Current through Register 1531, September 27, 2024
(A)
The superintendent of each hospital shall appoint an employee or employees to
inform direct pay patients about the availability of an assessment, to
distribute, monitor and evaluate the applications and to make the calculations
and determinations required under these regulations.
(1) Such hospital personnel shall inform
patients or prospective patients, either personally or in writing of the
availability of an assessment, shall answer questions about the program that
patients may have, shall deliver application forms to all direct pay patients,
and shall accept and process all applications submitted.
(2) The application form to be used by all
hospitals is incorporated herein as exhibit B.
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* 65.2% consists of 50.2% which as stated in
105 CMR
920.005(B), a family of "0"
does not have housing and food expenses. 15.% is the adjustment factor or
percentage of income for a family of "0" if the individual had housing and food
expenses. These two percentages summed together equals 65.2%.
(B) Determinations of the
assessment shall be made prior to the rendering of care so that patients will
not be discouraged from seeking medical care for fear they will not be able to
pay a hospital bill. The following exceptions are allowed:
(1) Determinations may be made after the
provision of services in the case of emergency admissions.
(a) An emergency admission shall be an
admission in which the patient requires immediate medical attention and is
therefore unable to complete an application prior to the rendering of medical
care.
(2)
Determinations may be made after the provision of services in case of a change
in circumstances as a result of the illness or injury occasioning such services
(e.g. the patient's financial condition has changed due to
loss of wages resulting from the illness) or in the case of insurance coverage
or other resources being less than anticipated or the costs of services being
greater than anticipated. (The hospital personnel as designated in 105 CMR
920.007(A) shall review and update determinations made for patients who are
still receiving services from (the hospital) on a periodic basis. Said period
of time shall be set at the discretion of the superintendent or his
designee(s). And shall follow the procedures set forth in 105 CMR
920.007(C),(D) and (E). (3) Determinations may be made after the provision of
services if the determinations was delayed by reason of erroneous or incomplete
information furnished by or on behalf of the patient.
(C) Determinations of the amount of an
assessment (or of eligibility for free care) shall not be delayed by an
application for medicaid, or other third party coverage.
(1) Whenever such an application is pending,
the employee designated by the superintendent in accordance with 105 CMR
920.007(A) shall proceed to determine the amount of the patient's assessment
(for his eligibility for free care).
(2) The patient shall be informed in writing
of the results of the above determination and shall receive assurance from the
designated employee that if the application for medicaid, medicare or other
third party payment is denied, the patient will be assessed (or given free
care, as the case may be) in accordance with the determination.
(D) The patient shall be informed
in writing of the determination made by the designated hospital employee of his
monthly and yearly maximum, his annual minimum payment . (Written notice of a
denial of an assessment shall also be given together with a written statement
of reasons.) This written determination shall be given to the patient prior to
the rendering of services in the situations set forth in 105 CMR 920.007(B)(1),
(2) and (3) of
105 CMR 920.000.
(E)
Verification.
Verification of the information submitted on the application shall not be
required prior to the determination of the assessment or prior to the provision
of medical services.
(1) The application must
be signed under the pains and penalties of perjury. If information on the
application is intentionally falsified, the matter shall be brought to the
attention of the Assistant Commissioner for Health Services who may refer the
case to the Attorney General for perjury prosecution.
(2) Calculations shall be verified by the
Treasurer of the hospital or his designate. He shall initial the application in
the appropriate space if the calculations are correct. If the calculations are
incorrect, the form shall be revised and resigned by the patient and/or the
financially responsible individuals.
(3) For Hill-Burton patients, verification in
the nature of substantiation of the information on an application shall be
permitted only to the extent permitted under the Regulations Requiring a
Minimum Level of Uncompensated Medical Services in Massachusetts.
(4) For direct pay patients who do not
receive Hill-Burton uncompensated service, verification in the nature of
substantiation shall be permitted in accordance with the following guidelines:
(a) Verification shall not be required of all
direct pay patients. Rather, a sampling of direct pay patients shall be
selected for verification.
(b) The
gross and adjusted incomes shall be verified by written documentation within
the possession of the patient and the financially responsible individuals
related to him, including W-2 forms, pay stubs, internal revenue forms, bank
books, canceled checks.
(c) The
employer of the patient and/or the financially responsible person related to
him shall not be contacted either orally or in writing.
(d) If the patient and his financially
responsible persons lack written documentation to substantiate the application,
the hospital may seek the written permission of the patient or financially
responsible persons to contact the internal revenue service regarding income
earned in the gross income year and the period of time up to the date of
hospitalization, and to contact the bank(s) where such persons hold
accounts.
