1. society
2. welfare
3. healthcare
4. hospital

EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 1 of 11
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
POLICY
El Campo Memorial Hospital will make available Charity Care to person’s eligible as part of its
mission to serve the health care needs of the community. El Campo Memorial Hospital will
provide Charity Care to patients who cannot afford to pay for their own medical care based on
set criteria and guidelines of the Texas Health and Safety Code, Chapter 61. Because ECMH
will provide care regardless of the patient’s ability to pay, there may be individuals who require
additional financial assistance. Such financial assistance is considered Charity Care.
Charity Care will be provided to all eligible patients who present themselves for care at El
Campo Memorial Hospital without regard to race, creed, color or national origin.
The evaluation of the necessity for medical treatment of any patient will be based upon clinical
judgment regardless of the financial status of the patient. The clinical judgment of the patient’s
personal physician or the Emergency Department physician will be the sole determining criterion
for a patient’s admission to El Campo Memorial Hospital in accordance with the Medical Staff
Bylaws. In cases where a medical emergency condition exists, El Campo Memorial Hospital’s
evaluation of possible payment alternatives will occur only after urgent medical care evaluation,
necessary stabilizing treatment, and/or appropriate transfer to another facility have been rendered
in accordance with federal [EMTALA], state or local law.
Expenses for Charity Care eligible patients shall not exceed Amounts Generally Billed (AGB)
for emergency or other medically necessary care. The percentage of financial assistance for
patients who qualify for a discounted rate is determined annually using a look-back method. The
amount generally billed is the amount of the bill that would have been the patient’s responsibility
had the patient had commercial insurance. The amount generally billed for patients that qualify
for financial assistance is determined using the Net Patient Service Revenue from all financial
payor classes from the prior year’s audit report.
PURPOSE
This policy establishes a framework by which El Campo Memorial Hospital identifies residents
who are eligible for Charity Care.
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 2 of 11
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
DEFINITIONS
Financially Indigent - Patients who are uninsured and are accepted for care with either no
obligation to pay or a discounted obligation for the services rendered
based on the El Campo Memorial Hospital’s eligibility criteria set forth in
this policy.
In no event will El Campo Memorial Hospital establish eligibility criteria
for financially indigent patients, which set the income level for Charity
Care lower than that required for counties under the Texas Indigent Health
Care and Treatment Act. The El Campo Memorial Hospital may,
however, adjust the eligibility criteria from time to time based on the
financial resources of the El Campo Memorial Hospital and as necessary
to meet the Charity Care needs of the community.
Medically Indigent - Patients whose medical bill after payment by third-party payers exceed
fifteen (15) percent of the patient’s annual household gross income and
who are unable to pay the remaining bill. El Campo Memorial Hospital
may consider other financial assets and liabilities of the patient when
determining ability to pay. A determination of a patient’s ability to pay
the remainder of the bill will be based on whether the person reasonably
can be expected to pay the account in full over a one-year period.
If a determination is made that the person has the ability to pay the
remainder of the bill, such a determination does not prevent a reassessment of the patient’s ability to pay at a later date.
Charity Care Patient – A patient that is treated without the expectation of full payment.
PROCEDURES
1.
APPLICATIONS
Each patient applying for Charity Care will be asked to complete an El Campo Memorial
Hospital Application for Health Care Assistance (“Assistance Application”). Assistance
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 3 of 11
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
Applications can be requested from the Indigent/Charity Program Coordinator at El
Campo Memorial Hospital, 303 Sandy Corner Road, El Campo, Texas 77437, 979-5785194. Assistance Applications can also be picked up in the Hospital Business Office and
from a Mid Coast Medical Clinic Receptionist. Applications may also be found on the
Hospital’s website at www.ecmh.org. El Campo Memorial Hospital staff must give or
mail Assistance Applications the same day they are requested. A brief explanation, if
possible, should be given to the applicant explaining the process and the applicant’s
responsibilities. Assistance in completing the Assistance Application will be provided if
needed. [1] Texas Health Safety Code 61.053 [d] Applicants shall be informed that they should
contact the Indigent/Charity Program Coordinator at El Campo Memorial Hospital at
979-578-5194.
An Assistance Application will be considered complete if it includes these components:
 The applicant’s full legal name, physical and mailing addresses;
 The applicant’s social security number;
 The names of all other household members and their relationship to the
applicant;
 Information about any medical insurance, hospital or health care benefits that
household members may be eligible to receive;
 Information about the applicant’s gross yearly household income;
 The applicant/spouse’s signature and the date the form is filled out; and
 All needed verifications, including but not limited to a form authorizing El
Campo Memorial Hospital Charity Care Program to utilize any and all resources
available to verify the validity of the applicant’s information.
The date that the Assistance Application and all information necessary to make an
eligibility determination are received by the Indigent/Charity Program Coordinator will
be considered the application completion date.
All uninsured or underinsured patients unable to pay the required deposits before
inpatient admission or prior to outpatient services will be screened for Charity Care
eligibility at time of pre-registration, registration or admission.
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 4 of 11
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
ECMH will make reasonable effort to determine if a patient is eligible for Charity Care
by providing notices via mail during the notification period which ends 120 days after the
date of the first billing statement.
If ECMH has not determined if a patient is eligible for financial assistance during the
notification period, the hospital will accept and process a Charity Care application for an
additional 120 days before engaging in extraordinary collection efforts.
Extraordinary Collection efforts include but aren’t limited to action requiring legal or
judicial process, reporting to credit agencies and the sale of individual’s debt to another
party.
In situations where the patient does not provide the requested documents and El Campo
Memorial Hospital personnel believe that the patient may have been treated without
expectation of payment, the Assistance Application may be used.
The Assistance Application should include information considered in classifying the
patient and document that an attempt was made to obtain more complete information
from the patient. The Assistance Application should have a written signature of the
person completing it. Final authorization for Charity Care designation of accounts
without complete documentation will be approved in writing by the Administrator and
documented on the Assistance Application.
2.
APPLICANT RESPONSIBILITY
The applicant is responsible for:
 Correctly filling out the Assistance Application and providing all needed
verification for all eligible household members;
 Reporting any individual, entity, or other third party that may be legally liable
for all or any part of the cost of health care services received by the household
during the period of eligibility. The applicant must provide El Campo
Memorial Hospital with all necessary information about the third party as
required by El Campo Memorial Hospital; and
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 5 of 11
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
 Keeping all appointments scheduled with the Indigent/Charity Program
Coordinator.
If the applicant is married and his or her spouse is a household member, the spouse also
must sign the Assistance Application. By signing the Assistance Application, the
applicant, spouse, or authorized representative:
 Swears to the truth of the information supplied, [2] Texas Health Safety Code 61.053 [e]
 Assigns to El Campo Memorial Hospital the household’s rights to recovery of
health care costs from any individual, entity, or other third party that may be
legally liable for any health care services paid by El Campo Memorial Hospital
not to exceed Amounts Generally Billed (AGB).
If approved for Charity Care, the applicant promises to report any changes in income and
resources within fourteen [14] calendar days after the change occurs. Persons who
intentionally misrepresent information are not entitled to receive benefits and are
responsible for reimbursing El Campo Memorial Hospital for the cost of benefits they
were ineligible to receive. [3] Texas Health Safety Code 61.053 [f].
3.
APPLICATION PROCESSING
El Campo Memorial Hospital shall process each Assistance Application without regard to
race, color, religion, creed, national origin, age, sex, disability, or political belief to
determine if the applicant meets the eligibility requirements for Charity Care. El Campo
Memorial Hospital shall review each Assistance Application and shall accept or deny the
Assistance Application no later than fourteen [14] calendar days after the date on which
El Campo Memorial Hospital received the completed Assistance Application. [4] Texas
Health Safety Code 61.053 [g]
If an incomplete Assistance Application is received, El Campo Memorial Hospital shall
request any needed information from the applicant. Reasonable Effort will be made by
the Hospital to determine if a patient is eligible for financial assistance for 120 days after
the date of the first billing statement before engaging in extraordinary collection efforts.
ECMH will accept and process Charity Care applications for an additional 120 days if the
hospital cannot determine financial eligibility during the notification period.
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 6 of 11
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
El Campo Memorial Hospital shall provide an applicant written notification of its
decision. If El Campo Memorial Hospital denies Charity Care, the written notification
shall include the reason for the denial and an explanation of the procedure for appealing
the denial. [5] Texas Health Safety Code 61.053 [h]
If the applicant is denied Charity Care, the applicant may re-submit an Assistance
Application at any time circumstances justify a re-determination of eligibility. [6] Texas
Health Safety Code 61.053 [k]
Applicants will be contacted/notified by the Indigent/Charity Program Coordinator to
schedule an appointment after the completed application is turned in with all the
necessary information.
4.
ELIGIBILITY REQUIREMENTS
Income [7] Texas Health Safety Code 61.052 [a] [2]; 25 Tex. Admin. Code 14.104 [d]
El Campo Memorial Hospital shall provide Charity Care with no obligation (100%
discount of AGB) to pay for services rendered to those uninsured and underinsured
patients who have a net monthly income less than or equal to 150% of the Federal
Poverty Guidelines for the household’s size. Those uninsured and underinsured patients
who have a net monthly income between 151% and 200% of the Federal Poverty
Guidelines for the household’s size shall receive 0% discount of amounts generally
billed.
Federal Poverty Guideline
At or below 150% FPG
151% - 200% FPG
Percentage of Financial Assistance
(Amount Generally Billed)
100% AGB
0% AGB
In addition, patients who are over 200% and are uninsured or underinsured can apply for
the Discount Card Program. The card is free and there is no asset or income
requirements to meet for patients to become eligible. Because the Discount Card Program
is not a means-tested Program, it is not considered Charity Care or Financial Assistance.
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 7 of 11
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
El Campo Memorial Hospital shall request that the applicant verify his or her gross
annual household income by supplying the following: Tax Return and IRS Form W-2,
Wage and Earnings Statement, Pay Check Remittance, Social Security, Workers
Compensation, Unemployment Compensation or Government Program Determination
Letters, telephone verification by employer of the applicant’s annual gross income,
and/or bank statements. If this information is not provided with the Assistance
Application, El Campo Memorial Hospital shall request such documentation from the
applicant.
El Campo Memorial Hospital balances owed by patients whose net monthly household
income equals or falls below 200% of the Federal Poverty Guidelines for the household’s
size and who submit a completed application will automatically be designated as Charity
Care.
Current eligibility begins on the first calendar day in the month that an identifiable
application is filed or the earliest, subsequent month in which all eligibility criteria are
met.
The applicant may be retroactively eligible in any of the three calendar months before the
month the identifiable application is received if all eligibility criteria are met.
5.
RIGHT TO APPEAL [8] Texas Health Safety Code 61.053 [h]
Applicants have the right to appeal a denial of their Assistance Application or eligibility
for Charity Care. To appeal a denial, the applicant should submit an appeal and the
reasons why the applicant should be considered eligible for Charity Care in writing to El
Campo Memorial Hospital, 303 Sandy Corner Road, El Campo, Texas 77437, Attention:
Administrator, within 90 calendar days of receipt of the notice of denial.
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 8 of 11
6.
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
ELIGIBILITY REVIEW
Applicants shall be informed that they must report to El Campo Memorial Hospital any
change in income or resources that might affect the applicant’s eligibility within fourteen
[14] calendar days after the date on which the change occurs.
Eligibility for Charity Care shall be reviewed by El Campo Memorial Hospital every six
[6] months after approval, at which time, the household must provide El Campo
Memorial Hospital with documentation establishing current eligibility.
7.
DOCUMENT RETENTION [9] Texas Health Safety Code 61.053 [j]
El Campo Memorial Hospital shall maintain the records relating to an Assistance
Application for at least three [3] years after the date on which the Assistance Application
is submitted. Such records shall include at least the Assistance Application, including the
applicant’s gross annual household income and any supporting documentation, and a
copy of the written notification of approval or denial of the Assistance Application.
8.
SERVICES [10] Texas Health Safety Code 61.055
El Campo Memorial Hospital shall provide the following services to the extent it is
financially able to do so as determined annually by the Board of Directors of El Campo
Memorial Hospital:
 Primary and preventive services, including immunizations, basic medical
screening services and annual physical examinations provided at El Campo
Memorial Hospital and/or Mid Coast Medical Clinic;
 Inpatient hospital services provided at El Campo Memorial Hospital;
 Outpatient hospital services provided at El Campo Memorial Hospital
excluding sleep studies (this includes physician billing only for Mid Coast
Medical Clinic providers which are listed below) ;
 Physician services rendered by a Mid Coast Medical Clinic provider – Tom
Baccam, D.O.; Carlos Duque, M.D.; Patrick E. Johnson, M.D.; Dana Foster,
PA-C; Ashley Koudela, MPAS, PA-C; Laura Williams, PA-C and Clay Zboril,
MPAS, PA-C limited to six (6) office visits per eligibility period; and
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 9 of 11
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
 Laboratory and X-Ray services provided at El Campo Memorial Hospital
and/or Mid Coast Medical Clinic.
Services provided at other facilities will not be paid for by El Campo Memorial Hospital.
The services provided by El Campo Memorial Hospital under this policy shall be
reviewed annually and may be revised as may be determined from time to time by the
Board of Directors of El Campo Memorial Hospital.
9.
CHANGES TO ELIGIBILITY STANDARDS OR SERVICES PROVIDED
El Campo Memorial Hospital may adopt any proposed changes if approved by the Board
of Directors of El Campo Memorial Hospital.
10.
PENALTIES FOR FRAUD/FAILURE TO REPORT CHANGE IN HOUSEHOLD
The following procedure will apply to all cases of applicants eligible for benefits through
the El Campo Memorial Hospital Charity Care Program:
A.
Failure to report income/resources on Assistance Application - PENALTY
1.
All household members disqualified from program for one year for each
Assistance Application in which information was not provided or
misrepresented to El Campo Memorial Hospital. Disqualification date
begins the date the office is informed or learns of omission or intentional
misrepresentation.
2.
Applicant[s] will be responsible for repayment of all expenditures, not to
exceed amounts generally billed, incurred by El Campo Memorial
Hospital Charity Care Program.
3.
Applicant[s] can reapply for program after one year if repayment has been
made in full or applicant has remained in compliance with repayment
agreement during the one-year period.
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 10 of 11
4.
B.
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
If restitution has been made in full prior to one year, applicant[s] are not
eligible to reapply or receive benefits prior to end of one year penalty.
Failure to report change in household status within 14 calendar days –
PENALTY
If change would have denied eligibility for Charity Care Program:
1.
Applicant[s] will be disqualified from program for six months from the
date El Campo Memorial Hospital Charity Care Program is informed of
change of household status.
2.
Applicant[s] will be responsible for repayment to El Campo Memorial
Hospital for all expenditures El Campo Memorial Hospital incurred from
the date the change occurred in the household.
3.
Applicant[s] cannot be placed on any other West Wharton County
Programs during the disqualification period.
If change would not have changed status of eligibility:
1.
Information will be documented in case file and, if first offense, then no
action against applicant.
2.
If second offense, then household will be disqualified for 90 calendar
days.
If household is found to be guilty of failure to report information or change of household
situation in more than two instances, the household will be disqualified from program for
a two-year period effective on the date the El Campo Memorial Hospital learns of status
change.
Reporting ANY changes in the household is the responsibility of the household
receiving services and failure to comply with the above will result in the above
EL CAMPO MEMORIAL HOSPITAL
DEPARTMENT: Administration
SUBJECT: Charity Care
Eff. Date: 02/01/04
Page: 11 of 11
Policy/Procedure No: _____
Approved By: ___________
Revised:
12/16/04
12/19/07
12/18/06
12/21/09
12/19/08
12/19/11
12/20/10
04/20/12
01/28/13
01/27/14
06/01/14
10/27/14
penalties. Residents are subject to criminal/civil charges for misrepresentation on
Assistance Applications or failing to comply with reporting requirements.
11.
PAYOR OF LAST RESORT
El Campo Memorial Hospital shall always be the payor of last resort. Therefore,
applicant must submit a denial letter from Medicaid before the Assistance Application
will be considered complete. Furthermore, if an applicant lives outside of the West
Wharton County Hospital District, the applicant must submit a denial letter including the
reason for denial from the respective County Indigent Program and/or Hospital District in
which they reside before the Assistance Application will be considered complete.
This policy shall not alter or modify other policies regarding efforts to obtain payments
from third-party payors, patient transfers, or emergency care.
12.
LIMITATION OF LIABILITY [12] Texas Health & Safety Code 61.035
El Campo Memorial Hospital’s maximum liability for each fiscal year for health care
services provided to each eligible applicant is: 1) $30,000; or 2) the payment of 30 days
of hospitalization or treatment in a skilled nursing facility, or both, or $30,000, whichever
occurs first.