Embedded Files
Medicare Learning Network - Web-Based Learning Courses (CMS)
National Drug Code Directory (NDC)
Center for Medicare and Medicaid - Organizations Determinations
FDA - Human Drug Compounding Laws
FDA - Human Drug Compounding Policies and Rules
Medicare Claims, Appeals, and Grievances
Centers for Medicare and Medicaid - Your Rights - Fact Sheets and FAQs
Department of State - Patient Rights and Responsibilities
Medicare Drug Formulary Guidance
Section 1927 of the Social Security Act - Payment of Outpatient Drugs
Medicare - Self-Administered Drug Coverage - PDF
CMS.gov Appeals Flow Chart - PDF
CMS.gov Managed Care Organization (MCO) Appeals Flow Chart - PDF
Center for Medicare and Medicaid - Know Your Rights - No Surprises Act
Resources and Financial Assistance
Healthcare System - Patient Advocate and Social Workers
If you feel like you are not receiving the care you deserve inpatient or outpatient in a healthcare setting, especially in a larger healthcare system, you may have access to a patient advocate who is an employee of the healthcare facility or system, who can help you navigate care and help you find resources to help you.
Many healthcare systems also have social workers who can help you find resources to help you.
Apply for Financial Assistance at the Healthcare System you use. You can usually find that information online or ask for an application at your next doctor's appointment.
(5) Specify what constitutes “medically necessary services” in a manner that—
(i) Is no more restrictive than that used in the State Medicaid program, including quantitative and non-quantitative treatment limits, as indicated in State statutes and regulations, the State Plan, and other State policy and procedures; and
(ii) Addresses the extent to which the MCO, PIHP, or PAHP is responsible for covering services that address:
(A) The prevention, diagnosis, and treatment of an enrollee's disease, condition, and/or disorder that results in health impairments and/or disability.
(B) The ability for an enrollee to achieve age-appropriate growth and development.
(C) The ability for an enrollee to attain, maintain, or regain functional capacity.
(D) The opportunity for an enrollee receiving long-term services and supports to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of their choice.
(b) Authorization of services. For the processing of requests for initial and continuing authorizations of services, each contract must require—
(1) That the MCO, PIHP, or PAHP and its subcontractors have in place, and follow, written policies and procedures.
(2) That the MCO, PIHP, or PAHP—
(i) Have in effect mechanisms to ensure consistent application of review criteria for authorization decisions.
(ii) Consult with the requesting provider for medical services when appropriate.
(iii) Authorize LTSS based on an enrollee's current needs assessment and consistent with the person-centered service plan.
(3) That any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, be made by an individual who has appropriate expertise in addressing the enrollee's medical, behavioral health, or long-term services and supports needs.
Steps to take for charity care or financial help with medical bills - According to Consumer Financial Protection Bureau:
Steps to take for charity care or financial help with medical bills
1. Ask for a copy of the policy.
Ask for a copy of the hospital’s financial assistance policy up front. By law, the policy must be provided free of charge and must tell you how to apply for help. You can ask whether the policy is available in your preferred language in addition to English.
2. Fill out an application form.
Fill out the application with information about your income, including last year’s tax forms or a current pay stub, and your expenses, including your rent or mortgage payment, utilities, credit cards, and other expenses.
3. Ask questions about the process.
Ask your provider how long it takes to process your application for financial assistance, how to get answers to questions about the application, and what happens with your bill in the meantime.
4. Notify any debt collectors, if they are trying to collect from you
Notify any debt collectors trying to collect on the hospital bill that you’re seeking financial assistance for the bill. You can tell them to pause collections while that is pending.
5. Follow up
Follow up with the service provider and its billing department about the status of your application as necessary.
More information about charity care or financial assistance policies is available on the IRS’s website . In exchange for nonprofit hospitals being treated favorably under federal tax laws, they are required to follow the requirements for providing help to people who need it. If you suspect the hospital is NOT following these requirements, notify the IRS .
Even if a hospital is for-profit or private, they may have a financial assistance policy that can help you pay your medical bills. Ask your hospital for information about their policy, including the eligibility requirements and how you can apply.
Some states have charity care laws that require hospitals to provide free or discounted care to patients meeting requirements, sometimes based on income. Here are some of the states that provide protections:
California, Connecticut, Illinois, Maine, Maryland, Nevada, New Jersey, New York, Rhode Island, and Washington have protections that apply to all hospitals.
Louisiana, Oregon, and Texas have protections that apply only to nonprofit or state hospitals.
Colorado, Massachusetts, and South Carolina have state-run financial assistance programs.
Even if your medical bill is in collection or you have been sued for the debt, you may still want to apply for charity care or financial assistance. You can also request that the debt collector stop collection activity while your application is pending with the hospital. Here is a sample letter that you can use or modify to send to the debt collector. Telling the debt collector to stop contacting you does not stop the debt collector or the hospital from using other legal ways to collect the debt from you if you owe it.
Page updated
Google Sites
Report abuse