Statement of Purpose
The Mount Sinai Health System recognizes that many of the patients it serves may be unable to access quality health care services without financial assistance. The Mount Sinai Financial Assistance Policy (“the Policy”) was developed to ensure that the member hospitals continue to uphold their mission of providing quality health care to the community while carefully taking into consideration the ability of the patient to pay, as applied in a fair and consistent manner.
Prior to or at the time of service; all patients of the member hospitals will have access to information regarding assistance for paying estimated or actual fees for Hospital services. As provided under New York State Public Health Law 2807-k (9-a) and the Affordable Care Act (ACA); patients will be provided guidance in applying for public insurance programs (Qualified Health Plans), Government or Hospital Financial Assistance programs based on financial need and eligibility for such. All uninsured patients are presumptively eligible for a discounted rate. In order for further reductions to be applied an application must be made through this policy within 90 days of discharge or point of service.
- Patients are considered eligible to qualify under the policy if:
- Their primary residence is in the State of New York, and
- They meet all financial requirements; and
- They are uninsured, have exhausted or will exhaust all available insurance benefits..
Medically Necessary Non-Emergency Services:
- Their primary residence located in the City of New York and
- They meet all financial requirements; and
- They are uninsured, have exhausted or will exhaust all available insurance benefits.
- Patients are considered ineligible to qualify under the policy if:
- False information was provided by the patient or responsible party; or
- The patient or responsible party refuses to cooperate with any of the terms of this policy; or
- The patient or responsible party refuses to apply for government insurance programs after it is determined that the patient or responsible party is likely to be eligible for those programs.
- The patient or responsible party refuses to adhere to their primary insurance requirements
- Patients may appeal a determination of ineligibility or unfavorable discount rate
- All hospital charges that are medically necessary including:
- Inpatient services
- Ambulatory surgery
- Emergency care
- Outpatient services including clinic and Diagnostic Treatment Center services
- Ruttenberg Treatment Center (RTC)
- In cases of dispute of medical necessity, the Utilization Review Department or The Hospital’s Chief Medical Officer will make the final determination of medical necessity.
- Services provided that are not medically necessary (i.e. cosmetic surgery / cosmetic contact lens and/or sleep study services)
- Non facility employed physician fees are not covered by this policy (speak to your advocate to see if this applies)
- Discretionary charges such as private room, private nurse, phone, TV, etc.
- Research related services
Policies and Procedures:
Administration of this policy will be through the Department of Patient Financial Services (“PFS”). Areas within the system are designated to assist in the application process as determined by the member hospitals.
- As identified in section 15 of this policy, the designated areas will determine if a patient has third party coverage (if coverage is determined, the treatment and plan of care must be covered and provided under any available third party coverage);
- If no third party coverage exists, a review and determination will be made to determine if the patient is eligible for government insurance programs;
- The applicant has 30 days in which to complete the application documentation process.
- In the event that the patient is fully eligible for Medicaid under the “Emergency Services Only” coverage or, be fully eligible for Medicaid; AND the services are not billable to the Medicaid program for payment (nor excluded under the policy), the applicant should be automatically deemed eligible for Charity Care under Level 1 of the program or, if employed, the appropriate discount level. No further documentation will be required other than confirmation from the State of New York via the institutional billing system (Eagle). Such determination for Charity Care will be for the specific date of service to which the visit (s) occurred and were not certified to meet the definition of an emergency as described on the DSS-4471 or the current New York State Certification of Emergency treatment form in use at the time in which the services were rendered.
- If approved under the policy, such eligibility period should not exceed one year commencing on the first of the month of which services were first delivered or up to the last day of the month of the “open enrollment period as established under the ACA (which ever come first). If the patient requires an ambulatory surgery procedure or inpatient hospitalization, they MAY BE required to recertify eligibility under the program (for the sole purpose of re-evaluating the patients eligibility for additional benefits). At the end of the eligibility period, patient will be required to recertify under the policy in effect at the time of the current application;
- If the patient is ineligible for government insurance programs and if application site agrees with such determination, the Policy and associated payment options should be explained to the patient and an application should be completed by the patient or responsible party;
- Patients must provide the following documentation with the Policy application (documentation must meet the standards of proof applied by Medicaid to Medicaid application documentation):
- Proof of address;
- Proof of Identity;
- Current financial management as evidenced by income verification (wages, disability benefits, compensation benefits, etc) by providing (as necessary):
- 30 days of the most recent payroll stubs; or
- Employer letter; or
- NYS Self attestation form (see below); or
- most current Federal Tax returns with all schedules; AND/OR
- Letter from the Social Security Administration or the New York State Department of Labor regarding unemployment benefits; AND/OR
- Letter of support from individuals providing for patient’s basic living needs;
- Proof of dependents (if claimed) ;
- Proof of child support, alimony (if claimed); and
- Proof of assets is not required to determine actual discount under the policy.
- As allowed in Medicaid documentation standards, self attestation (Currently Form MAP 2050a or any other acceptable form in use at the time of application) may be accepted if the above is not obtainable.
- Eligibility for Financial Assistance is determined based on family size and income level:
- For all covered services under the Policy, the application site will apply a means test and sliding fee scale based on gross income and family size.
- The sliding fee income guidelines will be adjusted to remain consistent with Federal Poverty Level updates;
- The Sliding Fee Table may be further revised by Mount Sinai System in accordance with New York State statute.
- As determined by each area, a departmental designee will review each application and make a final determination on Charity Care eligibility and payment agreements (if required under the policy);
- All application sites shall render decisions to determine eligibility for Charity Care within 30 days of receipt of a completed application (including all required supporting documentation);
- Patients who receive additional services beyond the originally agreed upon services shall remain financially liable for the additional services and such modification may result in a re-evaluation of the patient’s eligibility under this policy or any other government sponsored programs available.
- The Mount Sinai Health System reserves the right to evaluate any patient’s eligibility on a case-by case basis, especially where complex medical, scientific or financial situations exist;
Any deposit paid as part of this program will be included in the overall discount package.
- When a member hospital has found a patient eligible for Charity Care, an appropriate discount will be determined based on the current Sliding Fee Scale Discount Table in accordance with New York State regulations;
- The patient or responsible party will be notified in writing of eligibility and if eligible and if applicable, asked to sign a payment agreement;
- A New York State surcharge will be added to all amounts determined to be the patient’s responsibility, as appropriate under the Health Care Reform Act;
- Payment terms shall be compliant with the existing the New York State Financial Assistance Law. Payment terms shall not exceed the limits as set forth under the law and shall not include interest (all installment plans are interest free).
- Installment plans (if any) shall not exceed 10% of the head of household gross monthly income in accordance with New York State Statute for persons who qualify under this policy.
Appeal of Eligibility Determination:
- A patient has the right to appeal decisions on eligibility for Charity Care within 30 days of notification of non-eligibility;
- Appeals can only be submitted based on the following:
- Incorrect information was provided; OR
- A change in the patient’s financial status occurred; OR
- Due to extenuating circumstances;
- The Director of the DFC will decide appeals in cases as specified above.
- Appeals should be made in writing (or in person, only by appointment) to the appropriate parties as noted below:
- Each application site will issue an appeals decisions within 10 business days of receipt of a patient appeal (i.e., after receipt of letter or an in- person appeal)
- The DFC, at its discretion, may request that an application or additional appeal be filed for Government sponsored benefits as part of the Charity Care appeal process;
- Patients are responsible for promptly reporting changes in financial status and/or contact information to the appropriate application site;
- If a patient or responsible party is unable to comply with a signed payment agreement they must contact the appropriate application site;
- If a patient or responsible party defaults on a financial agreement with the member hospital, the account in question will be considered delinquent and the hospital reserves the right to refer the patients account to an outside collection service, where appropriate, consistent with guidelines set forth in section 13 of this and by applicable law.
Communication and Training:
- Patients obtain information on hospital fees, public insurance programs, government and/or hospital financial assistance programs (including the Policy) primarily from:
- designated application areas (see section 15);
- multi-lingual signage or brochures at points of patient service (Including but not limited to, intake and registration areas);
- information distributed in the admission package;
- responses to direct inquiries made to Mount Sinai;
- bills sent to all patients that have a Self-Pay balance which will include information on who to contact if the patient believes they will have difficulty in paying the balance due.
- All patients will be provided charge and/or rate information for specific procedures as requested.
- The member hospitals will provide estimates on total fees with the cooperation of the patient's physician. In the absence of input from the patient's physician, the member hospital will supply standard hospital fee (full fee rates) information to patients in addition to information regarding this Policy. Once the appropriate discount level has been determined, the bill will be adjusted down to the appropriate charge;
- For services rendered to diagnose or treat an emergency medical condition:
- Appropriate medical screening and stabilization services will be completed before a Financial Counselor seeks information concerning sources of payment;
- No staff associated with the process as defined under this policy shall take any action that might inhibit The Hospital’s compliance with its obligations under the Emergency Medical Treatment and Labor Act (“EMTALA”) and hospital policies on compliance with EMTALA;
- Emergency Department services will be billed at full charges with information about whom to contact if the patient believes they will have difficulty in paying the balance due.
- The member hospitals will assure that all staff responsible (ie Financial Counseling, REAP, HEAL, Customer Service) to engage or otherwise assist on the application for services covered under this policy are trained on the Financial Assistance Policy and subsequent revisions thereof.
Collection Agency Policy:
Collection agencies are instructed that they must follow the principles as outlined in the Policy and as are prudent, based on a patient’s or responsible party’s financial history and current financial situation. Certain legal actions (e.g. liens or garnishments) will only be approved in cases where the member hospital determines that a patient has the means to pay outstanding balances. For all legal actions, the collection agency must present documentation to the appropriate member hospital supporting such action.
- At no time will the Mount Sinai Health System or its member hospitals force the sale of a primary residence in order to settle a debt.
- No account will be placed with an Agency to collect on a debt so long as the application for assistance is in process.
- Unless otherwise prohibited, no account will be referred to an agency without 30 days written notice.
- All persons granted financial assistance will have 30 days after the final notice under this policy to either pay or dispute the debt before it can be turned over to an agency.
- Except as defined under the statute, any patient that is eligible for Medicaid shall not be referred to an Agency for collections.
- Collection agencies shall provide information on how to apply for financial assistance when appropriate
Policy Administration & Maintenance:
The member hospitals of the Mount Sinai Health System will centralize the reporting of the data for decisions rendered under this policy and document such in the Hospital’s accounting system. Such centralization will be limited only to decisions rendered under the terms of this policy for the purposes stated below as well as compliance with the New York State Financial Assistance Law.
The member hospital will collect and distribute information to The Hospital’s management team and Board of Trustees regarding its Charity Care Policy. This policy and the activities herein are subject to internal audits.
15. Designated Application Sites
Mount Sinai Beth Israel Brooklyn
Mount Sinai Beth Israel (New York)
Mount Sinai Hospital (New York)
Mount Sinai Queens
New York Eye and Ear Infirmary of Mount Sinai
Mount Sinai West
Mount Sinai St Luke’s