Charity Care- Rulemaking to amend the state’s charity care regulations (WAC 246-453) is currently in the CR-102 phase. This rulemaking is intended to update the charity care regulations following changes to state charity care law made by the legislature in 2022 by HB 1616 and in 2018 in SB 6273. For more information on HB 1616 please see our bulletin here. WSHA and hospital members are actively engaged in providing feedback to the Department of Health. Hospitals support improving patient awareness of and access to charity care. However, there are several major concernswith the language currently under consideration and the practical impact it will have on patients and hospital operations, including:
- Billing delays for patients with recurring visits and FSA spending concerns
The proposed rule creates a 30-day hold prior to billing a patient, whether or not a patient is eligible for charity care. This hold restarts with every patient encounter. For patients receiving ongoing treatment, such as dialysis or radiation therapy, bills could be delayed for months or longer. This could result in a mega bill when their recurring care ends.
There is no option for patients to opt out of this system. Because hospitals must send each patient a notice of their “initially determined eligibility” for charity care, even when a patient expresses no interest in applying or directly asks not to be screened for charity care, the patient cannot receive or pay their bill. This also precludes the patient from using funds from their Flexible Spending Accounts (FSA) in a timely way. Because these funds are “use or lose,” if the patient misses the window at the end of the year to use these funds because of billing holds, it negates the benefit of FSA accounts and will result in additional patient costs and dissatisfaction.
Patients should be able to decline charity care for a defined time period while preserving their ability to apply for charity care whenever they choose.
These billing holds will also create a cash flow issue for hospitals who cannot bill for services provided to patients who are not, and have never been, eligible for charity care.
- Verification of patient income is prohibited once a person claims to be eligible for Apple Health
The proposed rule requires hospitals to grant full charity care when a patient states that they are eligible, not enrolled, for Apple Health or other medical assistant programs. How hospitals are expected to know who is “eligible” if they are not enrolled in the program is totally opaque. Once the declaration is made, hospitals are prohibited from verifying their financial eligibility before making an initial and final determination. We have urged DOH to allow hospitals to verify financial eligibility before granting charity care.
- HIPAA and cyber security concerns
The rule requires hospitals to accept email applications for charity care. Email, however, is not secure enough to be compliant under HIPAA for transmission of personal health information. If a patient is sending sensitive health care and financial information electronically, it should be done in a manner that ensures the security and privacy of their information.
Additionally, when hospitals open electronic attachments from patients, this creates major cybersecurity risks. Requiring hospitals to allow email submission is contrary to all the cybersecurity guidance hospitals receive from federal and state agencies. Health care data is a major target for cybercriminals who will learn this system and exploit it.
- Challenges with the professional services requirement
The proposed rule would eliminate the existing exclusion for certain separately billed or identified professional medical staff services effective December 31, 2027.
This change would require substantial modifications to hospital billing systems, financial assistance procedures, contractual arrangements, and patient communication processes.
We think this is beyond the scope of rulemaking and that it is an unreasonable expectation to require hospitals to be responsible for charity requirements being imposed on outside providers and organizations.
- Impossible standard for establishing response deadlines
The proposed rule treats a charity care application as submitted on the date it is sent, even when the hospital has not yet received it. We have no reliable way to verify mailing dates and may be unable to determine when response timelines begin. Rural hospitals are particularly concerned given mail delivery can take several days or longer.
- Implementation Timeline
The proposed rule will require substantial changes to policies, staff training, workflows, billing operations, patient notices, vendor arrangements, and information technology systems. We have asked the department for a year to implement changes.
Request
We support the goal of expanding access to charity care. However, before these rules are finalized, we respectfully request that the Department:
- Work with hospitals to address the issues outlined above.
- Establish a realistic implementation timeline.
- Restart the CR-102 process once revisions are complete.
Taking these steps will help ensure the final rules improve access to charity care while remaining workable for hospitals and patients. (Cara Helmer).
