Patient Rights

Sharkey Issaquena Community Hospital

FINANCIAL ASSISTANCE PROGRAM (FAP)

As part of our mission, Sharkey Issaquena Community Hospital (SICH) will provide financial assistance, based on need, to patients who lack the ability to pay for emergency and other non-elective medically necessary care provided by the hospital and physician services associated with the hospital service, without regard to age, color, creed, ethnic background, sex, national origin, physical disability, race, or religion.

Regardless of an individual's ability to qualify under this Financial Assistance Policy, SICH will provide, without discrimination, care for any emergency medical condition as designated under the U.S. federal government Emergency Medical Treatment and Labor Act (EMTALA) of 1986.

The Financial Assistance Program (FAP) is intended for patients whose Annual Family Income does not exceed 150% of the Federal Poverty Income Guidelines (FPG) published by the U.S. Department of Health and Human Services and in effect at the date of service for awards of FAP under this policy.

In addition, financial assistance may be available on a sliding scale discount from normal charges for uninsured patients or patients with self-pay balances after insurance that have an Annual Family Income up to 250% of the FPG.

The hospital will limit the amount charged for any emergency or other medically necessary care it provides to a

FAP eligible individual to not more than the amounts generally billed (AGB) to individuals with insurance. See definitions on page two (2).

The eligibility criteria for financial assistance and the procedures for receiving financial assistance set out in this Policy are intended to ensure that SICH will have the financial resources necessary to meet its commitment to providing care to patients who are in the greatest financial need.

This program does not include coverage for independent provider groups not employed by the hospital, such as Cardiologists, Emergency Department Physician fees, Nuclear testing, Wound Care, and other Physician and Advanced Practice Nurse providers that may be involved in your care. See the FAP policy summary.

Collection Efforts:

SICH will not engage in extraordinary collection actions before making reasonable efforts to determine whether an individual who has an unpaid balance is eligible for financial assistance under this Policy. As used in this policy, "extraordinary collection actions" include but are not limited to; placing a lien on an individual's property, foreclosing on an individual's real property, attaching or seizing bank account or other personal property, commencing a civil action against an individual, causing an individual's arrest, and garnishing an individual's wages.

Commmunication:

SICH is committed to publicizing this Policy widely within the communities in which it serves. Notices will include the Hospital web address, contact numbers, and location addresses.

47 South 4th Street, P.O. Box 339, Rolling Fork, Mississippi 39159

Phone: (662) 873-4395 ¡ Fax: (888) 415-9802

The following steps are to ensure that members of the communities served are aware of the Policy and have access to the Policy:

A plain English summary of the Policy will be displayed at the SICH registration and emergency department registration areas
FAP copy will be offered during the hospital or emergency department registration process Information about FAP and who to contact will be listed on the patient's hospital statements
Policy and application will be available at hospital and emergency department registration areas
Financial Counselors are available during normal business hours, which includes availability to provide counseling to individuals currently admitted to SICH.
A plain English summary of the policy is available for distribution to community advocates in the SICH

Definitions:

I Amount Generally Billed (AGB) =The charge amount generally billed for any patient with similar condition, treatment, service, and/or diagnosis, regardless to having insurance coverage or not. AGB is based on the look back method that considers discounts allowed by Medicare fee-for service and commercial insurances that pay claims to SICH.

Emergency medical condition= As defined in Section 1867 of the Social Security Act (42 U.S.C. 1395dd)

Gross Charge = An established price, listed in the hospital charge-master, for a service or item that is charged consistently and uniformly to all patients before applying any contractual allowances, discounts, or deductions.

Family= Using the Census Bureau definition, a family is defined as a group of two or more people who reside together and who are related by birth, marriage, or adoption. According to Internal Revenue Service rules, if the patient claims someone as a dependent on their income tax return they may be considered a dependent on the FAP application. This includes individuals up to 24 years old and enrolled in school or college.

FAP = Financial Assistance Program as defined in this policy.

Family income = Calculated based on the income earned in the preceding 12-month period. Although proof of income for the preceding 12-month period is preferred, family income may be based on the current income, especially if there has been a significant change in the family's income.

FPG =Federal Poverty Income Guidelines that are published from time to time by the U.S. Department of Health and Human Services and in effect at the date of service for awards of financial assistance under this Policy.

Income = Income includes salary and wages, interest income, dividend income, social security, workers compensation, disability payments, unemployment income, business income (IRS Schedule C), pensions & annuities, farm income (IRS Schedule F), rentals & royalties, inheritance, strike benefits, and alimony income.

• Income is also defined as payments received from the state for legal guardianship or custody.

Social Services = Individuals who help consumers complete health coverage applications on the federally-facilitated Marketplace ( healthcare.gov ) or state-based insurance affordability program applications (such as Medicaid, the Children's Health Insurance Program ("CHIP"),

Medically necessary= Non-elective services for life threatening conditions outside the emergency room. (Other medically necessary services on a case-by-case basis)

Non-Elective Services= condition or injury that places the health of the individual in serious jeopardy, cause serious impairment to bodily functions, or serious dysfunction to a bodily organ.

Plain Language summary= A statement written in clear, concise, and easy to understand language notifying individuals that SICH offers financial assistance under a FAP

Prompt Pay Discount = A discount that is available to self-pay balances on hospital services if paid within 30 days of the first hospital statement.

Self-Pay or Uninsured= A patient who does not have third party coverage from a health insurance plan, Medicare, or state funded Medicaid, or whose injury is not a compensated injury for purposes of workers' compensation, automobile insurance, or other insurance as determined and documented by the hospital.

Insured Patient= A patient who has third party coverage or whose injury is a compensated injury for purposes of workers' compensation, automobile insurance, or other insurance as determined and documented by the hospital.

Standards of Practice:

Information about the Financial Assistance Program (FAP) will be posted in a plain language summary at main entrance points to the hospital. Main entrance points include Hospital and Emergency Department registration areas.

FAP posting will include instructions on how and where to obtain a printed version of the plain language summary and the FAP application.

The FAP summary and application is available through:

Customer Service office located in the hospital at 47 South 4th Street, Rolling Fork, MS 39159;
Customer Service office located in the Business Office Center at 44 North 4th Street, Rolling Fork, MS 39159
Calling Customer Service at (662) 873-4695 for printed copy to be mailed at no expense
Requesting by mail by writing to: Sharkey Issaquena Community Hospital
- .O. Box 339

Rolling Fork, MS 39159

Patients with balances after insurance (e.g. deductibles, co-pays, and co-insurance amounts) are eligible for

FAP if the eligibility requirements are met.

Patients who have exhausted policy limits are eligible for FAP if the eligibility requirements are met. (The remaining account balances after the policy limits are exhausted are considered uninsured and are eligible for the FAP)

Medicare patients are eligible for FAP if the eligibility requirements are met.

Patient shall cooperate in supplying all third-party insurance information and third-party liability information.

The patient must exhaust insurance/third-party liability coverage prior to patient receiving financial assistance through FAP.

If the account is with a collection agency, the patient can still apply for FAP.

Services Eligible for FAP

1. Any hospital service that is an emergency or a service that is medically necessary

2. Any SICH physician services provided in relationship to the approved hospital service(s).

Eligibility Requirements for FAP

1. Patient is a permanent resident within the SICH primary service area, which includes the Sharkey and Issaquena counties of Mississippi.

2. Patient's family income is at or below 150% of the existing Federal Poverty Guideline at the date of service or date of the FAP application.

3. Requested services are eligible for the FAP as noted above. The financial counselor may inquire with the attending physician regarding the medical necessity of services before awarding financial assistance.

4. Patient provides proof of ineligibility for Medicaid or other State programs.

5. Individuals with the financial capacity to purchase health insurance through the Healthcare Marketplace (Affordable Care Act) shall be required to meet apply as a means of assuring access to healthcare services, for their overall personal health, and for the protection of their individual assets.

6. Patient must be eligible on the date of service or date of application.

7. Patient does not have to be a U.S. Citizen.

Reason for not being Eligible for FAP

1. Family income exceeds 150% of the Federal Poverty Guidelines. However, the patient may be eligible for a prompt pay discount.

2. If a patient is eligible for Medicaid or other State programs and the patient fails to cooperate in the application, re-application, appeal process, or the patient does not pay the required monthly premium, thereby making the patient ineligible for the program.

3. If the patient is eligible and enrolled in a Healthcare Marketplace plan and does not pay the required monthly premium, thereby causing the health plan to revoke coverage.

4. Patient who resides outside of the SICH service area is not eligible for FAP except when the patient requires urgent or emergent services while visiting in the SICH service area.

5. Patient is in the custody of a unit of Government, which is responsible for coverage of the medical needs of the patient.

6. Patient is eligible for healthcare coverage through their employer

7. Services are not medically necessary or excluded from the program.

Excluded services include:

• Cosmetic surgery

• Infertility treatments, fertility services, birth control, sterilization, reversal of sterilization;

• Services denied by your insurance due to non-compliance with your insurance coverage requirements;

• Services deemed not medically necessary;

• Services reimbursed directly to you by your insurance company;

• Services reimbursed by another third party

• Services required for employment, schools, or athletics

Asset Test

A sliding fee scale will be used to determine the percentage of discount. The patient's liquid and non-liquid assets are considered in the final determination of financial assistance as possible sources of payment. An individual household is permitted to hold assets of an amount equal to 200% of the Mississippi Medicaid Maximum Household amount, published by the Mississippi Family & Social Services Administration. The family home, household goods like furniture or appliances, and personal items such as jewelry or clothes are excluded from the asset test.

Application Process

The patient's eligibility for FAP will be determined through an application process. The SICH Financial
form is the valid application form for the application process.
One signature is required on the application (the patient, guarantor, or legal representative).
Approved FAP applications are valid for a period of 6 months for medically necessary services
All FAP applications and records will remain on file for a minimum of 7 years
FAP applications are considered up to 240 days after the first billing statement is submitted to the patient or when a change in patient financial status is determined.
Patient may apply for FAP in advance of receiving medically necessary care.
The FAP Committee will determine the awarding of financial assistance.
It is the patient's responsibility to request consideration on future services within the 6-month period that would not have been reviewed during the initial application process.
The patient may appeal the decision to denied financial assistance by writing to:
Sharkey Issaquena Community Hospital
Attn: Director Patient Billing Services
P.O. Box 339
Rolling Fork, MS 39159

Proof of Income

Listed below are EXAMPLES of forms of acceptable documentation to establish current proof of income and/ or income at time of service. Documentation is required to determine financial assistance. SICH will apply income verification uniformly to all applicants.

Pay stubs for the last 90 days
A letter or written statement from employer verifying gross wages for the last 90 days
W-2’s
Federal Income Tax Returns ( Form 1040 or 1040A)
If self-employed, a financial statement of gross income less business expenses
Bank statements
If patients spouse is unemployed and not receiving any unemployment benefits. a letter from the patient/spouse indicating how long they have been unemployed will suffice as proof of income.
As a last resort, the Hospital may accept a written statement from the patient as proof of eligibility.
A witness who can substantiate the patient's income must also sign this written statement.
Alimony payments made to a spouse are an allowable deduction from family income. Child support payments are not an allowable deduction from family income.
Social Security or Retirement Benefits should be verified with the Social Security office or by obtaining a copy of the Social Security Benefits Determination letter from the patient.
SICH may obtain credit report if additional verification is needed.

Patient Payments & Refunds

Patient payments received prior to and/or subsequent to the decision to award financial assistance shall be refunded or transferred to other outstanding accounts not applicable for financial assistance.

Regulatory Requirements

In implementing this Policy, SICH management and facilities shall comply with all other federal, state, and local laws, rules, and regulations that may apply to activities conducted pursuant to this Policy.

Patient Rights And Responsibilities

The primary concern of the staff of Sharkey-Issaquena Community Hospital is to meet the health care needs of our community. Below is a statement of Patient Rights and Responsibilities of this facility. This listing is intended to be a statement of the ideas of the hospital and its patients, but does not presume to be a complete representation of all mutual rights and responsibilities. We affirm that all of these activities must be conducted with an overriding concern for the patient and a recognition of his/her dignity as a human being.

Patient Bill of Rights

You have the right to reasonable access to care and services based on the individual's need for services, and in accordance with the Hospital's mission, including matters of conscience, and applicable laws and regulations, regardless of race, sex, religion or handicap.
You have the right to receive information and explanation concerning the need for and alternatives for care prior to transfer to another facility when necessary and medically permissible.
You have the right to expect that a family member or authorized representative and your own physician (as identified by you or your authorized representative) will be notified promptly of your admission to the hospital, unless you request this not be done.
You have the right to considerate and respectful care including consideration of your psychosocial, spiritual, and cultural needs.
You have the right to receive care in a safe setting, free from abuse or harassment.
You have the right to the appropriate assessment and management of pain.
You have the right to have issues related to care at the end of life addressed with sensitivity.
You have the right to be informed about and participate in decisions regarding your care.
You have the right to accept medical care or to refuse medical treatment to the extent permitted by law and to be informed of the medical consequences of such refusal.
You have the right to be free from restraint or seclusion that is not medically and/or legally necessary.
You have the right to formulate advance directives, including but not limited to individual instructions and/or appointment of a health care agent through execution of a durable power of attorney for health care. You shall receive care regardless of whether or not you have advance directives. Your advance directives will be made a part of your medical record and they can be reviewed with you or your authorized decision maker periodically. The facility and care givers will follow your advance directives to the extent permissible by policy and law. You also have the right to designate a surrogate to make health care decisions for you when you cannot.
You have the right to a clear, concise explanation of your condition and any prognosis in terms and language that you can reasonably understand.
You and, when appropriate, your family have the right to be informed about the outcomes of care, treatment, and services that have been provided, including unanticipated outcomes.
You have the right to know the identity and professional status of individuals providing service to you and to know the physician or any other practitioner who is primarily responsible for your care.
You have the right to participate in the consideration of ethical issues that arise in regard to your care.
You have the right to be informed if Sharkey Issaquena Community Hospital engages in or performs human experimentation or any other research affecting your plan of care or treatment. Likewise, you have the right to refuse to participate in any research within the facility.
You have the right to be interviewed and examined in surroundings that ensure reasonable visual and auditory privacy.
You have the right to have your medical record read only by individuals directly involved in or supervising your treatment, monitoring the quality of your treatment, or authorized by law or regulation.
You have the right within the limits of the law, to expect personal privacy and confidentiality of information and records pertaining to your care.
You have the right to have reasonable access to information contained in your medical record within the limit of the law and Sharkey-Issaquena Community Hospital policy.
You have the right to request and receive an itemized explanation of your total charges for the services rendered in the facility regardless of source of payment.
Ordinarily you have the right to unrestricted access to communication, visitors, mail, telephone calls, unless clinically or legally contraindicated. Any restrictions are fully explained to the patient.
Legal guardians, custodians, parents, and other authorized representatives have the authority to exercise the above rights for unemancipated minor children.
The patient's legally authorized responsible person will have the authority permitted by law to exercise the rights delineated on behalf of the patient if:
- the patient has been adjudicated incompetent in accordance with the law.
- is found by his/her primary physician to lack the ability to understand the benefits, risk and alternatives to proposed health care and make and communicate a decision.
- is a minor.
You have the right to be informed of your rights in writing and are entitled to information about the process for initiation, review and resolution of complaints and grievances. We encourage you to raise questions or concerns about any aspect of your care by communicating with appropriate staff where you are receiving care. You may address your complaint by calling:

Mississippi State Department of Licensure at 1-800-227-7308

Medicare Information and Quality Healthcare at 1-800-844-0600

Patient Responsibilities

Doctors and the Sharkey-Issaquena Community Hospital staff care for the sick and injured. They recognize that to be effective, the effort must be a partnership with the patient and the health care team working together for the common goal. As a patient, you will be expected, within the limits of your abilities, to assume a share of the responsibility for your health care.

You have the responsibility to the best of your ability, to bring with you information about past illnesses, advance directives, including individual instructions, past hospitalizations, medications, designations of a surrogate and/or primary physicians, and other matters relating to your health.
You have the responsibility to participate in decisions regarding care, openly expressing any concerns or questions.
You have the responsibility to cooperate with all Sharkey-Issaquena Community Hospital personnel caring for you and to ask questions if you do not understand any directions given you.
You have the responsibility for your own actions if you refuse treatment or do not follow the physician's instructions.
You have the responsibility to be prompt in payment of your hospital bills, to provide the information necessary for insurance processing and to be prompt about asking questions you have concerning your bill.
You have the responsibility to abide by Sharkey-Issaquena Community rules and regulations and to see that your visitors do likewise.
You have the responsibility to be considerate of other patients and to see that your visitors are considerate as well, particularly in regard to noise.
You have the responsibility to be respectful of others, other people's property and that of the facility.
You have the responsibility to discuss pain relief options with your physician or caregiver and help them measure your pain.
You have the responsibility to help your doctors, nurses, and all other health care team members, in their efforts to return you to health by following their instructions.
You will be responsible for valuables kept in your room. We suggest that you send money or jewelry home with your family or deposit them in the hospital safe until you leave. Sharkey-Issaquena Community Hospital cannot assume responsibility for lost property.

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