- What are uncompensated services?
Uncompensated Services is the term applied to health services made available at no charge or at reduced charges under Titles VI (Hill-Burton) and XVI of the Public Health Service (PHS) Act to eligible persons unable to pay.
- Who must provide uncompensated services?
All health facilities which received grants, loans or loan guarantees for construction, modernization, or equipment under Titles VI or XVI of the PHS Act, or any assistance supplementary to the title VI or XVI assistance.
- How long does the obligation last?
Facilities which received grants under Title VI are obligated to provide uncompensated services for 20 years from the opening date. Facilities which received loans are obligated until the loan is repaid. These periods of obligation may be shortened or lengthened because of the excess and deficit provisions of the regulations. Facilities which received grant funds under Title XVI are obligated indefinitely.
- What are the requirements for public notice?
A facility must publish notice of its uncompensated services obligation in a local newspaper. The plan can take effect no earlier than 60 days following the date of publication. The notice must contain: 1) a description of the services intended to be provided and how they will be distributed throughout the year; 2) the financial criteria used to make eligibility determinations, including, if applicable, the methodology used to provide services on a discounted basis 3) the dollar amount of uncompensated services to be provided and 4) a statement inviting comment on the plan.
- What are the requirements for Individual Notice?
Each facility must prepare and distribute a notice to each person who is seeking services on behalf of himself or another. The notice must be provided to everyone even if an individual is over income, is seeking services not covered in your published allocation plan, is covered by insurance, or has not made a request for uncompensated services. A facility found in noncompliance with the individual notice requirement is subject to losing all of its uncompensated services credit for the period of noncompliance. The individual notice must: 1) explain that the facility is required by law to provide a reasonable amount of care without or below charge to people who cannot afford care; 2) set forth the criteria the facility uses for determining eligibility for uncompensated services (be sure to include the income figures from the poverty guidelines), the types of services covered in your published allocation plan, and the sliding scale or other method used for Category B and C patients, if applicable; 3) state where in the facility people can request uncompensated services and 4) state that the facility will make a written determination of eligibility within a specified time frames.
- What are the requirements for Posted Notice?
Signs provided by HRSA must be conspicuously posted in your admissions areas, business office, emergency room (if you have one), and in any other areas you believe are appropriate. The signs are in English and Spanish and both must be posted at all times that uncompensated services are available. You must also translate the signs into other languages and post them if 10 percent or more of the population in your service area (based on census reports) speaks other than English or Spanish and make efforts to communicate the contents of the signs to people you believe may not be able to read them.
- What is a request?
A request is any indication that a person is unable to pay for services. At all times that uncompensated services are available, the facility must make a written determination of eligibility in response to each request for uncompensated services.
- When may a request be made?
A request may be made at any time – before, during, or after services are received, including after institution of a collection action.
- What are the time frames for making a determination of eligibility?
All facilities except nursing homes: For requests prior to discharge or prior to receipt of outpatient services, determinations must be made within 2 working days following the request. For requests made after discharge or after receipt of outpatient services, determinations must be made no later than the end of the first full billing cycle following the request. Nursing homes: For requests made prior to admission, determinations must be made within 10 working days of the request, but no later than 2 working days after admission. For requests made after admission, determinations must be made no later than the end of the first full billing cycle following the request.
- Are illegal aliens eligible for Hill-Burton assistance?
Yes. Eligibility is not based on citizenship or residency status.
- What is a substantial compliance review?
A substantial compliance review is conducted by HRSA to determine a facility’s compliance with the uncompensated services regulations. HRSA will contact you when an audit has been scheduled. They will let you know what documentation you must provide to document compliance.
- How long must records be kept?
A facility shall retain the records for three years after submission of the Uncompensated Services Assurance Report or 180 days following the close of HRSA’s assessment investigation, whichever is less.
- What are the compliance alternatives?
Compliance alternatives are designed to accommodate facilities providing significant amounts of uncompensated services.
- How is uncompensated services credit determined?
At least once every 2 years, the Department will conduct a substantial compliance review to determine a facility’s compliance with the uncompensated services regulations. The facility will be contacted regarding the records needed:
a copy of each published notice, including proof of publication date;
a copy of each individual notice used during the period to be assessed, along with a description of the method used for distribution of the individual notice;
written policies and procedures concerning the Hill-Burton program;
supporting documentation for calculating the 3 percent compliances, if applicable, and the allowable credit factors;
log or listing of Hill-Burton accounts and total dollar amounts written off each year supported by ledgers or journals;
patient account information, including the determination of eligibility, income and family size information, and billing information for Hill-Burton approved accounts; for denied accounts, maintain the determination of eligibility, including the reason for denial.
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Frequently Asked Questions
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Hill-Burton Facilities Compliance
42 CFR Part 124, Subpart are the regulations to the Hill-Burton Act. The “Provider’s Guide to the Hill-Burton Uncompensated Services Regulations” provides guidance to grantees on how to operate an uncompensated services program in compliance with the regulations. Some grantees have been approved to operate under a compliance alternative to the hill-Burton regulations. The general Hill-Burton regulations require that grantees provide a specific amount of free or below cost health care services to persons unable to pay. The uncompensated services obligation lasts approximately 20 years for Title VI facilities and for Title XVI facilities in perpetuity.
Program Policy Notices are issued each year to grantees also providing guidance in the operation of their uncompensated services program.
The uncompensated services regulations have been amended several times to provide compliance alternatives for qualified facilities. These alternatives allow for facilities to reduce much of the procedural and reporting requirements. These facilities operate their own programs of discounted health services in lieu of operating under the general Hill-Burton requirements:
- Public Facility Compliance Alternative (PFCA): publicly or quasi-publicly owned and operated facilities. In support of their discounted health services programs, eligible facilities must receive over a 3 year period, an average of 10 percent of their revenues from State and local governments.
- Section 124.515 Compliance Alternative (515): Community Health Centers (CMC), Migrant Health Centers (MHC) and certain National Health Service Corps (NHSC) Sites that are current recipients of funds under Sections 329, 330 and 334 of the Public Health Service Act.
- Charitable Facility Compliance Alternative (CFCA): facilities whose mission and purpose are substantially supported by charitable and state and local governmental entities at an average level for the past 3 years equal to ten percent of total revenues: or which provide all of their services to all persons seeking services with incomes up to double (triple, if nursing home) the poverty guidelines.
- Unrestricted Availability Compliance Alternative (UACA): Title VI facilities which offer all of their services to all eligible individuals who request uncompensated services with incomes up to double (triple, if nursing home) the poverty guidelines.
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Hill-Burton Free and Reduced-Cost Health Care
In 1946, Congress passed a law that gave hospitals, nursing homes and other health facilities grants and loans for construction and modernization. In return, they agreed to provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area. The program stopped providing funds in 1997, but about 140 health care facilities nationwide are still obligated to provide free or reduced-cost care.
Since 1980, more than $6 billion in uncompensated services have been provided to eligible patients through Hill-Burton.
More about Hill-Burton Free or Reduced-Cost Care
You are eligible to apply for Hill-Burton free care if your income is at or below the current Federal Poverty Guidelines. You may be eligible for Hill-Burton reduced-cost care if your income is as much as two times (triple for nursing home care) the HHS Poverty Guidelines. Facilities may require you to provide documentation that verifies your eligibility, such as proof of income.
Care at Hill-Burton obligated facilities is not automatically free or reduced-cost. You must apply at the admissions or business office at an obligated facility and be found eligible to receive free or reduced-cost care. You may apply before or after you receive care — you may even apply after a bill has been sent to a collection agency.
Only facility costs are covered, not your private doctors’ bills.
Some facilities may use different eligibility standards and procedures. They are identified on the Hill-Burton list of obligated facilities as PFCA, CFCA, UACA and 515. Their programs may be called either a free care, charity care, discounted services, indigent care, etc.
Hill-Burton facilities must post a sign in their admissions and business offices and emergency room that notifies the public that free and reduced-cost care is available. When you apply for Hill-Burton care, the obligated facility must provide you with a written statement that tells you what free or reduced-cost care services you will get or why you have been denied.
You may file a complaint with the U.S. Department of Health and Human Services if you believe you have been unfairly denied Hill-Burton free or reduced-cost care. Send complaints to:
Director, Division of Poison Control and Healthcare Facilities
5600 Fishers Lane
Rockville, MD 20857
Our brochure entitled “Free Hospital Care” provides additional information about the Hill-Burton program and instructions for filing an application. It also explains circumstances under which a facility may refuse a request and what is needed to file a complaint, if you feel that you have been unfairly denied free or reduced-cost care.
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Free and reduced-cost health care is available to people who cannot afford to pay at Hill-Burton obligated facilities. These facilities must post a sign in their Admissions Office, Business Office, and Emergency Room advising people of their free and reduced-cost care obligation. The sign must read, “NOTICE Medical Care for Those Who Cannot Afford to Pay. ”
• Hill-Burton assisted facilities include hospitals, nursing homes, and other health care facilities. You can apply at the facility’s Admissions Office or Business Office, before or after care is received and even after bills have been sent for collection.
• Hill-Burton facilities determine which services are provided free of charge or at reduced costs.
• The program only covers facility costs; it does not cover private physician bills.
• Hill-Burton facilities must provide a written Individual Notice that specifies the types of Hill-Burton free and reduced-cost services available and the income criteria. These services are reflected in the facility’s published allocation plan.
Do I Qualify for Free Services?
• To qualify for services, an applicant’s income must fall within the annually published Poverty Guidelines of the U.S. Department of Health and Human Services.
• If your income is at or below the current Poverty Guidelines, facility services may be free. • If your income is more than the current Poverty Guidelines, but is less than double (or in the case of nursing homes less than triple), Hill-Burton facilities may provide services at full charge, reduced charge, or free. The Individual Notice will tell you what medical services and income levels qualify for free care.
How Do I Apply?
• Contact the Hill-Burton Hot Line for a list of obligated facilities.
• Contact the facility’s Admissions Office or Business Office. Ask for an application and a copy of the facility’s Individual Notice. This notice provides information on qualifying income levels, required documentation, where to apply, and the timeframe for the facility to make the eligibility determination.
• The types of documentation that may be required are proof of income to the facility, such as a pay stub and, if applying for Medicaid, Medicare, or some other medical assistance program, a letter of approval or denial.
• These documents must be submitted within a reasonable time after applying for Hill-Burton services.
• When you return the completed application, ask for a Determination of Eligibility. The facility must notify you in writing of its determination of your eligibility for free or reduced-cost services within the timeframes included on the Individual Notice.
Can I Be Denied?
The facility may deny your request if:
• Your income is more than the income levels in the Allocation Plan and as specified in the Individual Notice.
• The facility has given out the required amount of free care as specified in its Allocation Plan.
• The services you request or have received are not covered by the facility’s Allocation Plan as specified in the Individual Notice.
• The services you are requesting are fully covered by Medicare, Medicaid, insurance or another medical assistance program.
• You do not provide the documents the facility requires to verify your eligibility, such as a pay stub
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- What services are covered under the Hill-Burton program?
Each facility chooses which services it will provide at no or reduced cost. The covered services are specified in a notice which is published by the facility and also in a notice provided to all persons seeking services in the facility. Services fully covered by a third-party insurance or a government program (e.g., Medicare and Medicaid) are not eligible for Hill-Burton coverage. However, Hill-Burton may cover services not covered by the government programs.
- Can I receive Hill-Burton assistance to cover my Medicare deductible and coinsurance amounts or Medicaid co-pay and spenddown amounts?
Medicare deductible and coinsurance amounts are not eligible under the program. However, Medicaid co-payment amounts are eligible, except in a long-term care facility. In addition, Medicaid spenddown amounts (the liability a patient must incur before being eligible for Medicaid) are eligible in all Hill-Burton facilities.
- Where can I get Hill-Burton free or reduced cost care?
Hill-Burton obligated facilities are obligated to provide a certain amount of free or reduced-cost health care each year. Obligated facilities may be hospitals, nursing homes, clinics or other types of health care facilities. See the Hill-Burton Obligated Facilities List to find a Hill-Burton obligated facility in your State. You may apply for free or reduced-cost care before or after they are provided at the Admissions Office, Business Office or Patient Accounts Office at the obligated facility.
- Who can receive free or reduced cost care through the Hill-Burton program?
Eligibility for Hill-Burton free or reduced cost care is based on a person’s family size and income. Income is calculated based on your actual income for the last 12 months or your last 3 month’s income times 4, whichever is less. You may qualify if your income falls within the U.S. Department of Health and Human Services poverty guidelines or, at some facilities, if your income is as much as twice (or triple for nursing home services) the poverty guidelines. For complete information on the Hill-Burton program, including the list of facilities obligated to provide it and a link to the poverty guidelines, please see the Hill-Burton Web site.
- What does “income” include?
Gross income (before taxes), interest/dividends earned, and child support payments are examples of income. Assets, food stamps, gifts, loans or one-time insurance payments are examples of items not included as income when considering eligibility. For self-employed people, income is determined after deductions for business expenses. For more specific information, see the Federal poverty guidelines.
- When can I apply for Hill-Burton assistance?
You may apply for Hill-Burton assistance at any time, before or after you receive care. You may even apply after a bill has been sent to a collection agency. If a hospital obtains a court judgment before you applied for Hill-Burton assistance, the solution must be worked out within the judicial system. However, if you applied for Hill-Burton before a judgment was rendered and are found eligible, you will receive Hill-Burton even if a judgment was rendered while you were waiting for a response to your application.
- Is United States citizenship required for Hill-Burton eligibility?
No. However, in order for a person to have a Hill-Burton eligibility determination made, one must have lived in the U.S. for at least 3 months.
- Can I apply for Hill-Burton assistance on behalf of an uninsured relative or friend?
Yes. You can apply for Hill-Burton assistance on behalf of any patient for whom you can provide the information required to establish eligibility, (i.e., you must be able to provide information regarding the patient’s family size and income.)
- Do I have to wait until I am sick before I can apply for Hill-Burton assistance?
Hill-Burton is not health insurance. In order to apply for Hill-Burton assistance you must have already received services or know that you will require a specific service in the near future.
- What are some reasons I could be denied Hill-Burton care?
The facility may deny your request if:
for non-nursing homes, your income is more than the current poverty guidelines, or more than twice the guidelines if specified in the facility’s allocation plan;
for nursing home services, your income is more than the poverty guidelines, or double or triple the guidelines, if specified in the facility’s allocation plan;
the facility has given out its required amount of free care as specified in its allocation plan; the services you requested or received are not covered in the facility’s allocation plan;
the services you requested or received are to be paid by Medicare/Medicaid, insurance or other financial assistance program;
the facility asks you to first apply for Medicaid/Medicare or a financial assistance program, and you do not cooperate;
you do not give the facility requested proof of your income, such as a pay stub.
- What can I do if I have a complaint against a Hill-Burton facility?
If you feel you were unfairly denied free care or reduced cost care, a complaint must be filed in writing to the Central Office. You must include: 1) the name and address of the person making the complaint; 2) the name and location of the facility; and 3) a statement of the actions that the complainant considers to violate the requirements of the Hill-Burton program.
Division of Poison Control and Healthcare Facilities
5600 Fishers Lane
Rockville, Maryland 20857
- What other service obligation does a Hill-Burton facility have?
Under the community service assurance, Hill-Burton facilities are responsible for providing emergency treatment and for treating all persons residing in the service area, regardless of race, color, national origin, creed or Medicare or Medicaid status. This assurance is in effect for the life of the facility. If you feel you were unfairly denied services or discriminated against you should contact the Office for Civil Rights (OCR) at 1-800-368-1019.
- How do I apply for free care?
You should contact the Admissions, Business or Patient Accounts Office at a Hill-Burton obligated facility to find out if you qualify for assistance and whether or not a facility provides the specific services needed.
- How can I find out which facilities in my area are Hill-Burton facilities?
Check our Hill-Burton Obligated Facilities List for a facility in your State. Be aware that although a facility may be listed, you still need to call the facility to be certain that it still has funds available and that the service you desire would be covered.
Updated Apr 2017
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