Eligibility Process

(1) MassHealth Enrollment. If a patient is enrolled in MassHealth on the date that the service is provided, the Hospitalor Community Health Center may not bill the Pool for that service. Therefore, for any patient requesting Free Care, Hospitals and Community Health Centers must check Division of Medical Assistance eligibility verification systems to determine the patient’s MassHealth enrollment status. (2) Screening for Alternative Programs. Hospitals and Community Health Centers must screen patients for other sources of coverage and potential for eligibility in government programs before approving them for Free Care. Hospitals and Community Health Centers are required to document the results of each screening. If an Acute Hospital or Community Health Center determines that a patient is potentially eligible for Medicaid or another government program, said Acute Hospital or Community Health Center shall encourage the patient to apply for such program and shall assist the patient in applying for benefits under such program. A patient who declines to apply for another government program may apply and, if eligible, be approved for Free Care. (3) Application. Hospitals and Community Health Centers will use the appropriate application form provided by the Division to determine eligibility for Free Care, partial Free Care, and Medical Hardship. Copies ofthe applicationforms are attached hereto and incorporated herein by reference. Each application form must be signed by the patient or an authorized representative authorizing the release of information to the Division of Health Care Finance & Policy, and attesting that all information is correct. Hospitals and CommunityHealthCenters may use the Free Care application guide, which contains specific lists of acceptable forms of documentation, to assist with the Free Care application and eligibility determination process. (a) The Free Care Application (DHCFP-FC1). 1. All applicants for Free Care, except those patients who meet the conditions of 114.6 CMR 10.04(3)(b) or 114.6 CMR 10.04(3)(d), must complete the Free Care application (DHCFP­ FC1) and provide the required supporting documentation. 2. Supporting documentation is not required with the application for a single visit to a Hospital or Community Health Center when the total charge is $500 or less, but documentation must be provided in order to receive Free Care for subsequent visits. (b) The Condensed Free Care Application (DHCFP-FC2). In order to prevent patients from having to provide duplicative information, patients in the categories described below may apply for Free Care using a condensed Free Care form. 1. Patients Eligible for MassHealth, but not yet Enrolled. Any patient determined eligible for MassHealth by the Division of Medical Assistance may complete the condensed Free Care application to receive Free Care for Medically Necessary Services provided before the patient’s MassHealth enrollment date. Patients enrolled inthe EAEDC program may receive Free Care for Medically Necessary Services provided before the patient’s MassHealth enrollment date without signing an application form only if the Hospital or Community Health Center includes a copy of the EAEDC card with the application and verifiesEAEDC eligibility. 2. Patients Ineligible for MassHealth. A patient who applied for and was subsequently denied MassHealth may submit a completed Medical Benefit Request (MBR) and a condensed Free Care application, provided that the MBR was submitted to the Division of Medical Assistance within six months of the Free Care application. 3. Members ofChildren’s MedicalSecurity Plan or Healthy Start. A patient enrolled in any or all of these programs who meets the Free Care income eligibility criteria is eligible for Free Care for those Medically Necessary Services not covered by the program, provided that the patient completes a condensed FreeCareapplicationand provides the Hospital or Community Health Center with a copy of his or her valid membership card. With the patient’s consent, Providers may obtain verification of enrollment in these programs by mail or fax from the agency that administers the program. Ifthe patient provides a valid program enrollment card, Hospitals and Community Health Centers must include a copy of the card with the patient’s signed application form; both sides of the card must be copied if both sides are used. 4. Members ofCenterCare. Patients enrolled in the CenterCare program may receive Free Care for Medically Necessary Services not covered by the CenterCare program without signing a condensed Free Care application form only if the Hospital or Community Health Center verifies that the patient has signed the Division’s Assignment of Rights statement on the CenterCare application and includes a copy of the CenterCare card (front and back) with the Free Care application. If the patient has not signed the Assignment ofRights, the patient must complete and sign a condensed Free Care application form, and the Hospital or Community Health Center must attach a copy of the card (front and back) to the patient’s signed application form. 5. Patients who have been approved for Free Care at another Hospital or Community Health Center. Patients who have been determined eligible for Free Care at one Hospital or Community Health Center mayuse the Condensed Free Care Application when applying for Free Care elsewhere. The second Hospital or Community Health Center must obtaina copy of the full Free Care application and supporting documentation from the first Hospital or Community Health Center, and is responsible for making its own eligibility determination and verifying that the shared information is still reflective of the applicant’s eligibility status. (c) The Medical Hardship Supplement (DHCFP-FC3). The Hospital or Community Health Center must use the Medical Hardship supplement to determine the Allowable MedicalExpenses and available assets to be used in calculating eligibility for Medical Hardship. The Medical Hardship supplement is a supplement to the Free Care application. Patients applying for Medical Hardship must complete both forms and provide the required supporting documentation in order to be eligible for Medical Hardship assistance. (d) The Family Supplement (DHCFP-FC4). When one Family member has completed the Free Care application and supplied the necessary documentation, additional Familymembersmayapply for Free Care using the Family supplement form. The eligibility dates for Family members using the Family supplement form will be the same as those for the applicant who completed the Free Care application. (e) Facility Use Only Section. The Hospital or Community Health Center must document the process used to determine Free Care eligibility by completing the Facility Use Only section of each application described in 114.6 CMR 10.04. (4) Special Circumstances. (a) Balances after insurance. A copy of the insurance program or policy’s Explanation of Benefits (EOB) must be included with the Free Care application. If this is not available, a copy of the bill fromthe Provider indicating the balance due from the patient, or a copy of the patient’s insurance card or policy, may be substituted. A patient may apply for Free Care to cover his or her financial liability after any insurance program or policy has paid the amount for which it is responsible. (b) Medicare Bad Debt is eligible for payment from the Pool to the extent that: 1. such charges are related to Medicare co-payments and deductibles or to Medically Necessary Services that are not covered by the Medicare program, 2. such charges are for a patient who otherwise qualifies for Free Care pursuant to 114.6 CMR 10.03, 3. such charges were properly submitted for payment to the Medicare intermediary and were rejected by the intermediary as failing Medicare substantive rules. A Hospital need not submit for payment to the Medicare intermediary any charges for services for which Title XVIII of the Federal Social Security Act does not allow payment, and 4. the Hospital establishes that reasonable collection efforts were made pursuant to Title XVIII of the Federal Social Security Act and 114.6 CMR 10.05. (c) Patients injured in motor vehicle accidents may be eligible for Free Care if the Hospital or Community Health Center documents that it investigated whether the patient, driver, and/or owner of the other motor vehicle had a motor vehicle liability policy and, where applicable, properly submitted a claim for payment to the motor vehicle liability insurer. (d) Hospitals and Community Health Centers that recover payments for charges which were previously billed to the Pool must report such payments to the Division. These recoveries will be offset against Free Care charges to the Pool. (5) Time Frame. (a) Prior to billing the Pool, Hospitals must obtain a completed Free Care application and all supporting documentation from the patient within one year of determining the patient’s financial liability, unless the Hospital documents continuous Collection Action or regular patient payments during the intervening time. Patients are eligible to apply for Free Care for an account over one year old if the Hospital can document continuous collection action or patient payments during the intervening time. (b) Prior to billing the Pool, Community Health Centers must obtain a completed Free Care application and all supporting documentation from the patient within ninety days of determining the patient’s financial liability, unless the Community Health Center documents continuous Collection Action or regular patient payments during the intervening time. Patients are eligible to apply for Free Care for an account over ninety days old ifthe Hospitalcandocument continuous collection action or patient payments during the intervening time. (c) Hospitals and Community Health Centers must give the patient written notice of an eligibility determination within 30 days of receipt of a complete application. (d) The patient will remain eligible for Free Care for one year from the date of the eligibility determination, unless over the course of that year the patient’s Family Income or insurance status changes to such an extent that the patient becomes ineligible.