N.J. Admin. Code § 10:52-11.16

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

Section 10:52-11.16 - Charity care applications of patients admitted through emergency room

(a) If a charity care applicant is admitted through the hospital's emergency room, the requirements set forth in this section shall apply.

1. The hospital shall notify the patient, orally and by providing a copy of the individual written notice referenced in 10:52-11.5(a), of the availability of charity care. This notice shall be given prior to the patient's discharge from the hospital.

(b) The hospital shall correctly assess and document the applicant's eligibility for charity care, based upon the criteria set forth in this section. The applicant's financial file for audit purposes shall contain the supporting documentation described in this section.

(c) If the applicant's medical condition permits, the hospital shall ask the applicant, prior to discharge, if he or she has any third party health insurance, including, but not limited to, coverage through a parent or spouse or coverage for the services under an automobile insurance or workers' compensation policy. If the applicant claims to have insurance, the hospital shall document the name of the insurer and the insured, and all other information pertinent to the insurance coverage. The hospital shall also document that the insurance coverage was verified, or the reason why the coverage could not be verified. Verification of insurance shall include the hospital contacting the identified third party insurer. Charity care availability for persons with health insurance shall be subject to Federal disproportionate share rules.

(d) If the applicant's medical condition permits, the hospital shall also, prior to the applicant's discharge, request the following information, which shall be recorded by the hospital on a form approved by the Department of Health:

1. The applicant's name;

2. The address of the applicant's residence;

3. Whether the applicant intends to remain a resident of New Jersey (assuming current residence in New Jersey);

4. The applicant's home telephone number, if any;

5. Whether the applicant is employed and, if so, the employer's name and address;

6. Applicant's best estimate of annual income, including sources of income and income from each source; and

7. Whether the applicant has an account with a bank and, if so, the name and location of the bank.

(e) If the hospital is able to obtain the information listed in (d) above, the hospital shall, prior to the applicant's discharge, ask the applicant to read the form on which the information has been recorded, and verify the information's accuracy by signing the form. The form shall also include a statement authorizing the hospital to contact any person or entity listed on the form in order to obtain and/or verify information relating to the charity care application.

(f) The hospital shall verify that the applicant is not enrolled in a medical assistance program.

(g) If the applicant is determined to be uninsured and not enrolled in a medical assistance program, and the hospital has been able to obtain the information and applicant's signature described in (d) and (e) above, then the hospital shall process the charity care application based on the information obtained. (If the information and applicant's signature described in (d) and (e) above cannot be obtained by the hospital, in whole or in part, then the provisions of (h) below shall apply.) The applicant's charity care eligibility shall be determined based on the following requirements:

1. The applicant's self-identification shall be acceptable to establish identity;

2. The applicant shall be a resident of New Jersey at the time of service, and shall have the intent to remain in the State as demonstrated by the applicant's statement of intent. The hospital shall verify, by telephone or visit, that the applicant can be contacted at the address provided; if the address is in the State, this shall establish New Jersey residency for this purpose. The method of verification shall be documented in the financial file for audit purposes;

3. There shall be an assumption that the applicant's family size, for purposes of the charity care application, is one, consisting of the applicant. The charity care income eligibility guidelines set forth at 10:52-11.8(b) and (c) shall be applied to determine eligibility. If the applicant identified an employer, the hospital shall contact that employer to determine the applicant's income. The hospital shall record that information, if provided, and include it in the financial file for audit purposes. If the employer declines to provide that information, that fact shall likewise be documented. The hospital shall annualize any income amount provided by the employer, if necessary, to assess the applicant's eligibility. If the applicant did not identify an employer, or the employer declines to provide income information regarding the applicant, then the applicant's best estimate of annual income (see (d) above) shall be used to determine the applicant's annual income for this purpose; and

4. There shall be an assumption for the purposes of this section that bank account deposits constitute the only assets relevant to the application. If the applicant identified a bank at which he or she holds deposits, then the hospital shall contact the bank to verify the amount held. If the bank provides the requested information, then the amount shall be documented in the financial file for audit purposes. If the bank declines to provide the information, that fact shall likewise be documented. If no bank was identified by the applicant, or the bank declines to provide information regarding the account, there shall be an assumption that the applicant has no assets. Eligibility shall be assessed under the asset limitation set forth at 10:52-11.11(a)1.

(h) If the applicant is determined to be uninsured and not enrolled in a medical assistance program, and if the hospital was unable to obtain the information and applicant signature described in (d) and (e) above, then the hospital shall make the following efforts to determine whether the applicant is eligible for charity care. The hospital shall:

1. Make at least two attempts to contact the patient by phone, if a phone number is available, to try to schedule an in-person interview to obtain information relevant to the application. If such an interview can be arranged, the hospital shall obtain the relevant information and process the application based on that information. If such an interview cannot be arranged, this shall be documented in the financial file for audit purposes;

2. Visit the address given by the applicant, or otherwise obtained, and attempt to verify that the applicant lives there. If the applicant is homeless and has not provided the address of a shelter or other temporary residence, this requirement shall not apply. This shall be achieved by direct contact with the applicant, if possible, or by asking persons at the address, neighbors, or by observing the surroundings (for example, name on mailbox). The results of this attempt shall be documented in the financial file for audit purposes. If the hospital is able to achieve direct contact with the applicant, the hospital shall try to conduct or schedule an in-person interview to obtain information relevant to the application. If such an interview can be arranged, the hospital shall obtain the relevant information and process the application based on that information. If such an interview cannot be arranged, this shall be documented in the financial file for audit purposes; and

3. Attempt to determine the applicant's income and assets, that shall include observing the nature of the applicant's housing, to determine that there are no indications that the applicant would not likely be eligible for charity care, and obtaining information from persons at the applicant's address or from neighbors regarding the applicant's employment or other means of support. The results of these attempts shall be documented in the financial file for audit purposes.

(i) If the applicant is determined to be eligible for charity care under (g) above or, in the alternative, if the hospital has completed and documented the efforts set forth in (h) above, then the hospital may write off to charity care the claim(s) arising from the admission. Notwithstanding any other provision of this subchapter, if an applicant is determined to be eligible for charity care under (g) above, or in the alternative, if the hospital has completed and documented the efforts set forth in (h) above, and the patient is subsequently transferred to, and admitted at, another hospital, then the hospital admitting the transferred patient may rely upon the charity care determination of the transferring hospital, and write off to charity care the claim(s) arising from the transfer admission. See 10:52-11.3 regarding the charity care write off amount. The applicant shall not be deemed to be eligible for charity care for future services based on this determination but would, instead, be required to meet the requirements set forth at 10:52-11.5 through 11.10 and 11.12 at the time that future services were rendered unless the applicant was admitted through the emergency room in the future, in which case this section would apply.

(j) Claims that are written off to charity care under (i) above shall not be included when determining the "alternative documentation" adjustment. See 10:52-11.11 and 11.15.

N.J. Admin. Code § 10:52-11.16

Amended by 50 N.J.R. 1261(a), effective 5/21/2018