Financial Aid Law (FAL)

Attachment B

Patient Financial Assistance Asset Test Survey/Attestation
For 2007 and Subsequent Years´ Policies and Procedures

Hospital: ___________________________________________________________________________

Operating Certificate Number: __________________________________________________________

  1. Will your hospital take into consideration assets owned by a patient, and/or other legally responsible individuals, which have annual income at or below 150% of the federal poverty level in determining the patient's potential eligibility for financial assistance as specified in Subdivision 9-a(b)(i) & (ii) of Section 2807-k of the NYS Public Health Law? YES / NO (circle appropriate response)
    1. If NO, STOP here, certify below, and submit.
    2. If YES, your hospital is required to comply with conditions which are either statutorily required or, deemed necessary by the Department, to ensure that your hospital's consideration of assets doesn't unduly deny mandated financial assistance for patients in the above referenced low- income categories. Pursuant to Subdivision 9-a(b)(vi) of Section 2807-k of the NYS Public Health Law, you must obtain Department approval to consider assets in your eligibility procedures for patients with annual income at or below 150% of the federal poverty level. This approval shall be granted upon receipt of the following certification attesting that established eligibility policies and procedures related to services rendered on and after January 1, 2007, shall be in full compliance with the below stated conditions.
  2. Approval conditions for hospital consideration of assets in eligibility policies and procedures for mandated financial assistance for patients with annual income at or below 150% of the federal poverty level:
    1. The hospital will not consider as assets a patient's, and/or legally responsible individual's, primary residence, tax deferred or other comparable retirement account savings, college account savings, or cars (and other comparable primary transportation vehicles) regularly used by the patient or, immediate family, in determining potential eligibility for financial assistance.
    2. For the 2007 calendar year, assets which are not required to be disregarded pursuant to (a) above will only be considered if they exceed the asset levels specified in the below referenced chart.
      3. Household Size Asset Levels
      One $4,200
      Two $5,400
      Three $6,600
      Four $6,650
      Five $6,700
      Six $6,800
      Seven $7,650
      Eight $8,500
      Each Additional Person $850
    3. For subsequent calendar years, the hospital will revise the asset levels referenced in (b) above to comply with amended levels which will be annually published by the Department prior to the effective calendar year.




2007 PATIENT FINANCIAL ASSISTANCE ASSET TEST SURVEY

CERTIFICATION

I, (NAME: PLEASE PRINT) _______________________________________________________________ CERTIFY THAT I AM THE CHIEF EXECUTIVE/FINANCIAL OFFICER AND/OR ADMINISTRATOR OF THE HOSPITAL NOTED IN THE BEGINNING OF THIS SURVEY, AND FURTHER CERTIFY TO ALL OF THE FOLLOWING:

THAT THE RESPONSE PROVIDED TO THE QUESTION IN PARAGRAPH (1) OF THIS SURVEY CONFORMS TO THE APPLICABLE POLICIES AND PROCEDURES USED BY OUR HOSPITAL AND, IF OUR RESPONSE WAS YES, SUCH POLICIES AND PROCEDURES WILL BE IN FULL COMPLIANCE WITH THE CONDITIONS SPECIFIED IN PARAGRAPH (2).





SIGNATURE: ________________________________________________

DATE: _____________________________________________________

TYPE/PRINT NAME: ___________________________________________

TITLE: ____________________________________________________

HOSPITAL NAME: _____________________________________________