Initially effective April 1, 2009, the Hospital Uninsured Patient Discount Act (Public Act 95-965) was amended (Public Act 97-690) to include 100% discounts for uninsured patients at certain income levels—effective June 14, 2012. Major provisions of the law are as follows:
For 100% discount, family income can be no more than 200% of the federal poverty level (FPL) in urban areas and 125% at Critical Access Hospitals or in rural areas defined as outside a metropolitan statistical area.
For discount to 135% of cost, family income can be no more than 600% FPL in urban areas or 300% at Critical Access Hospitals or in rural areas.
Income is defined as a family’s annual earnings and cash benefits from all sources before taxes, including distributions and payments from pensions or retirement plans, less payments made for child support.
Charges are discounted by 100% at certain income levels or to 135% of cost at certain income levels. The discount to 135% of cost is determined by applying ratio of cost to charges (RCC) from the most recently filed Medicare cost report to the uninsured patient’s bill. The formula for the discount is [1-(RCC x 1.35)] x charges. The discount is applicable only to charges exceeding $300 in any one inpatient admission or outpatient encounter.
Hospitals must file a copy of Worksheet C Part I of their Medicare Cost Report with the Attorney General annually within 30 days of filing its Medicare Cost Report with the hospital's fiscal intermediary.
The maximum amount that can be collected in a 12-month period from an eligible patient is 25% of family annual gross income. The time period begins as of the first date of service determined eligible for discount. For subsequent services to be included in the maximum, the patient must inform the hospital that he/she had received prior services from that hospital that were determined eligible for discount.
Hospitals may exclude from the 25% maximum collectible amount a patient who has substantial assets—defined as a value in excess of 600% FPL in urban areas and 300% FPL at CAH and rural areas. Certain assets cannot be considered: primary residence, personal property exempt from collections under Section 5/12-1001 of the Illinois Code of Civil Procedure (see Appendix A), and any amounts held in a pension or retirement plan.
The discounts only apply to medically necessary healthcare services that would be covered under Medicare for beneficiaries with the same clinical presentation as the uninsured patient. The law does not apply to elective cosmetic surgery or non-medical services such as social and vocational services. The discount does not apply to physician services.
Hospitals must have a statement on or with each hospital bill, invoice or summary of charges about the availability of the uninsured discount and how to apply for it.
Patients may be required to apply for Medicare, Medicaid, AllKids, SCHIP or other public programs if there is reason to believe they would qualify. Patients may apply for the discount within 60 days of service. Patients must provide third-party verification of income, information regarding assets and documentation of residency within 30 days of request.
Income documentation shall include any one of the following:
- Copy of most recent tax return;
- Copy of most recent W-2 form and 1099 forms;
- Copies of two most recent pay stubs;
- Written income verification from an employer if paid in cash; or
- One other reasonable form of verification acceptable to the hospital.
Acceptable verification of Illinois residency shall include any one of the following:
- Valid state-issued identification card;
- Recent residential utility bill;
- Lease agreement;
- Vehicle registration card;
- Voter registration card;
- Mail addressed to the uninsured patient at an Illinois address from a government or other credible source;
- Statement from a family member who resides at the same address and presents verification of residency; or
- Letter from a homeless shelter, transitional house or other similar facility verifying that the uninsured patient resides at the facility.
Acceptable documentation regarding assets may include statements from financial institutions or some other third-party verification of asset value. If no third-party verification exists, then the patient shall certify to the estimated asset value.
The hospital may require patients to certify that all information provided on the application is true and if any information is untrue, the discount is forfeited and the patient is responsible for the full charges.
This law cannot be used by public or private insurers to reduce hospital payment rates. It does not require a hospital to provide any particular service to an uninsured patient. It also does not reduce any obligations under the Fair Patient Billing Act.
Enforcement is the same as outlined in the Fair Patient Billing Act.