Eligibility Categories

(1) Full Free Care. (a) Eligibility. 1. a Massachusetts Resident whose Family Income is equal to or less than 200% of the Federal Poverty Income Guidelines; 2. a non-Massachusetts Resident who receives EmergencyorUrgentCare and whose Family Income is equal to or less than 200% of the Federal Poverty Income Guidelines; 3. a person who receives benefits from the CenterCare or Emergency Aid to the Elderly, Disabled and Children (EAEDC) programs for Medically Necessary Services not covered by these programs; or 4. participants in the Children’s Medical Security Plan or Healthy Start whose Family Income is equal to or less than 200% of the Federal Poverty Income Guidelines. (b) Payment. The entire financial liability of a Resident whose income meets these criteria may be billed to the Pool for the period of Free Care eligibility described in 114.6 CMR 10.04. The entire financial liability for Emergency Care or Urgent Care ofa non-Resident whose income meets these criteria may be billed to the Pool for the period of Free Care eligibility described in 114.6 CMR 10.04. (2) Partial Free Care. (a) Eligibility. 1. a Massachusetts Resident whose Family Income is from 201% to 400% of the Federal Poverty Income Guidelines; 2. a non-Massachusetts Resident receiving Emergency or Urgent Care whose Family Income is from 201% to 400% of the Federal Poverty Income Guidelines. 3. participants in the Children’s Medical Security Plan whose Family Income is from 201% to 400% of the Federal Poverty Income Guidelines. 4. participants in Healthy Start whose Family Income is from 201% to 225% of the Federal Poverty Income Guidelines. (b) Annual Patient Deductible. 1. The patient’s Deductible equals 40% of the difference between the patient’s Family Income and 200% of the Federal Poverty Income Guidelines. The followingformula must be used in determining the amount of the Deductible: [Family Income - (2 x Federal Poverty Income Guidelines)] x 40% = Annual Patient Deductible The total amount of a patient’s co-payments is capped in any given year at the Deductible amount calculated in 114.6 CMR 10.03(2)(b)1.. The patient will remain responsible for all expenses for Medically Necessary Services that would otherwise be billed to the Pool up to this Deductibleamount.Thereisonly one partial Free Care Deductible per Family per eligibility period. If the patient is approved for partial Free Care at more than one Provider, or if additional members of a Family are approved for partial Free Care at the same or another Provider, the Medically Necessary Services from the other Provider(s) or for the additional Family members must be applied to a single partial Free Care Deductible for the Family. Family members must be approved for partial Free Care in order for their expenses for Medically Necessary Services to be applied towards the Deductible. Once a Hospital or Community Health Center has calculated the patient’s Deductible pursuant to 114.6 CMR 10.03(2)(b)1., the Hospital or Community Health Center must track the patient’s Free Care expenses until the patient meets the Deductible. If more than one Family member is approved for Free Care, or if the patient or Family members are approved for Free Care at more than one Hospital or Community Health Center, it is the patient’s responsibility to track the Deductible and provide documentation to the Hospital or Community Health Center that the Deductible has been reached. (c) Payment. 1. Hospitals. The patient must incur expenses for Medically Necessary Services to meet the Deductible before receiving partial Free Care. Once the patient has met the Deductible, the remaining balance for MedicallyNecessary Services may be billed to the Pool for the period of Free Care eligibility described in 114.6 CMR 10.04. Based on the guidelines established in 114.6 CMR 10.05, the Hospital may require a deposit and/or a payment plan. 2. Community Health Centers. A person who is eligible for partial Free Care must pay a percentage of the bill based on a sliding fee scale until the patient meets the Deductible as calculated pursuant to 114.6 CMR 10.03(2)(b)1.. The remaining balance may be billed to the Pool. Once the patient meets the Deductible, the entire visit may be billed to the Pool for the period of Free Care eligibility described in 114.6 CMR 10.04. Community Health Centers must report the co-payment amount as Free Care income, regardless of whether the payment was actually received. The sliding fee scale appears below: Income as a Percentage of Federal Poverty Income Guidelines Percentage of Rate Paid by Patient 201% to 250% 251% to 300% 301% to 350% 351% to 400% 20% 40% 60% 80% (3) Medical Hardship. (a) Eligibility. 1. A Massachusetts Resident at any income level may qualify for Medical Hardship if Allowable Medical Expenses have so depleted the family’s income and resources that he or she is unable to pay for Medically Necessary Services. In order to qualify for Medical Hardship, the patient must meet both the expense and the resource qualifications described below. 2. A non-Massachusetts Resident receiving Emergency or Urgent Care, at any income level, may qualify for Medical HardshipifAllowableMedical Expenses have so depleted the family’s income and resources that he or she is unable to pay for Medically Necessary Services. In order to qualifyfor Medical Hardship, the patient must meet both the expense and the resource qualifications described below. (b) Patient Contribution. 1. Expense Qualification. The patient’s Allowable Medical Expenses must exceed 30% of his or her Family Income determined as follows: a. The Hospital or Community Health Center will determine the Family Income. If a member of the Family is temporarily unemployed, the Hospital or Community Health Center will estimate the amount that Family member might reasonably be expected to earn over the next year. This amount plus the gross income of all other Family members shall be considered the Family Income. b. The Hospital or Community Health Center will multiply the Family Income, as determined in 114.6 CMR 10.03(3)(b)1.a., by 30%. c. The Hospital or Community Health Center will determine the patient’s Allowable Medical Expenses, as defined in 114.6 CMR 10.02. d. The Hospital or Community Health Center will compare 30% of the Family Income, determined pursuant to 114.6 CMR 10.03(3)(b)1.b., to the total amount of the patient’s Allowable Medical Expenses, determinedpursuant to 114.6 CMR 10.03(3)(b)1.c.. If the total of Allowable Medical Expenses is greater than 30% of the Family Income, then the patient meets the expense qualification. The Hospital or Community Health Center will subtract 30% of the Family Income from the Allowable Medical Expenses to determine the amount by which the Allowable Medical Expenses exceed the available income, or the “excess medical expenses” for the resource qualification test below. 2. Resource Qualification. The patient’s available assets must be insufficient to cover the cost of Allowable Medical Expenses that exceed 30% of the Family Income. a. The Hospitalor Community Health Center will calculate total available Family assets. Available assets do not include the primary residence, the first motor vehicle, and a resource exclusion of the first $4,000 of other assets for an individual, or $6,000 for a Family of two, and $1,500 for each additional Family member. b. The Hospital or Community Health Center will compare the available assets determined pursuant to 114.6 CMR 10.03(3)(b)2.a.. to the excess medical expenses, determined pursuant to 114.6 CMR 10.03(3)(b)1.d.. If the available assets are greater than the excess medical expenses, the patient is not eligible for Medical Hardship. If the available assets are less than the excess medical expenses, the patient is eligible for Medical Hardship. The Hospital or Community Health Center will determine the patient’s Medical Hardship contribution by adding 30% of the patient’s Family Income, determined pursuant to 114.6 CMR 10.03(3)(b)1.b., to the patient’s available assets, determined pursuant to 114.6 CMR 10.03(3)(b)2.a. This is the amount of the patient’s Medical Hardship contribution. There is one Medical Hardship contribution per Family per eligibility period. c. The patient will remain responsible for all Allowable Medical Expenses up to this Medical Hardship contribution. The patient is eligible for Free Care for all expenses for Medically Necessary Services in excess of the Medical Hardship contribution for the period of Free Care eligibility described in 114.6 CMR 10.04. (c) Payment. 1. The Hospital or Community Health Center will first apply the Allowable Medical Expenses billed by other Providers to the patient’s Medical Hardship contribution. If the Medical Hardship contribution exceeds the Allowable Medical Expenses billed by other Providers, the Hospital or Community Health Center will then apply its own Allowable Medical Expenses to the Medical Hardship contribution. The patient must pay that portion of the bill that the Hospital or Community Health Center applied to the Medical Hardship contribution. 2. The Hospital or Community Health Center may bill any balance above the patient’s Medical Hardship contribution to the Pool. (4) Emergency Bad Debt. (a) Eligibility. To be eligible for emergency Bad Debt, an account must meet the following conditions. 1. The patient must be uninsured for the services provided. 2. The patient must have received Emergency Care as defined in 114.6 CMR 10.02. 3. The patient’s condition must be determined by the responsible physician to require Emergency Care, as defined in 114.6 CMR 10.02 and in the Hospital’s Credit and Collection Policy. 4. The Hospital establishes that appropriate collection action was taken pursuant to 114.6 CMR 10.05. (b) Payment. 1. A Hospital may bill to the Pool all charges resulting from the emergency visit, including any ancillary services, and any charges for an inpatient or observation stay. 2. A Hospital may bill the Pool for Emergency Care screening and services, but not for other services provided to patients determined not to require Emergency Care. If a Hospital cannot distinguish charges for screening services from charges for other Medically Necessary Services, the Hospital may bill the Pool for the amount paid by the Medicaid program for emergency screening services.