Hospital Discounted Care Frequently Asked Questions

Hospital Discounted Care Question & Answer Training Session Slides

Appeals

What is the appeals process?

If a patient completes the application process and is either determined ineligible for Hospital Discounted Care, or they believe there was an error in their determination which resulted in a higher household income and higher payment plan, they are allowed to appeal. Patients have 30 days from the date of the determination to appeal. The Health Care Facility must acknowledge the receipt of the appeal within three business days and has 15 calendar days to review the appeal and make a redetermination of eligibility. The Health Care Facility must inform the patient and the Department of the redetermination of eligibility within the 15 calendar days. If the patient is not satisfied with the Health Care Facility’s redetermination, the patient can appeal to the Department in writing within 15 calendar days of the redetermination. The Department will review the appeal within 15 calendar days of receipt of the secondary appeal. If the Department finds that the Health Care Facility’s redetermination was inaccurate, the Health Care Facility must resend a determination letter to the patient and the Department stating they are eligible for discounted care for the care received in the Health Care Facility for that specific date or date span.

Can a patient be sent to collections during an appeal?

Patients accounts are put on hold during an appeal review, meaning they should not be billed or sent to collections until the appeal has been resolved.

Billing

How is billing handled for those services associated with a procedure but NOT billed by the Health Care Facility (e.g., external labs, at-home equipment, etc.)?

If services are provided by a facility that is operating under the hospital’s license, the billing rates determined by the state for the Hospital Discount Care apply. If the facility billing for services/equipment are not part of the hospital’s license, then the Hospital Discount Care rate does not apply.

If a patient has a high deductible plan, what rates will apply to their share of the bill?

If the patient is eligible for Hospital Discount Care, the rates will be the lower of the rates determined by the state or the patient’s out of pocket costs for their insurance, regardless of the insurance plan.

When a patient has separate visits related to an episode of care, can those charges be considered part of the initial visit?

Yes, any subsequent visits pertaining to the initial date of service will all be billed together and included in the 36-month payment plan, if applicable.

How will this work with Medi-Share plans?

Medi-Share plans are not considered health insurance, so these patients will be considered uninsured and must be screened for public health coverage and Hospital Discounted Care.

How does Hospital Discounted Care relate to balance billing?

Hospital Discounted Care does not replace any current laws surrounding balance billing. Providers are not allowed to include any services in the patient’s payment plan that were not covered by their insurance.

When insured patients are screened and meet the income eligibility does the Provider bill the insurance anyway and if so at what rates?

Providers are required to bill a patient’s insurance and may do so at their normal rates. Providers must bill the patient at the lower of the rates established by the Department or the patient’s out of pocket costs.

Does the new law apply only to Licensed Health Care Professionals that are employed directly by the Health Care Facility, or does it also apply to Licensed Health Care Professionals that are contracted by the Health Care Facility or who get called in to perform services at the Health Care Facility?

The new law applies to all Licensed Health Care Professionals who perform services at the Health Care Facility, regardless of whether they are directly employed by the facility.

For the 4% vs. 2% professional, does it matter if the providers are not employed by the hospital, even if one bill is sent?

If a bill is sent by the Health Care Facility the payment plan can only be up to the 4% max, even if the Licensed Health Care Professional is not employed by the hospital.

Forms

Must we provide the patient's rights form to all patients or only those who present as uninsured?

The Patient’s Rights Form must be provided to all patients. It is to be posted conspicuously on the Health Care Facility’s website, including a link to the information on the Health Care Facility’s main landing page; posted in patient waiting areas; must be available to each patient, or the patient’s legal guardian, verbally or in writing before the patient leaves the Health Care Facility; must be included on the patient’s billing statement.

Must we provide the Decline Screening form to all patients or only those who present as uninsured?

A Decline Screening form must be given to all uninsured patients that don’t want to be screened for discount programs. Insured patients do not need to fill out an opt-out form.

What reasonable efforts must a Health Care Facility make to track down a patient who refuses to sign a Decline Screening form? 

For patients who refuse to sign a Decline Screening form, Health Care Facilities must abide by the Screening Best Efforts, as described below and in the manual.

What are considered Patient Screening Best Efforts?

For an uninsured patient who has not signed the Decline Screening form or completed a screening, Health Care Facilities must attempt to contact the patient via the patient's preferred method of contact, which may include making phone calls and leaving detailed voicemails if the calls are not answered, sending short message service (SMS, commonly known as text) messages if the facility has the ability to send SMS messages, sending emails to any email on file for the patient or their guardian, and sending messages through any applicable patient portal the patient or their guardian may have access to. These communication attempts must be made at least once a month for six months following the patient’s date of service or date of discharge, whichever is later.

Must the patient's rights be given to patients at each encounter?

How are patient's rights handled for patients who are deceased?

In the case of a deceased patient, the Patient's Rights should be presented to whomever is legally responsible for the patient’s medical bills. Spouses are allowed to apply for Hospital Discounted Care on behalf of their deceased spouse. Additionally, guardians are allowed to apply on behalf of their deceased household member.

Given COVID-19, what methods of signing the Decline Screening form are acceptable?

Patient’s may sign the form in hard copy or electronically. If the Health Care Facility does electronic signature, the form’s content must be the same as would be in the hard copy.

What must be done if patient refuses to sign the Decline Screening form?

If a patient refuses to sign the Decline Screening form, Health Care Facilities are required to continue reaching out to the patient to complete the screening process. Facilities must follow the reasonable efforts as outlined a few questions above and in the manual.

Does the Decline Screening form have to be signed at every visit?

If the patient opted out on their previous visit, then yes, it must be signed again.

Does the patient's rights document have to be handed out as a piece of paper or can it be formatted by the Health Care Facility as a pamphlet?

The content of the published patient’s rights form can be put into any format by the Health Care Facility. The Department will have to review other formats to ensure information is being presented in an acceptable way.

What about ADA accessibility? 

Health Care Facilities must comply with the federal Americans with Disabilities Act. Health Care Facilities must ensure information is given to individuals in their preferred language and supply accommodation to ensure people understand their rights.

If patient refuses to sign the Decline Screening form, can we record the denial with a witness' signature?

A refusal to sign the Decline Screening form is not the same as a refusal to be screened, so a witness signature is not acceptable.

Income

Is household income based on the date of service or some other timeframe?

The household income amount should be determined at the time of the application, regardless of how long it has been since the date of service or date of discharge.

How are changes in household income dealt with?

Patients are allowed to request a redetermination if there has been a change in their household composition or income. Providers are not allowed to force a patient to be re-determined at any point in relation to an established payment plan.

What income sources are included when determining household income?

Household income is defined as income from employment and self-employment for all non-student adults listed in the household, Social Security Income (SSI), Social Security Disability Insurance (SSDI), Tips, Bonuses, and Commissions, Short Term Disability, Pension payments, Payments from retirement accounts, Lottery winnings disbursements, Monthly payments from trust funds, and Unemployment income. SSI and SSDI payments are not allowed to be counted for minors or adults with disabilities who are still under the care of their parents or guardians.

What happens in the case of labor/delivery when a household grows and income may be lost for a period? 

Patients are allowed to count unborn children in their household, so it may not be an issue if the patient is screened prior to the baby being born. Health Care Facilities should take their patient’s situation into account when calculating income. Generally pregnant persons and newborns at or below 250% FPL are likely eligible for CHP+ unless they are covered by private health insurance, or they are undocumented. They may also be eligible for Health First Colorado or Emergency Medicaid. The Health Care Facility should encourage the patient to be screened for public health coverage and refer or assist them with the application process.

How is income from self-employment activities treated?

Income from self-employed patients or their household members is included in the household income calculation.

Are both income and assets factored in the qualification for Hospital Discounted Care?

Assets are not allowed to be used when determining gross monthly income.

IRS/Taxes

How does Hospital Discounted Care align with IRS 501r regulations? 

The Health Care Facility will need to contact their accounting firm.

Will Health Care Facilities and Licensed Health Care Professionals be able to claim discounts as charity care?

The Health Care Facility and Licensed Health Care Professional should refer to federal IRS rules concerning charity care and should consult with their accounting firm.

Payment Plans

Are payment plans based off gross charges or amounts billed to patients?

Payment plans are based off the patient’s calculated household income. Payment plans are capped at 4% of the patient’s monthly household income for Health Care Facility charges and 2% of the patient’s monthly household income per Licensed Health Care Professional who bills separately from the facility, or the amount billed to patients using the rates determined by the Department, whichever is lower.

Are payment plans based on a percentage of gross or net income? 

Payment plans will be based on monthly gross income. The payment plan cannot be more than 4% of the patient’s monthly gross income for facility charges and no more than 2% of the patient’s gross monthly income on a bill from each Licensed Health Care Professional that bills separately from the facility.

Does the Health Care Facility or Licensed Health Care Professional have to give the patient a payment plan or can it just be an option?

Patients must be given the option of setting up a payment plan. However, if the patient pays the bill in full they are not responsible for more than what the bill would have been on the payment plan – in other words, the lower of the Department-established rates or the 36-month payment plan cap of 4% for Health Care Facility charges or 2% for each Health Care Professional’s charges.

What happens if a patient misses one or more payments on their payment plan? 

Providers are allowed to send patients a notice that collections actions may be started if the patient misses two consecutive payments after their payment plan has been established. The letter must be sent at least 30 days prior to when collections actions will begin and must provide an opportunity for the patient to complete a redetermination if something has changed regarding their household or income. If the patient misses the third consecutive payment and has not contacted the Provider to be redetermined, the Provider may begin collections actions if it has been at least 182 days since their date of service or date of discharge, whichever is later.

Can payment plans be updated if new services are provided within the 36 months the payment plan is already running?

Yes, payment plans can be updated if new services are provided within the 36-month payment plan period that is already running. Providers are not allowed to create payment plans that exceed the 4% facility limit and/or the 2% per professional limit for each episode of care or extend a payment plan on any one bill to more than 36 months of payments, but Providers are allowed to set up payment plans for less than those amounts or months if they choose.

How are multiple episodes of care provided to members of the same household to be processed for payment plans limited to 4% of the household income?

It would be 4% for each episode of care per family member. For example, if a patient has services in January that would be 4%. The patient’s spouse then has services in January, that would also be 4%. The payment plan could not be more than 8% for the Health Care Facility payment plan.

If a patient applies for a loan offered by the hospital, is that also capped like a payment plan would be?

If the patient is eligible for Hospital Discounted Care the answer would be yes. Providers are not allowed to create payment plans that exceed the 4% facility limit and/or the 2% per professional limit for each episode of care or extend a payment plan on any one bill to more than 36 months of payments, but Providers are allowed to set up payment plans for less than those amounts or months if they choose.

Screening and Application

If a patient is brought in by law enforcement for health care services, do we need to screen them and are they eligible?

If the patient is released from custody and is free to return home or otherwise leave the facility on their own, they should be screened if they are uninsured and would be able to receive discounted care under Hospital Discounted Care and/or CICP if found eligible. If the patient is to be taken back into custody after their health care has been provided, they are still in the custody of law enforcement and are not eligible for Hospital Discounted Care or the CICP. The law enforcement agency is responsible for their medical care.

Who is required to complete the Hospital Discounted Care application?

All uninsured patients must be screened using the Single Uniform Application developed by the Department or sign a Decline Screening form. Any insured patients requesting to be screened for Hospital Discount Care must be screened using the Single Uniform Application.

Must screening be done in person or can it be by phone, email, online portal, or letter?

Screening does not have to be completed in person, but it will be the responsibility of the Health Care Facility to ensure that answers to screening questions are transferred accurately into the screening tab of the Single Uniform Application.

Is the screening process and the application process the same thing?

No, these are two separate processes. All uninsured patients must either be screened using the first page of the Single Uniform Application or sign the Decline Screening form. If the patient appears to be eligible for Hospital Discounted Care or the CICP, they can complete the rest of the application if they choose.

Can we use an online tool to gather the answers to the screening questions?

Health Care Facilities may use an online tool to gather answers to the screening questions; however, the online tool must ask the same questions that are included in the Single Uniform Application and the Facility must ensure the screening is saved in the same place as the application should the household choose to apply.

Who is liable if a patient is not screened as required by law?

Under the legislation, Health Care Facilities must either screen an uninsured patient or have them sign the Decline Screening form. If the patient completes neither, the Health Care Facility is required to complete the Screening Best Efforts as outlined in the Forms section above and in the manual. Failure on the Health Care Facility’s part to follow the screening requirements will result in possible fines from the Department and leave the Health Care Facility open to litigation from the patients.

Do Health Care Facilities have to screen insured patients? 

If an insured patient requests to be screened for Hospital Discount Care, then the Health Care Facility must screen the patient.

What is the timeframe within which screening must take place? 

Uninsured patients must be screened within 45 days of their date of service or date of discharge, whichever is later. Insured patients must be screened within 45 days of the patient requesting to be screened. Insured patients have a secondary window to request screening, which is within 45 days of their first bill following their insurance adjustment. Health Care Facilities must allow patients to request to be screened up to the 181st day past their date of service or date of discharge, whichever is later. Facilities are allowed to screen patients past that date at the Facility’s discretion.

How are patient's screening handled for patients who are deceased?

A patient’s screening may be completed by any household member who would be legally responsible for their medical bills, usually a spouse or a guardian.

What reasonable efforts must a Health Care Facility make to contact a patient for screening? 

Health Care Facilities must abide by the Screening Best Efforts, as described in the Forms section above and in the manual.

What is the duration for which a screening is considered current?

If a household chooses to apply and is determined eligible, their determination is generally good for a year from the earlier of their date of service or the date of the application. If the household is determined ineligible, the determination is only good for the episode(s) of care the household was applying to discount. If the household were to seek additional services, they must again be screened or sign a Decline Screening form.

What must be done if patient refuses to be screened?

A patient who refuses to be screened must sign the Declined Screening form.

Is the same application used for CICP and Hospital Discounted Care?

Yes, there is one Uniform Application for the CICP and Hospital Discounted Care. This application was based on the existing CICP application and adjusted as needed to comply with the bill.

What happens if a Health Care Facility tries to contact a patient for screening and the patient does not respond within the 45 days? 

If a patient does not respond within the 45 day period after their date of service or date of discharge, the Health Care Facility must follow the Patient Contact Best Efforts described in the Forms section above.

Must each Health Care Facility use the uniform application even if they already have an application for their organization's own charity program?

Yes, the Uniform Application must be used when screening for Hospital Discount Care

How does this differ if a patient is experiencing homelessness?

Patients experiencing homelessness are exempt from the income documentation requirements and may self-attest their monthly income.

What are the residency requirements to receive Hospital Discounted Care?

The patient does not have to be lawfully present in the U.S. to be screened or to receive services under Hospital Discount Care. Hospital Discounted Care is generally only available for Colorado residents, but facilities may choose to extend it to non-residents either by policy or on a case-by-case basis. It should be noted that residency and lawful presence are two separate things. Someone may be a Colorado resident even if they are not lawfully present. Facilities must allow undocumented patients who reside in Colorado to apply for Hospital Discounted Care.

Will the patient need a Medicaid denial before qualifying for Hospital Discounted Care?

The patient does not need a Health First Colorado or CHP+ denial prior to qualifying for Hospital Discounted Care. It is the patient’s decision to apply for public health coverage programs like Health First Colorado.

What incentive is there for people to sign up for programs like Medicaid or CICP if they receive a discount under Hospital Discounted Care?

A patient’s financial responsibility is almost always going to be lower if they are covered by Health First Colorado or qualify for the CICP. Health Care Facilities are allowed to inform the patient of the differences in their potential copays in an attempt to encourage them to apply for public health coverage or the CICP. Additionally, Health First Colorado and CHP+ provide comprehensive coverage where CICP does not. Information on the differences between CICP and health insurance can be found at https://hcpf.colorado.gov/health-insurance-vs-cicp and information on the differences between CICP and Health First Colorado can be found at https://hcpf.colorado.gov/medicaid-vs-cicp.

What requirements apply to contacting patients by mail?

The only requirement for patient communications by mail is that a copy of the letter be included in the patient’s file, which is the rule for all communications. Providers should be contacting patients through the patient’s preferred method of communication.

If a patient qualifies for Hospital Discounted Care and comes back month after month does the Health Care Facility have to screen them each month?

No, once the patient qualifies, their determination is generally good for a year from the earlier of their date of service they originally applied to cover or the date of the application.

If the Health Care Facility knows the uninsured patient is over the 250% FPL does the screening still need to be completed?

Yes, and the screening documentation must be kept in the patient’s file showing they are over income.

Are patients who are referred by a provider to a Health Care Facility that is considered out-of-network eligible to be screened for Hospital Discounted Care?

Yes, if the patient is insured and requests a screening, the Health Care Facility must do a screening for Hospital Discounted Care.

Rates

Will the State set rates be lower than what Medicare would pay Critical Access hospitals?

No, the rates for all hospitals will be the higher of the Medicare or Medicaid rate for the facility. For Outpatient services performed by a Critical Access Hospital (CAH) for which there is no Medicare rate, the CAH received an adjustment factor to the Medicaid base rate. This adjustment factor was to better account for what would have been reimbursed through Medicare.

How does the Provider account for CPT code modifiers?

Hospital Discounted Care does not set rates for CPT code modifiers. Outpatient, Inpatient, and professional base rates for all CPT codes are based on the greater of either Medicaid or Medicare rates. Outpatient rates should be applied if the facility’s outpatient department is billing the patient. Professional rates should be applied if the licensed health care professional is billing the patient.

If the rates spreadsheet shows a $0 rate for a CPT code, should we bill our normal rate?

Outpatient, Inpatient, and professional base rates for all CPT codes are based on the greater of either Medicaid or Medicare rates. Any CPT code that is assigned a $0 rate has neither a Medicaid or Medicare set rate. Providers are not allowed to use their own rate for these $0 codes.

Reporting

Will Health Care Facilities be required to provide the same reporting for Hospital Discounted Care and CICP? 

After discussions with the Colorado Hospital Association and various hospitals, the Department has decided that beginning with data from July 1, 2022, providers may report data for Hospital Discounted Care and the CICP in the same data set. Data for CICP providers that covers January through June 2022 will be due to the Department in the spring of 2023. The Hospital Discounted Care legislation outlines specific reporting requirements, which are different than CICP’s. Beginning September 1, 2023, each Health Care Facility is required to report data necessary to evaluate compliance across race, ethnicity, age, and primary language spoken in regards to screening, discounted care, payment plans, collection practices, and any other information the Department deems necessary.

What if the Health Care Facility is not able to disaggregate the data required?

If a Health Care Facility is not capable of disaggregating the data required, then the Health Care Facility must report to the Department the steps the Health Care Facility is taking to improve and the date by which the facility will be able to disaggregate the reported data.

Are new online systems being developed for CICP and Hospital Discounted Care?

There are not any new online systems being developed for CICP or Hospital Discounted Care related to screening patients or completing the application. The Department is working to create new online portals for Health Care Facilities to submit data for the CICP and Hospital Discounted care.

How often will Health Care Facilities be audited for compliance?

The Department will audit for compliance each year. How frequently each facility may be audited will be determined when audit staff are hired and will be according to general auditing principles. Please note that state record retention rules require records are maintained records for a minimum of seven years, or until an audit is completed, whichever is longer, and providers may be subject to audit by the Department or the Office of the State Auditor for any time period for which records are maintained.

Rules

How will the rules for Hospital Discounted Care be enforced for Health Care Facilities, Licensed Health Care Professionals, and other billers?

Reporting and audits will be conducted annually to ensure all applicable rules are being followed. The Department will be keeping track of all appeals filed and all complaints filed with the Department. If the Department finds a repeated pattern of errors related to appeals and complaints filed, the provider may be required to file a corrective action plan and attend additional training with the Department.

What is the effective date for Hospital Discounted Care?

September 1, 2022

What accommodations must Health Care Facilities offer for translation, interpretation, or disability?

Health Care Facilities must comply with federal Americans with Disability Act (ADA) requirements to make appropriate accommodations for patients with disabilities and Title VI of the Civil Rights Act to ensure patients are not being discriminated against based on their race, color, or national origin. Explicitly under the Hospital Discounted Care HB 21-1198 legislation, Health Care Facilities must provide all patients with forms and verbal communication in their primary or preferred language.

How will primary care providers become aware of HB 21-1198?

The Department has put information about HB 21-1198 in multiple editions of the Provider Bulletin that is distributed to all Health First Colorado providers, as well as anyone else who has signed up to receive it. In addition, we are communicating information through the Department’s At A Glance newsletter, our HB 21-1198 newsletter, and through outreach to physician associations and organizations.

How will physicians that are not employed by the Health Care Facility know what the patient is eligible for through the screening and application process?

It is the Health Care Facilities responsibility to ensure that all providers that gave any type of care to the patient are notified of the final determination of eligibility.

Are providers receiving any payments to offset administrative burdens?

No, the HB21-1198 legislation did not allocate any funds to Health Care Facilities for administrative costs. However, all tax exempt, nonprofit hospitals must provide charity care, and the state’s tax paying, for profit hospitals all provide charity care. The state legislation creates minimum standards for hospitals’ charity care programs. While there may be administrative costs associated with changing existing policies to align with the legislation’s requirements, ongoing administrative costs should be no more than administering the hospital’s existing charity care practices.

Can a Health Care Facility choose not to perform an elective service under Hospital Discounted Care?

No. Health Care Facilities must provide medically necessary care usually provided by the facility to all patients. A Health Care Facility cannot deny discounted care on the basis that the patient has not applied for any public benefits program; or adopt or maintain any policies that result in the denial of admission or treatment of a patient because the patient lacks health insurance coverage, may qualify for discounted care, requires extended or long-term treatment, or has an unpaid medical bill.

How will CICP change based on the implementation of Hospital Discounted Care? 

Changes to the CICP are still in development. Changes are being made in order to align the CICP with Hospital Discounted Care as much as possible to reduce the administrative burden for CICP Providers and confusion for CICP Clients.

Can the hospital provide the result of the hospital patient screening for eligibility to doctors practicing in the hospital and billing separately for their services, i.e., Emergency Department doctors, cardiologists, surgeons, anesthesiologist, radiologists and pathologists?

It is the responsibility of the Health Care Facility to provide the eligibility determination for the patient to all providers that seen the patient on the date of service, so they know the correct billing amount to use.

Can we choose to structure our financial assistance plan to allow a complete write off for patients under 250% FPL and still be in compliance with the law?

Providers can always charge less or write off the charges for patients that are 250% and below. However, the screening and application process must still be completed prior to writing off the charges to be compliant with Hospital Discounted Care laws.

Services

Are providers required to provide elective services to uninsured patients who are eligible for Hospital Discount Care?

Providers must provide any services included in or incidental to the furnishing of medical, behavioral, mental health, or substance use disorder; dental, or optometric care; hospitalization; or nursing home care to a patient. As well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing, or healing human physical illness or injury, or behavioral, mental health, or substance use disorder.

Can providers deny elective services for uninsured patients?

Health Care Facilities cannot deny discounted care on the basis that the patient has not applied for any public benefits program, adopt or maintain any policies that result in the denial of admission or treatment of a patient because the patient lacks health insurance coverage, may qualify for discount care, requires extended or long-term treatment, or has an unpaid medical bill.

Are elective procedures included?

Yes. All medically necessary care and all care that is routinely provided at the facility is included. Elective surgery or elective procedure means a surgery or procedure that is scheduled in advance because it does not involve a medical emergency.

How are multiple providers providing care during the same episode of care prioritized?

Unlike the CICP, Hospital Discount Care does not prioritize services. Each Licensed Health Care Professional may set up a payment plan with the patient for up to 2% of the patient’s gross monthly household income. If the patient’s care spans over two or more unrelated facilities, each Health Care Facility may set up their own payment plan with the patient for up to 4% of the patient’s monthly household income.

Are transplant services to be covered by Hospital Discounted Care?

Yes, Health Care Facilities must provide any services included in or incidental to the furnishing of medical, behavioral, mental health, or substance use disorder; dental, or optometric care; hospitalization; or nursing home care to a patient. As well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing, or healing human physical illness or injury, or behavioral, mental health, or substance use disorder.