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OVERVIEW: Alaska has no free care mandate, though its current Medicaid regulations do make reference to “charity care.” In the absence of any mandate directly related to the provision of free care, the following analysis includes discussion of two public programs that may provide limited financial relief to individuals struggling to pay medical bills who are not eligible for Medicaid: the Chronic and Acute Medical Assistance (CAMA) and the Catastrophic Illness Assistance Programs. Eligibility and covered services differ for these programs, however, and are essentially provider reimbursement programs that are subject to available State funding. They do not impose additional requirements on providers who accept these reimbursements, with one exception: providers that accept CAMA funds must establish a payment schedule over a term of at least three years that allow the patient to repay any remaining balance in full.
Catastrophic Illness Assistance
Alaska Statutes §§ 47.08.010 to 47.08.140 ; 7 Alaska Admin. Code § 48.005
General Relief Assistance: Payment to Facilities for Treatment of Needy Persons
Alaska Statutes § 47.25.195
Medical Assistance for Chronic or Acute Medical Conditions
Alaska Statutes § 47.08.150; 7 Alaska Admin. Code §§ 48.500 to 48.598
Catastrophic illness assistance
Chronic and acute medical assistance
Payment to facilities for treatment of needy persons
The Department of Health and Social Services (hereinafter “the Department”) is authorized to administer and regulate both the Catastrophic Illness Assistance Program and the Chronic and Acute Medical Assistance Program. Alaska Stat. §§ 47.08.130 - 47.08.150.
DEFINITIONS AND DISTINCTIONS:
“Catastrophic illness” is defined as “illness or injury that results in medical expenses of over $1,000 during a [one-year] period…after all other sources of third-party payment have been exhausted.” Alaska Stat. § 47.08.140(3).
“Charity care” is defined in Alaska’s Medicaid regulations as health care services that “a facility does not expect to result in cash payments” as a result of its policy to provide free care to individuals who meet certain financial criteria. 7 Alaska Admin. Code § 43.709(10).
A “needy person” is defined as “a needy resident of the state who is not eligible for aid from another public agency or department providing similar services in the state.” Alaska Stat. § 47.25.300(3).
FREE CARE AS A COMMUNITY BENEFIT: N/A
Alaskans may apply for two types of financial assistance whereby the Department of Health and Social Services may reimburse providers for the unpaid cost of eligible services. Alaska Stat. §§ 47.08.010; 47.08.150(a); 7 Alaska Admin. Code § 48.040. They are as follows:
1. The Chronic and Acute Medical Assistance Program (hereinafter “CAMA”). The Department may reimburse providers for services rendered to “needy persons” living with “chronic and acute medical conditions” who are statutorily eligible for General Relief Assistance but not Medicaid. Alaska Stat. § 47.08.150(a); 7 Alaska Admin. Code § 48.500.
2. Catastrophic Illness Assistance. Subject to available funding, the Department must provide “catastrophic illness assistance” for health care consumers facing “financial catastrophe” due to the cost of medical services rendered for illness or injury. Alaska Stat. § 47.08.010. This program is a last-resort payor that provides coverage only when all other third-party resources have been exhausted. 7 Alaska Admin. Code § 48.005.
The CAMA Program. Eligibility for CAMA is determined by the Division of Public Assistance (hereinafter “the Division”), which is housed within the Department of Health and Social Services. As of July 31, 1998, eligibility determinations for the CAMA Program follow the same procedures as those established for Medicaid. 7 Alaska Admin. § 48.510. As of November 2002, CAMA eligibility is further limited to individuals living with a terminal illness, a cancer that requires chemotherapy treatment, or certain chronic medical conditions. 7 Alaska Admin. Code § 48.525(b); see also Alaska Stat. § 47.08.150(c)(1)(C)(i) - (iv) (listing the eligible chronic conditions). In order to be found eligible for CAMA, an applicant must provide adequate evidence demonstrating both medical eligibility and financial need. 7 Alaska Admin. Code §48.505(b). In determining eligibility, the Division considers the following factors:
- Financial need, including lack of income and lack of prior or personal resources;
- Residency in the state at the time of application;
- U.S. citizenship or legal alien status; and
- The “immediate and specific” need for covered services. 7 Alaska Admin. Code § 48.525(a).
The determination of financial eligibility hinges solely on the individual’s application for General Relief Assistance. Alaska Statutes § 47.08.150(b); see also Alaska Stat. § 47.25.120; 7 Alaska Admin. Code § 47.150 (listing the standard used for determining financial eligibility for General Relief Assistance).
Once granted, eligibility for the CAMA program lasts for one calendar month, though the Division of Public Assistance has discretion to extend the eligibility period for up to six (6) consecutive months. 7 Alaska Admin. § 48.515(a). If the applicant still requires CAMA assistance after six months, the Division may require the applicant to submit a new application and fully supporting documentation. Id.
Catastrophic Illness Assistance. Eligibility requirements for Catastrophic Illness Assistance are determined by the Catastrophic Illness Committee, which consists of a medical review officer from the Department of Health and Social Services, a consumer who has suffered a catastrophic illness, and an appointed representative from the Department of Commerce, Community and Economic Development. Alaska Stat. § 47.08.020. Because this program is, in effect, a cost-sharing program, the Committee is required to adopt, “as frequently as necessary,” a formula for determining the applicant’s share of catastrophic medical expenses—that is, the amount of the total expenses related to the catastrophic illness that the applicant can reasonably expected to pay, given his or her annual gross income, assets, and number of dependents. Alaska Stat. §§ 47.08.060(a)-(c); 47.08.140(2); see also 7 Alaska Admin. Code § 48.070 (containing the current formula). These factors are weighed against the amount of state funding available for the Program; the anticipated need for those funds; forthcoming third-party payments; and up to $500 in payments the applicant has made towards health care premiums or prepaid medical plans in the previous year. Alaska Stat. § 47.08.060(a)-(e).
The Department of Health and Social Services may pay hospitals to cover the costs of treating “needy” patients. Alaska Stat. § 47.25.195(a). In determining reimbursement rates, the Department must follow the same rules and procedures that govern the administration of Medicaid. Alaska Stat. § 47.25.195(b). If insufficient funds were appropriated for medical assistance in a given year, the Department may establish, by regulation, a prospective pro rata reduction of the hospitals’ established payment rates. Alaska Stat. § 47.25.195(c).
Under the CAMA Program. Coverage under the CAMA Program is limited by statute to cover the cost of certain drug and medical supply prescriptions; hospital emergency room visits and inpatient procedures; medical transportation for inpatient procedures and nursing facility services; outpatient laboratory and X-ray services; outpatient surgical procedures; and nursing facility care. Alaska Stat. § 47.08.150(c). However, the Department has authority to proscribe the amount, duration, and scope of services under this Program; and, where the cost of these services exceeds the funding available, the Department may limit coverage for certain services by regulation, thereby placing priority on the most critical forms of care. Alaska Stat. §47.08.150(e).
In reality, coverage under the CAMA Program for hospital services is extremely limited. As of 2004, CAMA will reimburse hospitals only for preauthorized chemotherapy or radiation treatment rendered to patients with cancer. 7 Alaska Admin. Code § 48.550. Moreover, the regulations expressly exclude “major medical care” from CAMA coverage. 7 Alaska Admin. Code § 48.555(9). By definition, this means that the CAMA Program will not pay for any inpatient hospital services. See 7 Alaska Admin. Code § 48.900(9).
Though limited with regard to hospitals, the CAMA Program will reimburse covered services offered by physicians in outpatient settings that are directly related to a covered condition. 7 Alaska Admin. Code § 48.550(d)(3).
Under the Catastrophic Illness Assistance Program. Reimbursement to providers under the Catastrophic Illness Assistance Program is limited to services related to the original injury or illness that were rendered over a one-year period, starting with the date the first charges were incurred. Alaska Stat. § 47.08.070(1). The following services are excluded from coverage:
- Dentistry and optometry unless prescribed by a licensed dentist or physician as medically necessary as the result of the injury or illness;
- Elective medical or surgical procedures;
- Drugs and medications not prescribed by a licensed physician;
- Services received as a result of a pregnancy or birth without unusual complications;
- Private psychological or psychiatric treatment or private alcoholism treatment, unless not available from public agencies or programs;
- Chiropractic and naturopathic services;
- Non-medical services; and
- Medical services to persons in the custody of the Department of Corrections. Alaska Stat. § 47.08.050.
The Catastrophic Illness Committee is required to enlist the help of medical providers in making the public aware of financial assistance for catastrophic illnesses. Alaska Stat. § 47.08.030.
The CAMA Program. Any individual or a person acting on that individual’s behalf may apply for CAMA assistance by submitting a “complete identifiable application.” 7 Alaska Admin. Code § 48.505(a). A “complete identifiable application” includes, at a minimum, the applicant’s name, mailing address, and signature or witnessed mark. 7 Alaska Admin. Code § 48.900(7). In most cases, the applicant must be interviewed by a caseworker before the Department can make a determination of eligibility. 7 Alaska Admin. Code §48.505(c). As of July 31, 1998, eligibility determinations for the CAMA Program follow the same procedures as those established for Medicaid. 7 Alaska Admin. § 48.510. Accordingly, once it receives an identifiable application for CAMA, the Division of Public Assistance has thirty (30) days to determine eligibility and to provide the applicant with written notice of its decision. 7 Alaska Admin. Code § 47.050 (stating also that applications must be complete before assistance will be granted).
Catastrophic Illness Assistance. Applications for Catastrophic Illness Assistance, along with the formula used to calculate the applicant’s share of the cost of care, are available at hospitals, local offices of the Division of Public Assistance, and offices of the Division of Medical Assistance. 7 Alaska Admin. Code § 48.030(b). An application for Catastrophic Illness Assistance may be filed by a person who has suffered catastrophic illness; by a parent, spouse, or legal guardian of the affected person; or by an interested party who has obtained the written consent of the person suffering from the catastrophic illness. Alaska Stat. § 47.08.040. The Catastrophic Illness Committee must promptly notify the applicant of its decision to award or deny relief, giving both the amount and the reasons for its decision in writing. Alaska Stat. § 47.08.080.
The CAMA Program. CAMA applicants or recipients whose applications are modified, denied, or ignored after 30 days of receipt by the Department of Health and Social Services have the right to a “prompt hearing” before a Division of Public Assistance representative. 7 Alaska Admin. Code § 47.070.
Catastrophic Illness Assistance. Applicants for the Catastrophic Illness Assistance Program who are dissatisfied with the Committee’s determination have the right to apply to the Committee for reconsideration within thirty (30) days of receiving the decision. Alaska Stat. § 47.08.080. The request for reconsideration must include a written statement of the grounds for reconsideration along with any supporting documentation that was unavailable to the Committee at the time of its original decision. Id. The Committee must promptly notify the applicant of its determination based on the request for reconsideration. Id. The Committee’s decision becomes final unless the applicant requests a hearing within thirty (30) days of receiving the decision. Alaska Stat. § 47.08.100(2). Applicants may appeal the Committee’s decision on a request for reconsideration in accordance with the procedures established under the General Relief Assistance Program, which states that an applicant for assistance has the right to a fair hearing conducted by a representative of the Department of Health and Social Services in the event his or her application is denied, discontinued, or not acted upon. Alaska Statutes §§ 47.08.090 and 47.25.180.
REPORTING REQUIREMENTS: N/A
PENALTIES FOR NONCOMPLIANCE: N/A
Payment to providers under the CAMA Program is conditioned on the providers’ establishing a payment schedule over a term of at least three years whereby the applicant can repay his or her remaining balance in full. Alaska Stat. § 47.08.070(3).