CurrentConnecticut Insurance DepartmentPolicy FIN0017

Financial Assistance Policy for Hospital Services

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This policy governs financial assistance for medically necessary geriatric hospital behavioral health inpatient services provided by Masonicare Health Center to uninsured, underinsured, or medically indigent patients who demonstrate an inability to pay. It establishes eligibility, documentation, application, billing, and excluded-service requirements.

Policy Summary

PayerConnecticut Insurance Department

PolicyFinancial Assistance Policy for Hospital Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionTreat all medically necessary care regardless of the patient's ability to pay and do not pursue extraordinary collection activity for hospital-service amounts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%Financial relief for qualifying services at or below 200% of the Federal Poverty Level

20%Patient-responsibility threshold for catastrophic-cost eligibility

66.2%Amount generally billed rate

30 days

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CurrentConnecticut Insurance DepartmentPolicy FIN0017

Financial Assistance Policy for Hospital Services

Customize your policy alerts

Sign up for Connecticut Insurance Department Policy FIN0017 alerts

Get alerted when Policy FIN0017 changes without checking for updates manually.

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Policy Summary

PayerConnecticut Insurance Department

PolicyFinancial Assistance Policy for Hospital Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionTreat all medically necessary care regardless of the patient's ability to pay and do not pursue extraordinary collection activity for hospital-service amounts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%Financial relief for qualifying services at or below 200% of the Federal Poverty Level

20%Patient-responsibility threshold for catastrophic-cost eligibility

66.2%Amount generally billed rate

30 days

Time to determine eligibility after receiving a completed application

180 daysApplication period from the date of the initial bill

6 monthsCoverage period for an approved application

Financial Assistance Eligibility and Exclusions

Standard financial assistance eligibility

Covered when all applicable eligibility, service, application, and documentation requirements are met.

ALL of the following

ALL of the following
- Service is medically necessary Hospital Services ordered by a physician and provided and billed by Masonicare Health Center.
- Patient is uninsured or underinsured and demonstrates an inability to pay.
- Household income is at or below 200% of the Federal Poverty Level Guidelines.
- Patient is ineligible for State Medicaid Assistance.
The required application and supporting documentation are completed.

Medical indigence and catastrophic costs

Financial assistance may be available for medically indigent patients whose patient-responsibility Hospital Service expenses exceed the specified household-income threshold.

ALL of the following

Patient claims catastrophic circumstances or medical indigence and submits an application.
Patient-responsibility Hospital Service expenses, including applicable copayments and deductibles, exceed 20% of family household income.> 20% of family household income
Financial assistance documentation and application requirements are satisfied.

Medicaid assistance pathway

Patients with verified income below the poverty guidelines must pursue the State Medicaid Assistance pathway.

ALL of the following

Patient has verified income below 100% of the poverty guidelines.< 100% of poverty guidelines
Patient completes a State Medicaid Assistance application.
ONE of
- Patient is approved for Medicaid with no spend-down, and the Connecticut Department of Social Services eligibility determination verifies income for 100% financial assistance.
- The account balance results from a Medicaid spend-down and eligibility is determined under the applicable income guidelines; the remaining balance may not qualify for financial assistance.

Presumptive support

Presumptive support may be approved without an application when limited available information supports eligibility.

ONE of

Patient is deceased.
Patient is homeless.
Patient has filed for bankruptcy.
Patient belongs to a religious organization, has taken a vow of poverty, and has no resources.
Patient qualifies for another income-based State Assistance Program.

Excluded services and denial conditions

The following services, providers, and circumstances are excluded from financial assistance under this policy.

ANY of the following applies

Service is a non-Hospital Service of Masonicare Health Center, including skilled nursing, independent living, or assisted living.
Account involves a secured lien or liability case.
Hospital-related care is provided by an independent hospitalist, radiologist, cardiologist, pathologist, or other provider whose services are not billed by Masonicare Health Center.
Patient is eligible for other funding, such as Medicaid, and refuses to apply for it.

Financial assistance eligibility determination

Applicants must provide the applicable financial documentation; the office then determines and records the assistance outcome.

ALL of the following

Applicant is uninsured or has income under the applicable Federal Poverty Level Guidelines.
Required documentation is provided, including applicable income information, tax return documentation, and—when applicable—a Connecticut Department of Social Services Medicaid determination letter.
All requested information is received within 30 days from the date of the request.Within 30 days
ONE determination outcome
- Applicant is eligible for the next 6 months.

Eligibility Thresholds and Billing Parameters

Federal Poverty Level Eligibility

Financial relief100% discount

Income limit200% or less of the Federal Poverty Level Guidelines

Covered careMedically necessary Hospital Services, subject to documentation and application requirements

Catastrophic-Cost Threshold

Patient-responsibility thresholdMore than 20% of family household income

Assistance100% financial assistance for eligible patient responsibility

Included amounts

Operational Requirements

Billing Rule

Provide Medically Necessary Care Regardless of Ability to Pay

Treat all medically necessary Hospital Services, including emergency medical conditions, regardless of the patient's ability to pay. Do not pursue extraordinary collection activities for Hospital Services, including reporting to a collection agency, selling the debt, or actions requiring a legal or judicial process.

Denial Risk

Apply Service and Provider Exclusions

Do not approve financial assistance for services, providers, or circumstances excluded from the policy.

Non-Hospital Services, including skilled nursing, independent living, and assisted living
Secured liens and liability cases

Policy Terms

Extraordinary Collection Activity

Collection agency reportingReporting an individual to a collection agency

Debt transferSelling an individual's debt to another party

Legal or judicial actionsActions that require a legal or judicial process, and other similar collection actions

Medically Necessary Care

DefinitionHospital care ordered by a physician

Covered settingHospital Services provided by Masonicare Health Center

Provider limitation

Policy Summary

PayerConnecticut Insurance Department

PolicyFinancial Assistance Policy for Hospital Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionTreat all medically necessary care regardless of the patient's ability to pay and do not pursue extraordinary collection activity for hospital-service amounts.

SourceLink

On This Page

Applicant is eligible for catastrophic event coverage.

Applicant is denied for being over income, failing to pursue available resources, failing to comply with application requirements, or another documented reason.

Copayments and deductibles are included in the catastrophic-cost calculation

Amount Generally Billed Rate

AGB rate66.2% of gross charges

Calculation methodFacility gross charges multiplied by the calculated average payment percentage of traditional Medicare claim payments

Calculation periodOctober 1, 2024 to September 30, 2025

Update frequencyUpdated annually no later than October 1

Medicaid Application Threshold

Income thresholdVerified income below 100% of poverty guidelines

Required actionComplete a State Medicaid Assistance application

Medicaid approvalDepartment of Social Services eligibility verification may establish eligibility for 100% financial assistance when Medicaid is approved without a spend-down

Uninsured or Underinsured Eligibility

Income limit200% or less of the Federal Poverty Level Guidelines

Patient statusUninsured or underinsured patients who are ineligible for State Medicaid Assistance

Available relief100% discount for medically necessary Hospital Services when documentation and application requirements are met

Catastrophic-Cost Threshold

Income conditionPatient earns more than 200% of the Federal Poverty Level Guidelines

Expense thresholdHospital Service expenses exceed 20% of family household income

Available relief100% discount for patient responsibility exceeding 20% when documentation and application requirements are met

Application Documentation Deadline

Submission deadlineWithin 30 days from the date of the request

Required materialsAll information requested for the financial-assistance application

Applicant acknowledgmentThe applicant certifies the information provided and authorizes employment verification for eligibility determination

Hospital-related services not billed by Masonicare Health Center, including independent medical services from hospitalists, radiologists, cardiologists, pathologists, and other non-covered providers

Denial Risk

Require Other Available Funding First

Deny financial assistance when a patient is eligible for other funding or refuses to pursue it. Patients with verified income below 100% of the poverty guidelines must complete a State Medicaid Assistance application; Medicaid eligibility documentation may verify income and support 100% assistance when there is no spend-down.

Require pursuit of Medicaid and other available funding before granting assistance.
Apply income guidelines and the look-back method when a Medicaid balance results from a spend-down.

Documentation Required

Determine Inability to Pay Case by Case

Review each completed financial assistance application and supporting documentation case by case. Financial Services Department personnel must determine whether the applicant demonstrates an inability to pay and satisfies the policy's income qualification and documentation requirements.

Documentation Required

Accept Applications Throughout the Permitted Period

Accept and process financial assistance requests during preadmission, registration, any time during or after services are rendered, and whenever the individual's circumstances change. Process applications received during the 180-day application period from the initial bill, including the permitted 30-day resubmission period.

An approved application covers previous services and future qualifying services for the next six months.

Denial Risk

Manage Incomplete Applications

If required documentation is missing, keep the application pending and send written notice identifying the missing materials, contact information, and questions regarding the missing information. Deny the application if the missing documentation is not received within 30 days of the notice.

Billing Rule

Limit Patient Billing for Eligible Services

Apply financial assistance so an eligible patient is billed no more than the amount personally responsible after applicable deductions, discounts, and insurance payments. For qualifying patients, assistance applies up to the Amount Generally Billed (AGB) for medically necessary Hospital Services.

The look-back method uses traditional Medicare claim payments compared with related gross published rates.
The discounted rate is 66.2% of gross charges for October 1, 2024 through September 30, 2025, and must be updated annually by October 1.
For catastrophic circumstances, provide 100% assistance for insured patient responsibility exceeding 20% of family household income, including applicable copays and deductibles, when requirements are met.

Note

Use Presumptive Support When Permitted

When limited available information supports eligibility, approve financial assistance as presumptive support without requiring an application.

Examples include deceased or homeless patients, patient bankruptcies, members of religious organizations who have taken a vow of poverty and have no resources, and patients qualified for income-based State Assistance Programs.

Documentation Required

Submit the Application and Supporting Documentation

Patients seeking assistance must submit a completed Financial Assistance Application for Hospital Services with all required supporting documents to the Masonicare Financial Services Department, PO Box 70, Wallingford, CT 06492-3048. Financial counselors are available to help complete the application.

Financial Services Department personnel must determine eligibility within 30 days after receiving a completed application.
Patients may contact a Financial Counselor at (203) 678-7882.

Denial Risk

Screen for Other Funding Sources

Before granting assistance, screen for State Medicaid and other available funding sources. Assistance may be denied when the patient is eligible for another funding source, such as State Medicaid, or refuses to apply.

Documentation Required

Collect Required Eligibility Documentation

Collect the information needed to evaluate eligibility and require applicants to provide all requested materials within 30 days of the request.

Income evidence, including four consecutive payroll stubs for each working household member or an employer salary letter, unemployment benefit letters, alimony or child support determinations, Social Security/disability/pension statements, support letters, interest/dividend or other income documentation, and household dependent information
For self-employed applicants, the prior two years of filed federal tax returns, including Schedule C or Schedule K-1
A Connecticut Department of Social Services Medicaid eligibility determination letter when uninsured or income is under the Federal Poverty Level Guidelines
The applicant must certify the information, authorize employment verification, and understand that untrue information may result in reevaluation and appropriate action.

Note

Maintain Public Access to Policy and Application Materials

Keep the Financial Assistance Policy for Hospital Services, application, and Plain Language Summary publicly accessible on Masonicare's website and at designated Health Center locations. Provide translations when Limited English Proficiency requirements are met.

Admissions Department: (203) 679-5007
Behavioral Health Hospital inpatient unit: (203) 679-5904 or (203) 679-5712; locations include Sturges 4, Central 4, and Wooster 4
Financial counselors can provide free copies, and copies may also be requested by mail.

Documentation Required

Collect Eligibility Documentation

Obtain and verify the core eligibility materials required for the determination, including income information, the applicable tax return, and the Medicaid determination letter when applicable.

Document whether income, tax return, and Medicaid determination documentation were provided.
Use the Medicaid determination materials for uninsured applicants or applicants below the Federal Poverty Level Guidelines when applicable.

Documentation Required

Complete and Authorize the Determination

Complete the eligibility determination record with the patient's name, medical record number, recipient of the application, and receipt date. Record the documentation reviewed and obtain the required Financial Services Department authorization, including the authorized signature, determination date, printed name, and title.

Documentation Required

Record the Eligibility Outcome

Record the eligibility outcome and its basis. Identify approval for the next six months, catastrophic event coverage with the original balance, assistance amount, and new balance, or denial with the applicable reason.

Denial reasons include over income, failure to pursue available resources, failure to comply with application requirements, or another documented reason.

No other providers are covered by this policy

Medical Indigence / Catastrophic Circumstances

DefinitionA condition in which a person cannot pay some or all medical bills because medical expenses exceed a specified percentage of family or household income

Qualifying circumstancesLoss of employment, death of a primary wage earner, or excessive medical expenses

Review standardEvaluated case by case, including review of family household income

Amount Generally Billed (AGB)

FormulaFacility gross charges for medically necessary care multiplied by the average payment percentage of traditional Medicare claim payments compared with related gross published rates

MethodLook-back method

Current stated rate66.2% of gross charges for October 1, 2024 through September 30, 2025

Presumptive Support

DefinitionFinancial assistance approved using limited available information when complete financial information cannot be provided

Application requirementNo application is required for this group

ExamplesDeceased patients, homeless patients, patient bankruptcies, persons with a vow of poverty and no resources, and patients qualified for income-based State Assistance Programs

Hospital Services

Inpatient servicesGeriatric hospital behavioral health inpatient services

Outpatient servicesHospital outpatient services

Policy termThese services are collectively referred to as Hospital Services

Amount Generally Billed

DefinitionThe traditional Medicare discounted payment rate

Patient charge limitEligible patients will not be charged more than the Amount Generally Billed for medically necessary Hospital Services

Eligibility contextApplies to patients eligible under the Financial Assistance Policy for Hospital Services

Catastrophic Costs

Income conditionPatient earns more than 200% of the Federal Poverty Level Guidelines

Expense thresholdMedical expenses for Hospital Services exceed 20% of family household income

Covered amount100% discount for patient responsibility in excess of 20% when policy documentation and application requirements are met