N.J. Admin. Code § 10:7-4.2

Current through Register Vol. 56, No. 9, May 6, 2024

Section 10:7-4.2 - Charity Care Fee Scale income eligibility criteria and documentation

(a) The county adjuster shall determine the applicant's family size in accordance with this section. Family size for an adult applicant includes the applicant, spouse, any minor children whom he or she supports, and adults for whom the applicant is legally responsible. The family size for a minor applicant includes both parents, the spouse of a parent, minor siblings and any adults in the family for whom the applicant's parent(s) are legally responsible. If an applicant documents that he or she has been abandoned by a spouse or parent, that spouse or parent shall not be included as a family member. A pregnant female counts as two family members.

(b) The Poverty Guidelines, revised annually pursuant to the requirement of 42 U.S.C. § 9902(2) by the United States Department of Health and Human Services (HHS), are hereby incorporated by reference. (For further information on the Poverty Guidelines, contact the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, Washington, D.C. 20201, Telephone (202) 690-6141.) A person is eligible for charity care or reduced charge charity care if he or she falls into one of the following categories:

1. A person whose individual or, if applicable, family income, as determined by (e) below, is less than or equal to 200 percent of the HHS Poverty Guidelines shall be eligible for charity care for necessary health services without cost; or

2. A person whose individual or, if applicable, family income as determined by (e) below, is greater than 200 percent of the HHS Poverty Guidelines but not more than 300 percent of these guidelines is eligible for charity care at a reduced rate as described in (c) below.

(c) A person who is eligible for reduced charge health services shall be charged a percentage of the normal charge for health services as described in the Charity Care Fee Scale below. The reduced percentage can be applied to the total bill or to any remainder after third-party payment.

Income as a percentage of	Percentage of charges
HHS Poverty Guidelines	paid by applicant
</=200	0
>200 to 225	20
>225 to 250	40
>250 to 275	60
>275 to 300	80
>300	100

(d) If qualified medical expenses, as defined for the purposes of Federal income tax deductibility, for applicants eligible for reduced charge charity care exceeds 30 percent of the applicant's or, if applicable, family's annual gross income as calculated by (e) below, such excess will be eligible for 100 percent coverage under charity care. The 30 percent threshold must be met once per family in a 12-month period.

(e) An applicant's income, for the purpose of determining eligibility for charity care or reduced charge charity care, shall be determined as follows:

1. The applicant may provide proof of the actual gross income for the 12 months immediately preceding the services;

2. The applicant may provide proof of actual gross income for the three months immediately preceding services. The county adjuster shall multiply this amount by four to determine the gross annual income; or

3. The applicant may provide proof of actual gross income for the month immediately preceding service. The county adjuster shall multiply this amount by 12 to determine the gross annual income.

4. If the applicant provides documentation for more than one salary period specified in (e)1 through 3 above, the county adjuster shall use the period of time during which the salary was the lowest.

5. If the applicant is a welfare recipient receiving cash benefits for living expenses, and has not documented income as described in (e)1 through 3 above, the county adjuster shall document income status by obtaining a photocopy of the applicant's welfare identification, and document that the staff of the county adjuster obtained verification in writing or by phone of the applicant's current benefit amount from the appropriate local welfare office.

6. An applicant shall supply a signed attestation showing his or her unreported income in order that that income be considered in the eligibility determination, as described in (b) above.

(f) Applicants for charity care shall provide the county adjuster with proof of income as listed below:

1. An applicant shall provide the county adjuster with proof of income, which includes the following items: Federal or State income tax return; pay check stubs; W-2 forms; a letter from an employer on company letterhead stating the applicant's income; or a statement of the gross benefit amount from any governmental agency providing benefit to the applicant. If an applicant has been employed for at least one month, he or she may document his or her income by providing one paycheck stub immediately prior to the date of service if the paycheck stub indicates a year-to-date income, and if the applicant documents the length of time he or she has been employed by the employer.

i. If an applicant is a recipient of Social Security benefits, he or she may document this income by either providing the annual benefits statement from the Social Security Administration, or copies of bank statements from three months prior which indicate direct deposit of the Social Security check, or a copy of one Social Security check.

ii. An applicant with no income or benefits of any type may present the county adjuster with a signed attestation to this effect. If the applicant is homeless, the county adjuster may accept a signed attestation which states that the applicant is homeless and receives no support, income or benefits.

iii. If the applicant is unable to provide one of the documents listed above in this paragraph, the county adjuster staff shall document reasons for the applicant's inability to comply and request the documentation listed in (f)2 below.

2. An applicant may document his or her income by providing one paycheck stub immediately prior to the date of service. If the applicant is unable to provide this documentation, the county adjuster staff must document reasons for the applicant's inability to comply and request the documentation listed in (f)3 below.

3. An applicant may document his or her income by providing an attestation which states the income received in one of the time periods described in (e)1 through 3 above.

(g) For adult applicants, only the income of the applicant will be considered for the eligibility determination. For a minor applicant, the income of the family, as determined by (a) above, will be considered. In situations where a minor applicant's parents are divorced, and the custodial parent(s) are remarried, the nonparental spouse's income shall be considered. In situations where both divorced parents have responsibility for the minor applicant's medical care, each parent shall complete a charity care application. For a minor applicant, the income of the family shall be considered, except for earned income of the minor child and siblings. In cases where an adult applicant has been abandoned by a spouse, or a minor applicant has been abandoned by a parent, the applicant may document that a spouse's or parent's income is not available by the following steps in (h) below.

(h) If a minor applicant's parents are divorced, and one of the parents is uncooperative, as defined in (h)1 through 3 below, with the application process, the requirement for that parent's income may be waived by the county adjuster based on the following:

1. A parent or spouse may be deemed uncooperative if the applicant documents at least one unsuccessful attempt to obtain the necessary information from the parent or spouse;

2. The parent or spouse does not respond to a letter from the county adjuster indicating the possibility of collection or legal action if he or she does not provide the necessary information for the application; and

3. The parent or spouse does not respond to the county adjuster's in-house information collection process.

(i) If a minor applicant's parents are separated, but not legally divorced, the applying spouse may document that he or she has no financial ties with the estranged spouse in accordance with (i)1 through 4 below, and the county adjuster may waive the requirement for the estranged spouse's income, if documentation has been provided in accordance with the following:

1. An applying spouse may be deemed to have no financial ties to the estranged spouse if the applying spouse provides proof to the county adjuster that he or she is not living with the estranged spouse, and does not own any property or share a lease to a rental property with the estranged spouse;

2. The applying spouse provides a copy of his or her most recent tax return indicating that he or she filed taxes separately. If estrangement occurred after filing jointly, the county adjuster may hold the application until the applying spouse files the next tax return separately. If an applying spouse does not file tax returns, he or she must sign an attestation to this effect explaining his or her reasons;

3. The applying spouse provides copies of all his or her financial accounts showing the applying spouse with sole ownership of his or her assets; and

4. The applying spouse provides an attestation stating that he or she is separated from and has no financial ties to the estranged spouse.

(j) The county adjuster may request that the applicant document his or her living expenses.

(k) A minor applicant who documents that both parents have abandoned him or her shall provide documentation of the income and assets of his or her guardian(s).

(l) The county adjuster may accept a charity care determination from another New Jersey county adjuster as proof of income, provided that the effective date of the charity care determination is not more than one year earlier than the date of service at the second hospital and that the second county adjuster verifies the determination with the county adjuster that issued the determination. The determination by the second county adjuster is valid for one year from the effective date of the first county adjuster's determination.

(m) An applicant shall provide proof that:

1. His or her individual assets as of the date of service do not exceed $ 7,500; and

2. His or her family's assets, if applicable, do not exceed $ 15,000 as of the date of service.

(n) The county adjuster shall consider the assets of the patient and all family members as defined in (a) above. In the case of an applicant who is married, determination of the spousal share of the combined assets of the couple will be consistent with the requirements of 10:71-4.8(a)1, except that the asset limitations set forth in (m) above shall be utilized.

(o) Assets, as used in this section, are items which are, or which can be readily converted into, cash. This includes, but is not limited to, cash, savings and checking accounts, certificates of deposit, treasury bills, negotiable paper, corporate stocks and bonds, Individual Retirement Accounts (IRAs), trust funds, and equity in real estate other than the applicant's or family's if applicable, primary residence. A primary residence, for the purposes of charity care, is defined as a structure within which the applicant currently lives or real property which the applicant owns but is not able to convey or sell because of a family member's legal or equitable interest in the property. If an applicant jointly owns assets with another person(s), for whom the applicant is not legally responsible, the value of these assets shall be prorated equally among all the owners.

(p) The applicant shall document the value of all applicable assets as described in (p)1 through 3 below.

1. The applicant shall present the county adjuster with a statement from a bank or other applicable financial institution showing the value of the asset(s) as of the date of service. If an applicant has no assets, he or she may sign an attestation to that effect, and this fulfills the requirement for proof of assets. If the applicant is unable to obtain such documentation, the county adjuster staff shall document, in writing, the reason why the proof could not be provided, and request proof of assets as described in (p)2 below.

2. The applicant shall provide the county adjuster with a statement from the bank or other applicable financial institution showing the average daily balance of the asset(s) within one month of the date of service. If the applicant is unable to obtain such documentation, the county adjuster staff shall document, in writing, the reason why the proof could not be provided, and request proof of assets as described in (p)3 below.

3. The applicant shall present the county adjuster with a signed statement attesting to the type and value of the assets.

(q) The assets of an applicant for charity care shall be counted only after the applicant has had an opportunity to apply any amount of assets in excess of the limits in (a) above toward qualified medical expenses. Qualified medical expenses are those amounts deductible for the purpose of calculation of Federal income tax liability and include expenses for psychiatric hospitalization and other mental health related costs.

(r) A county adjuster shall, as a condition of finding any applicant eligible for charity care or reduced charge charity care, require the applicant to furnish any information that is reasonably necessary to substantiate the applicant's income and assets and that is within the applicant's ability to supply.

(s) An applicant who willfully presents false information, or fails to submit requested information without good cause, will be liable for all hospital charges.

N.J. Admin. Code § 10:7-4.2

New Rule, R.2007 d.71, effective 3/5/2007.
See: 38 N.J.R. 1978(a), 39 N.J.R. 772(b).