CHARITY CARE

A REQUIREMENT FOR ASCs IN NEW YORK

Debbie Comerford, RN BSN, CNOR, CASC, LHRMVice President of Operations, ASCOA

Charity Care Requirement

• All ASCs whether freestanding or hospital-based, are required to provide charity care

• Definition: Care provided at no charge or reduced charge for the services the facility is certified to provide to patients who are unable to pay full charges, are not eligible for covered benefits under Title XVIII (Medicare) or XIX (Medicaid) of the SSA or are not covered by private insurance

How much is enough?

• Previously the Department expected a minimum charity level of 2% of projected cases and a Medicaid level of 5%.

• Many freestanding ASC fail to reach their projections within their 5 year limited life period.

• The Department formed a committee to identify obstacles to attainment of targets and to consider how to tailor the application of the regulation 709.5 in light of the changing circumstances of the health care system.

Challenges

Affordable Care Act’s Impact• In 2013 16% of all New York

residents were without health insurance coverage.

• More than 2.1 million people—over ten percent of the State’s population—enrolled in health insurance through the Marketplace by February 28, 2015.

• http://info.nystateofhealth.ny.gov/sites/default/files/2015%20NYSOH%20Open%20Enrollment%20Report.pdf

Fewer Uninsured • Among the 2014 enrollees,

more than 80 percent were uninsured prior to enrolling in coverage, so NY is certainly making a huge dent in its uninsured population.”

• (http://www.healthinsurance.org/new_york-state-health-insurance-exchange/)

Committees recommendations to PHHPC

• The committee recognized that the health care system is undergoing continuous changes

• No specific minimum or optimum proportion of Medicaid and charity cases that can be prescribed uniformly to meet the requirements of 709.5 was recommended

• Committee recommended that each ASC be evaluated individually, according to its proposed and actual volume of services to the underserved.

Prospective Assessment of Effort

• In the initial application ASCs should propose a targeted volume of Medicaid and charity cases reflective of their services and service area

• Helpful hints: – Include two or more Medicaid managed care plans or letters of

intent from the plans– Include documentation of efforts and contracts obtained with

FQHCs (Federally Qualified Health Centers) or other organizations and advocacy groups for the underserved

– A written plan, including a staffing plan, to conduct outreach to underserved groups, develop referral arrangements with FQHCs, and navigate patients through the scheduling of appointments, surgery and post-surgical follow up.

Retrospective

• The goal is to achieve an indefinite certification at the end of the initial 5 year period.

• If unable to reach the goals proposed in the initial CON, a freestanding ASC must prove that they should be adjusted.

• Document the effects of health system changes and facility activities that have had a bearing on the ASC’s ability to reach the underserved

FQHC’s: Federally Qualified Health Centers

• 57 in New York State• May have an arrangement with local

hospital-based ASCs– Attempt to work with local FQHC’s to obtain patient referrals

to center’s surgeons– Document all efforts– Track patients referred to the center from FQHCs

• Activities that may help compensate for a low volume of charity care cases:

• Higher than expected Medicaid population• Incursion of higher than expected bad debt attributable

to services to individuals covered by policies with high co-pays and deductibles under ACA

• ASC enrollment into Medicaid of patients who initially present as uninsured but are found to be Medicaid eligible.

Examples

Medicaid Visits Exchange Visits

Blue Cross Blue Shield Cases 365Blue Cross/Blue Shield Exchange patients 15Percentage of Blue Cross Exchange 4.11%

Conclusion

• All ASCs must provide free care• Know your community and its demographics• Document all efforts• Track all data related to free and reduced care

– Medicaid cases– Bad debt from high deductible plans– Exchange patients– Reduced commercial fees based on charity care

policy sliding scale