PetitionCal. Super. - 6th Dist.October 28, 2019KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO Fred W. Schwinn (SBN 225575) Raeon R. Roulston (SBN 255622) Matthew C. Salmonsen (SBN 302854) CONSUMER LAW CENTER, INC. 1435 K011 Circle, Suite 104 San Jose, California 95 1 12-4610 Telephone Number: (408) 294-6100 Facsimile Number: (408) 294-6190 Email Address: fred.schwinn@sjconsumerlaw.com Attorneys for Petitioners EMILY JEANNE HEPNER, MARIA ANGELA CORTEZ, and DIEGO ARMANDO GALLEGOS Electronically Filed by Superior Court of CA, County of Santa Clara, on 10/28l2019 12:55 PM Reviewed By: L Del Mundo Case #1 9CV357560 Envelope: 3575473 SUPERIOR COURT OF THE STATE OF CALIFORNIA COUNTY OF SANTA CLARA EMILY JEANNE HEPNER, individually and 0n behalf 0f the general public; MARIA ANGELA CORTEZ, individually and 0n behalf of the general public; and DIEGO ARMANDO GALLEGOS, individually and on behalf of the general public, Petitioners, V. COUNTY OF SANTA CLARA, D/B/A SANTA CLARA VALLEY MEDICAL CENTER; PAUL E. LORENZ, in his official capacity; and DOES 1 through 10, inclusive, Respondents. Case NO. 19CV357560 (Unlimited Civil Case) VERIFIED PETITION FOR WRIT OF MANDATE AND VERIFIED COMPLAINT FOR DECLARATORY RELIEF, EQUITABLE RELIEF, AND INJUNCTIVE RELIEF [Code 0f Civil Procedure § 1085] Petitioners, EMILY JEANNE HEPNER, MARIA ANGELA CORTEZ, and DIEGO ARMANDO GALLEGOS (hereinafter collectively “Petitioners”), individually and 0n behalf 0f the general public, based 0n information and belief and investigation 0f counsel, except for those allegations which pertain t0 the named Petitioners 0r their attorneys (Which are alleged on personal knowledge), hereby make the following allegations: INTRODUCTION 1. This Petition for Writ of Mandate and Complaint for Declaratory Relief, Equitable PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO Relief, and Injunctive Relief, pursuant t0 California Code 0f Civil Procedure § 1085, seeks to compel COUNTY OF SANTA CLARA, D/B/A SANTA CLARA VALLEY MEDICAL CENTER (“SCVMC”), to comply with the California Hospital Fair Pricing Policies Act, California Health & Safety Code §§ 127400-127446 (“HFPA”). Specifically, Petitioners 0n behalf of themselves, and the general public, seek an Order mandating, inter alia, that SCVMC charge Petitioners and members 0f the general public for medical services received at the rates for which they were and are qualified based 0n their family size and income, pursuant t0 the HFPA and Respondents’ own Charity and Discount Policy. In n0 instance should Petitioners and other eligible SCVMC patients be charged more than the Medi-Cal reimbursment rate. 2. Health & Safety Code § 127405(d) provides: A hospital shall limit expected payment for services it provides t0 a patient at or below 350 percent of the federal poverty level, as defined in subdivision (b) 0f Section 127400, eligible under its discount payment policy to the amount 0f payment the hospital would expect, in good faith, t0 receive for providing services from Medicare, Medi-Cal, the Healthy Families Program, or another government-sponsored health program 0f health benefits in Which the hospital participates, whichever is greater. If the hospital provides a service for Which there is n0 established payment by Medicare 0r any other government-sponsored program of health benefits in Which the hospital participates, the hospital shall establish an appropriate discounted payment. 3. Under California’s HFPA, hospitals such as SCVMC must provide free or discounted care t0 “financially qualified patients.” Additionally, hospitals are required to provide to its patients written notice 0f the discount payment and charity care policies, including information about eligibility. In this regard, Health & Safety Code § 127410(a) states: Each hospital shall provide patients with a written notice that shall contain information about availability 0f the hospital’s discount payment and charity care policies, including information about eligibility, as well as contact information for a hospital employee or office from which the person may obtain further information about these policies. This written notice shall be provided in addition t0 the estimate provided pursuant t0 _ 2 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO Section 1339.585. The notice shall also be provided t0 patients Who receive emergency 0r outpatient care and who may be billed for that care, but Who were not admitted. The notice shall be provided in English, and in languages other than English. The languages to be provided shall be determined in a manner similar t0 that required pursuant t0 Section 12693.30 0f the Insurance Code. Written correspondence to the patient required by this article shall also be in the language spoken by the patient, consistent with Section 12693.30 of the Insurance Code and applicable state and federal law. (Emphasis added). 4. Whether uninsured or under-insured, all eligibility under the HFPA is predicated 0n the patient’s income being less than 350% 0f the Federal Poverty Level (“FPL”). HFPA notices and written correspondence t0 the patients are required t0 be in the patient’s spoken language and posted notices must be clear and conspicuous. 5. For purposes of eligibility for discounted payment, documentation of income is limited t0 recent pay stubs 0r income tax return. Thus, t0 be compliant With the HFPA’s mandate t0 include information about eligibility, all notices and financial aid applications should state that the various financial aid programs require that the patient’s family income being less than 350% of the FPL, and ideally should include the actual dollar amounts for family sizes 0f 1-4 persons. 6. Despite receiving hundreds 0f millions 0f taxpayer dollars to provide charity and discount care t0 eligible members of the public such as Petitioners, Respondents are Violating the mandates 0f the HFPA in that its notices provide n0 information about eligibility. Respondents’ Violations 0f the HFPA result in patients who, regardless of their financial status 0r ability t0 pay, do not know that financial assistance may be available t0 them and are therefore charged unreasonable and excessive self-pay rates for medical care, and many are thereafter subjected t0 debt collection lawsuits. 7. The Petitioners are three uninsured individuals, who each received medical treatment at SCVMC. At the time 0f service, Petitioners each met the eligibility criteria to qualify for discount 0r charity rates pursuant t0 the HFPA, and under Respondents’ own Charity and Discount _ 3 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO Policy. However, due t0 lack of proper notice, screening, information, follow up, and follow through by Respondents, Petitioners were all denied the opportunity t0 apply and/or qualify for and receive these State mandated benefits. 8. Petitioner, EMILY JEANNE HEPNER, specifically advised SCVMC’s representative 0f her lack 0f insurance and concern about payment before agreeing t0 have a medical procedure preformed. SCVMC’S representative assured Ms. Hepner that she would qualify for discount 01‘ charity rates, and would only be liable for a maximum of $125 under SCVMC’S self-insurance program (i.e., “Ability t0 Pay Program”). Ms. Hepner completed an Application for Financial Assistance with SCVMC’S representative, but never received an approval or denial, and was never asked t0 provide any additional information 0r documentation regarding her income or family size. 9. Petitioner, MARIA ANGELA CORTEZ, a Spanish language speaker, was never screened or provided any information 0r notice regarding Respondents’ discount payment 0r charity programs in her spoken language (Spanish). 10. Petitioner, DIEGO ARMANDO GALLEGOS, was homeless and unemployed when he was taken by ambulance to SCVMC, but he was never screened or provided any information 01‘ notice regarding Respondents’ discount payment 0r charity programs. 11. Rather than comply With the HFPA, Respondents instead billed each 0f the Petitioners for hospital and medical services at very high self-pay rates, turned Petitioners over to collections, and then filed separate collection lawsuits against each Petitioner. Petitioners EMILY JEANNE HEPNER and MARIA ANGELA CORTEZ were each sued for amounts in excess 0f $32,000, and Petitioner, DIEGO ARMANDO GALLEGOS, was sued for an amount in excess of $8,000 plus attorneys’ fees and court costs. 12. Respondents have failed to properly implement either the mandated requirements _ 4 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO 0f the California HFPA, 0r Respondents’ own charity and discount policies to screen patients and provide proper notice 0f the mandated financial assistance programs Which include eligibility information. As a result, Petitioners and the general public have been denied, and are currently being denied, benefits t0 Which they were and are lawfully entitled. 13. Petitioners and the general public should receive the benefits that the California Legislature intended, and for which Respondents receive millions 0f dollars 0f Federal and State funding t0 provide this community benefit and serve this vulnerable population. 14. Petitioners seek, 0n behalf 0f the general public, a Writ 0f Mandate directing and enjoining Respondents to fully comply with the California HFPA and ensure that eligible members of the general public receive the mandated notices and benefits t0 Which they are entitled. 15. Petitioners further request that the Court’s mandate direct Respondents t0 grant all of their patients an opportunity t0 apply 0r reapply for financial assistance even if their accounts have been sent t0 collections and/or legal proceedings commenced against them, t0 refund any excess monies paid in excess 0f the amounts said patients were eligible t0 pay at the time 0f service, and to release any liens and cease any gamishments of these excess amounts. 16. Petitioners further seek a public injunction t0 specifically enjoin Respondents from their current business practices, in Which Respondents: 1) fail t0 properly inform patients of the eligibility criteria to qualify for discount or charity rates pursuant to the HFPA; 2) fail t0 properly screen patients for such eligibility; 3) fail to provide clear and conspicuous notice t0 patients which includes eligibility information; 4) fail t0 provide notice and written correspondence in the patient’s spoken language; 5) fail to inform patients of the required income documentation; 5) fail t0 provide notification t0 patients that an Application for Financial Assistance has been rejected With information regarding the patient’s right t0 appeal; 6) fail t0 affirmatively track and follow up With patients t0 _ 5 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO document their eligibility; and 7) fail t0 give patients an opportunity t0 prove their eligibility at any point in the process even after collections and legal proceeding have commenced. PARTIES 17. Petitioner, EMILY JEANNE HEPNER (“HEPNER”), is a natural person, and is and was a resident 0f Santa Clara County at all relevant times. On the date 0f service, HEPNER was a “financially qualified patient” as that term is defined by Health & Safety Code § 127400(c), and “a patient with high medical costs” as that term is defined by Health & Safety Code § 127400(g). 18. Petitioner, MARIA ANGELA CORTEZ (“CORTEZ”), is a natural person, and is and was a resident 0f Santa Clara County at all relevant times. On the date 0f service, CORTEZ was a “financially qualified patient” as that term is defined by Health & Safety Code § 127400(c), and “a patient With high medical costs” as that term is defined by Health & Safety Code § 127400(g). 19. Petitioner, DIEGO ARMANDO GALLEGOS (“GALLEGOS”), is a natural person, and is and was a resident of Santa Clara County at all relevant times. On the date 0f service, GALLEGOS was a “financially qualified patient” as that term is defined by Health & Safety Code § 127400(c), and “a patient with high medical costs” as that term is defined by Health & Safety Code § 127400(g). 20. Respondent, COUNTY OF SANTA CLARA, D/B/A SANTA CLARA VALLEY MEDICAL CENTER (“SCVMC”), owns and operates a “hospital” as that term is defined by Health & Safety Code § 127400(d); and a “general acute care hospital” as that term is defined by Health & Safety Code § 1250(a); and a “designated public hospital” as that term is defined by Welfare and Institutions Code § 14166.1(d)(20). SCVMC is a Disproportionate Share Hospital (DSH) and receives state and federal funds t0 subsidize the costs associated With providing care to uninsured and very low-income people.1 1 In 2012, SCVMC received $197 million in Disproportionate Share Hospital (DSH) payments. _ 6 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO 21. Respondent, PAUL E. LORENZ (“LORENZ”), is a natural person and is sued in his capacity as the Chief Executive Offer 0f SCVMC. Petitioners are informed and believe, and thereon allege, that LORENZ sets and approves SCVMC’S collection policies, practices, procedures, and he directed, approved, and/or ratified the unlawful activities described herein. 22. The true names and capacities, whether individual, corporate, associate, governmental, or otherwise, of Respondents, DOES 1 through 10, are unknown to Petitioners at this time, who therefore sue said Respondents by such fictitious names. When the true names and capacities of said Respondents have been ascertained, Petitioners will amend this Petition accordingly. Petitioners are informed and believe, and thereon allege, that each Respondent designated herein as a DOE is responsible, negligently 0r in some other actionable manner, for the events and happenings hereinafter referred t0, and caused damages thereby to Petitioners and eligible members 0f the general public, as hereinafter alleged. 23. At all times herein mentioned, each 0f the Respondents was the agent, servant, employee, and/or joint venturer of his/her/its Co-Respondents, and each 0f them, and at all said times, each Respondent was acting in the full course and scope of said agency, service, employment, and/or joint venture. Any reference hereafter t0 “Respondents” without further qualification is meant by Petitioners t0 refer t0 each Respondents, and all 0f them, named above. 24. Petitioners are informed and believe, and thereon allege, that at all times herein mentioned, Respondents, DOES 1-10, inclusive, were and are individuals, corporations, partnerships, unincorporated associations, sole proprietorships, and/or other business entities organized and existing under and by Virtue 0f the laws 0f the State of California, or the laws of some other state or foreign jurisdiction, and that said Respondents, and each 0f them, have regularly conducted business in the County of Santa Clara, State 0f California. _ 7 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO JURISDICTION AND VENUE 25. Venue is proper in the Santa Clara Superior Court, pursuant t0 California Code 0f Civil Procedure § 395, because Respondents’ primary place 0f business is in the County of Santa Clara. CALIFORNIA HOSPITAL FAIR PRICING ACT 26. On September 29, 2006, Governor Arnold Schwarzenegger signed AB 774, a bill sponsored by Assemblywoman Wilma Chan regarding hospital fair pricing policies for uninsured (self- pay) and under-insured patients. The statute known as the Hospital Fair Pricing Policies Act became effective 0n January 1, 2007, and is codified as Health & Safety Code §§ 127400-127446. 27. The intended purpose ofAB774 was to address fair pricing policies specifically as they relate t0 the prices paid by uninsured and under-insured patients for hospital services. Prior t0 the passage of AB774, hospitals provided charity 0r discounted care t0 patients With incomes in excess of the FPL voluntarily, some following guidelines published by the California Hospital Association, but compliance was not mandatory. Health Care California, a consumer protection organization that supported the bill, claimed that very few hospitals adhered to the voluntary guidelines. 28. Once enacted, California’s HFPA law mandated that hospitals provide free 0r discounted care t0 financially qualified patients as a condition of licensure. Hospitals are now required by law t0 have written financial assistance policies and t0 notify patients that financial assistance is available. The law sets minimum eligibility requirements for free 0r discounted care for the uninsured and under-insured members 0f the public, and limits What hospitals can charge patients Whose family income is less than 350% 0f the FPL. These guidelines are mandatory, not voluntary. The HFPA clearly states that hospitals “shall comply with the provisions 0f this article ...” Heath & Safety Code § 127401. Paramount to the Legislature’s goal is that hospitals provide the “community benefit” of charity and discount medical care t0 its “vulnerable populations” as those terms are defined in Heath & _ 8 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO Safety Code §§ 127345(c) and (h). “FINANCIALLY QUALIFIED PATIENTS” AS DEFINED BY THE CALIFORNIA HOSPITAL FAIR PRICING ACT 29. The HFPA directs hospitals t0 provide charity and discounted care t0 the “vulnerable populations” in California by identifying and serving “financially qualified patients” who are defined in Health and Safety Code § 127400(c): (c) “Financially qualified patient” means a patient Who is both 0f the following: (1) A patient who is a self-pay patient, as defined in subdivision (f), or a patient with high medical costs, as defined in subdivision (g)- (2) A patient who has a family income that does not exceed 350 percent 0f the federal poverty level. The definition of “financially qualified patient” references a “self-pay patient” who is defined in Health and Safety Code § 127400(0: (f) “Self-pay patient” means a patient Who does not have third-party coverage from a health insurer, health care service plan, Medicare, 0r Medicaid, and whose injury is not a compensable injury for purposes of workers’ compensation, automobile insurance, 0r other insurance as determined and documented by the hospital. Self-pay patients may include charity care patients. The definition of “financially qualified patient” also references “a patient With high medical costs” Who is defined in Health and Safety Code § 127400(g): (g) “A patient with high medical costs” means a person whose family income does not exceed 350 percent of the federal poverty level, as defined in subdivision (b). For these purposes, “high medical costs” means any 0f the following: (1) Annual out-of-pocket costs incurred by the individual at the hospital that exceed 10 percent of the patient’s family income in the prior 12 months. (2) Annual out-of-pocket expenses that exceed 10 percent 0f the patient's family income, if the patient provides documentation 0f the patient’s medical expenses paid by the patient or the patient's _ 9 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO family in the prior 12 months. (3) A lower level determined by the hospital in accordance with the hospital’s charity care policy. CALIFORNIA HOSPITAL FAIR PRICING ACT NOTICE RE UIREMENTS 30. In addition to identifying the financially qualified patients to whom hospitals are required to provide charity 0r discount services, the Legislature directs hospitals t0 provide patients notice 0f this community benefit for Which they are potentially entitled. Health and Safety Code § 127410 (emphasis added) mandates the notice requirements: (a) Each hospital shall provide patients with a written notice that shall contain information about availability of the hospital’s discount payment and charity care policies, including information about eligibility, as well as contact information for a hospital employee or office from which the person may obtain further information about these policies. This written notice shall be provided in addition to the estimate provided pursuant t0 Section 1339.585. The notice shall also be provided t0 patients who receive emergency 0r outpatient care and Who may be billed for that care, but Who were not admitted. The notice shall be provided in English, and in languages other than English. The languages to be provided shall be determined in a manner similar t0 that required pursuant to Section 12693.30 0f the Insurance Code. Written correspondence t0 the patient required by this article shall also be in the language spoken by the patient, consistent with Section 12693.30 0f the Insurance Code and applicable state and federal law. (b) Notice 0f the hospital’s policy for financially qualified and self-pay patients shall be clearly and conspicuously posted in locations that are Visible t0 the public, including, but not limited t0, all of the following: (1) Emergency department, if any. (2) Billing office. (3) Admissions office. (4) Other outpatient settings. 31. The HFPA also requires hospitals t0 provide their uninsured patients With notice 0f the hospital’s discount payment and charity care programs at the time 0f discharge and in any patient billing statements. See, Health and Safety Code § 127420(b). _ 10 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO RESPONDENTS HAVE FAILED TO PROVIDE PATIENTS INFORMATION ABOUT ELIGIBILITY IN THEIR WRITTEN AND POSTED NOTICES 32. In order t0 give Petitioners and the general public notice 0f SCVMA’S discount payment and charity care programs available t0 them, Respondents are required t0 include eligibility information in the required HFPA notices. The eligibility requirements are enumerated in the HFPA’s definition of “financially qualified patient” as cited and quoted above. 33. Pursuant t0 Health and Safety Code § 127400(c)(2), the threshold for eligibility is whether “a patient has a family income that does not exceed 350 percent of the federal poverty level.” And Health and Safety Code §§ 127410(a) and (b) mandates that hospitals “shall provide patients With a written notice including information about eligibility” as well post its “policy for financially qualified and self-pay patients clearly and conspicuously in locations Visible t0 the public.” 34. On August 9, 2019, John Aron was deposed as the Director 0f Patient Access for SCVMC in the litigation captioned County ofSanta Clara v. Emily Hepner, Santa Clara Case N0. 18- CV-330989. Mr. Aron testified that he supervises approximately 97 people at SCVMC and that he is: responsible for a department that performs registration and admission duties for our Emergency Department and for our In-Patient Unit. I am also responsible for units that provide financial counseling services both at the hospital and also at the primary care and specialty clinics owned by Valley Medical Center throughout the County? 35. In his deposition, Mr. Aron provided sworn testimony regarding the notices used by SCVMC intended to comply with the HFPA? 36. Exhibit “15” attached t0 Mr. Aron’s deposition transcript is an example of the notice that Respondents have posted throughout SCVMC’S facilities. It is clear from the notice itself, and Mr. Aron acknowledges, that the notice does not contain any information about eligibility, as 2 Relevant exhibits and testimony from Mr. Aron’s sworn deposition testimony are attached hereto and Exhibit “A” and are incorporated herein by this reference. 3 See, Deposition of John Albert Aron (Exhibit “A”) at 9428-21. _ 11 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO required by Health and Safety Code § 127410(a).4 37. Exhibit “16” attached t0 Mr. Aron’s deposition transcript is an example 0f the notice that Respondents use 0n the back 0f their billing statements. Again, it is clear from the notice itself, and Mr. Aron acknowledges, that the notice does not contain any information about eligibility, as required by Health and Safety Code §§ 127410(a) and (b).5 38. An example of the notice that Respondents use at their “Express Care and other drop-in clinics” is also attached t0 Mr. Aron’s deposition as Exhibit “17.”6 39. Adequate notice regarding eligibility for discount payment 0r charity care must inform its patients and the general public that the key qualifying factor is that their family income does not exceed 350 percent 0f the FPL. It does not. Whether a patient qualifies for Medicare or Medi-Cal, for example, is immaterial t0 that patient’s eligibility determination. Moreover, simply stating “350 percent of the federal poverty level” is not a clear and conspicuous disclosure about eligibility information-the actual dollar amounts should be provided in the required HFPA notices. 40. In contrast t0 Respondent’s notices, the HFPA notice and application used by Kaiser Permanente clearly and conspicuously include eligibility information and the actual income limits expressed in dollars. A true and accurate copy of Kaiser Permanente’s HFPA notice and application form are attached hereto as Exhibit “B.” RESPONDENTS FAIL TO PROVIDE WRITTEN NOTICE IN THE LANGUAGE SPOKEN BY THEIR PATIENTS 41. Although Respondents post purported “Notice” of SCVMC’s charity and discount care programs in multiple languages, these too lack the required information about eligibility. As alleged above, Without actual disclosure about eligibility language, specifically that an uninsured 0r 4 See, Deposition of John Albert Aron (Exhibit “A”) at 90: 11 through 91 : 14. 5 See, Deposition 0f John Albert Aron (Exhibit “A”) at 91 : 17 through 92:18. 6 See, Deposition 0f John Albert Aron (Exhibit “A”) at 92: 19 through 94:7. _ 12 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO underinsured patient whose family income does not exceed 350 percent of the FPL may be eligible, the purported notice does not comply With the clear and conspicuous notice requirements mandated by Health and Safety Code § 127410(a). 42. Moreover, Respondents do not effectively disclose the availability of the charity and discount payment programs “in the language spoken by the patient.” Like many, 0r even the majority, of the members of the general public which Respondents serve in the Santa Clara County area, CORTEZ is a native Spanish language speaker. After being admitted through SCVMC’s emergency room, CORTEZ was not provided any notice informing her 0f a charity 0r discount payment program. In fact, Respondents’ purported HFPA notice printed 0n the last page of CORTEZ’S hospital discharge papers is written in English, in contrast to the discharge information in Spanish above the notice. A true and accurate redacted copy of the last page of CORTEZ’s hospital discharge documents is attached hereto as Exhibit “C,” and is incorporated herein by this reference. Health and Safety Code § 127410(a) provides that, “[W]ritten correspondence to the patient required by this article shall also be in the language spoken by the patient. . .” RESPONDENTS FAIL TO REQUEST DOCUMENTS NECESSARY TO DETERMINE ELIGIBILITY 43. Health and Safety Code § 127405(e)(1) provides that a hospital can request the patients “recent pay stubs 0r income tax return” to determine whether a patient meets the eligibility requirements as a “financially qualified patient” 0r “patient With high medical costs” as those terms are defined by Health and Safety Code §§ 127400(c) and (g). A patient, 01‘ patient’s legal representative, Who requests a discounted payment, charity care, or other assistance in meeting his 0r her financial obligation t0 the hospital shall make every reasonable effort t0 provide the hospital With documentation of income and health benefits coverage. If the person requests charity care 0r a discounted payment and fails to provide information that is reasonable and necessary for the hospital to make a determination, the hospital may consider the failure in making its _ 13 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO determination.7 44. The predicament faced by Petitioners and other eligible members 0f the general public is that they are not receiving the charity or discount care they are entitled to receive, in part, because Petitioners and the general public cannot request charity 0r discount care if they d0 know that such programs exist. Like CORTEZ and GALLEGOS, eligible patients and the public may fail t0 ask for financial assistance because Respondents do not provide them an effective notice that includes information about eligibility requirements, 0r notice in their spoken language. Similarly, for HEPNER and others who request financial assistance, Respondents apparently fail to qualify patients, fail request documentation regarding family size and income, 0r otherwise fail to follow through altogether. Patients who apply for financial assistance, like HEPNER, are required t0 “make every reasonable effort t0 provide the hospital With documentation 0f income and health benefits coverage.” If otherwise qualified patients fail “to provide information that is reasonable and necessary for the hospital to make a determination, the hospital may consider that failure in making its determination,” but qualified patients simply d0 not know What additional documentation is necessary unless it is requested of them by Respondents. 45. The end result is that eligible members 0f the public, like Petitioners herein, are not receiving charity and discount medical benefits that Respondents have been publicly funded and mandated to provide. Instead, Petitioners and the general public are charged very high self-pay rates for medical services provided by Respondents, and they are then sued When they are unable t0 pay. Thus, not only are taxpayers paying Respondents millions 0f dollars t0 provide charity and discount medical services to Petitioners and eligible members 0f the general public, taxpayers are also paying for the Santa Clara County Attorney’s office and California Superior Court system t0 collect monies that should not be owed. If Respondents simply complied with the HFPA, financially qualified patients 7 Health and Safety Code § 127405(e). _ 14 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO would receive the benefits t0 Which they are entitled and the Santa Clara County Attorney’s office and California Superior Court system would not be burdened with unnecessary collections cases. 46. To effectuate the HFPA’S purpose, Respondents should not only provide notice that includes information about eligibility (strictly speaking “family income not exceeding 350% 0f the federal poverty level”), but should also be required t0 provide notices that state the 350% FPL in then current dollar amounts. Respondents HFPA notice should also clearly state that supporting documents such as “recent pay stubs 0r income tax return” must be provided. The notices should also appear on Respondents” Application for Financial Assistance, and include a request that the patient provide the documentation. Kaiser Permanente’s notice and application (Exhibit “‘B”) is a good example of proper notice that informs patients and the public of the eligibility requirements and supporting documentation that may be required. ELIGIBILITY FOR CHARITY OR DISCOUNTED PAYMENT CAN BE DETERMINED AT ANY TIME 47. As 0f the date this Petition for Writ of Mandate was filed, Petitioners are each being sued by Respondents in the Santa Clara County Superior Courtg in an effort t0 collect excessive self-pay rates for Respondents’ medical services despite the fact that Petitioners were each a “financially qualified” patient at the time services were received, and therefore eligible for charity 0r discount payment rates. 48. Respondents failed t0 provide Petitioners With written notice 0f Respondents’ charity and discount payment programs which included information about eligibility. Respondents did not provide CORTEZ written notice, including information about eligibility, in her spoken language. Respondents did not ask any 0f the Petitioners t0 provide documentation supporting their eligibility. Doubtless, there are numerous members 0f the general public that are similarly situated. 8 See generally, County ofSanta Clara v. Hepner, N0. 18-CV-324929; County ofSanta Clara v. Cortez, N0. 17-CV-314164, and County ofSanta Clara v. Gallegos, N0. 19-CV-346054. _ 15 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO 49. Health and Safety Code § 127405(e)(4) is explicit: “[e]ligibility for discounted payments 0r charity care may be determined at any time the hospital is in receipt 0f information specified in paragraph (1) 0r (2), respectively.” Petitioners and other eligible members 0f the general public Who (1) have not been provided the required HFPA notice (i.e., everyone), and/or (2) have not had the Opportunity t0 provide supporting documentation, have suffered and Will continue to suffer harm as long as they are denied the opportunity to apply (or reapply) and have Respondents determine their eligibility t0 receive benefits under the HFPA and other available financial aid programs even after collection efforts, including litigation, has been commenced. 50. Health and Safety Code § 127405(d) provides that, “[a] hospital shall limit expected payment for services it provides t0 a patient at 0r below 350 percent of the FPL, as defined in subdivision (b) 0f Section 127400, eligible under its discount payment policy t0 the amount 0f payment the hospital would expect, in good faith, to receive for providing services from Medicare, Medi-Cal, the Healthy Families Program, or another government-sponsored health program 0f health benefits in Which the hospital participates, Whichever is greater.” For qualified patients, this expected payment could be as little as $0. Thus, the amount Respondents are allowed by law to collect from Petitioners and eligible members 0f the public may still be adjusted downward. This adjustment may allow for a patient t0 work out a payment plan, or avoid a judgment in an unjust and unlawful amount and the resulting potential property liens or wage garnishments. RESPONDENTS’ FAILURE TO MAKE CHARITY OR DISCOUNTED ELIGIBILITY DETERMINATIONS FOR PAST, PRESENT, AND FUTURE PATIENTS RESULTS IN SUBSTANTIAL INJUSTICE TO ELIGIBLE PATIENTS AND THE PUBLIC 51. Not only may eligibility for discounted payment 0r charity care be determined at any time, Health and Safety Code § 127440 provides that, “[t]he hospital shall reimburse the patient 0r patients any amount actually paid in excess 0f the amount due under this article, including interest.” _ 16 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO 52. The vulnerable population 0f patients that the HFPA was enacted t0 protect, like Petitioners and eligible members of the general public, are being subject t0 a cascading series 0f injustices by Respondents’ actions. Respondents receive hundreds of millions of taxpayer dollars to provide charity 0r discount payment for medical services, yet actually over charge Petitioners and eligible members 0f the general public thousands and even tens 0f thousands 0f dollars. Then Respondents turn Petitioners and eligible members 0f the general public over t0 collections and file lawsuits against them t0 collect self-pay rates. After judgment is entered, Respondents can put liens 0n real property and garnish wages, although these debt collection methods are explicitly prohibited as against eligible patients. Health and Safety Code § 127425(f)(1) provides that, “[t]he hospital or other assignee that is an affiliate 0r subsidiary of the hospital shall not, in dealing With patients eligible under the hospital’s Charity care 0r discount payment polices, use wage garnishments 0r liens 0n primary residences as a means 0f collecting unpaid hospital bills.” After failing to determine whether their patients qualify for benefits under the HFPA and then suing t0 collect, Respondents Will doubtless believe themselves unconstrained by such limitations. 53. In sum, Respondents fail to give patients notice of their charity and discount program including information about eligibility; fail t0 provide written correspondence With notice in the patient’s spoken language including information about eligibility; fail t0 provide clear and conspicuous notice Visible t0 the public including information about eligibility in any language; and fail t0 even inform, much less request, documents from patients needed to establish their eligibility; Respondents charge otherwise “financially qualified patients” and “patients With high medical costs” the excessive non-qualifying self-pay rates, sue them, and get judgments. Thereafter, because Respondents never determined that the patient’s family income did not exceed 350% 0f the FPL, Respondents are free t0 place liens 0n the patient’s primary residence and/or garnish their wages. Such _ 17 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO conduct is egregious and reprehensible. FACTS REGARDING PETITIONER EMILY JEANNE HEPNER 54. In May of 2014, HEPNER was a single mother with two children, residing in Santa Clara County, and a full-time student at Santa Clara University School 0f Law. She had n0 medical insurance and relied 0n the Santa Clara University’s Student Health Service clinic for her medical needs. Her only source of income was the alimony and child support payments she received. According t0 HEPNER’S 2013 Federal Tax Return, Which would have been the document relied on t0 determine her income in May 2014, her annual income was $44,732 and her family size was three (3). 55. On or about May, 21, 2014, HEPNER was experiencing severe abdominal pain and went t0 Student Health Services at Santa Clara University. She was examined and a CT scan was performed that revealed blood in her abdomen. Her caregiver advised her t0 g0 t0 the emergency room. Since HEPNER had no insurance and was an unemployed full-time student, they discussed going t0 the emergency room 0f Good Samaritan Hospital 0r SCVMC. HEPNER’S caregiver told her that if she went t0 Good Samaritan, she would have a large bill. Whereas, if HEPNER went t0 SCVMC, she would have to wait longer, but SCVMC provide insurance coverage for those that do not have it. Based 0n this information, HEPNER chose to go to SCVMC’S emergency room. 56. After waiting five hours in SCVMC’S emergency room, HEPNER was seen and sent for an ultrasound. The doctors determined that she required surgery and she was assigned a room t0 await her surgery the next day. 57. Sometime between 10:00 pm. and 11:00 pm. that same evening, SCVMC’S financial counselor Visited HEPNER regarding her insurance coverage status. HEPNER told the financial counselor that she was uninsured. The financial counselor completed an Application for Medi- Cal and a Financial Assistance Application With HEPNER. The financial counselor told HEPNER that _ 18 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO for purposes of the applications, child support was excluded from income, and only HEPNER’s spousal support 0f $1,200 per month should be counted. The financial counselor assured HEPNER that based on her annual income and family size, she would qualify for Medi-Cal which would cover her entire hospital stay for a $125 copay. Alternatively, the financial counselor told HEPNER that if she did not qualify for Medi-Cal, SCVMC’S own insurance program would cover her, and she would have a similarly 10w copay. HEPNER was not asked t0 provide any documentation 0f her income nor did the applications forms for Medi-Cal 0r Financial Assistance request documentation. HEPNER’S surgery was performed 0n May 22, 2014, and she was discharged from SCVMC later that day. 58. Almost one year later, in April 2015, HEPNER began receiving bills from Respondents. Respondents alleged she owed them $34,883.69. In August 2015, approximately 109 days after receiving the first bill, HEPNER called one 0f the phone numbers 0n the bill t0 dispute the charges, based 0n the representations 0f SCVMC’S financial counselor prior to her surgery. At that time Respondents’ employee told HEPNER that she had not qualified for Medi-Cal and the time limit t0 apply for the hospital’s program had passed. Respondents told HEPNER that her only option was t0 contact collections to set up a payment plan. 59. Respondents’ employee made a material misrepresentation t0 HEPNER. As noted above, Health and Safety Code § 127405(e)(4) states that, “[e]ligibility for discounted payments 0r charity care may be determined at any time the hospital is in receipt 0f information specified in paragraph (1) 0r (2), respectively.” Respondents should have requested HEPNER’S recent pay stubs 0r income tax return t0 establish her eligibility, but they failed t0 d0 so, representing t0 her instead that she was too late. Second, Respondents’ Application for Financial Assistance does not request any documentation. Had Respondents’ employee asked HEPNER t0 provide her income tax return, she would have. Instead, Respondents told her that she was too late. 9 Emphasis added. _ 19 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO 60. As stated above, HEPNER’s 2013 Federal Income Tax return shows a family of three With an income 0f $44,732, including both spousal and Child support. The FPL for a family 0f three in 2014 was $19,790, and 350% of that amount is $69,265. Because HEPNER’S family income did not exceed 350% of the FPL at the time of service, she was a “financially qualified patient” eligible for and entitled t0 receive charity 0r discount medical care. Moreover, With an annual income 0f $44,732 and a medical bill 0f $34,883.69, HEPNER was also a “patient With high medical costs.” 61. In February 2018, HEPNER received correspondence from Respondents’ collection department, threatening t0 sue her. Thereafter, in March 2018, Respondents filed a lawsuit against HEPNER, seeking to collect $34,883.69, plus attorney fees. HEPNER thereafter contacted Respondents’ attorney t0 explain that SCVMC’S employee had represented that HEPNER would qualify for Medi-Cal, and if not, then for SCVMC’S own insurance program, With a copay not t0 exceed $125. Instead of requesting documentation to establish HEPNER’S eligibility for charity or discount medical care, Respondents’ attorney from the County Counselor’s Office responded that the matter was non-negotiable and that HEPNER had t0 pay the full amount due. FACTS REGARDING MARIA ANGELA CORTEZ 62. CORTEZ is a Spanish language speaker, and does not read 0r write English. On 0r about November 5, 2013, CORTEZ was seen at one 0f Respondents’ clinics. Due to blood loss, she was advised t0 g0 to the emergency room at SCVMC, which she did. There was no discussion with CORTEZ regarding payment at the clinic. 63. After waiting at SCVMC’s emergency room for over three hours Without being seen, CORTEZ had t0 leave t0 go to her job. CORTEZ is a driver, employed t0 drive patients t0 and from hospitals and doctor appointments. 64. CORTEZ returned t0 SCVMC’S emergency room the next afternoon, November -20- PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO 6, 2013, and remained there for the next three days, during Which time she underwent surgery, including a blood transfusion. When asked for proof of insurance, CORTEZ provided Respondents’ employee with a business card she had received from an AFLAC salesman. CORTEZ was 0f the belief at that time that AFLAC provided a form 0f medical insurance. Respondents’ employee asked CORTEZ if she had Medi-Cal. CORTEZ replied that she had been denied Medi-Cal, and that is why she obtained AFLAC. Respondents’ employees did not further discuss whether CORTEZ had medical insurance coverage after that, and never provided CORTEZ with an application for financial assistance. 65. CORTEZ had a few follow up Visits t0 SCVMC thereafter in Which billing, charges, 0r charity and discount programs were never offered or discussed. 66. Respondents’ purported notice 0f charity and discount programs, which does not include information regarding eligibility as required by statue, does appear - in English - 0n Respondents’ discharge paperwork t0 CORTEZ dated November 8, 2013 (Exhibit “C”), the remainder 0f Which is in Spanish. 67. At some point Respondents must have learned, as eventually did CORTEZ, that the AFLAC supplemental insurance that CORTEZ thought provided medical insurance coverage did not s0 provide. However, instead 0f making reasonable efforts t0 determine Whether CORTEZ was insured 0r uninsured, or providing her notice (including information regarding eligibility) 0f their charity or discount programs (in Spanish), Respondents filed a lawsuit against CORTEZ seeking $32,682.60, plus attorney’s fees. During discovery in the collection lawsuit, Respondents provided their internal notes which clearly indicate that they knew CORTEZ was uninsured. 68. At the time CORTEZ received medical services at SCVMC, she met the eligibility requirements 0f a “financially qualified patient” as that term is defined in Health & Safety Code § 127400(c). CORTEZ’s 2012 Federal Tax Return shows that her three-person household earned _ 21 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO $43,099, which is less than 350% 0f the FPL for a family 0f three in 2012. The FPL for a family of three in 2013 was $19,530, and 350% 0f this amount is $68,355. Because CORTEZ’s family income did not exceed 350% of the FPL, she was a “financially qualified patient,” eligible for, and entitled to, charity 0r discount medical care. 69. CORTEZ was also a “self-pay patient” as well as “a patient With high medical costs” as those terms are defined in Health & Safety Code §§ 127400(f) and (g). The fact that CORTEZ’s medical bill was $32,682.60, Which exceeds 10% of her annual family income 0f $43,099, also makes her “a patient With high medical costs” as that term is defined in Health & Safety Code § 127400(g)(1). FACTS REGARDING PETITIONER DIEGO ARMANDO GALLEGOS 70. On April 28, 2017, GALLEGOS was transported to SCVMC by ambulance as a result of someone calling 911 when he appeared to be having convulsions. GALLEGOS does not recall anything until he woke up in the emergency room. After being kept for a few days for observation, GALLEGOS was discharged. 71. At the time 0f his hospitalization, GALLEGOS had been unemployed for a few weeks; he was living in his car and sometimes staying With his parents or girlfriend. At the time GALLEGOS received medical services at SCVMC, he met the eligibility requirements of a “financially qualified patient” as that term is defined in Health & Safety Code § 127400(c). GALLEGOS’ 2017 Federal Tax Return shows that he earned $15,083, which is less than 350% 0f the FPL for a family of one in 2017. The FPL for a family 0f one in 2017 was $12,060, and 350% 0f this amount is $42,210. Because GALLEGOS’ family income did not exceed 350% of the FPL, he was a “financially qualified patient,” eligible for, and entitled t0, charity or discount medical care. 72. Despite his eligibility, Respondents never provided GALLEGOS with a written -22- PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO notice of the charity and discount programs for Which he was eligible, as required by Health & Safety Code § 127410(a). Likewise, Respondents breached their duty t0 make all reasonable efforts t0 determine ifGALLEGOS was insured 0r uninsured, as required by Health & Safety Code §§ 127420(a) (1-3). 73. GALLEGOS received a bill from Respondents dated November 7, 2017, alleging he owed $8,482.79, with a payment 0f $125 due. He received another bill from Respondents dated December 7, 2017, alleging he owed $8,482.79. GALLEGOS received a notice dated December 19, 2017, stating that Respondents intended t0 initiate a small Claims action against him for $8,482.79. Additionally, GALLEGOS received a letter from Respondents dated October 24, 2018, regarding his alleged debt. Although he was eligible, none of Respondents’ billing statements provided GALLEGOS with the written notice 0f the charity and discount programs available, including information about eligibility, as required by Health & Safety Code § 127410(a). 74. Thereafter, on April 12, 2019, Respondents filed a collection lawsuit against GALLEGOS seeking $8,482.79, plus attorneys’ fees. 75. Respondents breached their duty to provide the clear and conspicuous notices required t0 be included in bills t0 patients that have not provided proof of insurance coverage. Health & Safety Code §§ 127420(b)(1-5)(enumerating the information and applications t0 be provided including information regarding financially qualified patient and charity care applications and Medi-Cal application). 76. As noted above, GALLEGOS and other eligible members of the public may understandably fail to ask for financial assistance because Respondents d0 not give them notice of the eligibility requirements. This resulting asymmetry of information between Respondents and their patients has harmed Petitioners herein and unknown numbers 0f eligible members 0f the general public. -23- PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO Respondents’ actions will cause future harm t0 the general public if not corrected by this Court. CONCLUSION 77. As a Disproportionate Share Hospital (DSH),1° SCVMC is entrusted by United States Congress and the people of California and the United States t0 serve the significantly disproportionate number 0f low-income patients in the Santa Clara County area. T0 this end, Respondents receive a disproportionate share of federal funding from the Centers for Medicaid and Medicare Services t0 cover the costs 0f providing care t0 these uninsured patients. 78. Unfortunately, as evidenced by the experiences 0f the Petitioners described herein, Respondents are Violating the public’s trust and not effectively acting as a safely net hospital to provide the vulnerable populations of the Santa Clara County area with the community benefits they have been funded and charged with the responsibility t0 provide, namely charity and discount medical services for uninsured and underinsured members 0f the public. Instead, Respondents are charging maximum self- pay rates for medical services t0 financially qualified patients like Petitioners herein, and wasting valuable State and Santa Clara County resources in efforts to collect these exorbitant medical bills through the Courts. 79. Petitioners, on behalf 0f themselves and the general public, request this Court examine Why financially qualified patients, as defined by Health & Safety Code § 127400(c), are not being identified as such, are being charged maximum self-pay rates for medical services, turned over to collections, and sued. 80. It is highly unlikely that Petitioners and the general public would know t0 try t0 demonstrate to Respondents that they are eligible for charity or discount medical care when Petitioners and the general public are not given notice that includes eligibility information. Because Respondents 1° See, Social Security Act § 1186(d)(1)(B)(defining Disproportionate Share Hospital) (codified at 42 U.S.C. § 1395ww). _ 24 _ PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO fail t0 request documentation from them, Petitioners and the general public are hindered from making a “reasonable effort t0 provide the hospital With documentation 0f income and health benefits coverage” so Respondents can determine their eligibility for charity or discount care as they are required to by the statute. 81. California’s HFPA places n0 time limit 0n the determination of eligibility of a “financially qualified patient.” Health & Safety Code § 127405(e)(4) provides that, “[e]1igibi1ity for discounted payments or charity care may be determined at any time the hospital is in receipt of the information specified in paragraph (1) 0r (2), respectively.” The information specified in paragraph (1) is the patient’s recent pay stubs or income tax returns, which is used to determine whether the patient’s household income is less than 350% 0f the Federal Policy Level. The information specified in paragraph (2) is the patient’s asset information for determining eligibility for charity care. 82. Accordingly, Petitioners and members 0f the general public that were charged self-pay rates but actually met the eligibility requirements (“financially qualified patient”) should be provided an opportunity to provide Respondents With documentation (116., relevant income tax return) t0 prove their eligibility and receive the community benefits for Which they were entitled (charity or discounted medical services). This is necessary t0 correct an injustice upon the vulnerable population 0f Santa Clara County. 83. Petitioners, on behalf 0f themselves and other financially qualified patients including future financially qualified patients in the general public, respectfully request an injunction against Respondents’ current business practices. Specifically the Court should enter a Writ enjoining Respondents from failing t0 properly screen, inform, and give proper notice of the eligibility criteria t0 those qualified for charity and discounts. 84. Petitioners, 0n behalf 0f themselves and general public, further seek a Writ -25- PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO ordering Respondents t0 clearly and conspicuously, in the patient’s spoken language, include the eligibility information defining a financially qualified patient expressed in dollars 0n all notices required by law. These notices are necessary t0 inform patients 0f their rights to these benefits so they are able t0 make an informed decision as t0 whether they qualify and should apply. 11 Any applications for financial assistance should also include a request in writing, in the language spoken by the patient, for the patient’s recent pay stubs 0r income tax return, so that the patient is informed or given notice of the documentation required t0 make the determination 0f their eligibility for charity or discount payment programs available.” REQUEST FOR RELIEF WHEREFORE, Petitioners pray that this Court issue a Writ 0f Mandate and order Respondents t0: 1. Comply with the letter and spirit of California Hospital Fair Pricing Policies Act; 2. Provide an additional one (1) year opportunity for any patients identified as uninsured and Charged self-pay rates Within the last four (4) years t0 submit 0r resubmit documentation (pay stubs 0r income tax return relevant for the date of medical services), so that it can be determined whether the patient was eligible for charity 0r discount payment 0r other available financial aid programs for those services; 3. Recalculate and adjust the medical bills for any patients who were charged self-pay rates Within the last four (4) years if they submit documentation Which verifies said patient’s eligibility for charity 0r discount payments 0r other available financial aid programs; 4. Cease and desist any collection efforts 0r lawsuits against any self-pay patients that 11 The excuse that the patient did not request charity 0r discount care, and therefore Respondents were justified in charging uninsured patients at the self-pay rates for medical care, must end. 12 The excuse that the patient did not “make every reasonable effort to provide the hospital With documentation of income and health benefits coverage” as required by Health & Safety Code § 127405(e), must end. -26- PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO provide verification 0f eligibility for charity 0r discount payments or other available financial aid programs at the time medical services were received and declaring that these patients are liable only for the amount they should have been charged at the time medical services were received; . Reimburse the patient any amount actually paid in excess 0f the amount due under the HFPA, including interest,” for any patients that during the past four (4) years are determined t0 have been eligible for charity or discount payment 0r other available financial aid programs at the time they received medical services from SCVMC; . Extinguish any liens and cease and desist any garnishments resulting from any amount actually paid in excess of the amount due under the California HFPA, for any patients that during the past four (4) years are determined to have been eligible for charity 0r discount payment 0r other available financial aid programs at the time they received medical services from SCVMC; Send a clear and conspicuous written notice t0 any patient receiving medical services from Respondents within the last four (4) years, and billed at self-pay rates, regarding the Respondents’ charity and discount programs including eligibility information expressed in dollars, point 0f contact information, and a request for documentation if the patient believes they may be eligible, in English and in any other language spoken by the patient; 8. Stay any collection proceedings against any and all self-pay patients until a clear and conspicuous written notice is sent to each patient regarding Respondents’ charity and 13 Interest owed by the hospital to the patient shall accrue at the rate set forth in Section 685.010 of the Code 0f Civil Procedure, beginning 0n the date payment by the patient is received by the hospital. However, a hospital is not required t0 reimburse the patient 0r pay interest if the amount due is less than five dollars ($5.00). The hospital shall give the patient a credit for the amount due for at least 60 days from the date the amount is due. Health & Safety Code §127440. -27- PETITION FOR WRIT OF MANDATE KOOOQONUl-RUJNH NNNNNNNNNr-‘r-‘r-‘r-‘r-ir-‘Hr-Ar-‘r-A OONONUI-PUJNHOKOOOQONUI-RUJNHO 10. 11 discount programs including eligibility information expressed in dollars, point of contact information, and a request for documentation if the patient believes they may be eligible, in English and in the language spoken by the patient; Publish in the San Jose Mercury News once per week for at least six (6) months a clear and conspicuous written notice in English, Spanish, Chinese, Tagalog, Vietnamese, and Korean,” to inform past, present, and future patients about the Respondents’ charity and discount programs including eligibility information expressed in dollars, point of contact information, a request for documentation if the patient believes they may be eligible, and notice that patients that have received medical services within the past four (4) years may be eligible for reimbursement 01‘ readjustment of their medical bills if determined t0 have been eligible for charity 0r discount payment at the time 0f medical services; Post clear and conspicuous written notice in English, Spanish, Chinese, Tagalog, Vietnamese, and Korean in areas Visible to the public as mandated in Health & Safety Code § 127410, regarding Respondents’ charity and discount programs Which includes the eligibility information expressed in dollars, point of contact information, and a request for documentation if the patient believes they may be eligible; .Provide clear and conspicuous written notice in English and in the patient’s spoken language, in written correspondence to patients as mandated in Health & Safety Code § 14 See, Civil Code § 1632(a)(3) (“According t0 data from the American Community Survey, which has replaced the decennial census for detailed socioeconomic information about United States residents, approximately 15.2 million Californians speak a language other than English at home, based on data from combined years 2009 through 2011. This compares t0 approximately 19.6 million people who speak only English at home. Among the Californians Who speak a language other than English at home, approximately 8.4 million speak English very well, and another 3 million speak English well. The remaining 3.8 million Californians surveyed d0 not speak English well or d0 not speak English at all. Among this group, the five languages other than English that are most Widely spoken at home are Spanish, Chinese, Tagalog, Vietnamese, and Korean. These five languages are spoken at home by approximately 3.5 million of the 3.8 million Californians with limited or no English proficiency, who speak a language other than English at home.”). -28- PETITION FOR WRIT OF MANDATE \OOOflQUl-RUJNr-A NNNNNNNNNr-tr-tb-tr-tr-tr-‘r-‘r-tr-‘r-A OOQONUI-PUJNHOKOOOQQUI-PUJNF-‘O 127410, regarding Respondents” charity and discount programs Which includes the eligibility information expressed in dollars, point of contact information, and a request for documentation if the patient believes they may be eligible; 12. Include 0n their Application for Financial Assistance clear and conspicuous written notice in English and in languages other than English, as mandated in Health & Safety Code § 127410, regarding Respondents’ charity and discount programs which includes the eligibility information expressed in dollars, point of contact information, and a request for documentation if the patient believes they may be eligible; 13. Pay Petitioners’ counsel the costs of this action and reasonable attorney’s fees, pursuant to Civil Code § 1021.5; and 14. For such other and further relief as may be just and proper. Dated: October 28 2019 CONSUMER LAW CENTER, INC. By: Fred W. Schwinn (SBN 225575) D Raeon R. Roulston (SBN 255622) D Matthew C. Salmonsen (SBN 302854) CONSUMER LAW CENTER, INC. 1435 K011 Circle, Suite 104 San Jose, California 951 12-4610 Telephone Number: (408) 294-6100 Facsimile Number: (408) 294-6190 Email Address: fred.schwinn@sjconsumerlaw.com Attorneys for Petitioners EMILY JEANNE HEPNER DIEGO ARMANDO GALLEGOS, MARIA ANGELA CORTEZ, individually and on behalf of the general public -29- PETITION FOR WRIT OF MANDATE \OOOQGUI-RUJNr-A NNNNNNNNNr-tr-tr-tr-tr-tr-‘r-‘r-tr-‘r-A OOQONUI-PUJNHOKOOOQQUI-PUJNF-‘O VERIFICATION State 0f California ) ) ss: County of Santa Clara ) I have read the foregoing and know its contents. I am one of the attorneys for the Petitioners in this action. Petitioners DIEGO ARMANDO GALLEGOS and MARIA ANGELA CORTEZ have limited English proficiency, therefore, I am verifying the foregoing document 0n their behalf. The matters stated in the foregoing document are true 0f my own knowledge except as t0 those matters which are stated on information and belief, and as to those matters Ibelieve them t0 be true. I declare under penalty 0f perjury under the laws of the State of California that the following is true and correct. Dated: October 28 2019 F Fred W. Schwinn -30- PETITION FOR WRIT OF MANDATE \DOONQUI#UJNh-‘ NNNNNNNNNr-‘i-‘Ht-‘Ht-‘h‘Hn-io-n OOQQLh-bDJNr-‘OOWQQUI-waF-‘O VERIFICATION State of California ) ) ss: County of Santa Clara ) I have read the foregoing and know its contents. I am a party to this action. The matters stated in the foregoing document are true of my own knowledge except as to those matters which are stated on information and belief, and as to those matters I believe them to be true. I declare under penalty of perjury under the laws of the State of California that the following is true and correct. Dated: October 28 2019 Emily Jeanne epner _ 31 _ PETITION FOR WRIT OF MANDATE SUPERIOR COURT OF CALIFORNIA, SANTA CLARA COUNTY COUNTY OF SANTA CLARA, Plaintiff, vs. Case No. EMILY HEPNER, et al., 18CV330989 Defendants. CERTIFIED TRANSCRIPT DEPOSITION OF JOHN ALBERT ARON BE IT REMEMBERED: That pursuant to Notice of Taking Deposition, and on Friday, the 9th day of August 2019, commencing at the hour of 10:05 a.m. of said day, before me, LINDA STITES KIRBY, C.S.R., License Number C-5258, a Certified Shorthand Reporter, personally appeared JOHN ALBERT ARON, called as a witness herein at CONSUMER LAW CENTER, INC., 1435 Koll Circle, San Jose, California, and being by me first duly EXFHBI affirmed, was examined as a Wltness 1n sald cause. 10 ll 12 13 l4 15 l6 l7 l8 19 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON COUNTY OF SANTA CLARA VS EMILY HEPNER August O9, 2019 Videotaped by: Mr. Schwinn A P P E A R A N C E S: For the Plaintiff: OFFICE OF THE COUNTY COUNSEL 7O West Hedding Street 9th Floor, East Wing San Jose, CA 95110 BY: MARK BERNAL Attorney at Law **** For the Defendants: CONSUMER LAW CENTER, INC. 1435 Koll Circle Suite 104 San Jose, CA 95112 BY: FRED W. SCHWINN Attorney at Law **** Mr. Schwinn **** INDEX OF EXAMINATIONS PAGE **** m TALTY COURT REPORTERS, INC.408.244.1900 - www.taltys.com lO ll 12 13 14 15 16 17 18 l9 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, 2019 COUNTY OF SANTA CLARA vs EMILY HEPNER (WHEREUPON, the Notice was marked as Defendant'lexhibit l for identification.) MR. SCHWINN: Good morning, my name is Fred W. Schwinn from the Consumer Law Center, Inc. located at 1435 Koll Circle, Suite 104, San Jose, California, 95112. This is the deposition of John Aron in the matter of the County of Santa Clara versus Emily Hepner, et al., in the Superior Court of California, Santa Clara County, Case Number l8-CV-330989. The deposition is taking place at Consumer Law Center, Inc., 1435 Koll Circle, Suite 104, San Jose, California, 95113. We're being videotaped and audio taped at all times unless otherwise specified. We are now commencing at 9:04 a.m. on August 9th, 2019. Would all present please identify themselves for the record, please beginning about the witness. THE WITNESS: John Aron. MR. BERNAL: Mark Bernal, Deputy County Counsel attorney for the Witness and Defendant -- or excuse me, Plaintiff, County of Santa Clara. MR. SCHWINN: And I am Fred Schwinn representing Emily Hepner, the Defendant. Would the Court Reporter please swear in the 4m TALTY COURT REPORTERS, INC.408.244.1900 - www.taltys.com 10 ll 12 13 l4 15 l6 l7 l8 19 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, COUNTY OF SANTA CLARA VS EMILY HEPNER 2019 Witness. JOHN ALBERT ARON, having been first duly affirmed by the Certified Shorthand Reporter to tell the truth, the whole truth, and nothing but the truth, testified as follows: EXAMINATION BY MR. SCHWINN Q Would you please state your full name for the record. A John Albert Aron. Q You're currently employed at Valley Medical Center? A That's correct. Q How long have you been there? MR. BERNAL: Did you hear the question? THE WITNESS: I'm sorry? Q (BY MR. SCHWINN) How long have you been there? A I'm sorry, I have been with Valley Medical Center since 2009. Q And what is your current position at Valley Medical Center? A Mv current position is Director of Patient Access. Q And as Director of Patient Access, what are your duties, generally? A I am responsible for a department that performs m TALTY COURT REPORTERS, INc.408.244.1900 - www.taltys.com lO ll 12 13 14 15 16 17 18 l9 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, COUNTY OF SANTA CLARA VS EMILY HEPNER 2019 registration and admission duties for our Emerqencv Department and for our In-Patient Unit. I am also responsible for units that provide financial counselinq services both at the hospital and also at the primary care and specialtv clinics owned bv Vallev Medical Center throuqhout the Countv. Q Approximately how many people are you in charge of? A Approximately 97. MR. SCHWINN: Mark this next. (WHEREUPON, the Job Description was marked as Defendant's Exhibit 2 for identification.) THE WITNESS: I'm sorry? MR. BERNAL: She'll hand you these original exhibits, don't write on them unless instructed to do so and after the deposition, you have to return them to the Court Reporter. Q Have you ever had your deposition taken before? A Once. Q How long ago was that? A More than 15 years. Q Was it in connection with your employment at Valley Medical Center or was it something unrelated? A Separate. m TALTY COURT REPORTERS, INC.408.244.1900 - www.taltys.com lO ll 12 13 14 15 16 17 18 l9 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, 2019 COUNTY OF SANTA CLARA VS EMILY HEPNER with regard to the hospital? A For ED registration, admitting, and the financial counselors. Q Very good. And then the next down, halfway down, it says, "the manager in ED Registration, Admitting, and PBS, displays written notices in the ED, Admitting and PDS Customer Service lobby," and a sample is attached. So the next page, this is the notice that's posted? A That is the notice. Q Is this the same notice that's used todav? A I believe so. Q And this notice is posted at the hospital now? A YEA Q I believe that's this one. (WHEREUPON, the Notice was marked as Defendant's for identification.) Q (BY MR. SCHWINN) JE;;;;;;;;§1 is this the notice that's posted? A léé; Q And this notice is posted and it's designed to inform patients and others about the existence of financial services, financial systems? A Yes. m TALTY COURT REPORTERs, INc. 90408.244.1900 - www.taltys.com lO ll 12 13 14 15 16 17 18 l9 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, 2019 COUNTY OF SANTA CLARA VS EMILY HEPNER Q And this includes, in addition to the Abilitv to Pav Proqram that's listed, this also would include the Discount and the Charitv Care Proqrams as well? A Xgé; Q How do patients or others find out the elicibilitv criteria for the various financial assistance Droqrams? MR. BERNAL: Objection, calls for speculation. You can answer, if you know. THE WITNESS: That's hard to answer because patients can find out in manv wavs. Q (BY MR. SCHWINN) But it's not, eliqibilitv criteria is not part of the notice that's posted? A No, the notice is as vou have the sample. MR. SCHWINN: And then the next one is going to be l6. (WHEREUPON, the Notice was marked as Defendant's Exhibit l6 for identification.) MR. SCHWINN: I believe this one is the back of the billing statements. THE WITNESS: Okay. Q (BY MR. SCHWINN) Do vou know anvthinq about that? A This is from the back of the Datient‘s statement. m TALTY COURT REPORTERs, INc. 91408.244.1900 - www.taltys.com lO ll 12 13 14 15 16 17 18 l9 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, 2019 COUNTY OF SANTA CLARA VS EMILY HEPNER Q Right. So this is on Page 2 of Exhibit l4 where it says, "Patient Business Services includes the notice on bills to unsponsored patients." This is the notice that's being talked about there A This is a copv of what's included on the back of the statement. Q But is that the notice that's being talked about on Page 2 of the procedures and policies for the Ability to Pay Program? A Yes. Q And this notice informs patients and others about the Abilitv to Pav Proqram and all of the financial assistance programs available; including Charity Care and the Discount Plans? A Yes. Q And aqain the notice doesn't contain anv information about eligibility? A No, it does not. (WHEREUPON, the Notice was marked as Defendant'leXhibit l7 for identification.) Q (BY MR. SCHWINN) And then this one is another notice that is provided to patients; is that correct? A Yes. Q And when is this notice provided? m TALTY COURT REPORTERs, INc. 92408.244.1900 - www.taltys.com 10 ll 12 13 l4 15 l6 l7 l8 19 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, 2019 COUNTY OF SANTA CLARA VS EMILY HEPNER A This notice is notice about precautions regarding Ebola. Q But above that -- A Above that -- Q -- the very top. A -- is also informing them about the availability of programs to assist. MR. BERNAL: And his question is, When is this provided to patients? MR. SCHWINN: That is correct. THE WITNESS: This is provided to patients in the Expressed Care and other drop-in clinics. Q (BY MR. SCHWINN) Not at the hospital? A I'm sorry? Q Not at the hospital? A We have an Expressed Care Clinic in the hospital and this is provided to them at that location. Q This is not a form that's used by people in your direct line of supervision? A It is not the form used in ED registration or Admitting. Q I'm sorry, because you're responsible for other departments as well. Okay, so this informs people at the drop-in clinics and other places about the availability of financial assistance programs? m TALTY COURT REPORTERS, INc. 93408.244.1 900 - www.taltys.com 10 ll 12 13 l4 15 l6 l7 l8 19 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, 2019 COUNTY OF SANTA CLARA vs EMILY HEPNER A Correct. Q Including the Ability to Pay, Charity Care, and Discount Plans? A Including those programs. Q And again, there's nothinq in this disclosure or notice that talks about eligibilitv criteria? A _HQ; Q Are you familiar with State law known as the -- let's see what it's called. I think it's called Hospital Fair Pricing Policies, do you know anything about that statute? A Yes. Q Have you had training on that statute? A Yes, when it was first enacted. Q And vou believe that the hospital complies with that statute? A That is mv belief. Q The notices which have been marked Exhibits 15, l6, and 17, these are the notices that the hospital uses to complv with that statute? A That is -- ves. MR. BERNAL: Objection, calls for speculation. Q (BY MR. SCHWINN) And to your knowledge, were these notices provided to the hospital by some outside TALTY COURT REPORTERS, INC. 94m 408.244.1 900 - www.taltys.com 10 ll 12 13 l4 15 l6 l7 l8 19 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, 2019 COUNTY OF SANTA CLARA VS EMILY HEPNER A Q these A Q A Q these W K) 3’ E) W K) W Q A Q A Q A agency? I do not know. Do you know if an outside agency has approved notices for use by the hospital? I do not personally, no. Do you know who it is that drafted these notices? No, I do not. Do you know who it is who approved the use of notices? NO. Somebody above you? I would be speculating. Not anybody below you? No. And not you? I contribute and make suggestions about the language. You did? The level of literacy. The level of literacy on which notice? I believe it was the one vou have marked 15. And that's the one posted at various locations in and around the hospital? Yes. m TALTY COURT REPORTERS, INC. 95408.244.1900 - www.taltys.com lO ll 12 13 14 15 16 17 18 l9 20 21 22 23 24 25 DEPONENT: JOHN ALBERT ARON August O9, COUNTY OF SANTA CLARA VS EMILY HEPNER 2019 CERTIFICATE I, LINDA STITES KIRBY, a Certified Shorthand Reporter, CSR No. 5258, in and for the State of California, duly appointed and licensed to administer oaths and so forth, do hereby certify: That the Witness in the foregoing deposition, named JOHN ARON, was by me duly sworn to tell the truth, the whole truth, and nothing but the truth; That the deposition was reported by me, a Certified Shorthand Reporter and disinterested person, and thereafter transcribed into typewritten form under my direction; That the Witness shall be given an opportunity to read and, if necessary, correct said deposition and to subscribe the same. IN WITNESS WHEREOF, I have hereunto set my hand this 20th day of August 2019. LINDA STITES KIRBY, Certified Shorthand Reporter in and for the State of California, CSR No. 5258 m TALTY COURT REPORTERS, INc.408.244.1 900 - www.taltys.com 127 Attachment 1 VMC # 760.4 FINANCIAL ASSISTANCE Santa ClaraiValley Medical Center (SCVMC) is committed to providing medical services to Santa Clara County residents regardless of their ability to pay. If you need assistance in paying for the services provided at SCVMC please contact the Customer Service Unit in Patient Business Services, 408 885-7470, to obtain information regarding the Ability to Pay Determination (APD) Program. You must be a Santa Clara County resident and APD does not cover those with third party payer or Workman’s Compensation claims. ************************** ASISTENCIA FINANCIERA Santa Clara Valley Medical Center (SCVMC) esta comprornetido a proveer sewicios médicos a los residentes del Condado de Santa Clara sin importar su habilidad para pagar. Si usted necesita ayuda para pagar por los servicios recibidos en SCVMC por favor comuniquese con la Unidad de Servicios al Cliente de “Patient Business Services” al teléfono 408-885-7470 para obtener informacion sobre el Programa de Habilidad Para Pagar “Programa de Bajos Ingresos” [Ability to Pay Determination (APD) Program]. Para calificar para el Programa de Bajos lngresos “APD” usted debe ser residente del Condado de Santa Clara y no cubre a aquellos que tengan coberturas por terceras personas ni reclamos del Seguro del Trabajador (Worlnibk;:5 para 1‘esia:ient¢s indecumcntados, Pm‘ favor contacts a nuestro departaxnsntc dc; “Patient. Access” al te}«é~fc:n1o L186-6« 96?-46??; en ti sitio Internet w33:w.§cvm@.org/vai lgycarc: ea visitenos an 31 779 S. Bascam Avenue en San Jrasé, para Ustesci puede suIic.itar un cstimado de laces cargos por el servicia previste covntactando a. la Unidad dis Intagridaci dc Cobras a14{)8-885-6884, Per preguntas a facmracién par favar llama. 2.1 40-8 -3854470. Thfiang tin quan trgng elm uhfing bénh nhén khfing cé bio hifizm slit: khée tai Santa Clara Vailey Health & Hospital System: Tmng chiéu htrflng thi nhiém V1; vi tréch nhiém xi héi, Santa Clara Valiey Heaith 8: Hzaspitafl System ctmg c§'p nhiéu chu’c¥ng't1*inh tn; gifip téi chénh. Céc chufisng nay sé gifip 136:1}; nhfin {Ii man 13:3 hofic mm phén ~C1{tC box‘: @311 3’: phi, trong 36 dd cé nhfing chlfdng cbn £fii;1.;rt;5 cho nhfing cu’ dfifif; khfing C6 giéfy 15$! hcgsp lé. Qutj vi :6 thé lién lac Patient Access Depamnem. qua 36' 1-866-967-4677, viéng trang mgng Va! :3 3 heat: £1611 gap chx1ing£6i tai 7'70 S. Bascom Avxmue, San Jase, 415 bi€£ thém chi tié't.. (33? vi cf; thé yéu cfiu mét bén mite tinh y phi bfing cfich lién lac Revenue In.teg1'ity Unit, SE27 408-885-6834. Mnéfii héi vé héa mm 3,: phi, xin gqi 468-885-7470, ‘ ~ ~ ~ Wdslalbb Transiated’ by VMC. L5. 912.013 ?age 8 {if} 1 day appointments are avaifabie in our Pediatric -Urgent Care ciinicsi Have year medicai reccird number avaiiabie for faster service when Sailing Valley Connection at 1«888-33-’-M080. __‘~(_-_a_I¥§ Medicai Gamer ~ ~ Vaiiey Medicai Center undersiancis that health. care casts can be oven.-ihelming. VMC can heip you obtain coverage far your visit from a number of different programs. if you wouid iike assisiance in paying for your visii. please: request a Financial Assistance Appiicaiion from a flrzariciai Counseior or Heaith Services Representative at the registration desk. For questions about prsgrams or the appiicatioa process piease Cali 886~967~4677. Patéentfémardian Signature: Date: ' ‘$a|NTA CLIJBK VALLEY !!§llli$!O§D'(‘lII. Wiiif Ebaia information A message about Einoia We want you to know that Santa Clara Vaiteg Niedicai Ceniei is getting heady for the uniiiceiy event that a patient with Eboia comes to our hosvitai or ciiriics. ‘White them is no Eboia in Santa Ciara -Caunty. we are zaking action to be sure we are ready. Your he:-31:3} and weEi»being axe important to us. While the outbreak of Ebola in West Africa and receni cases here in me United States are serious, pubiiz; heaith experts beliéve the chance for an epidemic in the United States is very tow, Even so, we are taking acfiion Io mates? Gui‘ patienisi visiiars, doctors, nurses and eniére staff from being exposed to the disease if a case ever comes here, What is Santa Clara Valiey Meéical Center doing £o prepare? We are making sure we can safely test and ireat anyone whiz: might have 83033: - Screening patients far Eboia. - Putiing into piaca guideiénes from the Centers for Disaase Control and Preventizm (CDC). ° Working cioseiy with public heaiih officiais. * Making sure caregivers have the right equipment and the training they need. - Updating medical practices and training with the iaiest informaiien aboui the Ehoia outbreak. We have an expert team of infectious disease. emeigency speciaiists and nurse ieaders to guide mesa activities afid make sisre our paiients and staff are protecaed. What to do if you have symptoms or think you may have been expased. ?ubiic heaiih experts confirm ma! Ebola can oniy be spread through direc! comes: with the blood or body fluids of someone sick with Eimia, or objects coniaminated wiih {he virus, like needies. This means; - Ebota is N0‘? spread through casuai contact - Ebota can may be spraad when peopie who have the virus have symptoms. if you gust iraveied to Sierra Leone. Guinea. Liberia or Mai? and have a fgver or are sick, or you have been in coniaci with someone who has Ebola, caii #888-334-1006. They wiii tel} ycu whai '10 6:) next Printefi by CASTANLEDA, JEESSE [609] at 30/6/2016 3:31:42 PM Highly Confidential COUNTY_OOOO265 KAISER PERMANENTE Medical Financial Assistance Policy Summary Kaiser Permanente’s Medical Financial Assistance (MFA) program provides financial assistance for qualifying patients who need help paying for emergency or medically necessary care they receive in a Kaiser Permanente facility or by a Kaiser Permanente provider. Patients can apply for the MFA program in several ways including in person, by phone, or by completing and submitting a paper application. Patients must meet the eligibility requirements below to qualify. Who is eligible for Financial Assistance and what are the requirements? The program helps Iow-income, uninsured, or underserved patients who need help paying for all or part of their medical care. In general, patients are eligible for Financial Assistance when their Gross Household Income is at or below 350% of the Federal Poverty Guidelines (FPG) or have unusually high medical costs. Patients should talk with a Patient Financial Advisor to determine eligibility and for help applying. Patients who are eligible for medical financial assistance are not charged more than amounts generally billed (AGB) for emergency or other medically necessary care. Refer to kp.org/mfa/ncal forAGB information. Does Kaiser Permanente screen patients for public and private program eligibility? Kaiser Permanente provides patients with help to identify potential public and private health coverage programs that may help with health care access needs. A patient who is presumed eligible for any public or private health coverage program is required to apply for those programs. What does the program cover? The Medical Financial Assistance program covers medically necessary care provided at a Kaiser Permanente medical office, hospital, pharmacy or provided by a Kaiser Permanente provider. The types of services not covered include services that are not considered emergency or medically necessary by a Kaiser Permanente provider, infertility treatments and surrogacy services as well as health care premiums. Please see a more complete list in the MFA policy. ls there language assistance? Interpreters are available to you at no cost. The medical financial assistance application, policy, and this policy summary may be available in your language. For more information, call 800-464-4000 or visit our website at kp.org/mfa/ncal. eSe ofrece asistencia con el idioma? Hay intérpretes disponibles sin costo para usted. Es posible que la solicitud para recibir asistencia financiera para los gastos médicos, Ia péliza y este resumen de Ia péliza estén disponibles en su idioma. Para obtener més informacién, Ilame al 800-464-4000 o consulte nuestro sitio web en kp.org/mfa/nca|. ©2018 Kaiser Foundation Hospital; Kaiser Foundation Health Plan, Inc. E§flffi駧§1fifi ‘? Wfifi%§§3%fi§ El ?ifilfi’fi gfifijfigfifl EF'3% flfiflfl: fififfigi’aflfifimfi’aégéfiffio Ei‘ffiéfifiéfi 800-464-4000 fififlfifffififi kp.org/mfa/nca|0 Does Kaiser Permanente have a Financial Assistance policy? You may request your free copy of Kaiser Permanente’s Medical Financial Assistance policy by calling 800-390- 3507, mailing P.O. Box 30006, Walnut Creek, CA 94598, or visiting our website at kp.org/mfa/nca|. Need Help? For help or questions about the medical financial assistance application process, please call 800-390- 3507, or talk to a Patient Financial Advisor within the Patient Financial Advisors Department at any Kaiser Permanente hospital. How do | Apply? You can apply for medical financial assistance in several ways -- either by requesting program information in person or by phone or requesting a paper application from any of the following sources: o Patient Financial Advisor within the Patient Financial Advisors Department at any Kaiser Permanente hospital o Call 800-390-3507 o By mail (at no cost) at P.O. Box 30006, Walnut Creek, CA 94598 o Download an application through the Kaiser Permanente Community website at kp.org/mfa/ncal. Please return completed applications (including all required documentation and information specified in the application instructions) to the nearest Kaiser Permanente Hospital Admitting or Emergency Department or mail the application to: MFA Program, P.O. Box 30006, Walnut Creek, CA 94598. Kaiser Permanente will review submitted applications when they are complete and wi|| determine whether you are eligible according to the Kaiser Permanente Medical Financial Assistance Policy. Incomplete applications may result in a delay in processing or denial of your MFA application, but Kaiser Permanente will notify applicants and provide an opportunity to send in the missing documentation or information, by the required deadline. EXHIBIT SW; KAISER PERMANENTE® Kaiser Permanente Medical Financial Assistance (MFA) Program HELP IN YOUR LANGUAGE English: This is important information from Kaiser Permanente. If you need help understanding this information, please call 1-800-464-4000 and ask for language assistance. Help is available 24 hours a day, 7 days a week, excluding holidays. Chinese: EzaEfiEEKaiserPermanentefififi§fiiflo flflfiffi'fififiafii’lfiflflfififltfiifl. EfifiE1-800-757-7585 fififigfififio fififiiflfii. EiZM‘fi’EEfiffifij} (fifiiflfififiifi) o Spanish: La presente incluye informacién importante de Kaiser Permanente. Si necesita ayuda para entender esta informacién, llame al 1-800-788-0616 y pida ayuda linguistica. Hay ayuda disponible 24 horas al dia, siete dias a Ia semana, excluidos Ios dias festivos. {a Please recycle. January 2019 SW; KAISER PERMANENTE® Kaiser Permanente Medical Financial Assistance (MFA) Program If you need help paying for health care services or prescriptions you’ve gotten, or are scheduled to get, from Kaiser Permanente, our MFA program may be able to help you. How the program works The program offers temporary “awards” to help qualified applicants pay for care based on their financial needs. It’s available to all Kaiser Permanente patients, whether you’re a member or not. If awarded, the program will cover emergency or medically necessary care from Kaiser Permanente providers or at Kaiser Permanente facilities for a specified time period. How to qualify You must meet one of the following eligibility requirements:* 1. Your gross household income is no more than 350% of the federal poverty level. 3:00? Oflfed?dra:. *Note: If your gross household income is more than pave y eve gu' e mes 350% of the federal poverty level and/or you’re a |f your Your household income Kaiser Permanente member with a deductible plan household must be n0 more than: in California, you must meet the criterion below. Size iSi Mommy Annuauy 2. Your out-of-pocket health care costs for 1 $3,643 $43,71 5 emergency or medically necessary care, 2 $4,932 $59,185 dental care, and medication over a 12-month 3 $6,221 $74,655 period are equal to or more than 10% of your 4 $7,510 $90,125 gross household income. 5 $8,800 $105,595 o Out-of-pocket costs include copays, 6 $10,089 $1 21 ,065 coinsurance, and deductible payments. o Out-of-pocket costs do not include any payments for your health plan itself, like your monthly premium. Visit aspe.hhs.govlpoverty to find the guidelines for larger households. Have questions? For more information about qualifying for the MFA program, or to see which health care services it pays for, visit ww.kp.orglmfalncal. If you don’t have health insurance, you may be required to apply for it. Because the MFA program only provides temporary financial awards, we may require you to apply for coverage that will cover you in the long term. This could include any other public or private health programs you’re eligible for- like Medi-Cal or subsidized plans available on the health insurance marketplaces. We may ask you to show proof that you’ve applied to these programs, or that you’ve been approved or denied by them. But you may still be able to get financial help from the MFA program while waiting for a decision from these other programs. For more information about other health coverage you may be eligible for, visit healthcare.gov or call 1-800-318-2596. SW; KAISER PERMANENTE® How to apply If you meet the eligibility requirements, you can apply in any of these ways. Mail it Complete the MFA application on the following page. Mail your completed application to: Kaiser Permanente MFA Program PO Box 30006 Walnut Creek, CA 94598 Fax it Complete the MFA application on the following page. Fax your completed application to 1-800-687-9901. EL? Drop it off Complete the MFA application on the following page. Drop off your completed application at the Patient Financial Operations at any Kaiser Permanente facility. %> Call us Call us at 1-800-390-3507 (TTY 711), Monday through Friday, 8:00 a.m. to 5:00 p.m. PST. Be prepared to provide the information listed on the MFA application on the next page. Important: When applying by mail or fax, or dropping off your application in person, please be sure to fill out the application as much as you can. Any missing information may delay the application process. What to expect after you apply After we review your completed application, we’ll let you know one of the following outcomes: - Your application was approved and you’ll get a financial award. . To complete your application, we need additional information or paperwork, which you can send us in the mail or drop off in person; this could include proof of income or copies of your out-of-pocket expenses. - Your application was denied and why it was denied, in which case you can appeal our decision. Need help? If you have any questions or need help with your application, please call 1-800-390-3507 (TTY 711), Monday through Friday, 8:00 a.m. to 5:00 p.m. PST. You can also talk to a financial counselor at any Kaiser Permanente location. WI W/ o x\\§0 KAISER PERMANENTE® Medical Financial Assistance (MFA) Program application Name: Medical record #: Date of birth:_/_/_ Contact #: ( ) SSN: Address: City: State: Household size: Number of family members (including you) who live in your home. May include a spouse or qualified domestic partner, children, a non-parent caretaker relative, etc. ZIP code: Household income (monthly): Total gross income for all family members in the household. Check ALL income types that apply: D Employment Income/Wages D Alimony/Child Support D Business Income/Rental Property D Pension or Retirement/Annuities D Unemployment Benefits/ D Social Security/Supplemental Disability Income Security Income/Veterans Benefits Health care costs: Total out-of-pocket expenses you had over a 12-month period for emergency or medically necessary services provided by Kaiser Permanente or any other health care provider. May include copays, deposits, coinsurance, or deductible payments for eligible medical, pharmacy, or dental services. Please list all members of your household applying for the program. Name Date of birth Relationship / / Medical record # / / / / / / / / Uninsured? Kaiser Permanente can help. If you do not have health care coverage, we can help you understand your options. Check this box if you would like Kaiser Permanente to contact you to discuss your options. D Yes, contact me | hereby declare under penalty of perjury that all information set forth above in this application is true and accurate in all respects. | also acknowledge and agree that | am liable to Kaiser Foundation Health Plan and Hospitals for all amounts owing to Kaiser Foundation Health Plan and Hospitals for medical goods and services that are not eligible underthe Program (the “Remaining Amounts”). Signature: Date: Note: Kaiser Foundation Health Plan and Hospitals reserves the right to use information from consumer credit reporting agencies and other third-party information sources to determine eligibility for federal, state, and private medical programs, including the MFA Program. o Afiarece una erupcién cuténea. o Siente dolor o irritacidn en la zona de la insercién de Ia via intravenosa. - Se siente débil o mareada. o Necesita analgésicos més fuertes. o Desarrolla aiguna reaccién o efecto secundario por los medicamentos administrados. SOLICITE ATENCION MEDICA DE INMEDtATO Si: o Presents enrojecimiento. hinchazén o secrecién en Ia zona de Ia incisién. - Siente dolor, hinchazén e irritacién en la pierna. o Siente dolor en el pecho. - Se desmaya. - Comienza a sentir falta de aire. . - - Observa pus que drena por la zona de la herida. o La incisién se abre. ASEGURESE DE QUE; - Comprende estas instrucciones. - Controlaré su enfermedad. a Solicitaré ayuda de inmediato si no mejora o empeora. Document Released: 05/09/2012 Document Revised: 03/1 1/2013 ExitCare® Patient Information ©2013 ExitCare. LLC. Information from Valley Medical Center Valley Medical Center understands that health care costs can be overwhelming. VMC can help you obtain coverage for your visit from a number of differerit programs. If you would like aSSistance in paying for your visit, please request a Financial Assistance Applicati0n from a Financial Counselor or Health Services Representative at the registration desk. For questions about programs or the application process please call 866-967-4877. Patienthuardian Signature: {Mnme- 6M“ Cortez, Maria (MR#_) Printed by Anna Donovan. RN-1 at 11/8/13 5:23 PM CORTEZ 000596
