101 CMR, § 613.08

Current through Register 1536, December 6, 2024

Section 613.08 - Other Requirements

(1)Provider Responsibilities.

(a)Nondiscrimination. A Provider must not discriminate on the basis of race, color, national origin, citizenship, alienage, religion, creed, sex, sexual orientation, gender identity, age, or disability in its policies or in its application of policies, concerning the acquisition and verification of financial information, preadmission or pretreatment deposits, payment plans, deferred or rejected admissions, or Low Income Patient status.

(b)Legal Execution. A Provider or agent thereof must not seek legal execution against the personal residence or motor vehicle of a Low Income Patient determined pursuant to 101 CMR 613.04 without the express approval of the Provider's Board of Trustees. All approvals by the Board must be made on an individual case basis.

(c)Credit and Collection Policies.

1.Filing Requirements. Each Provider must electronically file a Credit and Collection Policy that is reflective of its practices with the Health Safety Net Office in each of the following circumstances:

a. a new Provider must file a copy of its Credit and Collection Policy prior to Health Safety Net Office approval to submit claims for payments;

b. within 90 days of adoption of amendments to 101 CMR 613.00 that would require a change in the Credit and Collection Policy;

c. when a Provider changes its Credit and Collection Policy; or

d. when two Providers merge and request to be paid as a single merged entity.

2.Content Requirements. A Provider's Credit and Collection Policy must contain

a. standard collection policies and procedures;

b. policies and procedures for collecting financial information from Patients;

c. for Acute Hospitals, a detailed emergency care classification policy specifying

i. its practices for classifying persons presenting themselves for unscheduled treatment, the urgency of treatment associated with each identified classification;

ii. the location(s) at which Patients might present themselves; and

iii. any other relevant and necessary instructions to Acute Hospital personnel that would see these Patients.

iv. The policy must include the classifications that qualify as Emergency Services and other services including "elective" or "scheduled" services;

d. the policy on deposits and payment plans for qualified Patients as described in 101 CMR 613.08(1)(g);

e. copies of billing invoices, award or denial letters, and any other documents used to inform Patients of the availability of assistance;

f. description of any program by which the Acute Hospital offers discounts from charges for the uninsured;

g. for an Acute Hospital with Hospital Licensed Health Center, Satellite Clinic, or school-based health center locations that provide Eligible Services, an indication whether each location offers Patients a deductible payment plan for outpatient services per 101 CMR 613.04(8)(c)5.; and

h. direct URL(s) where the Provider's Credit and Collection Policy, Provider Affiliate list (if applicable), and other financial assistance policies are posted.

(d)Provider Affiliate List. Acute Hospitals must establish a list of all Provider Affiliates. The list must clearly indicate or delineate which Provider Affiliates provide services that are eligible for reimbursement by the Health Safety Net.

1. For the purposes of this requirement, Acute Hospitals may use any method adequate to identify Provider Affiliates. This may include, but is not limited to:

a. listing the names of each individual practitioner;

b. listing the names of individual practitioners, practice groups, or any other entities that are providing emergency or medically necessary care in the Acute Hospital by the name used by such entities either to contract with the Acute Hospital or to bill patients for care provided; or

c. list by reference to a department or a type of service if the reference makes clear which Provider Affiliate services are and are not eligible to be reimbursed by the Health Safety Net.

2. If a Provider Affiliate is eligible to be reimbursed by the Health Safety Net in some circumstances but not in others, the Acute Hospital must describe the circumstances in which the emergency or other medically necessary care delivered by the Provider Affiliate will and will not be eligible for reimbursement by the Health Safety Net.

3. Acute Hospitals must take reasonable steps to ensure that their Provider Affiliate lists are accurate by updating their Provider Affiliate lists at least quarterly to add new or missing information, correct erroneous information, and delete obsolete information.

4. The requirements set forth in 101 CMR 613.08(d)1. through 3. are effective as of the first day of the Acute Hospital's fiscal year beginning after December 31, 2016.

(e)Notices.

1. In the following circumstances, a Provider must notify the individual of the availability of financial assistance programs to a Patient expected to incur charges, exclusive of personal convenience items or services, whose services may not be paid in full by third party coverage:

a. during the Patient's initial registration with the Provider;

b. on all billing invoices; and

c. when a Provider becomes aware of a change in the Patient's eligibility or health insurance coverage.

2. In the following circumstances, a Provider or its designee must notify the individual about Eligible Services and programs of public assistance, including MassHealth, the Premium Assistance Payment Program Operated by the Health Connector, the Children's Medical Security Plan, and Medical Hardship:

a. during the Patient's initial registration with the Provider;

b. on all billing invoices; and

c. when a Provider becomes aware of a change in the Patient's eligibility or health insurance coverage.

3. A Provider must include a brief notice about the availability of financial assistance in all written Collection Actions. The following language is suggested, but not required, to meet the notice requirements of 101 CMR 613.08(1)(e): "If you are unable to pay this bill, please call [phone number]. Financial assistance is available."

4. A Provider must notify the Patient that the Provider offers a payment plan as described in 101 CMR 613.08(1)(f), if the Patient is determined to be a Low Income Patient or qualifies for Medical Hardship.

(f)Distribution of Financial Assistance Program Information.

1. Providers must post signs in the inpatient, clinic, and emergency admissions/ registration areas and in business office areas that are customarily used by Patients that conspicuously inform Patients of the availability of financial assistance programs and the Provider location at which to apply for such programs. Signs must be large enough to be clearly visible and legible by Patients visiting these areas. All signs and notices must be translated into languages other than English if such languages are the primary language of 10% or more of the residents in the Provider's service area. Signs must notify Patients of the availability of financial assistance and of other programs of public assistance. The following language is suggested, but not required:

a. "Are you unable to pay your hospital bills? Please contact a counselor to assist you with various alternatives."; or

b. "Financial assistance is available through this institution. Please contact____________."

2. Providers must make their Credit and Collection Policies filed in accordance with 101 CMR 613.08(1)(c)1. and Provider Affiliate lists (if applicable), as described in 101 CMR 613.08(1)(d), available on the Provider's website.

(g)Deposits and Payment Plans.

1. A Provider may not require preadmission and/or pretreatment deposits from individuals that require Emergency Services or that are determined to be Low Income Patients.

2. A Provider may request a deposit from individuals determined to be Low Income Patients. Such deposits must be limited to 20% of the deductible amount, up to $500. All remaining balances are subject to the payment plan conditions established in 101 CMR 613.08(1)(g).

3. A Provider may request a deposit from Patients eligible for Medical Hardship. Deposits are limited to 20% of the Medical Hardship contribution up to $1,000. All remaining balances are subject to the payment plan conditions established in 101 CMR 613.08(1)(f).

4. A Patient with a balance of $1,000 or less, after initial deposit, must be offered at least a one-year, interest-free payment plan with a minimum monthly payment of no more than $25. A Patient with a balance of more than $1,000, after initial deposit, must be offered at least a two-year, interest-free payment plan.

(h)Patient Responsibilities. Providers must advise Patients of the rights and responsibilities described in 101 CMR 613.08(2) in all cases where the Patient interacts with registration personnel.

(2)Patient Rights and Responsibilities.

(a) Patients have the right to

1. apply for MassHealth, the Premium Assistance Payment Program Operated by the Health Connector, a Qualified Health Plan, Low Income Patient determination, and Medical Hardship; and

2. a payment plan, as described in 101 CMR 613.08(1)(g), if the Patient is determined to be a Low Income Patient or qualifies for Medical Hardship.

(b) A Patient who receives Reimbursable Health Services must

1. provide all required documentation;

2. inform MassHealth of any changes in MassHealth MAGI Household income or Medical Hardship Family Countable Income, as described in 101 CMR 613.04(2), or insurance status, including but not limited to, income, inheritances, gifts, distributions from trusts, the availability of health insurance, and third-party liability. The Patient may, in the alternative, provide such notice to the Provider that determined the Patient's eligibility status;

3. track the Patient deductible and provide documentation to the Provider that the deductible has been reached when more than one Premium Billing Family Group member is determined to be a Low Income Patient or if the Patient or Premium Billing Family Group members receive Reimbursable Health Services from more than one Provider; and

4. inform the Health Safety Net Office or the MassHealth Agency when the Patient is involved in an accident, or suffers from an illness or injury, or other loss that has or may result in a lawsuit or insurance claim. In such a case, the Patient must

a. file a claim for compensation, if available; and

b. agree to comply with all requirements of M.G.L. c. 118E, including but not limited to

i. assigning to the Health Safety Net Office the right to recover an amount equal to the Health Safety Net payment provided from the proceeds of any claim or other proceeding against a third party;

ii. providing information about the claim or any other proceeding, and fully cooperating with the Health Safety Net Office or its designee, unless the Health Safety Net Office determines that cooperation would not be in the best interests of, or would result in serious harm or emotional impairment to, the Patient;

iii. notifying the Health Safety Net Office or the MassHealth Agency in writing within ten days of filing any claim, civil action, or other proceeding; and

iv. repaying the Health Safety Net from the money received from a third party for all Eligible Services provided on or after the date of the accident or other incident after becoming a Low Income Patient for purposes of Health Safety Net payment, provided that only Health Safety Net payments provided as a result of the accident or other incident will be repaid.

(3)Populations Exempt from Collection Action.

(a) A Provider must not bill Patients enrolled in MassHealth and Patients receiving governmental benefits under the Emergency Aid to the Elderly, Disabled and Children program except that the Provider may bill Patients for any required copayments and deductibles. The Provider may initiate billing for a Patient who alleges that he or she is a participant in any of these programs but fails to provide proof of such participation. Upon receipt of satisfactory proof that a Patient is a participant in any of the above listed programs, and receipt of the signed application, the Provider must cease its collection activities.

(b) Participants in the Children's Medical Security Plan whose MAGI income is less than or equal to 300% of the FPL are also exempt from Collection Action. The Provider may initiate billing for a Patient who alleges that he or she is a participant in the Children's Medical Security Plan, but fails to provide proof of such participation. Upon receipt of satisfactory proof that a Patient is a participant in the Children's Medical Security Plan, the Provider must cease all collection activities.

(c) Low Income Patients, other than Dental-only Low Income Patients, are exempt from Collection Action for any Reimbursable Health Services rendered by a Provider receiving payments from the Health Safety Net for services received during the period for which they have been determined Low Income Patients, except for copayments and deductibles. Providers may continue to bill Low Income Patients for Eligible Services rendered prior to their determination as Low Income Patients after their Low Income Patient status has expired or otherwise been terminated.

(d) Low Income Patients, other than Dental-only Low Income Patients, with MassHealth MAGI Household income or Medical Hardship Family Countable Income, as described in 101 CMR 613.04(2), greater than 150% and less than or equal to 300% of the FPL are exempt from Collection Action for the portion of his or her Provider bill that exceeds the deductible and may be billed for deductibles as set forth in 101 CMR 613.04(8)(b). Providers may continue to bill Low Income Patients for services rendered prior to their determination as Low Income Patients after their Low Income Patient status has expired or otherwise been terminated.

(e) Providers may bill Low Income Patients for services other than Reimbursable Health Services provided at the request of the Patient and for which the Patient has agreed to be responsible, with the exception of those services described in 101 CMR 613.08(3)(e) l. and 2. Providers must obtain the Patient's written consent to be billed for the service.

1. Providers may not bill Low Income Patients for claims related to medical errors including those described in 101 CMR 613.03(l)(d).

2. Providers may not bill Low Income Patients for claims denied by the Patient's primary insurer due to an administrative or billing error.

(f) At the request of the Patient, a Provider may bill a Low Income Patient in order to allow the Patient to meet the required Common Health one-time deductible as described in 130 CMR 506.009: The One-time Deductible or the required MassHealth asset reduction defined in 130 CMR 520.004: Asset Reduction.

(g) A Provider may not undertake a Collection Action against an individual who has qualified for Medical Hardship with respect to the amount of the bill that exceeds the Medical Hardship contribution. If a claim already submitted as Emergency Bad Debt becomes eligible for Medical Hardship payment from the Health Safety Net, the Provider must cease collection activity on the Patient for the services.

(4)Administrative Bulletins. The Health Safety Net Office may issue administrative bulletins to clarify policies and understanding of substantive provisions of 101 CMR 613.00 and specify information and documentation necessary to implement 101 CMR 613.00.

(5)Severability. The provisions of 101 CMR 613.00 are severable. If any provision or the application of any provision is held to be invalid or unconstitutional, such invalidity shall not be construed to affect the validity or constitutionality of any remaining provisions of 101 CMR 613.00 or the application of such provisions other than those held invalid.