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KINGSBROOK JEWISH MEDICAL CENTER

Financial Assistance Program Summary

It is the policy of Kingsbrook Jewish Medical Center to provide comprehensive quality health care and medically essential services without regard to a patient's ability to pay or their immigration status. Kingsbrook Jewish Medical Center recognizes that there are times when patients in need of medical care may have difficulty paying for the services provided. Kingsbrook Jewish Medical Center's Financial Assistance Program provides discounts to qualifying individuals based on your income. In addition, we can help you apply for free or low-cost insurance if you qualify. Please contact our Financial Counselor's at (718) 604-5499 or go to the Admissions Department (Patient Access Services Department), Located in the Katz Building, First Floor for free, confidential assistance.

Who qualifies for a discount?

Kingsbrook Jewish Medical Center has implemented a Financial Assistance Program which evaluates those who are underinsured, have exhausted their insurance benefits or are fully uninsured. Current clinic patients without adequate financial resources can receive care in our primary / specialty clinics for fee schedules based on their income and family size. A determination will be made if the patient is eligible for reduced fees. Non-Clinic patients seen in the Emergency Department, Inpatient, or for Outpatient Services can apply for assistance, based on financial need, through the Financial Assistance process in Patient Accounts, Patient Access Services/Financial Counseling or Ambulatory Care.

Everyone in New York State who needs emergency services can receive care and get a discount if they meet the income limits. Any individuals residing in Kingsbrook Jewish Medical Center's primary service area, which is defined as: East Flatbush, Flatbush, Canarsie, Flatlands, Bedford-Stuyvesant, Crown Heights and/or East New York (zip codes 11203, 11236, 11213, 11226, 11212, 11208, 11207, 11225, 11216), can get a discount on non-emergency, medically necessary services at Kingsbrook Jewish Medical Center if they meet the income limits. Kingsbrook Jewish Medical Center will never deny medically necessary care because you may need financial assistance. You may apply for a discount regardless of your immigration status.

What are the income limits?

The amount of the discount varies based on your income and the size of your family. Kingsbrook Jewish Medical Center's Financial Assistance Program is based upon up to 300% of the March 2010 Department of Health and Human Services Federal Poverty Guidelines, as listed below.

What if I do not meet the income limits?

If you cannot pay your bill, Kingsbrook Jewish Medical Center offers an extended, interest-free, payment plan to those patients that meet the income limits. The amount of your payment installment depends on amount of your income and ability to pay.

Can someone explain the discount? Can someone help me apply?

Yes, free, confidential help is available. Please contact our Financial Counselor's at (718) 604-5499 or go to the Admissions Department (Patient Access Services Department, Located in the Katz Building, First Floor for free, confidential assistance. If you do not speak English, someone will help you in your own language.

The Financial Counselor can tell you if you qualify for free or low-cost insurance, such as Medicaid, Child Health Plus and Family Health Plus.

If the Financial Counselor finds that you don't qualify for low-cost insurance or Medicaid, they will assist you in accessing the Medical Center's Financial Assistance program for any applicable discounts, including helping you with the appropriate forms and documentation requirements.

What do I need to apply for a discount?

Patients are requested to provide the following documentation, as available or applicable, in order to be evaluated for Financial Assistance:

  • Picture Identification
  • Proof of Address (letter/bill mailed to the patient at their address)
  • Income Tax 1040 (to verify dependents)
  • Proof of income
  • Four (4) most recent pay stubs (and/or)
  • a letter from the patient's employer (and/or)
  • a statement from the patient stating income (and/or)
  • if the patient does not work, a letter from the person supporting them

If you can not provide any of these, you may still be able to apply for financial assistance.

What services are covered?

All medically necessary services provided by Kingsbrook Jewish Medical Center are covered by the Financial Assistance Program. This includes outpatient services, emergency care and inpatient admissions.

Charges from private doctors who provide services in the hospital may not be covered by this program. You should talk to private doctors to see if they offer a discount or payment plan.

How much do I have to pay?

The amount for outpatient service or the emergency room starts from $18.00 to $237.60, depending on your Financial Assistance qualification category. Our Financial Counselor will give you the details about your specific discount(s) once your application is processed.

How do I get the discount?

You have to fill out an application form. As soon as we have proof of your income, we can process your application for a discount according to your income level.

You can apply for a discount before you have an appointment, when you come to the hospital to get care, or when the bill comes in the mail.

Send the completed form and supporting documentation to our Financial Counselor's in the Patient Access Services (Admissions) Department or bring it to the Patient Access Services (Admissions) Department, located in the Katz Building, First Floor.

How will I know if I was approved for the discount?

Kingsbrook Jewish Medical Center will send you a letter, within 30 business days, after receipt of your completed application and supporting documentation, telling you if you have been approved for Financial Assistance and the level of discount you are eligible for.

What if I receive a bill while I'm waiting to hear if I can get a discount?

You cannot be required to pay a hospital bill while your application for a discount is being considered. If your application is turned down, Kingsbrook Jewish Medical Center will tell you why and provide you with a way to appeal this decision to a higher level within the hospital.

What if I have a problem I cannot resolve with the hospital?

You may call the New York State Department of Health complaint hotline at 1-800-804-5447.

KINGSBROOK JEWISH MEDICAL CENTER

Financial Assistance Policy & Procedure

Revised 8/1/07

Policy:

It is the policy of Kingsbrook Jewish Medical Center to provide comprehensive quality health care and medically essential services without regard to a patient's ability to pay.

Kingsbrook Jewish Medical Center has implemented a Financial Assistance Program which evaluates those who are underinsured, have exhausted their insurance benefits or are fully uninsured. Current clinic patients without adequate financial resources can receive care in our primary / specialty clinics for fee schedules based on their income and family size. A determination will be made if the patient is eligible for reduced fees. Non-Clinic patients seen in the Emergency Department, Inpatient, or for Outpatient Services can apply for assistance, based on financial need, through the Financial Assistance process in Patient Accounts, Patient Access Services/Financial Counseling or Ambulatory Care.

Procedure:

ESTABLISHED CLINIC PATIENT

  • The Financial Assistance Fee Schedule must be used to establish a fee scale for new clinic patients who have no applicable insurance coverage.
  • Patients are informed, at the time of scheduling, to bring the following documentation, as available or applicable, to their first visit in order to be assigned a fee scale:
  • Picture Identification
  • Proof of Address (letter/bill mailed to the patient at their address)
  • Income Tax 1040 (to verify dependents)
  • Proof of income
  • 4 most recent pay stubs (or)
  • a letter from the patient's employer (or)
  • a statement from the patient stating income (or)
  • if the patient does not work, a letter from the person supporting them
  • The highest income level on the Financial Assistance Fee Schedule is 300% of the Federal Poverty Level.
  • When an existing clinic patient presents for their first visit under this policy, the Registrar will fee scale the patient using the Financial Assistance Fee Schedule and input "CHC" as the registration financial class and comment in GNE notes.
  • All fee scales for clinic patients must be re-evaluated annually using the Financial Assistance Fee Schedule.
  • A fee scale approval is good for 1 year from the date of application and must be noted as such in the insurance comments by the approving clinic registrar.
  • Most ancillary testing related to a clinic visit is included in the KJMC Financial Assistance program. Exclusions are Pet Scans, MRI's, CT Scans and Ultrasounds.
  • All ancillary testing related to a clinic visit, performed on the same day as the clinic visit, must be put on the clinic account.
  • All ancillary testing done on a day besides the clinic visit, the registrar will perform a distinct P/A registration and assign the "CHC" financial class and add in GNE notes the date of the related clinic visit.

CLINIC PATIENTS (with established Fee Scales) SCHEDULED FOR AMBULATORY SURGERY PROCEDURES

  • When a clinic patient, who is already qualified for Financial Assistance, schedules an Ambulatory Surgery Procedure the patient is responsible for a percentage of the estimated self-pay/Medicaid rate. The rates are as follows:
    • All Ambulatory Surgical procedures = $2,500.00
    • Colonoscopy, Endoscopy, Bronchoscopy = $1,000.00
  • The percentage of the Medicaid rate the patient will be responsible for is determined by the patient's family size and total family income.
    • Existing clinic patients, who are already qualified for Financial Assistance and whose income and family size are above 300% of the poverty level will be responsible for the highest percentage (35%) of the self-pay/Medicaid rate.
  • The clinic staff arranging the ambulatory surgery procedure will fill out a Responsibility Contract and indicate the qualified level of Financial Assistance the patient is eligible for and forward a copy to Patient Access Services. The original form will be kept on file in the originating Clinic.
  • At the time of Pre-Registration or Registration for the procedure, the Patient Access Scheduled IV staff will confirm the patient's Charity Care status as a registered clinic patient with a current valid Financial Assistance Program approval.
  • The patient will be registered with the "CHC" financial class and the appropriate payment amount collected at the time of service.
  • If there is no Responsibility Contract on file, the Pre-Registration/Registration staff will refer the patient to Patient Access Financial Counseling for a Financial Assistance eligibility screen.
  • The Patient Access Financial Counseling staff will review and enter their comments in the GNE notes.
    • If qualified, the staff will register that patient with financial class "CHC" and note the same in GNE.
  • The registration staff will ask the patient for the reduced payment amount at the time of the procedure/PST.
  • When the patient has been registered, the Registration staff will forward a copy of the registration face sheet to Michelle Davis with a copy to Kiran Batheja in Patient Accounts.
  • When the procedure has been coded, Patient Accounts will confirm the allowance on the account to the percentage of the Medicaid rate approved.
  • The bill will go out to the patient at the reduced rate.

CLINIC PATIENTS (with established Fee Scales) SCHEDULED FOR INPATIENT ADMISSION OR ADMITTED VIA EMERGENCY ROOM

  • All clinic patients who become inpatients MUST be evaluated by Patient Access Financial Counseling to see if they may be eligible for Medicaid for the inpatient service.
  • If the patient was assessed for Medicaid and was not eligible, the Patient Access Financial Counseling staff should enter an additional GNE note stating "Evaluated for Medicaid not eligible."
  • At the time of the Patient Access Scheduled IV review, the staff will confirm the patient is a registered clinic patient with or without Charity Care approval in Eagle and their fee scale.
  • When a clinic patient is scheduled for an inpatient admission or is admitted through the Emergency Room, the patient is eligible for a percentage of the Medicaid DRG base rate, case mix neutral, of $9,000.00, based on the patient's family size and total family income.
    • Existing clinic patients, who are already qualified for Financial Assistance and whose income and family size are above 300% of the poverty level will be responsible for the highest percentage (35%) of the self-pay/Medicaid rate.
  • The Patient Access Financial Counseling staff will verify the patient's family size and total family income. Using the Financial Assistance Fee Schedule, the staff will confirm the fee scale percentage of the Medicaid rate that the patient is responsible for.
  • The Patient Access Financial Counseling staff will review and enter their comments in the GNE notes.
  • When confirmed, the admitting staff will admit the patient with financial class "CHC."
  • When the patient has been admitted, the Admitting staff will forward a copy of the registration face sheet to Nancy Cook with a copy to Kiran Batheja in Patient Accounts.
  • When the procedure has been coded, Patient Accounts will confirm the allowance on the account to the percentage of the Medicaid rate.
  • The bill will go out to the patient at the reduced rate.

NON-CLINIC PATIENTS SCHEDULED FOR OUTPATIENT / AMBULATORY PROCEDURES AND INPATIENT ADMISSIONS

  • All self-pay patients who become inpatients MUST be evaluated by Patient Access Financial Counseling to see if they may be eligible for Medicaid for the inpatient service.
  • Patient Access Scheduled IV staff will review all self-pay patients scheduled for an elective scheduled procedure.
    • At the time of the IV review, the Patient Access staff will check if the patient is a registered clinic patient with or without Charity Care approval in Eagle and handle accordingly.
  • Once it is confirmed that the patient is not an established clinic patient and states they are unable to pay for the procedure, the Patient Access Scheduled IV staff will ask the patient if they have been assessed for Medicaid or have community Medicaid pending.
  • If the patient responds "No" then the case must be referred to the Patient Access Financial Counseling staff. They will review and enter their comments in the GNE notes.
    • If qualified, the Patient Access Financial Counseling staff will pursue a Medicaid application.
    • If the patient was assessed for Medicaid and was not eligible, the Patient Access Financial Counseling staff should enter an additional GNE note stating "Evaluated for Medicaid not eligible."
  • If the patient has previously applied for Medicaid and is ineligible, explain that Kingsbrook Jewish Medical Center has a Financial Assistance Program for patient's who have no health insurance or have exhausted health benefits and are without financial resources to pay for medically necessary health care needs.
  • These patients should then be referred to the Patient Access Financial Counseling staff for qualification in the Medical center's Financial Assistance Program.
  • Patients are informed, to bring the following documentation, as available or applicable, to their first visit in order to be assigned a fee scale:
  • Picture Identification
  • Proof of Address (letter/bill mailed to the patient at their address)
  • Income Tax 1040 (to verify dependents)
  • Proof of income
  • 4 most recent pay stubs (or)
  • a letter from the patient's employer (or)
  • a statement from the patient stating income (or)
  • if the patient does not work, a letter from the person supporting them
  • The Patient Access Financial Counseling staff will ask the patient for his/her family size and total family income. Using the Financial Assistance Fee Schedule, the staff will determine the percentage of the Medicaid rate which the patient will be responsible for.
  • When a non-clinic patient, who qualifies for Financial Assistance, is scheduled for an Inpatient or Ambulatory Surgery Procedure, the patient is responsible for a percentage of the estimated self-pay/Medicaid rate. The rates are as follows:
    • Inpatient Medicaid DRG base rate, case mix neutral = $9,000.00,
    • All Ambulatory Surgical procedures = $2,500.00
    • Colonoscopy, Endoscopy, Bronchoscopy = $1,000.00
  • The percentage of the Medicaid rate the patient will be responsible for is determined by the patient's family size and total family income.
    • For a patient that is qualified for Financial Assistance and whose income and family size are above 300% of the poverty level will be responsible for the highest percentage (35%) of the self-pay/Medicaid rate.
  • The Patient Access Financial Counseling staff will fill out a Responsibility Contract and indicate the qualified level of Financial Assistance the patient is eligible for and forward a copy to Patient Access Services. The original form will be kept on file in Patient Access.
  • At the time of Pre-Registration or Registration for the procedure, the Patient Access Scheduled IV staff will confirm the patient's Charity Care status and register that patient with financial class "CHC."
  • When the patient has been registered, the Registration staff will forward a copy of the registration face sheet to Nancy Cook for inpatients and Michelle Davis for outpatients with a copy to Kiran Batheja in Patient Accounts.
  • When the procedure has been coded, Patient Accounts will confirm the allowance on the account to the percentage of the Medicaid rate.
  • The bill will go out to the patient at the reduced rate.

NON-CLINIC PATIENTS ADMITTED THROUGH THE EMERGENCY DEPARTMENT

  • All self-pay patients who become inpatients MUST be evaluated by Patient Access Financial Counseling staff to see if they may be eligible for Medicaid for the inpatient service.
  • Patient Access "IV staff" will review all self-pay patients admitted via the ED.
    • At the time of the IV review, the Patient Access staff will check if the patient is a registered clinic patient with or without Charity Care approval in Eagle and handle accordingly.
  • If the patient is not an established clinic patient and states they do not have insurance coverage, the Patient Access "IV staff" will ask the patient if they have been assessed for Medicaid or have community Medicaid pending.
  • If the patient responds "No" then the case must be referred to the Patient Access Financial Counseling staff. They will review and enter their comments in the GNE notes.
    • If qualified, the Patient Access Financial Counseling staff will pursue a Medicaid application.
  • If the patient was assessed for Medicaid and was not eligible, the Patient Access Financial Counseling staff should enter an additional GNE note stating "Evaluated for Medicaid not eligible."
  • OR if the patient has previously applied for Medicaid and are ineligible, explain that Kingsbrook Jewish Medical Center has a Financial Assistance Program for patients who have no health insurance or have exhausted health benefits and are without financial resources to pay for medically necessary health care needs.
  • These patients should then be referred to the Patient Access Financial Counseling staff for qualification in the Financial Assistance Program.
  • Patients are informed, to bring the following documentation, as available or applicable, to their first visit in order to be assigned a fee scale:
  • Picture Identification
  • Proof of Address (letter/bill mailed to the patient at their address)
  • Income Tax 1040 (to verify dependents)
  • Proof of income
  • 4 most recent pay stubs (or)
  • a letter from the patient's employer (or)
  • a statement from the patient stating income (or)
    • if the patient does not work, a letter from the person supporting them
  • The Patient Access Financial Counseling staff will ask the patient for his/her family size and total family income. Using the Financial Assistance Fee Schedule for Non-Clinic Patients, the staff will determine the percentage of the Medicaid rate the patient is responsible for.
    • The qualified patient is eligible for a percentage of the Medicaid DRG base rate, case mix neutral, of $9,000.00, based on the patient's family size and total family income.
  • The Patient Access Financial Counseling staff will review and enter their comments in the GNE notes.
    • If qualified, the staff will admit that patient with financial class "CHC."
  • The Admitting staff will forward a copy of the registration face sheet to Nancy Cook with a copy to Kiran Batheja in Patient Accounts.
  • When the procedure has been coded, Patient Accounts will confirm the allowance on the account to the percentage of the Medicaid rate.
  • The bill will go out to the patient at the reduced rate.

KINGSBROOK JEWISH MEDICAL CENTER

FINANCIAL ASSISTANCE APPLICATION (FRONT)

Application Date: ______________ Patient # ________________

Patient Name: _________________________ Phone: ______________

Patient Address: ______________________________________________

Financial Class: ___________ Amount Owed: $_________

ExpensesMonthly Income Monthly

Rent/Mortgage: ___________________ Self: __________________

Fuel: ___________________ Spouse: __________________

Gas/Electric: ___________________ Other: __________________

Water/Sewer: ___________________ Savings: __________________

Trash/Garbage: ___________________ Cable: __________________

Phone: ___________________ Installment Loan: ________________

Food: ___________________ Car: _______________________

Insurance/Life: ___________________ Gas: _______________________

Insurance/Hosp: ___________________ Loans: _______________________

Insurance/Auto: ___________________ Med. Bills: ____________________

Insurance/Home: __________________ Drugs: _______________________

Other: __________________ Other: _______________________

TOTAL: __________________ TOTAL: _____________________

INCOME TOTAL: ______________________

EXPENSES TOTAL: ______________________

LOANS TOTAL: ______________________

PT MARGINAL HOUSEHOLD: ______________________

# OF DEPENDENTS: ______________________

I affirm that the above information is true, complete, and correct to the best of my knowledge.

Signed____________________________ Date__________

KINGSBROOK JEWISH MEDICAL CENTER

FINANCIAL ASSISTANCE APPLICATION (BACK)

If you have questions or need help completing this application, please contact our Financial Counselor's at (718) 604-5499 or go to the Admissions Department (Patient Access Services Department, Located in the Katz Building, First Floor for free, confidential assistance.

You do not have to make any payment to the hospital until the hospital sends you a letter with its decision on your application.

Please return this completed and signed form, along with all supporting documentation, in the enclosed postage-paid envelope, or to:

Financial Counseling Representative

Kingsbrook Jewish Medical Center

585 Schenectady Avenue

Patient Access Services (Admissions) Department

Katz Building – 1st Floor

Brooklyn, NY 11203-1891

585 Schenectady Avenue, Brooklyn, NY 11203