District of Columbia
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OVERVIEW: Free care requirements in the District of Columbia are tied to the District’s Certificate of Need process. For Certificate of Need holders, this process mandates the provision of uncompensated care to certain patients, sets minimum eligibility thresholds, and imposes notification and reporting requirements.
Health Services Planning (includes Certificate of Need requirements)
District of Columbia Official Code §§ 44-401 to 44-422
Provision of Uncompensated Care
District of Columbia Municipal Regulations Title 22, §§ 4400 to 4499
The State Health Planning and Development Agency (hereinafter “SHPDA”) in the Department of Health is responsible for administering and operating D.C.’s Certificate of Need (hereinafter “CON”) program. D.C. Code § 44-402(b). SHPDA’s responsibilities also include establishing requirements and standards around the amount of uncompensated care that health facilities receiving a CON are required to provide and establishing an annual monitoring mechanism to ensure that facilities are in compliance with this requirement. Id.
SHPDA has established a Statewide Health Coordinating Council (hereinafter “SHCC”) comprising health care consumers, members of the public, providers, and a representative from the health insurance industry that, among other things, makes recommendations to SHPDA about Certificate of Need applications. D.C. Code § 44-403.
DEFINITIONS AND DISTINCTIONS:
In order to qualify as “bad debt,” an account receivable must be based on medical or hospital service for which payment is expected; must not be charity care or the obligation of any government payor; and must have been found uncollectible after making reasonable attempts to collect the balance due. D.C. Code § 44-401(2A)(A-B).
“Charity care” is defined within the CON statute as follows: “the physician and hospital medical services provided to persons who are unable to pay for the cost of services, especially those persons who are low-income, uninsured and underinsured, but excluding those services determined to be caused by, or categorized as, bad debt.” D.C. Code § 44-401(3A).
“Uncompensated care” is defined as the “cost of health care services rendered to patients for which the health care facility does not receive payment.” D.C. Code § 44-401(20). The term encompasses both bad debt and charity care; it excludes contractual allowances. Id.
FREE CARE AS A COMMUNITY BENEFIT: N/A
D.C. requires health care facilities to provide a certain amount of uncompensated care to eligible persons as a condition of holding a Certificate of Need or through contract with the District of Columbia. D.C. Code § 44-401; D.C. Mun. Regs Title 22, §§ 4400.1,4404.1. To qualify for uncompensated care under this section, a person must:
- Be unable to pay for health care services;
- Have an annual individual or family income that does not exceed 200 percent FPL;
- Lack coverage through either third-party insurance or government program; and
- Request services. D.C. Mun. Regs. Title 22, § 4406.1.
Hospitals obligated to provide uncompensated care must make it available without discrimination on the basis of “race, color, creed, national origin, sex, age, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, political affiliation, physical handicap, source of income, or any other grounds unrelated to an individual's need for the service or the availability of the needed service.” D.C. Mun. Regs. Title 22, § 4400.5.
FINANCING SOURCE: N/A
SERVICES COVERED: N/A
A CON holder must publish notice of its uncompensated care obligation annually in a D.C. newspaper of general circulation. D.C. Mun. Regs. Title 22, § 4405.1.
Under Title 22, Section 4405 of the D.C. Municipal Regulations, each CON holder must post the following notice in plain view in areas that are easily accessible to the public, including admissions, business offices, and the emergency room:
"Under District of Columbia law, this health care provider must make its services available to all people in the community. This health care provider is not allowed to discriminate against a person because of race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, political affiliation, physical handicap, source of income, or place of residence or business, or because a person is covered by a program such as Medicare or Medicaid.
"This health care provider is also required to provide a reasonable volume of services without charge or at a reduced charge to persons unable to pay. Ask the staff if you are eligible to receive services either without charge or at a reduced charge. If you believe that you have been denied services or consideration for treatment without charge or at a reduced charge without a good reason, contact the Admissions or Business Office of this health care provider, and call the State Health Planning and Development Agency through the Citywide Call Center at 202-727-1000.
"If you want to file a complaint, forms are available from the State Health Planning and Development Agency." D.C. Mun. Regs. Title 22, § 4405.2.
The notice must include the facility’s eligibility criteria for uncompensated care. D.C. Mun. Regs. Title 22, § 4405.3. It must be posted in English, Spanish, and any other language spoken by 10 percent or more of the District’s population. D.C. Mun. Regs. Title 22, § 4405.5. The CON holder must communicate the contents of the notice to any person the CON holder has reason to believe cannot read it. D.C. Mun. Regs. Title 22, § 4405.6.
In addition to these posting requirements, CON holders must provide a written copy of this notice to all persons seeking services, whether on their own behalf or on behalf of another person. D.C. Mun. Regs. Title 22, § 4405.7. This written notice must also include information about where in the facility one can request uncompensated care; a statement that the CON holder is required to issue a written determination regarding the application for uncompensated care; and the date or period within which the determination will be made. Id. Unless impractical for emergency reasons, this written notice must be given before providing services. D.C. Mun. Regs. Title 22, § 4405.8. In all circumstances, the CON holder must provide notice no later than when presenting the first bill for services. Id.
Anyone can make a request for uncompensated care. CON holders are permitted to require that, as a condition of receiving uncompensated care, applicants a) provide information “reasonably necessary” to make an eligibility determination; and b) apply for government assistance or third party payer benefits for which they may be eligible. D.C. Mun. Regs. Title 22, § 4408.4(a)-(b).
Upon receiving an applicant’s request, CON holders with uncompensated care obligations must make a determination of eligibility within the following time frames:
- Hospitals must make the determination prior to discharge, if for inpatient services, and within five (5) business days of the request, if for outpatient services;
- Ambulatory surgical facilities must make the determination within five (5) business days of the request for outpatient services;
- All other CON holders must make the determination within ten (10) business days following the date of admission or delivery of services. D.C. Mun. Regs Title 22, § 4408.6.
CON holders must provide a written notice of the determination of eligibility for uncompensated care. This notice may be provided in person, by mail, or, if the applicant cannot be reached by mail, by posting notice in the facility that a determination has been made. D.C. Mun. Regs. Title 22, § 4408.1. The notice of determination must state the following:
- The outcome of the request and any reasons for a denial, if applicable;
- The applicant’s annual individual/family income and family size;
- That there is no charge for the uncompensated care;
- The date of the applicant’s request;
- The date of the CON holder’s eligibility determination; and
- The date(s) of services to which the care applies. D.C. Mun. Regs. Title 22, § 4408.3.
Any person may file a complaint with the Director of SHPDA alleging that a CON holder is not complying with the uncompensated care regulations. D.C. Mun. Regs. Title 22, § 4412.1. The Director must provide notice to the CON holder and must initiate an investigation within 30 days of receipt of the complaint. D.C. Mun. Regs. Title 22, §§ 4412.4, 4412.5.
SHPDA may require hospitals to show that they are complying with their uncompensated care obligations. D.C. Mun. Regs. Title 22, § 4400.3.
Each hospital holding a Certificate of Need must provide an annual report to SHPDA on uncompensated care. D.C. Mun. Regs. Title 22, § 4410.1. The report must include, among other information, the dollar value of the holder’s obligation; the dollar value of uncompensated care it actually provided, broken down into charity care and bad debt; the dollar value of services provided to DC residents; and, if the holder failed to meet its obligation, a reason with documentation for the failure. Id.
PENALTIES FOR NONCOMPLIANCE:
If the Director of SHPDA finds that a CON holder has not complied with these regulations, he or she may take any action authorized by law to secure compliance, including a voluntary agreement, court action, or the denial or withdrawal of the Certificate of Need. D.C. Mun. Regs. Title 22, § 4413.1.
Certificate of Need requirements. A Certificate of Need (CON) is required by any person, partnership, or corporation proposing to:
- Construct, develop, or otherwise establish a new health care facility, health care service, or home health agency.
- Make a capital expenditure of $2.5 million or more in connection with a health service or health facility.
- Make a capital expenditure of $1.5 million or more by a health care facility or by or on behalf of any private group practice of diagnostic radiology or radiation therapy to acquire major medical equipment.
- A single piece of diagnostic or therapeutic equipment which is acquired by lease, purchase, donation, or other comparable arrangement by or on behalf of a physician or group of physicians, or an independent owner or operator of the equipment, and for which the cost or value is in excess of $250,000.
- Relocate beds from one facility to another.
- Redistribute the beds of a health care facility by 10 beds or 10 percent, whichever is less, in any two-year period.
- Offer any health service, which was not offered on a regular basis by the health care facility within the previous 12-month period.
- Increase the number of renal dialysis stations in a facility, or move stations from one facility to another. Acquire an existing health care facility or major medical equipment by purchase, lease, or other arrangement. D.C. Code § 44-406(a).
In order to obtain a Certificate of Need, the proposed owner of a health care facility, or part of a facility, must certify in writing that the facility will provide uncompensated care for five (5) years at a level equal to or greater than the level provided by the facility during the previous two (2) years. D.C. Code §44-406(b)(2)(a). Currently, CON holders are required to provide uncompensated care that is either equal to at least three percent of its operating expenses, not including reimbursement for Medicare and Medicaid, or as contractually obligated to the District of Columbia—whichever standard results in a higher dollar amount. D.C. Code §44-405(a); 22 DCMR 4400.2, 4404.1.