Discrimination is Against the Law
Montgomery Hospice and Prince George’s Hospice complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sexual orientation or sex. Montgomery Hospice and Prince George’s Hospice does not exclude people or treat them differently because of race, color, national origin, age, disability, sexual orientation or sex.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Template provided by U.S. Department of Health and Human Services.

If you need these services, contact Montgomery Hospice and Prince George’s Hospice.

If you believe that Montgomery Hospice and Prince George’s Hospice has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sexual orientation or sex, you can file a grievance with: Civil Rights Coordinator, 1355 Piccard Drive, Suite 100 Rockville MD 20850, (301)921-4400, FAX: (301)921-4433. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

Montgomery Hospice and Prince George’s Hospice Charity Care/ Financial Aid Policy

Policy Number: 8-006
Initial Financial Assistance Request Form
Financial Assistance Application

PURPOSE

All hospice eligible patients will have access to hospice services regardless of an individual’s ability to pay. Hospice services will be offered on a charitable basis to qualified indigent persons. Consistent criteria will be applied when enrolling patients for charity care or reduced fee care employing the Financial Assistance Application and the Federal Poverty Guidelines.

POLICY

In accordance with Maryland regulation, patients who are uninsured, have a pending Medicaid application or who are unable to pay out of pocket for hospice care will be accepted for charity care or reduced fee care after completing a Financial Assistance Application.

Also, patients who reach their private insurance cap will be accepted for financial aid after completing a Financial Assistance Application. This may consist of charity care or reduced fee care depending on the results of the application.

PROCESS

1. Probable Eligibility – If the patient or family wishes to request financial support in the form of charity care or a reduced fee, the patient or designated person responsible for financial matters will complete the Initial Financial Assistance request form with the assistance of a Montgomery Hospice and Prince George’s Hospice clinical staff person. No documentation is required for completion of this initial form. The Director of Clinical Access will make an initial determination of probable eligibility for financial assistance. Probable eligibility will be communicated to the patient or responsible party within two business days of the submission of a completed Initial Financial Assistance request form. A copy of the Initial Financial Assistance Request form with the determination of the Director of Clinical Access will be provided to the patient and family.

2. Final Determination of Eligibility – A social worker or clinical staff person will assist the patient and/or decision maker in completing the Financial Assistance Application and will help gather supporting documents. The Financial Assistance Application includes the eligibility guidelines and the sliding fee scale. The final determination of eligibility for charity care or reduced fee care will be made by the Director of Finance and the Chief Financial Officer when it is identified that the patient has no source of payment for services or has reached the limit of benefits with a private insurance. A sliding fee scale can be offered to the patient/decision maker with terms of payment that takes into account the patient’s ability to pay. This is based on the following criteria:

Eligibility Criteria for the Montgomery Hospice & Prince George’s Hospice Financial Assistance Program

Based upon Federal Poverty Guidelines, Gross Income Levels, 2019; Source: Federal Poverty Guidelines – 48 Contiguous States and D.C.

• If family income is at or below the 200% guideline, they will receive a full write-off of charges.
• If family income exceeds the 200% guideline, but is below the 500% guideline, a sliding scale will be used to determine the percent reduction that will apply. The method for calculating the sliding payment scale is included on page 4 of the Financial Assistance Application.
• The final decision will be relayed to the patient and/or responsible party within 7 days of from the completion of the Financial Assistance Application form with supporting information.

3. Provision – Financial assistance will include staff visits, 24 hour availability of On Call support, durable medical equipment and necessary medical supplies and medication related to the terminal prognosis. A social worker will meet with the patient to provide support for any patient applications for Medical Assistance or other community resources.

4. Documentation – From the initial request to the final determination for Financial Assistance, progress will be documented in the Medical Record on the Patient’s chart under Billing Comments. The Financial Assistance Application and accompanying documents shall be kept with the patient’s financial record.

5. Discharge – If the patient is no longer medically eligible for hospice care and needs to be discharged, the social worker will provide appropriate referrals to available community resources as part of the discharge plan.

As a nonprofit hospice, Montgomery Hospice and Prince George’s Hospice is committed to providing hospice care to everyone in our community who needs it, including those who have no insurance or not enough coverage. In 2019, we provided $426,632 of charity care.

Montgomery Hospice, Inc. dba Montgomery Hospice and Prince George’s Hospice is a community-based 501(c)(3) nonprofit serving residents of Montgomery and Prince George’s Counties in Maryland.