity care

Affirmative Litigation Roberson v. Ray Klein, Inc. et al.

Affirmative Litigation Roberson v. Ray Klein, Inc. et al.

Charity Care Outreach Tony Gonzalez Columbia Legal Services, Wenatchee Problem: so few patients, community members and social service providers know about charity care, especially in rural areas and immigrant communities Outreach to tell community members and train service providers to get more patients into the charity care system

Brief Recap What have we learned? People are being sued over medical debt! What Charity Care is and how it works Examples on how to defend against a collection lawsuit Examples on how to use Charity Care in affirmative litigation Finally, outreach

Why do Outreach?

Did the hospital offer to help? Common answers: Apply for Insurance Payment plans The collection agency can help

Hospitals know the community

Resources Northwest Justice Project Debt Collection Defense Clinics CLEAR Intake Line: 1-888-201-1014 https://nwjustice.org/get-legal-help Columbia Legal Services Make an appointment: 206-287-9661 or 1-509-662-0911, ext. 134 www.columbialegal.org/fair-access-to-hospital-care Washington Law Help http://www.washingtonlawhelp.org/ NJP YouTube Video on Charity Care https://www.youtube.com/watch?v=qNrXdl-bPQ4