San Francisco Health Network Charity Care and Payment Program Policy and Procedure

Patient Financial Services Department

Tim Arnold, Deputy Director Patient Accounting
Jenine Smith, Patient Financial Services Manager
Glenn Levy, Deputy City Attorney

Original Date: December 14, 2006

Revision dates: March 8, 2007, September 12, 2007, December 14, 2007, June 22, 2008, June 1, 2009, July 15, 2009, April 1, 2011, April 1, 2012, April 1, 2014, January 1, 2015, July 15, 2016, December 1, 2017, August 3, 2019, January 1, 2023, January 1, 2024, May 22, 2024, January 1, 2025.

Section 1 Purpose

The purpose of this policy is to define the Charity Care and Discount Payment Programs financial assistance guidelines and eligibility for the San Francisco Health Network (SFHN) consistent with the provisions of Assembly Bills (AB) AB774, AB1020, AB532, and AB2297, and Senate Bill (SB) SB1276.

Section 2 Policy

It is the policy of the SFHN to comply with all federal, state, and local regulations to provide financial assistance through the Charity Care Program for qualified patients who have been determined ineligible for federal, state and county programs and have accounts where they owe money for services received, and through the Discount Payment Program for qualified patients who have been screened for federal, state, and county programs and have accounts where they owe money for services received. If any regulation, current or future, conflicts with this policy, the regulation will supersede this policy.

Section 3 Scope

This policy covers Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), Specialty Outpatient Clinics, Community Primary Care (CPC) Clinics, Laguna Honda Hospital and Rehabilitation Center (LHH), Behavioral Health Services (BHS), and the Population Health Division (PHD) of the San Francisco Department of Public Health (SFDPH). This policy applies to services that do not qualify for other discount packages or programs such as the hospital’s maternity package, abortion services package or other package programs that are provided to patients at a global rate with significant discounts below government rates and are not subject to additional discounts. All accounts where the patient owes money will be considered.

This policy also does not apply to emergency, inpatient, radiology, and procedure room physician fees which are billed by and covered in the policy Page 2 of 12 and procedure of the University of California San Francisco (UCSF) Clinical Practice Group, Business Services/dba SFGH Medical Group. An emergency physician, as defined in California Health & Safety Code Section 127450, who provides emergency medical services in a hospital that provides emergency care is also required by law to provide discounts to uninsured patients or patients with high medical costs who are at or below 400% of the Federal Poverty Limit (FPL).

Section 4 History

Effective January 1, 2007, for ZSFG patients, and September 17, 2007 for CPC patients, SFHN made available the Charity Care and Discount Payment Programs to assist uninsured or underinsured patients with limited income of up to 350 percent of the FPL and who are not eligible for the Sliding Scale Program, government programs, or other payers including when a third party is responsible for paying.
Effective November 1, 2010, SFHN made the Catastrophic High Medical Expense Program available to assist uninsured or underinsured patients ineligible for the Sliding Scale, Charity Care, or Discount Payment Programs with medical expenses exceeding 120 percent of their household annual income and who a) were not eligible for the Charity Care and Discount Payment Programs, the Sliding Scale Program, or other government charity care programs, and b) who did not have other payers, including payments they may have received because of a third party who is responsible for paying.
Effective January 1, 2015, ZSFG amended this policy per SB1276 legislation providing that:
1. The definition of a person with high medical costs includes those persons who do receive a discounted rate from the hospital as a result of third-party coverage.
2. The hospital shall negotiate with a patient regarding a payment plan, taking into consideration the patient’s family income and essential living expenses.
3. The hospital shall determine a reasonable payment formula where monthly payments are not more than 10 percent of a patient’s family income, excluding deductions for essential living expenses.
4. If the hospital and the patient cannot agree to a payment plan, the hospital shall use the specified formula of deducting 60% for essential living expenses from patient’s gross household income and then calculate 10% of the remaining income to determine a reasonable monthly payment amount. The hospital provides patients with a referral for assistance to the Health Consumer Alliance at (888) 804-3536 or The Health Consumer Center/Bay Page 3 of 12 Area Legal Aid at (855) 693-7285.
Effective August 3, 2019, this policy was amended in accordance with the City and County of San Francisco Health Commission Resolution No. 19-8, which resulted in the following changes:
1. The Charity Care Program qualifying FPL was increased to 500 percent,
2. The Discount Payment Program qualifying FPL was changed to include all FPL levels,
3. The high medical cost qualifying criteria was eliminated, and
4. The Catastrophic High Medical Expense program was eliminated.
Effective January 1, 2023, this policy was amended in accordance with AB1020: Health Care Debt and Fair Billing and AB532: Fair Billing Policies.
Effective May 22, 2024, this policy was amended to include Specialty Mental Health and Substance Use Disorder outpatient services through Behavioral Health Services.

Section 5 Definitions

“Allowance” means, with respect to services rendered to a financially qualified patient, money credit or discount that is applied after the hospital’s charges are imposed on the patient, due to the patient’s determined financial inability to pay the charges.
“Financial Assistance” means to provide charity care or discounted payment to financially qualified patients.
“Financially Qualified Patient” means an uninsured or underinsured patient who owes money and meets the Charity Care or Discount Payment program’s eligibility criteria.
“Federal poverty level (FPL)” means the measure of income as issued annually by the Federal Register by the United States Department of Health and Human Services under authority of subsection (2) of Section 9902 of Title 42 of the United States Code. FPL is based on a patient’s family size and income and used by hospitals to determine financial assistance eligibility.
“Hospital” means the following City and County of San Francisco Department of Public Health facilities: ZSFG, Specialty Outpatient Clinics, Community Primary Care Clinics, Laguna Honda Hospital and Rehabilitation Center, the Population Heath Division of SFDPH, and Behavioral Health Services.
“Patient” refers to the person for whom services were rendered or the guarantor if they are different.
“Guarantor” means the person or entity who is financially responsible for payment on a patient’s account.
“Patient’s Family” means the following according to the age of the patient:
1. For persons 18 years of age and older, the spouse, domestic partner (as defined in Section 297 of the Family Code), and dependent children under 21 years of age, or any age if disabled, consistent with Section 1614(a) of Part A of Title XVI of the Social Security Act, whether living at home or not.
2. For persons under 18 years of age or for a dependent child 18 to 20 years of age, inclusive, the parent, caretaker relatives, and parent’s or caretaker relatives’ other dependent children under 21 years of age, or any age if disabled, consistent with Section 1614(a) of Part A of Title XVI of the Social Security Act, whether living at home or not.
“Self-pay” means a patient who does not have third-party financial coverage from a health insurer, health care service plan, Medicare, or Medicaid, and whose injury is not a compensable injury for purposes of workers’ compensation, automobile insurance, or other insurance as determined and documented by the hospital. Self-pay patients may include charity care patients.
“Uninsured” means a patient who has no third-party source of payment for any portion of the patient’s medical expenses, including without limitation, commercial or other private insurance, government-sponsored healthcare benefit programs, or a third-party who is responsible for paying and includes a patient whose benefits under all potential sources of payment have been exhausted prior to an admission or rendered service.
“Underinsured” means a patient who has a third-party source of payment for a portion of the patient’s medical expenses with the remaining portion applied to the amount of money that a patient owes. This excludes patients who are covered by Medi-Cal/Medicaid.

Section 6 Health Care Coverage and Financial Assistance Notices

Notice of the hospital’s policy of providing financial assistance to qualified self-pay patients is provided in multiple ways:
1. Notices are clearly and conspicuously posted in locations that are visible to the public in the ZSFG emergency room waiting room, urgent care waiting room, outpatient waiting rooms, the ZSFG Hospital main lobby, and the Behavioral Health Access Center lobby. It is also posted on hospital website at https://zuckerbergsanfranciscogeneral.org/ with the Charity Care and Discount Payment program application available to download.
  1. Financial Assistance Policies and Applications (English) are uploaded every other year beginning 01/01/2024 to the HCAI Hospital Fair Billing Program HCAI website located at https://hcai.ca.gov/affordability/hospital-fair-billing-program/hospital-fair-pricing-policy-lookup/
  2. The submitter of these policies is duly authorized to submit such policies.
  3. The submitted policies are true and correct copies of the hospital’s policies.
2. Written notices will be provided at the time of service in the Terms and Conditions of Admission for inpatient admissions, in the ZSFG Patient Guidebook provided to patients admitted as inpatient, in the Behavioral Health Beneficiary Handbook, and as a patient handout in outpatient clinics. These notices will include the following information:
  1. The internet address of the Health Consumer Alliance (https://healthconsumer.org) and a statement that there are organizations that will help the patient understand the billing and payment process.
  2. Information about Covered California.
  3. Information about Medi-Cal presumptive eligibility if the hospital participates in the presumptive eligibility program.
  4. The internet address for the hospital’s list of shoppable services, as required by federal law.
The SFDPH MyChart patient electronic health record portal provides information about financial assistance as well as preliminary screening tool, and the portal allows patients to send a message to the Patient Financial Services Department to request financial assistance.
Patient billing statements include information about:
1. Obtaining billing assistance.
2. Requesting an itemized bill.
3. Requesting health care application assistance.
4. Requesting financial assistance. The final patient billing statement will also include a Charity Care and Discount Payment program application.
5. Contacting Health Consumer Alliance at https://healthconsumer.org/ (888) 804-3536, and Bay Area Legal Aid at https://baylegal.org/ (855) 693-7285.
6. Overdue accounts, which are assigned to the Bureau of Delinquent Revenue (BDR) in the Office of the Treasurer and Tax Collector.

Section 7 Health Care Coverage and Financial Assistance Notices

Patient Access Eligibility Workers collect the patient’s demographic, financial and insurance information to determine if the patient has insurance to cover the services and if the patient is uninsured or under- Page 6 of 12 insured with only partial coverage. They will refer uninsured or under-insured patients to schedule an appointment with the ZSFG or BHS Patient Access Enrollment Department or financial counselor located in the clinic where services are being provided, if available.
Patient Access Financial Counselors provide uninsured and under-insured patients with healthcare coverage screening and application assistance depending on the program or package for which the patient is determined preliminarily eligible.
Programs and packages may include the following:
1. AIDS Drug Assistance Program (ADAP).
2. Breast and Cervical Cancer Treatment Program (BCCTP).
3. California Children Services.
4. California Victim Compensation Program.
5. Child Health & Disability Prevention Gateway to Health Coverage.
6. Covered California.
7. Every Woman Counts, Breast and Cervical Cancer Detection program.
8. Family Planning Access, Care and Treatment Program.
9. Medi-Cal, which provides free or low-cost health insurance to eligible California residents with limited income.
10. Hospital Presumptive Eligibility Medi-Cal Program, which provides immediate access to temporary, no-cost Medi-Cal services while individuals apply for permanent Medi-Cal.
11. Healthy San Francisco Program.
12. OB Package Program for prenatal care and delivery at ZSFG.
13. Department of Public Health Sliding Scale Program.
14. Presumptive Eligibility Medi-Cal for Pregnant People.
15. VIP Package Program for pregnancy termination.
When a Patient Access Financial Counselor determines that a patient is ineligible for a healthcare program or package to cover their service, they will refer the patient to the ZSFG or BHS Patient Financial Assistance Department to apply for the financial assistance programs which may reduce the amount of money the patient owes.

Section 8 Financial Assistance Programs

There are two (2) financial assistance programs available, the Charity Care Program and the Discount Payment Program and the following are required for both programs:
1. Patients must make every reasonable effort to provide documentation of income and health benefits coverage. Failure to provide information that is reasonable and necessary may be considered in making a determination of eligibility.
2. Patients and guarantors who receive a legal settlement, judgment, or award from a third-party in relation to any lawsuit or other legal action that includes payment for health care services or medical care related to the injury, must reimburse the Hospital for the related health care services rendered up to the amount reasonably awarded for that purpose.
3. Patients who receive a payment check directly from their insurance for services rendered by the San Francisco Health Network are required to relinquish those payments in full to the ZSFG or BHS Patient Accounting Department, whichever is applicable.
4. The Charity Care and Discount Payment programs cannot be applied to services that qualify for discount packages or programs, such as the hospital’s maternity OB package, VIP abortion services package, or other package programs that are provided to patients at a global rate with significant discounts below government rates. These are not subject to additional discounts.
In addition to the requirements listed above, the following are also required for the Charity Care program:
1. Patients must cooperate with pursuing and communicating with any commercial or employer-sponsored insurance plans for payment of their services, including appeals.
2. Patients must cooperate with applying for a government program or hospital package and must submit a completed application with required verification for that entity to make an eligibility determination.
The Charity Care and Discount Payment program are in a single application but have different eligibility requirements as described in the following sections. Patients must provide a completed application and all required verification within 30 days of starting an application.
Patients may contact the appropriate Patient Financial Assistance Department for assistance by:
1. Calling ZSFG Patient Financial Assistance Department at (628) 206-3275, Monday – Friday between 8:00am – 11:30am and 1:00pm – 5:00pm.
2. Calling BHS Member Services Department at (888) 246-3333.
3. Sending a message in the request financial assistance section of the patient’s MyChart patient portal account.
Applications must be mailed to the address listed below for the appropriate department/facility:
1. 1. Applications for care provided by ZSFG, CPC, or PHD must be mailed to Zuckerberg San Francisco General Hospital Patient Financial Assistance Department 1001 Potrero Ave., Building 20, San Francisco, CA 94110.
  2. Applications for care provided by BHS must be mailed to BHS Member Page 8 of 12 Services Department, 1360 Mission St., 2nd Fl, San Francisco, CA 94103.

Section 9 Charity Care Program

The eligibility requirements for the Charity Care program are:
1. The Charity Care Program eligibility is based on income.
2. A patient’s household income may not exceed 138% of the Federal poverty level.
3. Charity Care eligibility requires full cooperation with program requirements to pursue and exhaust insurance and third-party liability.
4. Patients must also cooperate with eligibility screening and application for Medicare, Medi-Cal, or other coverage.
5. Charity Care program eligibility removes the entire amount that a patient owes.
Income Verification
1. Patients may provide any of the following for income verification purposes:
  1. The most recent three (3) months of pay stubs prior to date of application or a complete copy of the most recent year’s income tax return for all sources of income. This is required for all qualified household members.
  2. Recent tax returns, which are tax returns that document a patient’s income for the year in which the patient was first billed or 12 months prior to when the patient was first billed.
  3. Recent paystubs, which are paystubs within a 6-month period before or after the patient is first billed by the hospital.
2. Patients on a student visa may provide I-20 form as verification.
3. Patients without an accepted verifiable source of income will be determined ineligible.
4. Patients active with a county or state program that does not cover the dates of service being billed to them, may have their income verification substituted as follows to qualify for a financial assistance program.
  1. Patients confirmed with active Medi-Cal may replace the income verification with current eligibility in the Medi-Cal program.
  2. Patients confirmed with active Healthy San Francisco may replace the income verification with current enrollment with Healthy San Francisco.
  3. Patients confirmed with active with a County Medical Services Program (CMSP) may replace the income and assets with current eligibility in the CMSP program.
5. Information provided by patients to verify income eligibility shall not be used for collections activities.
6. Patients who are determined ineligible for the Charity Care program due to excess income will be evaluated for the Discount Payment program.

Section 10 Discount Payment Program

The eligibility requirements for the Discount Payment program are:
1. Discount Payment Program eligibility is based on income.
2. A patient’s household income may be at or above 139% of the FPL.
3. There is no FPL limit for a patient to qualify. The patient’s FPL determines the amount of the discount.
4. Patients must also cooperate with eligibility screening for Medicare, Medi-Cal, or other coverage.
5. Discount Payment program eligibility reduces the amount that a patient owes.
Income Verification
1. Patients may provide either of the following for income verification purposes:
  1. Recent tax returns, which are tax returns that document a patient’s income for the year in which the patient was first billed or 12 months prior to when the patient was first billed.
  2. Recent paystubs, which are paystubs within a 6-month period before or after the patient is first billed by the hospital.
2. This policy also allows patients to provide the most recent three (3) months of pay stubs prior to date of application or most recent year income tax return for all qualified household members.
3. Patients without an accepted verifiable source of income will be determined ineligible.
4. Patients active with a county or state program that does not cover the dates of service being billed to them, may have their income verification substituted as follows to qualify for a financial assistance program:
  1. Patients confirmed with active Medi-Cal may replace the income verification with current eligibility in the Medi-Cal program.
  2. Patients confirmed with active Healthy San Francisco may replace the income verification with current enrollment with Healthy San Francisco.
  3. Patients confirmed with active with a County Medical Services Program (CMSP) may replace the income and assets with current eligibility in the CMSP program.
  4. Information provided by patients to verify income eligibility shall not be used for collections activities.

Section 11 Financial Assistance Application Decisions

Approvals
1. Patients will be notified in writing if approved with the final amount of their account balance after the discount has been applied.
2. Patients will be billed for the discounted payment responsibility if a balance remains after the discount is Page 10 of 12 applied.
Denials
1. Patients will be notified in writing if denied with the denial reason.
2. Patients will continue to be billed for the original payment responsibility on their accounts.

Section 12 Appeals Review Process

Patients may request an appeal of their Charity Care or Discount Payment program eligibility decision in writing with the reason for appeal and supporting verification to support the appeal reason within 15 business days of receiving an application decision.
Appeals must be mailed to:
1. Application appeals for care provided by ZSFG, CPC, or PHD must be mailed to Zuckerberg San Francisco General Hospital Patient Financial Assistance Department 1001 Potrero Ave., Building 20, San Francisco, CA 94110.
2. Application appeals for care provided by BHS must be mailed to BHS Member Services Department, 1360 Mission St., 2nd Fl, San Francisco, CA 94103.
The appeals reason and supporting verification will be reviewed per each program’s eligibility requirements. Additional information and/or verification may be required.
Patients will be notified in writing of the appeal decision.

Section 13 Patient Cap

SFDPH also applies a Patient Cap for certain patients. The Patient Cap policy reduces the amount a patient owes without an application or action from a patient or guarantor. The Patient Cap policy is a predetermined maximum amount that a patient is held responsible to pay for outpatient and inpatient accounts. It is applied based on system rules that determine if a patient and account qualify. When patients and their accounts qualify, a system adjustment is made that reduces the balance to the Patient Cap amount.
The following patients and accounts do not qualify for the Patient Cap and will continue to be billed for the full amount that the patient owes.
1. Patients with services that are covered by workers compensation or third-party payer source.
2. Patients whose accounts which have been assigned to the Bureau of Delinquent Revenue.
3. Services that are eligible for the OB package or VIP package.
4. Patients who have received a direct payment from their insurance for their services and have not surrendered the payment to the San Francisco Health Network.
5. Patients whose accounts have been outsourced to DPH Page 11 of 12 contractor, Health Advocates for eligibility and insurance recovery assistance.

Section 14 AB1020 Expected Payment Limit

The SFHN also limits the expected payment for services it provides to patients at or below 400% of the FPL, to the amount of payment the hospital would expect to receive from Medicare.

Section 15 Payment Plans

Payment plans are available with ZSFG Patient Accounting Customer Service Department, the BHS Member Services Department, or the City & County of San Francisco Office of the Treasurer & Tax Collector Bureau of Delinquent Revenue (BDR) depending on which entity the account is with and the terms of the payment plan.
Patients may request a payment plan from ZSFG Patient Accounting Department or the BHS Member Services Department if the account(s) have not been assigned to BDR.
Payment plans may be established in the following ways:
1. Patients may create their own payment plan in their MyChart patient portal.
2. Patients may contact Customer Service for assistance with creating a payment plan by any of the following:
  1. Sending a message in their MyChart patient portal account
  2. Emailing one of the following:
    1. For care provided by ZSFG, CPC, or PHD: SFHNPatientFinancialServices@sfdph.org
    2. For care provided at BHS: BHSMemberServices@sfdph.org
  3. Calling one of the following:
    1. For care provided by ZSFG, CPC, or PHD: (628) 206-8448 Monday – Friday 8:00am – 11:30am and 1:00pm – 5:00pm
    2. For care provided at BHS: (888) 246-3333
  4. The hospital and patient may decide the terms of the payment plan. The hospital shall determine a reasonable payment formula where monthly payments are not more than 10 percent of a patient’s family income, excluding deductions for essential living expenses.
  5. If the hospital and the patient cannot agree to a payment plan, the hospital shall use the specified formula of deducting 60% for essential living expenses from patient’s gross household income and then calculate 10% of the remaining income to determine a reasonable monthly payment amount. The hospital provides patients with a referral for assistance to the Health Consumer Alliance at (888) 804- 3536 or The Health Consumer Center/Bay Area Legal Aid at (855) 693- 7285.
  6. Patients with delinquent payment plans will receive billing statements notifying them of the delinquent payments and to make Page 12 of 12 a payment to bring their account current.
  7. Patients may contact the Customer Service Office to request a renegotiation of payment plan if it meets the department requirements.
  8. Patients who request a payment plan that is less than twenty U.S. dollars ($20) per month or that exceeds twelve (12) calendar months will have their accounts assigned to the BDR for payment plan assistance. Refer to City & County of San Francisco Office of the Treasurer & Tax Collector Bureau of Delinquent Revenue Zuckerberg San Francisco General Hospital Debt Collection Policies and Procedures.

References

Assembly Bill 1020: Health Care Debt and Fair Billing 2022
Assembly Bill 532 Health Care Fair Billing Policies 2021
UCSF Clinical Practice Group, Business Services/dba SFGH Medical Group Guarantor/AB1020 Policy and Procedure
City & County of San Francisco Office of the Treasurer & Tax Collector Bureau of Delinquent Revenue Zuckerberg San Francisco General Hospital Debt Collection Policies and Procedures
Senate Bill 1276 Health care: fair billing policies 2014
Assembly Bill 774 Hospitals: fair pricing policies 2007