HMH Charity - Combined Documents (00107744).DOC



HUNTSVILLE MEMORIAL HOSPITAL

Financial Assistance Plain Language Summary

Financial Assistance and Charity care are available if you do not have the ability to pay for healthcare services. Huntsville Memorial Hospital offers two program types. The program types are Walker County Indigent Care, and Charity Care. The type of assistance you may receive depends upon your financial need. The current Federal Poverty Income Requirements are provided within the table below.

|Size of Family Unit |HMH - Charity Walker County |Charity Care |

| |100% Poverty |200% Poverty |

|1 |$12,140.00 |$24,280.00 |

|2 |$16,460.00 |$32,920.00 |

|3 |$20,780.00 |$41,560.00 |

|4 |$25,100.00 |$50,200.00 |

|5 |$29,420.00 |$58,840.00 |

|6 |$33,740.00 |$67,480.00 |

|7 |$38,060.00 |$76,120.00 |

|8 |$42,380.00 |$84,760.00 |

|For families/households with more than 8 persons, add $4,320.00 for each additional person to calculate |

|100% Poverty. |

| |

To apply for Financial Assistance, please complete an application, and provide the completed application with the required documents listed below. Financial Assistance applications are valid for six months. You will need to apply for Financial Assistance every six months if you are still receiving care at the hospital.

Individuals qualified for charity assistance will not be charged more than the amounts generally billed (AGB) for emergency or other medical care provided to individuals with insurance coverage. Additional information regarding the Financial Assistance Policy, Application, and information regarding amounts generally billed (AGB) can be found at .

The Financial Assistance Application can be found online at: dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8590001321

A paper copy of the application is available at the hospital Admissions or Financial Counseling Departments.

Translations of the Financial Assistance Policy, Application, information regarding amounts generally billed (AGB) and the Plain Language Summary are available in Spanish.

Please contact us at 936-291-4543 if you need help with your application.

Required Documents:

Citizenship:

1. Valid Certificate of Naturalization

Identity: Two Types of Identification

1. Driver’s license or other form of picture identification.

2. One other form of identification – (Social Security card, Employee ID, voter’s registration card, birth certificate, or marriage license).

Income: All applicable items must be presented for proof of household income

1. Proof of employment – Paycheck stubs or letter from employer or previous employer with employer’s name, address, telephone number, length of service and money earned.

2. Social security award letter or copy of current check.

3. Copy of current check from any other source such as retirement, disability, or VA benefits,

unemployment, child support, or housing.

4. Food stamp printout / letter or reason for denial.

5. Previous year’s income tax return, W-2 forms, or 1099.

6. Medicare, Medicaid, or CHIP card for any household members.

Residency: Two items must be presented for proof of residence

1. Current telephone bill with your address.

2. Current utility bill with physical address of your residence.

3. Voter’s registration card.

4. Property tax statement for residence.

5. Rent receipt or rental/lease agreement.

Need help completing your application? Call our Financial Counseling Department at: 936-291-4543

Applications can be submitted by:

1. Mail to: Huntsville Memorial Hospital

Attn: Financial Counseling Department

125-B Medical Park Lane

Huntsville, TX 77340

2. Fax to: 936-291-4271

3. Bring completed application in to office, 125 B Medical Park Lane.

Financial Counseling hours: Monday -Thursday 8a.m. to 5p.m

Frequently Asked Questions:

How Will I be notified if I am approved for Financial Assistance?

The process of application review, approval or denial, and patient notification of decision shall not take more than fourteen (14) days for the Walker County Indigent Care, and thirty (30) days for the Charity program, from the date that the application is received with all required information. Notification to patient is by mail.

If I am Approved for the Walker County Indigent Program, What Do I Need to Know?

Walker County Indigent Care Program Facts

|SCHEDULE OF BENEFITS |

|Benefit Plan Year: |January 1st through December 31st |

|Benefit Plan Maximums per Plan Year: |The first of the following to occur in any one Benefit Plan Year: |

| |Total plan payments of $30,000 or |

| |30 days Inpatient Hospital and/or Skilled Nursing Care maximum |

|Eligibility Re-certification: |Every 180 days or as needed |

|Mail all Claims and Correspondence to: |Payor: Huntsville Memorial Hospital |

| |Attn: Financial Counseling |

| |Mailing Address: 125-B Medical Park Lane |

| |Huntsville, TX 77340 |

| |Customer Service: (936)291-4543 |

|Claims Filing Deadline: |95 days from Date of Service |

|Referral Requirements |

The HMH Medical Clinic – Huntsville is the primary care provider (PCP) for this patient population. A referral from the patient’s HMH Medical Clinic PCP is required for any and all services provided outside of their PCP. If a referral to a specialist is granted and the Specialist refers the patient to another Specialist, the patient must first report back to their HMH Medical Clinic PCP to secure the additional referral. ALL REFERRALS MUST ORIGINATE FROM THE HMH MEDICAL CLINIC.

Basic Health Care Services

A. Inpatient hospital services must be medically necessary and provided in an acute care hospital to hospital inpatients, by or under the direction of a physician, and provided for the care and treatment of patients. An itemized bill is required.

B. Outpatient hospital services must be medically necessary and provided in an acute care hospital or hospital-based ambulatory surgical center provided to outpatients and provided by or under the direction of a physician, and are diagnostic, therapeutic or rehabilitative. An itemized bill is required.

C. Physician services must be medically necessary and provided by a physician in the doctor’s office, a hospital, a skilled nursing facility, or elsewhere.

D. Colostomy medical supplies and equipment.

E. Durable medical Equipment including but not limited to crutches, canes, walkers, wheelchairs, hospital beds, home oxygen equipment including all supplies associated with, and glucometers.

F. Immunizations, only when deemed a medically necessary service.

G. Skilled Nursing facility services (SNF) must be medically necessary, ordered by a physician, and provided in a skilled nursing facility that provides daily services on an inpatient basis.

H. Rural health clinic services must be provided in a rural health clinic by a physician, a physician’s assistant, a nurse practitioner, a nurse midwife, or other specialized nurse practitioner.

I. Laboratory and x-ray services are technical laboratory and radiological services ordered by and provided by, or under the direction of, a physician in an office or a similar facility other than a hospital outpatient department or clinic.

J. Medical screening services include blood pressure, blood sugar, and cholesterol screening.

K. Annual physical exams are examinations provided once per calendar year by a physician or a physician’s assistant (PA). Associated testing, such as mammograms, can be covered with a physician’s referral. These services may also be provided by an Advanced Practice Nurse (APN) if they are within the scope of practice of the APN in accordance with the standards established by the Board of Nursing Examiners and published in 22 Texas Administrative code, 221.13.

L. Ambulance transportation when medically necessary due to an immediate life (or limb) threatening situation or with preapproval for transportation from one facility to another.

M. Ambulatory Surgical Center (ASC) services. These services must be provided in a freestanding ASC, and are limited to items and services provided in reference to an ambulatory surgical procedure, including those services on the Center for Medicare and Medicaid Services (CMS) approved list and selected Medicaid-only procedures. An itemized bill is required.

N. Physician Assistant (PA) services. These services must be medically necessary and provided by a PA under the direction of a physician and must be billed by and paid to the supervising physician.

O. Advanced Practice Nurse (APN) services. An APN must be licensed as a registered nurse (RN) within the categories of practice, specifically, a nurse practitioner, a clinical nurse specialist, a certified midwife (CNM), and a certified registered nurse anesthetist (CRNA), as determined by the Board of Nurse Examiners, APN services must be medically necessary, provided within the scope of practice of an APN and covered in the Texas Medicaid Program.

Exclusions and Limitations

1. Services not specifically provided by the Walker County Indigent Care Program.

2. Services that are not medically necessary or performed outside of the United States.

3. Services that are provided to a patient before or after the time period that the patient is eligible for the program.

4. Separate fees for completing or filing a claim under the program.

5. Services or supplies that are not reasonable and necessary for diagnosis and/or treatment.

6. Immunizations. See the HMH Medical Clinic – Huntsville for immunizations.

7. Services provided by a patient’s immediate relative or household member.

8. Services that are payable by or available under any health, accident, or any other insurance coverage; by any private or other governmental benefit system; by any legally liable third party; or under any other contract.

9. Services that are provided by military medical facilities; Veterans Administration facilities; or United States public health service hospitals.

10. Services that are related to any condition covered under the worker’s compensation laws.

11. Services resulting from a vehicular accident.

12. Separate payments for services and supplies to an institution that receives a vender payment or has a reimbursement formula that includes the services and supplies as a part of institutional care.

13. Whole blood or packed red cells available at no cost to the patient.

14. Take home items and drugs or nonprescription drugs.

15. Acupuncture.

16. All podiatry services (except for diabetics).

17. Prosthetic devices. Orthotic devices, except for diabetics.

18. Recreational therapy.

19. Custodial care (except for skilled nursing facility care).

20. Autopsies.

21. Prescriptions for and the cost of supportive devices for the feet.

22. Hearing aids and hearing exams.

23. Chiropractors.

24. Dental care.

25. Routine vision care including eyeglasses, except for diabetics.

26. Family planning services.

27. Maternity.

28. Infertility.

29. Hospice services.

30. Mental Health / Counseling Services. Social and educational counseling. Psychotherapy services must be medically necessary based on a physician referral and provided by a licensed professional counselor (LPC), a licensed master social worker-advanced clinical practitioner (LMSW-ACP), a licensed marriage family therapist (LMFT), or a PH. D. psychologist. These services may also be provided based on an APN referral if the referral is within the scope of their practice in accordance with the standards established by the Board of Nurse Examiners and published in 22 Texas Administrative Code 221.13.

31. Services for Alcohol, Chemical dependency or Substance abuse.

32. Diabetic medical supplies and equipment including but not limited to lancets, syringes, test strips, and pens.

If I Am Approved for Huntsville Memorial Hospital and Clinic Charity Care, What Do I Need to Know?

Financial Assistance applications are valid for six months. You will need to apply for Financial Assistance every six months if you are still receiving care at the hospital.

In addition to hospital charges, you may receive separate bills from physicians and other providers who participated in your care. These providers include your referring physician, attending physician, and specialists who are separately contracted and may not be network providers for your healthcare plan. They may be governed by billing rules and procedures that are not the same as the hospital or clinic. They may have different criteria for financial assistance application and qualification. Application and qualification for financial assistance at the hospital and/or clinic is separate from any financial assistance application and qualification that may be required by other providers. Billing questions for these providers should be directed to their individual offices. Contact information is provided below for Emergency Room Physicians, Radiologists, Pathologists, Anesthesiologists, and Hospitalists. If you have questions regarding a specific provider of service who is not listed below, please contact us at 936-291-3411.

|HMH Hospital Emergency Room Physicians |Anesthesiologists |

|Team Health |Premier Anesthesia |

|2620 Ridgewood Road #300 |2655 Northwinds Pkwy |

|Akron, OH 44313 |Alpharetta, GA 30009 |

|(888) 952-6772 |(877) 742-0399 |

|Pathologists |Radiologists |

|Community Pathology Associates |Bryan Radiology Associates |

|P.O. Box 4677 |2722 Osler Blvd., P.O. Box 5306 |

|Houston, TX 77210-4677 |Bryan, TX 77805 |

|(800) 262-8848 or (713) 798-3677 |(979) 776-8291 |

|Hospitalists |Madisonville Emergency Room Physicians |

|Hospitalist Doc |Emergency Physician Billing Services |

|PO BOX 946 |3303 South Meridian |

|Montgomery TX 77356 |Oklahoma City, OK 73119 |

|(281) 408-4108 |(800) 225-0953 |

What Are My Rights If My Application is Denied?

If your request for uncompensated services has been denied, you may appeal within thirty (30) days after you have received the Notice of Denial of Application.

The Application for Appeal is located on the Huntsville Memorial Hospital internet at: . A paper copy of the appeal form is available at the hospital Admissions or Financial Counseling Departments.

Need help? Call our Financial Counseling Department at: 936-291-4543

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