THE RIGHTS OF THE UNINSURED IN NEW YORK CITY
TRAINING MANUAL
2002
By New York Lawyers for the Public Interest, with input from the Commission on the Public’s Health System. Special thanks to the Commonwealth Fund for its support of this project.
TABLE OF CONTENTS
Preface ...... iv
I. Emergency Medical Services: Getting to the Hospital ...... 1
Supplement I-A New York City Trauma Centers Supplement I-B List of Permanent Hospital Diversion
II. Access at Private and Public Facilities: Patients’ Rights to Emergency Care ...... 13
Supplement II-A Sample Statement of Deficiencies and Plan of Correction for St. Lukes- Roosevelt Hospital
III. Health and Hospitals Corporation: Patients’ Rights at New York City’s Public Hospitals and Clinics ...... 45
Supplement III-A HHC Facility Addresses and Phone Numbers Supplement III-B HHC Patient Relations Offices Supplement III-C New HHC Plus Program Supplement III-D Adult Fee Scale for Outpatient Services Supplement III-E Fee Scale for Ambulatory Surgery Supplement III-F Fee Scale for Inpatient Services Supplement III-G NYS Patients’ Bill of Rights Supplement III-H HHC Executive Order No 29 Supplement III-I Basic Collection Advice for Low-Income People
IV. Hill-Burton Facilities: Patients Rights at Facilities in Receipt of Hill-Burton Funding ...... 87
Supplement IV-A NYC Uncompensated Care Facilities (20 years) Supplement IV-B NYC Uncompensated Care Facilities (Forever) Supplement IV-C Where to Send Complaints Supplement IV-D NYC Community Services Facilities
V. Civil Rights at Public and Private Health Care Facilities . . . . .109
VI. Appendices ...... 115
- ii -
A. New York City District Attorney’s Offices B. HHS Poverty Guidelines (2002) C. Medicaid Financial Eligibility Levels for New York (2001) D. Office of Civil Rights Discrimination Complaint Form E. Community Health Centers F. Federally Qualified Health Centers G. Child Health Plus H. Facilitated Enrollers I. Family Health Plus J. Medicaid K. Medicaid Managed Care L. Medicare M. Medicare Buy-In N. School-Based Health Centers O. COBRA P. EPIC Q. HIV Uninsured Care Programs R. NYS Partnership for Long-Term Care S. Immigrant and Refugee Eligibility for Public Benefits in New York State
VII. Glossary ...... 179
VIII. Endnotes ...... 187
- iii -
PREFACE
Despite its incredible human and financial resources, New York City’s health care system does not adequately provide health services to a large and growing number of its residents. Indeed, the percentage of New Yorkers who are uninsured is significantly higher than the numbers for the state and the nation as a whole, and study after study reveals that the “system” is unprepared or unwilling to deal with them.
Recent changes in the way that governmental agencies are providing benefits to low-income Americans compound the health care problems facing New York City’s most vulnerable residents. Now more than ever New Yorkers must have information about how to access services and the rights of the uninsured. New York Lawyers for the Public Interest, Inc. (NYLPI) and the Commission on the Public’s Health System in New York City (CPHS) launched a collaborative effort to create a manual and training program for community- based advocates on how to overcome obstacles to access in order to help meet this need.
The training manual is intended to provide advocates with information about the laws governing health care, as well as practical ideas on how to overcome obstacles to access. The first five chapters (I-V) provide questions and answers about the laws, rules and regulations governing New York City’s health care delivery system. We focus on the rights of the uninsured to ambulance service, emergency care, and inpatient and outpatient services at both private and public hospitals, paying particular attention to patients’ rights at public hospitals and clinics because it is their mission to provide care regardless of a patient’s ability to pay. While the emphasis of this manual is on the rights of the uninsured, we note here that the laws, rules and regulations also apply to all individuals, regardless of their race, color, national origin, disability or immigration status. The final chapter (VI) is devoted to a series of appendices that provide information on additional resources, including the eligibility criteria for Medicaid and other programs that offer coverage to otherwise uninsured individuals and families, such as Child Health Plus and Family Health Plus.
This is the first revision of the manual and it incorporates the comments and suggestions of many people who have used it since it was first published. The manual is intended for use in conjunction with training to be led by CPHS, and it is to CPHS’s Judy Wessler that NYLPI is indebted first and foremost. Judy is a tireless advocate who has shared her knowledge and experience, provided material for the manual, and given detailed feedback on drafts, and we complete this text with confidence that any errors or omissions will be addressed in the training sessions by our extraordinarily knowledgeable partner in this effort.
- iv -
A number of key individuals contributed to the manual, including NYLPI’s Pauline Yoo, Jyothi Desai, Rose Cuison-Villazor, Denise White, Michael Silverman and Liana Harper and our wondrous interns Jill Lebwohl, Erin Barton, Dimple Abichandani, Josephine Yeh and Aly Stang, as well as CPHS’s Allison Harriott.
Special thanks to the many others at NYLPI and CPHS who also worked on this project, adding materials and insight. Thanks are also due to the individuals at the New York City Health and Hospitals Corporation (HHS), New York City Fire Department, the Health Resources and Services Administration (HRSA), and other government agencies that provided information on their programs and activities. Thanks to Advocates for Children and the Children’s Defense Fund, which were among the many agencies that provided assistance in tracking down forms, numbers and program information.
Much appreciation is due the law firm of Shearman & Sterling for publication of the manual and, especially, to Shearman & Sterling’s Karen Flynn and Bernie Wein, who guided the manual through their able production department.
Of course, we are indebted to all for their contributions, but we feel particular gratitude toward the Commonwealth Fund for its support of this project. We hope that this manual, together with the training program, will provide needed information on the rights of the uninsured to communities across New York City.
Though this is truly a collaborative effort, all responsibility for errors and omissions rests with NYLPI.
Marianne Engelman Lado NYLPI
Contact Information:
Access to Health Care Program Commission on the Public’s New York Lawyers for the Public Health System for New York City Interest, Inc. c/o Ryan Health Center 151 West 30th Street 110 West 97th Street 11th Floor New York, NY 10025 New York, NY 10001 (212) 749-1227 (212) 244-4664 Fax: (212) 749-1189 Fax: (212) 244-4570 E-mail: [email protected] E-mail: [email protected]
- v -
CHAPTER I
Emergency Medical Services: Getting to the Hospital
All persons, without regard to ability to pay, are entitled to emergency medical care. This chapter outlines the rights of patients in need of emergency medical treatment and ambulance service. The statement of policy introducing New York State’s Emergency Medical Services (EMS) law states that “prehospital emergency medical care, the provision of prompt and effective communication among hospitals and safe and effective care and transportation of the sick and injured are essential public health services.”1
Nevertheless, uninsured persons often face obstacles in trying to access these essential public health services. In particular, uninsured patients may face two barriers to emergency care:
· steering — being taken to particular hospitals based on their ability to pay, rather than based on which hospital is closest and has the most appropriate services; and
· diversion — being refused and rerouted inappropriately at the emergency room because a hospital does not want to take on an uninsured patient.
The New York statutes and Fire Department of New York policies are designed to ensure access to at least minimum levels of service to which all people are entitled.
What rights do patients have to pre-hospital emergency medical care?
The Fire Department of New York, which operates the EMS/911 system in New York City, has EMS operating policies that set forth guidelines for EMS operations in New York City. These guidelines apply to both city and private ambulances. According to these policies, ambulance staff shall:2
• Render pre-hospital emergency care as necessary to resuscitate, stabilize, extricate, remove and/or transport the patient.
• Render pre-hospital emergency care if flagged down except when transporting a patient whose status is critical or unstable.
• Take to the patient all equipment necessary to render appropriate care.
- 1 -
• Be responsible for moving and transporting the patient to an appropriate designated receiving hospital with a maximum of safety while continuing all required patient care.
• While transporting individuals with disabilities, ensure that any prostheses, appliances, equipment devices (e.g., wheelchairs) or other aids that the patient requires for mobility are transported to the medical facility along with the patient.
Who operates EMS in New York City?
The Fire Department of New York (FDNY) operates the EMS/911 system in New York City. The Fire Department orders the dispatch of an ambulance when 911 receives an emergency call. According to EMS policy, the dispatcher will send the ambulance that is closest to the scene of the emergency. The ambulance that is dispatched may be either a municipal ambulance or a “voluntary” ambulance. The City operates municipal ambulances. Private hospitals such as St. Vincent’s, Beekman and Beth Israel operate “voluntary” ambulances. These voluntary ambulances are required to follow all rules and procedures that govern municipal ambulances.
How many ambulances serve New York City?
According to preliminary statistics from the Fire Department for 2000, approximately 289 municipal ambulances serve the City each day. Approximately 109 “voluntary” ambulances serve the City each day.
How are ambulances assigned?
Each ambulance receives a “Primary Area of Response” or “PAR” assignment. In effect, ambulances are assigned a street corner and wait for instructions to respond to an emergency.
Can a 911 operator refuse to send an ambulance?
If a caller indicates the need for an ambulance, the dispatcher must send one. The ambulance that is closest to the scene of the emergency is to be sent.
What happens once an ambulance arrives at the scene?
According to New York state law, EMS, including both city and private ambulance staff, must provide a person in need of emergency medical care with medical treatment and care, regardless of the person’s ability to pay.3 In New York City, ambulance personnel may refuse to transport a patient when
- 2 -
the emergency medical technician believes that the individual is not in need of emergency care and receives approval from a physician to decline to transport the individual.4 The purpose of this exception is to eliminate unnecessary runs to the hospital and thereby reduce ambulance waiting time. A patient cannot be rejected under this exception on the basis of his or her ability to pay.
How does EMS determine where to transport the patient?
Fire Department policy requires that a patient be taken to the closest and most appropriate 911 “ambulance destination.”5 As described in more detail below, a medical facility is “appropriate” if it has the capability to treat the patient. For example, a facility with a burn unit might be required for a burn victim.
A person meeting the criteria for care at a specialty referral center— such as a trauma center, which provides high level care for patients who are acutely ill or victims of serious sudden injury, or a burn unit—shall be transported in accordance with applicable operating guide procedures. See Supplement I-A for a list of New York City trauma centers.
Can a patient request to be taken to a facility other than the closest appropriate 911 Ambulance Destination?
Yes. Under the “Ten Minute Rule,” patients in New York City, who request to be taken to a facility other than the closest appropriate facility, can be taken to another hospital as long as they are in stable condition, and it is not more than ten minutes further than the closest 911 ambulance destination.
Under what circumstances can a hospital divert patients?
A hospital can divert patients from its emergency department if it is under a diversion status.
What is diversion?
Diversion refers to the practice of hospitals informing EMS that their emergency rooms are closed and that they therefore cannot accept a certain category of patients (e.g., critical, obstetric, psychiatric, etc.) because of inadequate facilities, overcrowding or temporary understaffing.
What are the types of diversion and when may a hospital be put on a certain type of diversion status?
There are two major types of diversion: temporary and permanent.6 All hospitals on temporary diversion must revert to accepting patients as soon as the facility no longer meets the diversion criteria.7 The maximum duration of a
- 3 -
temporary diversion depends on the category of patients being diverted. If a hospital is on critical or total diversion (described below), the diversion may not exceed four hours without re-authorization.8 Hospitals on any other temporary diversion status must resume accepting patients by the end of the eight-hour shift in which the diversion status was granted, unless there are extenuating circumstances.9
The types of temporary diversion are:
• Critical Patient Diversion: This is a temporary status that enables hospitals to decline any additional critical patients. Critical patients are those with potentially life-threatening conditions requiring emergency medical treatment as quickly as possible.10 Under state law, New York City hospitals only qualify for critical patient diversion when “acceptance of an additional critical patient may endanger the life of that patient or the life of another patient.”11 A hospital may not request critical patient diversion status merely because of a shortage of beds.12
• Total Diversion: Total diversion is a temporary status that enables a hospital to decline any patient due to a major physical plant dysfunction, strike or a catastrophe overwhelming the emergency department.13
• Obstetric Diversion: Obstetric diversion enables a hospital temporarily to decline any obstetric patients due to a lack of obstetric or neonatal beds. The hospital must withdraw this request as soon as a bed is available.14
• Psychiatric Diversion: A hospital may receive a temporary psychiatric diversion when its inpatient psychiatric census exceeds 100%.15
Permanent diversion may be requested by a hospital that lacks in-house services to treat specific types of patients—for example, obstetric or emotionally disturbed persons.16 Permanent diversion is granted indefinitely. See Supplement I-B for a list of permanent hospital diversions.
What rights do patients have when they are being transferred by EMS as a result of a diversion request?
If in the judgment of the ambulance crew, the patient will not survive diversion, it must transport the patient to the closest facility regardless of diversion status.17 Except in such cases, EMS members must comply with the hospital diversion notifications and transport the patient to the closest available and appropriate medical facility that has the capability to treat the patient.18
- 4 -
Whenever a patient is transported to a hospital on diversion status, or transported to a hospital other than the closest, most appropriate hospital, or there is a problem encountered with the acceptance of a patient at a specific hospital, the EMS member must document it on the Ambulance Call Report.19
Must EMS always follow diversion requests?
No. If, in the judgment of the crew, the patient will not survive diversion to the next closest hospital, EMS must disregard the diversion request and take the patient to the closest hospital.
Who oversees the diversion process?
The Emergency Medical Dispatch (EMD) Specialty Desk Operator is responsible for evaluating requests and determining whether the required criteria for diversion have been met.20
The EMS Command Major Chief has discretion to verify the conditions at hospitals that are requesting diversions. The Chief of Emergency Medical Dispatch is responsible for reviewing all diversion requests and Diversion Verification Forms for compliance with appropriate procedures.21 The Chief of Emergency Medical Dispatch also provides a monthly report to the Chief of EMS Command and to the FDNY Medical Director indicating each hospital’s diversion requests, how many were granted and how long each hospital was on diversion for each category. The Chief of EMS Command is responsible for reviewing this monthly diversion report and taking appropriate action as necessary.22
Advocacy Tip: Advocates interested in investigating or confirming a hospital’s diversion status may find it useful to know the chain of command overseeing the diversion process.
Are ambulances from private hospitals required to follow the same EMS rules about steering and diversion?
Yes. But a recent report by City Comptroller Alan Hevesi found that ambulances operated by private hospitals often ignore closer public and private hospitals to deliver patients to their own facilities. These ambulances should be following New York State’s EMS law.
What can patients do if they are diverted or denied ambulance service?
First, patients and their advocates should know their rights and insist on compliance by EMS. In sum, these rights include:
- 5 -
• The right to be taken to the closest and most appropriate 911 ambulance destination.
• The Ten Minute Rule: Under the “Ten Minute Rule,” patients can request to be taken to another hospital if the patient is in stable condition and the other destination is not more than ten minutes further than the closest 911 hospital. Patients may wish to use this “Ten Minute Rule,” for instance, to go to a hospital where they have previously received services or where their health practitioner and medical records are located.
• Sometimes ambulances seek to take patients back to their “home” hospital, but patients have a right to go to the closest and most appropriate 911 ambulance destination.
• The EMS crew must transport a patient to the closest facility regardless of diversion status if the patient will not survive diversion to the next closest hospital.
Individuals who are nonetheless inappropriately diverted or denied emergency services should complain in writing to the New York State Department of Health, EMS Division. The Health Department may decide, on the basis of information provided in a citizen complaint, to pursue sanctions against EMS.23 Possible sanctions include the revocation, suspension, limitation or annulment of an ambulance service’s certificate of operation.24
The complaint should include the date of the incident, what transpired, any identifying information of EMS personnel if available, and the name, address and phone number of the person making the complaint.
Complaints should be sent to:
New York State Department of Health 5 Penn Plaza, 2nd Floor, EMS New York, NY 10001 (212) 268-6632
Advocacy Tip: Individuals may find it helpful to have a copy of their EMS Ambulance Call Report (ACR) in writing up a complaint. For purposes of documentation, all calls made to 911 are recorded and all denials must be reported. In addition, the ambulance staff must fill out a form describing the patient’s condition. Individuals may request a copy of this report by calling the Fire Department of New York at (718) 999-1998.
- 6 -
It is important to encourage individuals to file complaints if they are diverted or denied services in order to create a record of those events. This record can form the basis for improving the system. For example, the Health Department recently investigated a complaint that a Buffalo, New York ambulance service failed to transport an unresponsive patient to the hospital.25 After a hearing, the Health Department decided that the ambulance service’s failure to transport the patient demonstrated an “inability to provide adequate ambulance services in violation of Public Health Law former § 3012(1)(b),” although the Department declined to sanction the ambulance service because of corrective steps it took after the incident.26 This case demonstrates that the Health Department is willing to pursue complaints.
One word of caution: in New York City, it is sometimes legal for an EMT to refuse to transport a patient to the hospital. An EMT may refuse to transport if, upon consultation, a physician determines that the patient is not in need of emergency care or ambulance transportation. But if an EMT were to refuse to transport a patient without following these procedures, she may be guilty of a misdemeanor.27 If you believe these procedures have not been followed, you have two options:
1. You can send a complaint to the Health Department at the above address.
2. You can contact your local District Attorney’s Office. (See Appendix A, Chapter VII, in the back of this manual.) Note that it is the state, and not a private individual, that may bring suit under this law because it is a criminal law. However, private citizens can help enforce the law by alerting state prosecutors of violations.
- 7 -
- 8 -
SUPPLEMENT I-A NEW YORK CITY TRAUMA CENTERS
Bronx
1. Jacobi Medical Center 2. City Hospital 1400 Pelham Parkway South Center at Elmhurst Bronx, NY 10461 79-01 Broadway Elmhurst, NY 11373 2. Lincoln Medical & Mental Health Center 3. Jamaica Hospital 234 East 149th Street 89th Avenue & Van Wyck Bronx, NY 10451 Expressway Jamaica, NY 11418 3. St. Barnabas Health Center 2021 Grand Concourse 4. New York Hospital Bronx, NY 10453 Center of Queens 56-45 Main Street Brooklyn Flushing, NY 11315
1. Brookdale Hospital Medical Manhattan Center 1 Brookdale Plaza 1. Babies & Children’s Hospital # Room 186 Columbia Presbyterian Medical Brooklyn, NY 11212 Center 622 East 168th Street 2. Kings County Hospital Center New York, NY 451 Clarkson Avenue Brooklyn, NY 11203 2. Bellevue Hospital Center East 27th Street & First Avenue 3. Lutheran Medical Center New York, NY 10016 150 55th Street Brooklyn, NY 11220 3. Harlem Hospital Center 506 Lenox Avenue, 11th Floor Queens New York, NY 10037
1. Catholic Medical Center of 4. New York Hospital Brooklyn & Queens 525 East 68th Street Mary Immaculate Hospital New York, NY 10021 Parson’s Manor 86-25 153 Street Jamaica, NY 11432
- 9 -
Staten Island
1. St. Vincent’s Medical Center 5. St. Luke’s/Roosevelt Hospital Richmond Center 355 Bard Avenue Amsterdam Avenue & 114th Staten Island, NY 10310 Street New York, NY 10019 2. Staten Island University Hospital 475 Seaview Avenue 6. St. Vincent’s Hospital and Staten Island, NY 10305 Medical Center of New York 153 West 11th Street New York, NY 10011
- 10 -
SUPPLEMENT I-B PERMANENT HOSPITAL DIVERSIONS
- 11 -
- 12 -
CHAPTER II
Access at Private and Public Facilities: Patients’ Rights to Emergency Care
There are federal and state laws protecting patients who need emergency care. During the past several decades, the denial of emergency services and premature transfers of patients from one hospital to another because the person cannot guarantee payment became an issue of interest to Congress, as well as many state and local governments. The public concern about “patient dumping” led to the passage of an anti-dumping law to make this unethical practice a violation of federal law. Meanwhile, the state legislature in New York passed a state anti-dumping statute that in some ways provides greater protections than its federal counterpart.
EMTALA: Federal Protection of Your Rights at Hospitals
The Emergency Medical Treatment and Active Labor Act (EMTALA) covers all hospitals that accept Medicare and have an emergency room, which includes virtually all hospitals.28
EMTALA guarantees the following rights:
• When an individual comes to the emergency department and a request is made for examination or treatment, the hospital must provide for an appropriate medical screening examination.
• The hospital cannot delay screening a patient order to inquire about ability to pay.
• If it is then determined that an emergency medical condition exists, the hospital must stabilize the patient’s medical condition.
• The hospital may transfer the patient to another facility only under limited circumstances, which are detailed in this chapter.
Hospitals and physicians may be liable for EMTALA violations for: 1) the improper screening of patients; 2) the failure to screen patients; 3) screening a patient differently from other patients perceived to have the same condition; and 4) the improper transfer of a patient prior to stabilization.
- 13 -
Who is protected by EMTALA?
All patients. While EMTALA was passed, in part, to address Congress’ concern over “patient dumping” of indigent patients, EMTALA’s protections are not limited to indigent or uninsured patients. All patients, regardless of economic status, insurance status, race, gender, etc., are protected by EMTALA’s appropriate medical screening requirements.29
What hospitals are bound by EMTALA?
All hospitals that accept Medicare and have emergency departments are subject to the requirements of EMTALA.30 These hospitals are required to adopt and enforce policies to ensure compliance with EMTALA.31 See Supplement II-A for a sample statement of deficiencies and plan of correction for St. Lukes – Roosevelt Hospital.
What is a hospital with an emergency department?
A hospital with an emergency department is one that offers services for emergency medical conditions.32
Does EMTALA apply to physicians?
Yes. EMTALA applies to any physician who provides services at a hospital which is required to comply with EMTALA and who is in a position to examine, treat or transfer individuals presenting themselves at the hospital.33
SCREENING REQUIREMENTS:
Under EMTALA, hospitals are required to provide an “appropriate medical screening examination” to any individual who “comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition.”34
What is “comes to the emergency department”?
There is some conflict over how the language “comes to the emergency department” should be interpreted, as EMTALA does not define the term within the statute. Some courts have held that this requirement is triggered only when a patient comes to the emergency department, and not when s/he enters the hospital via an outpatient department for a pre-arranged appointment,35 is brought directly to the intensive care unit,36 or is admitted directly to the psychiatric ward.37
In contrast, the EMTALA regulations broadly define “comes to the emergency department” as when a patient is on any hospital property,
- 14 -
including the main hospital campus, sidewalks and ambulances—even if the patient is in a hospital-owned ambulance while off hospital property. 38
Advocacy Tip: For advocates’ purposes, assume and argue that “comes to the emergency department” follows the broader definition in the regulations, which is that EMTALA applies when a patient is on any hospital property.
Can a hospital delay screening a patient in order to inquire about ability to pay? No. A hospital subject to the “appropriate medical screening” requirement may not delay the screening in order to ask about the patient’s method of payment or insurance status.39
What is an “Appropriate Medical Screening Examination?”
The medical screening examination is supposed to determine whether the individual has an “emergency medical condition.” Unfortunately, neither the EMTALA statute not its implementing regulations provide a definition of an “appropriate medical examination.”
EMTALA does not require that a patient, in fact, suffer from an emergency medical condition when s/he arrives at the emergency room.40 Rather, EMTALA’s screening provisions require hospitals to treat patients with similar symptoms in the same way. To state a claim under EMTALA, a patient merely needs to show that she was examined differently than other similarly situated patients,41 or patients perceived to have the same medical condition.42
Courts have generally held that a hospital is required to adhere to its own internal screening protocols, not some national or malpractice standard.43 While it is up to the hospital itself to determine what its screening procedures will be, once it has done so, it must apply those procedures to all patients with similar health conditions. Thus, appropriate screening for EMTALA purposes is when the hospital treats the patient in a manner that is consistent with its own screening policies and does not differ from other patients in similar circumstances.44 Individuals who are asked for insurance information and then turned away by an emergency room if they are uninsured, or who are not screened by medical personnel, may have a claim under EMTALA.
- 15 -
Advocacy Tip: Advocates working with patients who received only a cursory examination might want to determine whether the exam was consistent with hospital protocol. This might require an investigation. It is not clear, and courts have not yet ruled, on whether EMTALA requires some minimum standard for screening procedures.
How much deviation from the hospital’s standard policy is required for an EMTALA violation?
There is no uniform answer to the question how much deviation from a hospital’s standard screening procedure would be necessary to constitute an EMTALA violation. Therefore advocates should encourage individuals who feel they have not been appropriately screened to document how they were treated and in what way they believe they were treated differently than others.
A person seeking to show that s/he did not receive an appropriate medical screening examination will have a stronger case if the violations are numerous, serious or related to the question of whether the screening was sufficient to find the emergency medical condition.
What is an “Emergency Medical Condition”?
An individual has an “emergency medical condition”45 when s/he has:
• a medical condition with acute symptoms of sufficient severity, (including severe pain); and
• the absence of immediate medical attention could reasonably be expected to have one of the following consequences:
· serious jeopardy to the health of the individual (or the health of the pregnant woman or her unborn child; or
· serious impairment or dysfunction to bodily functions, an organ or body part.
For a pregnant woman who is having contractions, an “emergency medical condition” also includes:
• inadequate time to transfer a patient safely to another hospital before delivery; or
• a transfer that poses a threat to the health or safety of the woman or the unborn child.
- 16 -
Does EMTALA require hospitals to treat patients who have been screened and who have no emergency medical condition?
No. If a hospital determines that the patient does not have an emergency medical condition, the hospital has no further obligations to treat the patient under EMTALA. If the hospital determines that the patient does have an emergency medical condition, other provisions of EMTALA, including the stabilization or appropriate transfer requirements, may be triggered, as described below.46
AFTER AN EMERGENCY CONDITION HAS BEEN DETERMINED:
Once a hospital has determined that an individual has an emergency medical condition, it must either stabilize the medical condition or transfer the individual in accordance with the requirements in the law.47
What does “stabilize” mean?
The hospital is required to “stabilize” the patient, which means it must provide such medical treatment as may be necessary to assure that no material deterioration of the condition is likely to result from or occur during any transfer of the individual from the facility. Whether there has been a material deterioration of a condition is decided on a case-by-case basis.
• A patient is “stabilized” if the treating physician has determined that the emergency medical condition has been resolved. The treating physician’s determination must be “within reasonable clinical confidence” and, therefore, must be based on reasonable medical judgment. It cannot be an arbitrary decision.
• For a pregnant woman with an emergency medical condition, the hospital must either deliver the baby or make an appropriate transfer. (For discussion of appropriate transfer, see below.) 48
Does a patient have to be admitted via the emergency room in order to receive stabilizing treatment?
No. The stabilization obligation is not dependent on the patient being admitted through the emergency room.49 For example, a hospital must stabilize a patient even if the emergency condition arose in the operating room.50 Similarly, a patient who had been directly admitted by his physician to the hospital for a pre-arranged surgical procedure was not precluded from bringing an EMTALA stabilization claim.51
- 17 -
Are hospitals responsible for stabilizing emergency conditions that they did not detect?
No. Hospitals are only required to stabilize conditions that they actually detect.52 Thus, in order to bring a claim under EMTALA that a hospital violated its duty to stabilize an emergency medical condition, a patient must show that the hospital knew of the emergency medical condition.53 Moreover, courts have held that the patient actually must have an emergency medical condition.54
Are physicians required to provide stabilizing treatment that they believe is medically or ethically inappropriate?
Maybe. In one prominent case, physicians wanted to withhold stabilizing treatment for an anencephalic infant, because the aggressive treatment would not serve any therapeutic or palliative purposes and the state law exempted physicians from having to provide care that they consider medically or ethically inappropriate.55 The court held that despite the physicians’ objections, EMTALA still required them to provide stabilizing treatment.56 Other courts, including the federal courts in the New York area, have not yet ruled on this issue.
What if the patient refuses to consent to treatment?
If an individual refuses examination and treatment that a hospital has offered and the hospital has informed the individual of the risks and benefits of the offered examination and treatment, the hospital is considered to have met its stabilization obligations.57 Under such circumstances, the hospital is required to take all reasonable steps to obtain the written informed consent of the individual (or the person acting on his/her behalf) regarding the refusal of further examination or treatment.58
Is an improper motive required to show that a hospital failed to stabilize a patient under EMTALA?
No. The patient does not need to show that the hospital was motivated by some improper motive, such as race, sex, or economic status.59
How long is the hospital required to “stabilize” a patient?
The stabilization requirement does not extend to longer-term treatment. The stabilization requirement only applies to the immediate aftermath of admitting a patient for emergency treatment.60 Although the amount of time it takes to stabilize patients will vary, EMTALA does not require hospitals to provide treatment outside of an emergency context. Neither does it require the hospital to provide follow-up care.
- 18 -
What is a “transfer”?
A “transfer” is the movement of an individual outside a hospital's facilities at the direction of any person employed by or associated with the hospital. A transfer can include the discharge of a patient. A transfer does not include the movement of any individual who (a) has been declared dead or (b) leaves the facility without the permission of an employee or person associated with the hospital.61
When can a hospital transfer a patient?
A hospital may transfer a patient who has been stabilized. If the hospital has not stabilized the patient, it may transfer only under certain conditions.
When can a hospital transfer an individual who has not been stabilized?
If an individual at a hospital has not been stabilized, the hospital may only transfer the individual if it meets the following conditions:
• the individual (or a legally responsible person acting on the individual's behalf), after being informed of the hospital's obligations under this section and of the risk of transfer, makes a written request to transfer to another medical facility; or
• a physician (or in certain limited circumstances, other medical personnel) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of labor, to the unborn child from effecting the transfer;
AND
• the transfer is an appropriate transfer as described below.62
What is an “Appropriate Transfer”?
An appropriate transfer requires that:
• the transferring hospital provide the medical treatment within its capacity which minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child;
- 19 -
• the receiving facility (i) has available space and qualified personnel for the treatment of the individual and (ii) has agreed to accept transfer of the individual and to provide appropriate medical treatment;
• the transferring hospital send to the receiving facility all medical records (or copies thereof) related to the emergency condition for which the individual is presented available at the time of the transfer; and
• that the transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support during the transfer.63
What if the hospital is not aware of the patient’s emergency medical condition when it transfers the patient?
A hospital must be aware of an emergency medical condition for the restricted transfer provisions to apply.64 In addition, an individual must, in fact, have an “emergency medical condition” in order to be protected under EMTALA’s transfer provisions.65
Do the transfer requirements apply when a person does not come to the emergency room?
Probably. There is disagreement in the courts whether a person needs to have come to the emergency department in order to be protected by EMTALA’s restricted transfer requirements.
Are the hospital’s obligations fulfilled when an unstabilized patient refuses a transfer? Even though medical personnel believe that the benefits of transfer outweigh the costs?
Yes. A hospital is deemed to have met its obligations if the hospital offers to transfer the individual to another medical facility and informs the individual (or a person acting on the individual's behalf) of the risks and benefits to the individual of such transfer, but the individual (or a person acting on the individual's behalf) refuses to consent to the transfer.66 Under these circumstances, the hospital must take all reasonable steps to secure the individual's (or person's) written informed consent to refuse such transfer.67
When must a hospital accept an appropriate transfer?
A participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units) may not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.68
- 20 -
Are staff members of a facility protected by EMTALA if they report a violation of the statute by their employer?
Yes. A participating hospital may not penalize a qualified medical person or physician because s/he refuses to authorize the transfer of an individual with an emergency medical condition that has not been stabilized. Neither can a participating hospital penalize a hospital employee because s/he reports a violation of a requirement of this section.69
ENFORCING EMTALA:
How is the law enforced?
EMTALA can be enforced in three different ways:
1) The government can impose civil money penalties on hospitals70 or physicians71 who violate EMTALA. The government can also terminate a hospital’s Medicare participation agreement72 and exclude a physician from participation in the Medicare program.73 Individuals can complain to the government to start this process.
2) An individual who suffers harm as a result of an EMTALA violation may bring a private lawsuit against a hospital for damages sustained and for appropriate equitable relief against the hospital.74
3) Other medical facilities that suffer direct financial harm as a result of another hospital’s violation of EMTALA are entitled to sue that hospital for damages and appropriate equitable relief.75
How can a patient make a complaint?
An individual may file a complaint about a possible EMTALA violation with the Centers for Medicare and Medicaid Services (CMS) at HHS.76 Complaints should contain the following information: the patient’s name, address and phone number of the complainant and a description of the alleged violation, including the date and time of the incident. Telephone calls are preferred; however, complaints can also be sent to:
HHS HCFA DMSO MSOB Leila Meltzer Lois Suntzenich Federal Building Nurse Consultant Nurse Consultant Attn: Nurse Consultant (212) 264-3852 (212) 264-3492 26 Federal Plaza, Room 3800 New York, NY 10278
- 21 -
Once CMS receives a complaint, it will arrange for the claim to be investigated. If CMS determines that a hospital has negligently violated EMTALA, possible penalties include: imposition of civil monetary penalties and/or termination of a hospital’s Medicare participation agreement. CMS may impose a fine of up to $50,000 per violation ($25,000 for hospitals with fewer than 100 beds) on a hospital.77 CMS also may terminate a hospital’s Medicare participation agreement if it violates EMTALA. The hospital must be provided advance notice of the termination, and may avoid termination if it reaches a settlement agreement with CMS before the termination date.78
The government may impose a fine of up to $50,000 per violation against a physician who is responsible for the examination, treatment, or transfer of an individual in a participating hospital who has been determined to have negligently violated EMTALA.79 If the physician’s violation is “gross and flagrant or is repeated,” CMS may exclude the physician from participation in Medicare and/or any State health care programs.80
What kinds of suits may individuals bring under EMTALA?
Patients can sue a hospital in court for damages and ask a court to require changes in the hospital’s policies or practices, but there is no private cause of action against physicians under EMTALA.81 (Note that individuals may be able to obtain damages from physicians based on medical malpractice under state law.)
Can patients collect any part of any civil penalties CMS collects from a physician for violating EMTALA?
No. Plaintiffs have no right to civil penalties against a physician under EMTALA. Any civil penalties recovered go to the government, not the patient.82
What kinds of suits may other medical facilities bring under EMTALA?
Any medical facility that suffers a financial loss as a direct result of another hospital’s violation of EMTALA may sue that hospital for damages and equitable relief.83 For example, if one hospital transferred patients to another hospital before the patients were stabilized, this might cause a financial loss to the receiving hospital. Even if the receiving hospital elects not to sue the transferring hospital, the receiving hospital must report to CMS or the appropriate state agency “any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition from another hospital in violation of the requirements of [42 C.F.R.] § 489.24(d).”84
- 22 -
The Emergency Medical Services Reform Act: NY State’s Patient Protection
What are the purposes of the anti-dumping law and why do we need it?
In 1983, the New York State legislature enacted the Emergency Medical Services Reform Act (EMSRA), and the Department of Health has since provided regulations, to prevent hospitals from dumping patients requesting emergency medical services, or transferring them based on their perceived inability to pay or lack of insurance. The Act was drafted to prevent unnecessary deaths or disabilities by correcting flagrant abuses in the Emergency Medical Services (EMS) system in New York City.85
The Act now contains provisions that impose criminal sanctions for failure to comply, adding teeth to a statute that previously allowed orders to change policies and practices, not damages. On the other hand, the 1983 Act currently leaves no remedy for money damages available.
How does EMSRA differ from the federal anti-dumping law, EMTALA?
Unlike the federal statute, EMTALA, which imposes a duty on hospitals and physicians only to treat and stabilize patients in need of emergency medical treatment, New York’s EMSRA imposes a further duty to admit patients if such patients are in need of immediate hospitalization.86 Like EMTALA, EMSRA also imposes a duty on hospitals to provide emergency care and treatment to all persons in need of such care (but for purposes of EMSRA, only in cities, such as New York City, with a population of one million or more).87
Furthermore, criminal sanctions against the hospital are available under EMSRA whereas they are not available under federal law.
Patients who are treated at hospitals in New York City are entitled to the protection of both EMTALA and EMSRA, provided the hospital has an emergency room and accepts Medicare.
- 23 -
- 24 -
A COMPARISON OF EMTALA AND EMSRA
EMTALA EMSRA
Federal Law New York State law
Imposes duty on hospitals and Imposes duty on hospitals and physicians to treat and stabilize physicians to treat and stabilize patients who need medical treatment. patients who need medical treatment AND admit patients if they need immediate hospitalization.
Applies to all hospitals that accept Applies to all hospitals in cities in New Medicare and have an emergency York, with a population of 1 million or room. more, that have emergency rooms.
No criminal sanctions available for The District Attorney can prosecute violations. Private individuals can sue hospitals or medical professionals for the hospital, but not the physicians. violations. Private individuals can sue the hospital or its staff in order to stop them from violating EMSRA. In certain cases, the Attorney General can sue the hospital or its staff to stop them from violating EMSRA.
The federal government can collect Plaintiffs cannot collect money money damages from hospitals or damages. physicians. Plaintiffs can also collect money damages, but only from hospitals.
Complaints are sent to the New York Complaints can be filed with the Office of CMS. District Attorney, New York Office of CMS, or the New York Department of Health.
What hospitals are obligated by EMSRA?
Under the statute, both public and private “general hospital[s]” are bound by the requirements of EMSRA. A “general hospital” is defined as a hospital with an emergency room.88 Explicitly excluded from the definition of “general hospital” are residential health care facilities, public health centers,
- 25 -
diagnostic centers, treatment centers, dispensaries and laboratories or central service facilities serving more than one institution.
The state health commissioner may exempt a general hospital from the obligations of the statute if she determines that the particular hospital is structured to provide specialized or limited treatment. The following hospitals have been exempted by the New York State Department of Health from EMSRA:
Calvary Hospital, Inc., Bronx Goldwater Memorial Hospital, Manhattan Coler Hospital, Manhattan Hospital for Joint Diseases, Orthopedic Institute, Inc., Manhattan Hospital for Special Surgery, Manhattan Memorial Hospital for Cancer and Allied Diseases, Manhattan New York Eye and Ear Hospital, Manhattan Rockefeller University Hospital, Manhattan
Who is protected by EMSRA?
While EMSRA was passed to address concerns over dumping of indigent and uninsured patients, its protections extend to “any person” who is in need of emergency medical care, regardless of economic status, insurance status, race, gender, etc.89
EMERGENCY TREATMENT OF NONADMITTED PATIENTS:
When must a hospital provide emergency medical care and treatment to an individual under EMSRA?
Hospitals covered by EMSRA must provide emergency medical care and treatment “to all persons in need of such care and treatment who arrive at the entrance to such hospital.”90 A hospital may not deny emergency treatment to a patient in need of such emergency treatment for any reason.
When is the need for medical care an “emergency”?
EMSRA does not provide a definition of “emergency.” Some New York courts have refused to go beyond the commonly understood meaning of the word “emergency” among medical professionals.91 Other courts have invoked the definition of “emergency” found in another section of New York State law, Public Health Law § 3001(1) to interpret the definition of emergency under EMSRA. Public Health Law § 3001(1) defines “emergency medical service” as a service engaged in providing “initial emergency medical assistance, including, but not limited to, the treatment of trauma, burns, respiratory, circulatory and obstetrical emergencies.”92 One New York court has held that EMSRA “covers
- 26 -
only people who need acute care” and does not establish a right to drug treatment on demand at hospital emergency rooms.93
Can a patient be transferred to another hospital?
Yes, although under very limited circumstances. A patient may be transferred to another hospital only if s/he has been treated and sufficiently stabilized to allow transportation to another facility AND the attending physician decides it is in the best interests of the patient to be transferred. The only circumstances under which it is in the best interests of a patient to be transferred to another hospital are when:
• the hospital where the patient was initially treated and stabilized does not have proper equipment or personnel at hand to deal with the patient’s particular medical emergency; or • all appropriate beds are filled and none are likely to become available within a reasonable time after the patient has been stabilized.94
What procedures must be followed to transfer a patient properly?
EMSRA sets out detailed instructions for what information must be given to the paramedic or emergency medical technician who accompanies the transferred patient in the ambulance. A completed form must be given to the attendant that includes:
1) The patient’s name; 2) The diagnosed condition of the patient; 3) Any treatment administered to the patient; 4) Any medication given to the patient; 5) The name of the physician ordering the transfer; 6) The name of the hospital from which the patient is being transferred; 7) The name of the physician or physicians who is or are willing and authorized to receive the patient at the new location; 8) The name of the hospital or other facility that is to receive the patient; 9) The date and time of transfer; and 10) The signature of the physician ordering the transfer.95
Does EMSRA address the problem of improper diversion or dumping of patients?
Yes. EMSRA forbids hospitals from diverting patients from their emergency rooms, unless the hospital is under an approved diversion status.96 See Chapter I for a discussion of when a hospital may divert patients.
- 27 -
ADMISSION OF PATIENTS IN NEED OF IMMEDIATE HOSPITALIZATION:
When must a hospital admit a patient?
Under EMSRA, a hospital must admit “any person” in need of immediate hospitalization “with all convenient speed.”97 The hospital may not question the patient or any member of his or her family concerning the patient’s insurance status or ability to pay before admitting the patient, provided that the patient or a member of his or her family agrees to supply this information promptly after the patient’s admission.98
Note that the requirement to admit any person in need of immediate hospitalization applies to ALL general hospitals in New York State. But only cities with a population of one million or more must provide emergency treatment, short of hospitalization, to all persons in need of such treatment.
May a hospital refuse to admit a patient because of the patient’s insurance status or inability to pay?
No. Under EMSRA, a hospital must admit all patients in need of immediate hospitalization, regardless of the patient’s ability to pay.99
May a hospital with a facility for providing out-patient emergency care deny treatment to a patient in need of such care?
No. EMSRA was amended in 1976 to require every general hospital that maintains facilities for providing out-patient emergency medical care to provide such care to any person who, in the opinion of a physician, requires it.100
May a hospital transfer a patient to another hospital because the patient is unable to pay for hospitalization?
No.101
After a patient is admitted to the hospital, is s/he responsible for the bill even if s/he can’t pay?
The patient is responsible for paying the hospital bill. However, Medicaid may cover the bill if the patient is eligible, and the hospital must help the patient apply for Medicaid if the patient is not yet enrolled. Furthermore, the patient should inquire whether the hospital offers uncompensated care under the Hill-Burton Act (See Chapter IV).
- 28 -
ENFORCING EMSRA:
Advocacy Tip: Call both the State Department of Health and CMS to file complaints.
What should a patient do if s/he feels her rights have been violated under EMSRA?
Patients may file complaints with the New York State Department of Health. Complaints may be called in or sent to:
New York State Department of Health Metropolitan Region New York City Office 5 Penn Plaza New York, NY 10001-1803 (212) 268-6477
Center for Medicare and Medicaid Services 26 Federal Plaza New York, NY 10278 212-264-3657
Patients who believe that a physician or physician assistant has violated EMSRA may also file a complaint with the New York State Department of Health’s Office of Professional Medical Conduct:
New York State Department of Health Office of Professional Medical Misconduct 433 River Street, Suite 303 Troy, New York 12180-2299 1-800-663-6114 (complaints/inquiries) 518-402-0836 (main number)
Note that the New York State Department of Health sometimes can impose sanctions more severe than the courts, such as suspension of licenses and heavy fines.
Finally, patients may also contact their local District Attorney’s Office about alleged violations of EMSRA. See Appendix A for a list of phone numbers and addresses.
- 29 -
What kinds of claims are available under EMSRA?
EMSRA can be enforced as follows:
1. The District Attorney’s Office may sue a hospital or medical professional for failing to provide emergency care and treatment to someone in need of such care. 2. Private individuals may sue for alleged violations of EMSRA. 3. The Attorney General’s Office may sue for alleged violations of EMSRA.
When will the District Attorney’s Office sue a hospital or medical professional under EMSRA? What are the penalties?
The District Attorney’s Office relies on complaints from private individuals to prosecute EMSRA claims against a hospital or its staff.
A violation of EMSRA is a misdemeanor offense. The District Attorney’s Office may bring criminal proceedings against any of the following parties:
• a general hospital, • a staff member at a hospital, • any person who excludes, obstructs or interferes with the entrance of a patient into a hospital or prevents the patient from being treated.102
Any fines imposed by a court against a hospital or individual go to the State, not private individuals. Any hospital found guilty under EMSRA is subject to a fine no more than $2,000.103 Any individual found guilty under EMSRA is subject to a term of imprisonment up to one year and a fine no more than $2,000.104 Successful prosecutions have been brought in at least two cases since EMSRA was enacted in 1983.105
Where can a private individual sue under EMSRA? What relief may be recovered?
Private individuals may sue in State Supreme Court to stop violations or threatened violations of EMSRA.106 Private individuals may not recover money damages under the Act.107 The only possible relief is an injunction—to prevent a hospital or its staff from denying emergency treatment to individuals in need in the future.
- 30 -
Do patients have to prove that the attending physician or hospital intended to deny them needed care?
No. Proof of intent is not necessary to establish liability. The intent of the attending physician or other hospital employees is irrelevant if the patient was actually in need of emergency treatment. Even if there are no beds available at the time a critically injured patient arrives at the hospital, the hospital cannot refuse to provide emergency treatment to such a patient.108
Under the Act, New York State courts impose “strict liability” on licensed medical professionals. Actual knowledge that the person who is refused emergency medical treatment is actually in need of such treatment is not a necessary element of a violation.109
When can the Attorney General’s Office sue under EMSRA? What relief may be recovered?
Upon the request of the New York Public Health Council or the Commissioner of the New York State Department of Health, the Attorney General’s Office may bring an action on behalf of the People of the State of New York to enjoin any violation under EMSRA. This suit must be brought in State Supreme Court. The only relief possible is an injunction.110
- 31 -
- 32 -
SUPPLEMENT II-A SAMPLE STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION FOR ST. LUKES – ROOSEVELT HOSPITAL .
- 33 -
- 34 -
- 35 -
- 36 -
- 37 -
- 38 -
- 39 -
- 40 -
- 41 -
- 42 -
- 43 -
- 44 -
CHAPTER III
Health and Hospitals Corporation: New York City’s Public Hospitals
What is the Health and Hospitals Corporation?
In 1969, the New York State Legislature created the New York City Health and Hospitals Corporation (“HHC”), to operate the City’s public hospitals. The stated purpose of HHC is:
to deliver high quality and dignified health and medical services and provide health facilities for comprehensive care and treatment for the ill and infirm, both physical and mental, particularly to those who can least afford such services.111
HHC facilities provide a wide range of medical services in a variety of settings, and are located in all five boroughs. Services include preventive care, outpatient, inpatient and post-discharge care, home care, physicians’ care, nursing care, medical care provided by interns or residents-in-training and other para-medical care, ambulance service and bed and board. HHC facilities also provide drugs, biologicals, supplies, appliances, equipment, laboratory services and x-ray, radium and radio-active-isotope therapy.112
Specifically, HHC operates 11 acute care hospitals, 6 diagnostic and treatment centers (D&TCs), 4 long-term care facilities, and many clinics across the five boroughs of New York City. The names and addresses of HHC facilities are attached as Supplement III-A. In addition, the contact information for Patients Relations Offices at HHC is provided in Supplement III-B. Acute care facilities are regular hospitals that provide both inpatient and outpatient care. D&TCs provide routine, preventive and primary care services like immunizations, regular check-ups, treatment of common illnesses like the flu, and some specialty services such as the developmental evaluation clinic at Renaissance, which specializes in diagnosing and treating children with developmental disabilities. Long-term care facilities provide extended care for people who require ongoing medical attention. In addition, HHC runs Communicare Centers, which are community-based facilities that provide preventive and primary care for all members of the family113; Child Health Clinics, which provide primary and preventive care to children and teenagers; free Oral Health Clinics, which provide children and adults routine dental examinations, care, and treatment for gum and teeth disease; HMO subsidiary MetroPlus; and HHC’s Home Health Care Agency, which provides medical care to individuals in their own homes.
- 45 -
In 1999, the New York courts stopped attempts by Mayor Rudolph Giuliani and HHC to turn these public hospitals into private ones. 114 The New York Court of Appeals held that the City could not shirk its statutory duty to provide “comprehensive, quality health care services to the poor and uninsured residents of the City” by transferring the operation of these public hospitals to private entities.115 One court noted that when the legislation creating HHC was passed, both the governor of New York and the mayor of New York City stated that providing health care services was, and would continue to be, government's responsibility.116
Can an HHC facility refuse to treat an uninsured or indigent patient?
No. HHC facilities are required to provide care regardless of ability to pay. This is required by state law, which explains the purpose of HHC: “A system permitting legal, financial and managerial flexibility is required for the provision and delivery of high quality, dignified and comprehensive care and treatment for the ill and infirm, particularly to those who can least afford such services.”117 But patients will receive a bill that they are expected to pay. See below for information regarding HHC’s fee settlement program. See also Supplement III-I for basic collection advice for low-income people.
Private and public hospitals alike cannot question patients requiring emergency treatment about insurance or ability to pay, and they cannot transfer patients requiring emergency treatment to other hospitals because of the inability to guarantee payment.118 (For further discussion of this point, see Chapter II.) They can, of course, ask patients such questions after treatment is given.
With respect to non-emergency treatment, however, private hospitals may turn away legally patients who do not have insurance and who cannot otherwise pay for services. Under state law, HHC facilities may not turn away patients requesting non-emergency treatment because of inability to pay despite the fact that private hospitals also receive hospital funds.119 HHC medical staff nonetheless retain some discretion to determine what procedures are medically indicated.
Will the HHC facility ask for an insurance (including Medicaid, Family Health Plus or Child Health Plus) before a patient sees the doctor? If patients do not have insurance or Medicaid, will the HHC health care provider ask them to pay for service before seeing the doctor?
If the patient is in need of emergency care, the hospital, whether public or private, may not ask for proof of insurance before treating the patient.120 With respect to non-emergency care, HHC hospitals will likely have patients go through “registration” before seeing a doctor. The hospital will ask the patient
- 46 -
about insurance information, and, if appropriate, help the patient apply for Medicaid and/or other benefits for which s/he may be eligible.
Advocacy Tip: If a patient at an HHC facility is asked for payment up front, the patient or advocate should report this to the facility’s Patient Advocate or Ombudsman’s Office. All HHC hospitals have a designated Patient Advocate.
Advocacy Tip: It is helpful for community organizations to develop an ongoing relationship with a staff person at facilities where their clients receive care.
What is the cost of receiving medical care at an HHC facility?
It depends on the service provided and the patient’s financial and health insurance status. Medicaid beneficiaries will receive most services at no cost to them. (See Appendices G, I and J for a description of services covered by Child Health Plus, Family Health Plus and Medicaid, respectively.) Low-income individuals who are not Medicaid-eligible and do not have third-party insurance may get reductions in their bills through HHC’s fee settlement programs, described below. There is no charge for children and young adults up to age 22 receiving ambulatory care. However, there is a charge for medications (see below).
Please note that a few HHC facilities are obligated under the Hill-Burton Act (see Chapter IV) to provide “uncompensated care” to low-income patients. These facilities are listed in Supplement IV-A in italics. The uncompensated care obligation requires covered facilities to provide free or below-cost services to low-income individuals.121 Low-income patients should inquire about their eligibility for Hill-Burton uncompensated care, as well as for HHC’s fee settlement program, described below.
How can I get my bill reduced through HHC's sliding fee scale and fee settlement programs?
HHC facilities are supposed to inform patients of the fact that fees may be reduced based on the patient’s ability to pay. Where HHC fails to inform patients about fee settlement, patients and advocates should request that fees be reduced in accordance with the fee settlement program. HHC requires individuals to apply for Medicaid, Family Health Plus or Child Health Plus or demonstrate their ineligibility for these programs before considering their eligibility for fee settlement. Once HHC has verified that an individual is not eligible, HHC will determine whether the patient’s income is low enough to qualify for fee settlement. The amount by which a qualified patient’s bill will be reduced depends on the patient’s net income, family size and the type of service received, including whether it was an inpatient or outpatient service. For example, a single person with a gross annual income up to $13,290 must pay only $20 for outpatient services. A single person with a gross annual
- 47 -
income up to $22,150 is responsible for paying $60 for the same services. A single person who earns more than $22,151 per year is responsible for the full amount of her bill. HHC has developed different fee scales for different services. See Supplement III-D for the adult fee scale for outpatient services. Supplement III-E is the fee scale for ambulatory surgery services. Supplement III-F is the fee scale for inpatient services.
On November 1, 2002, HHC implemented a program called HHC Plus. Under HHC Plus, HHC will provide ambulatory care coverage for persons who are uninsured and not eligible for other public insurance programs regardless of their immigration status. HHC will cover individuals and childless couples up to 100 percent of the federal poverty level and families with children up to 150 percent of the federal poverty level. Patients whose incomes are above 150 percent of the federal poverty level will be asked to pay $20, $40, or $50 per visit, depending on their income. Patients who meet the income requirement (i.e., 150 percent of federal poverty levels or at the poverty levels if a single individual) but do not qualify on the basis of their immigration status will be nonetheless enrolled in HHC Plus for a period of one year. These patients will be asked to pay $15.00 per visit at any HHC facility. For more information, see Supplement III-C.
Note: While a patient’s application for Medicaid is pending, HHC facilities have discretion to assign the patient to a certain income group for purposes of HHC’s Fee Settlement Program. Of course, HHC ultimately may determine that the patient is not eligible for fee settlement because the individual qualifies for Medicaid.122 If the patient qualifies for Medicaid, Medicaid will pay bills accumulated during the three months preceding the start of coverage. If the patient was receiving treatment at an HHC facility more than three months prior to the start of Medicaid coverage, that treatment will not be paid for by Medicaid, but remains subject to HHC’s Fee Settlement Program.
What if I can’t pay the fee settled amount in full?
Upon request, HHC facilities will offer the patient a contract to pay in installments. This applies even when the bill goes to collection agencies.
What if I still can’t make payments under an installment plan? Will I still be able to get treatment, or will the facility turn me away?
HHC facilities claim never to turn anyone away, regardless of whether the patient is able to pay or not. According to an HHC Hospital public affairs director, an exception to this rule is when the patient belongs to a health maintenance organization (HMO) that does not cover the HHC facility at which the patient is trying to get care. In that case, in non-emergency situations, the patient will need to go to a health care provider approved by the HMO.
- 48 -
The New York State Patients’ Bill of Rights states that public and private medical facilities, including hospitals, health centers, diagnostic centers and treatment centers may not turn away a patient in need of emergency care.123 See Supplement III-G for the New York State Patients’ Bill of Rights.
Of course, when the HHC facility does provide care, patients will later be responsible for the bill, either through their insurance or based on HHC’s sliding fee scale. HHC eventually sends all unpaid bills to a collection agency— even bills of patients whose fees were adjusted through the settlement program—if they are unpaid.124
What if I have third-party insurance, but I am unable to meet my deductible and coinsurance amounts and have uncovered days?
HHC facilities will consider these amounts eligible for fee settlement if the financial determination indicates that the patient is unable to pay.
Are non-citizens eligible for fee settlement?
Yes. HHC should not consider immigration status.
What if my treatment plan requires frequent outpatient visits creating undue financial hardship?
In 1985, HHC adopted a policy known as “Executive Order No. 29” which provides fee adjustments to patients with chronic conditions or mental illnesses for whom prolonged or intense treatments would create “undue financial hardship.”125 See Supplement III-H for a copy of Executive Order No. 29. Under this policy, a patient with a chronic condition may request a “statement of need” from his or her physician, indicating diagnosis, expected length and frequency of treatment. The patient may then meet with the HHC Financial Counseling Office to make an equitable payment arrangement. This arrangement must be approved by the Executive Director’s office and may not last for longer than one year at a time.
Advocacy Tip: Most HHC staff will not know about Executive Order No. 29. The patient or advocate will have to lobby hard for consideration under this policy. Patients may wish to show HHC staff a copy of this policy, reproduced at Supplement III-H.
Are there any services HHC will provide free to uninsured patients?
Yes. HHC provides free well-child care, HIV testing and counseling, chest TB treatment, non-grant-covered family planning and treatment of sexually-transmitted disease to uninsured patients. HHC also has a policy of
- 49 -
providing free services to adolescents seeking confidential reproductive health care. Furthermore, all outpatient services for uninsured children are provided free of charge at HHC facilities.126
Do HHC facilities provide free or reduced price pharmacy services?
Almost all HHC facilities have outpatient pharmacies that will fill prescriptions for their patients, but they charge a “handling fee” for each prescription filled. These handling fees (called administrative fees) historically have varied from pharmacy to pharmacy. In response to community concern about the variation in these charges, HHC has agreed to adopt a uniform policy regarding fees and waivers for medications. The Commission on the Public’s Health System (CPHS), which advocates for the complete elimination of fees for medications in the public system, nevertheless advocated that there be a uniform policy, albeit one that incorporates a sliding fee scale.
Key features of the policy are as follows:
1. $10 administrative handling charge per prescription for uninsured and underinsured patients, up to maximum of $40 per visit;
2. Pharmacies will fill more than four prescriptions per patient per visit, but maximum charge remains $40;
3. Categories of patients who will not be charged any fees for prescriptions: i. Emergency room patients ii. Discharged patients who require medication as a component of their immediate post-discharge care iii. Medicaid and Medicaid Managed Care patients iv. AIDS Drug Assistance Program (ADAP) patients v. Patients with tuberculosis vi. Prenatal Care Assistance Program (PCAP) patients vii. Adolescent patients receiving any form of contraception.
4. It is possible for patients to get a waiver of this fee if they are unable to pay. The patient must see a financial counselor to request the waiver. HHC has $3 million funded by the City Council to pay for these waivers.
- 50 -
5. Additional waivers may be available for patients who demonstrate financial hardship and for patients with chronic diseases. See discussion of Executive Order No. 29 above.
6. For patients who enroll in HHC Plus, the maximum they will have to pay per visit, no matter how many prescriptions they have, is $10.
Advocacy Tip: There are efforts to roll back this policy, but in the meantime, advocates should encourage patients to see a Financial Counselor. There will probably be a long wait to meet with a Financial Counselor.
Advocacy Tip: No patient should leave an HHC facility without necessary medication.
Do I have the right to an interpreter at an HHC facility?
Yes. As is described in Chapter V below, individuals have the right to be treated by HHC facilities (and private health care facilities) without discrimination as to race, color, national origin, sex, religion, sexual orientation, disability, or source of payment. Under federal and state law, public and private facilities must make American Sign Language interpreters available or provide other means to ensure effective communication with both patients and family members who are vision or hearing impaired. Health care facilities must also provide interpreters for patients and family members who are non-English speaking.
According to HHC’s website, HHC provides interpreters at all of its facilities.127 HHC’s website states that “HHC facilities have interpreters in most Asian, Spanish and African dialects, as well as several dozen other languages.” HHC also states that it provides signage and printed materials in multiple languages. Furthermore, HHC states that several of its facilities provide bilingual clinical services. For example, according to HHC’s website, Lincoln Medical and Mental Health Center provides bilingual and bicultural inpatient and outpatient psychiatric services in Spanish and English. Additionally, both Gouverneur Healthcare Services and Elmhurst Hospital Center provide Spanish and Chinese mental health services.
For more information on filing a complaint if a patient believes s/he has been denied an interpreter or discriminated against on the basis of race, color, national, origin or other prohibited grounds, please see Chapter V.
- 51 -
Advocacy Tip: If a patient believes she has been denied an interpreter and/or translated materials in violation of Title VI or the Rehabilitation Act, the patient or advocate can file a complaint with OCR. See Appendix D for a copy of an OCR discrimination complaint form.
Complaints should be sent to:
Michael Carter, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services Region II Jacob Javits Federal Building 26 Federal Plaza, Suite 3312 New York, NY 10278 Voice Phone: (212) 264-3313 FAX: (212) 264-3039 TDD: (212) 264-2355
Furthermore, individuals who feel their rights have been violated under the ADA can contact the Department of Justice:
Disability Rights Section Civil Rights Division U.S. Department of Justice P.O. Box 66738 Washington, D.C. 20035-6738 Voice Phone: (800) 514-0301 TDD: (800) 514-0383
Chapter V below provides additional information on the right to an interpreter, as well as other resources that may be helpful. This includes contact information for the New York State Department of Health where complaints against HHC facilities (and private health care facilities) may also be filed for the facility’s failure to provide interpreters.
May a patient sue an HHC facility for medical malpractice or wrongful death?
Yes. However, parties must follow a number of time requirements. Parties suing for personal injuries must provide an HHC director or officer with a notice of intention to commence a lawsuit within 90 days after such cause of action shall have accrued.128 The suit must be brought within one year and 90 days of the accrual of the cause of action.129 But parties may not bring the suit until 30 days have elapsed since providing an HHC officer or director notice of
- 52 -
the claim.130 (This is intended to give HHC time to respond to the claim without having to go to court.)
Parties suing for wrongful death must provide an HHC director or officer with a notice of intention to commence a lawsuit within 90 days after the appointment of a representative of the decedent’s estate.131 The suit must be brought within two years of the patient’s death.132 But parties may not bring the suit until 30 days have elapsed since providing an HHC officer or director notice of the claim. 133
- 53 -
- 54 -
SUPPLEMENT III-A HHC FACILITY ADDRESSES AND PHONE NUMBERS134
Acute Care Hospitals 9. North Central Bronx Hospital 1. Bellevue Hospital Center 3424 Kossuth Avenue 462 First Avenue Bronx, NY 10467 New York, NY 10016 (718) 519-5000 (212) 562-4141 10. Queens Hospital Center 2. Coney Island Hospital 82-68 164th Street 2601 Ocean Parkway Jamaica, NY 11432 Brooklyn, NY 11235 (718) 883-3000 (718) 616-3000 11. Woodhull Medical and Mental 3. Elmhurst Hospital Center Health Center 79-01 Broadway 760 Broadway Elmhurst, NY 11373 Brooklyn, NY 11206 (718) 334-4000 (718) 963-8000
4. Harlem Hospital Center Diagnostic and Treatment Centers 506 Lenox Avenue 1. Cumberland New York, NY 10037 100 North Portland Avenue (212) 939-1000 Brooklyn, NY 11205 (718) 260-7500 5. Jacobi Medical Center 1400 Pelham Parkway South 2. East New York Bronx, NY 10461 2094 Pitkin Avenue (718) 918-5000 Brooklyn, NY 11207 (718) 240-0400 6. Kings County Hospital Center135 451 Clarkson Avenue 3. Gouverneur Nursing Facility Brooklyn, NY 11203 227 Madison Street (718) 245-3131 New York, NY 10002 (212) 238-7000 7. Lincoln Medical and Mental Health Center 4. Morrisania 234 East 149th Street 1225 Gerard Avenue Bronx, NY 10451 Bronx, NY 10452 (718) 579-5000 (718) 960-2777
8. Metropolitan Hospital Center 5. Renaissance (Sydenham 1901 First Avenue Clinic) New York, NY 10029 215 West 125th Street (212) 423-6262 New York, NY 10027 (212) 932-6500
- 55 -
Birth through 18 (adult services 6. Segundo Ruiz Belvis available) 545 East 142nd Street Bronx, NY 10454 3. Health Center at Tremont (718) 579-4000 1826 Arthur Avenue Bronx, New York 10457 Long-term Care Facilities (718) 918-8700 1. Coler-Goldwater Memorial Birth through 18 years (adult Hospital services available) Franklin D. Roosevelt Island New York, NY 10044 4. Hylan Communicare (212) 318-8000 (Goldwater 2971 Hylan Boulevard Campus) Staten Island, NY 10306 (212) 848-6000 (Coler Campus) (718) 351-6473 Birth through 18 (adult services 2. Gouverneur Nursing Facility and available) Diagnostic & Treatment Center 227 Madison Street 5. Parsons Communicare New York, NY 10002 90-37 Parsons Blvd. (212) 238-7000 Jamaica, NY 11432 (718) 334-6443 3. Sea View Hospital Rehabilitation Birth through 18 (adult services Center and Home available) 460 Brielle Avenue Staten Island, NY 10314 6. Ridgewood Communicare (718) 317-3000 769 Onderdonk Ave. Ridgewood, NY 11385 4. Dr. Susan Smith McKinney (718) 334-6190 Nursing and Rehabilitation Center Birth through 18 (adult services 594 Albany Avenue available) Brooklyn, NY 11203 (718) 245-7000 7. Smith Communicare Health Center Communicare Centers 60 Madison Street 1. Bushwick Communicare New York, NY 10038 335 Central Ave. (212) 346-0500 Brooklyn, NY 11221 Birth through 18 (adult services (718) 573-4853 available) Birth through 18 (adult services available) Child Health Centers 2. Dyckman Family Health Care Center Child Health Centers provide free 176 Nagle Avenue services for children who are New York, NY 10034 uninsured (212) 544-2001
- 56 -
Bronx Birth through 18 1. Daniel Webster Houses 401 East 168th Street 8. Tremont Bronx, NY 10458 1836 Arthur Ave. (718) 538-1982 Bronx, NY 10457 Birth through 18 (718) 918-8700
2. Forest Houses Brooklyn 1005 Tinton Avenue 1. Brevoort Houses Bronx, NY 10456 258 Ralph Ave. (718) 589-1242 Brooklyn, NY 11233 Temporarily closed for (718) 756-1458 renovation; patients referred to Birth through 18 Melrose Child Health Clinic 2. Brownsville 3. Glebe Avenue 259 Bristol Street 2527 Glebe Avenue Brooklyn, NY 11212 Bronx, NY 10461 (718) 495-7263 (718) 792-0100 Birth through 18 Birth through 18 years 3. Crown Heights 4. Health Center at Gunhill 1218 Prospect Place 3450 White Plains Road Brooklyn, NY 11213 Bronx, NY 10467 (718) 735-0561 (718) 918-8850 Birth through 18
5. James Monroe Houses 4. Eleanor Roosevelt Houses 816 Soundview Avenue 388 Pulaski Street Bronx, NY 10472 Brooklyn, NY 11206 (718) 328-4477 (718) 443-6595 Temporarily closed for Birth through 18 renovation; patients referred to Glebe and Tremont Clinics 5. Fifth Avenue 503 Fifth Ave. 6. John Mitchell Houses Brooklyn, NY 11215 185 Willis Avenue (718) 768-4081 Bronx, NY 10454 (718) 292-4235 6. Fort Greene Temporarily closed for 295 Flatbush Ave. Ext. renovation; patients referred to Brooklyn, NY 11201 Melrose Child Health Clinic (718) 643-4467 Birth through 18 7. Melrose Houses 348 East 156th Street 7. Homecrest Bronx, NY 10451 1601 Avenue S (718) 292-2820 Brooklyn, NY 11229
- 57 -
(718) 692-9558 Birth through 18 15. Wyckoff Gardens Houses 266 Wyckoff St. 8. Howard Houses Brooklyn, NY 11217 1620 E. New York Ave. (718) 875-3975 Brooklyn, NY 11212 Birth through 18 (718) 385-3690 Birth through 18 Manhattan 1. Alexander Hamilton Child Health 9. Jonathan Williams Houses Care Center 33 Roebling Street 2690 Eighth Ave. Brooklyn, NY 11211 New York, NY 10030 (718) 387-6407 (212) 862-8002 Birth through 18 Birth through 18
10. Lafayette Houses 2. Baruch Houses 434 DeKalb Ave. 280 Delancey Street Brooklyn, NY 11205 New York, NY 10002 (718) 638-8258 (212) 673-5990 Birth through 18 Birth through 18
11. Sheepshead Bay Houses 3. East Harlem 3525 Nostrand Ave. 158 East 115th Street Brooklyn, NY 11229 New York, NY 10029 (718) 332-3522 (212) 360-5919 Birth through 18 Birth through 18 (temporarily closed for renovation) 4. Manhattanville Child Health Care 12. Sumner Avenue Houses Center 47 Marcus Garvey Blvd. 21 Old Broadway Brooklyn, NY 11206 New York, NY 10027 (718) 456-4700 Temporarily closed for Birth through 18 renovation; patients relocated to St. Nicholas Houses 13. Sutter Avenue 1091 Sutter Avenue Brooklyn, NY 11208 5. Riverside (718) 647-0800 160 West 100th Street Birth through 18 New York, NY 10025 (212) 280-9240 14. Williamsburg Birth through 18 151 Maujer Street Brooklyn, NY 11206 6. St. Nicholas Child Health Care (718) 387-2211 Center Birth through 18 281 West 127th Street
- 58 -
New York, NY 10027 (212) 865-1300 2. St. George Birth through 18 81 Stuyvesant Place Staten Island, NY 10301 7. Washington Heights Child Health (Temporarily closed for Care Center renovation as of June 2000) 600 West 168th Street New York, NY 10032 3. Stapleton (212) 795-0880 111 Canal Street Birth through 18 Staten Island, NY 10304 (718) 390-0712 Queens Birth through 18 1. Astoria (Temporarily Closed) 2-26 31st Ave. Long Island City, NY 11106 Oral Health Clinics (718) 334-6120 1. Washington Heights Health Birth through 18 Center 600 W. 168th St. 2. Corona New York, NY 10032 104-04 Corona Ave. (212) 304-5406 Corona, NY 11377 (718) 334-6100 2. Fort Greene Health Center 295 Flatbush Ave. Ext. 3. Junction Blvd. Brooklyn, NY 11201 34-33 Junction Blvd. (718) 262-5506 Jackson Heights, NY 11372 (718) 334-6150 3. Jamaica Health Center Annex Birth through 18 90-37 Parsons Blvd. Jamaica, NY 11432 4. Woodside Houses (718) 262-5506 50-63 Newtown Road Woodside, NY 11373 4. Bushwick Health Center (718) 334-6140 335 Central Ave. Brooklyn, NY 11221 (718) 573-4958
5. Brownsville Health Center Staten Island 259 Bristol Street 1. Mariner’s Harbor Houses Brooklyn, NY 11212 142 Brabant St. (718) 495-7294 Staten Island, NY 10303 (718) 761-2060 Birth through 18
2. Richmond Health Center 51 Stuyvesant Place
- 59 -
Staten Island, NY 10301 (718) 983-4518
Home Health Care Agency 1. HHC Health and Home Care 230 W. 41st St., 3rd Floor New York, NY 10036 (212) 302-5622
Metro Plus
11 West 42nd St., 2nd floor New York, NY 10036 (212) 597-8600
- 60 -
SUPPLEMENT III – B HHC PATIENT RELATIONS OFFICES’ CONTACT INFORMATION (INFORMATION PROVIDED BY THE NEW YORK IMMIGRATION COALITION)
Bellevue Hospital Center 462 First Avenue, New York, NY 10016 General Information: 212-562-4141
Patient Advocacy: Lynn Lambardi, Director Phone: 212-562-4771
Coler-Coldwater Specialty Hospital and Nursing Facility Roosevelt Island, New York, NY 10044 Coler Campus: 212-848-6000 Goldwater Campus: 212-318-8000
Patient Relations: Anu Iyer, Director Phone: 212-318-4436
Coney Island Hospital 2601 Ocean Parkway, Brooklyn, NY 11235 General Information: 718-616-3000
Patient Relations: Brian Palmer, Director Phone: 718-616-4165
Elmhurst Hospital Center 79-01 Broadway, Elmhurst, NY 11373 General Information: 718-334-4000
Patient Relations: Diana Wasenius, Director Phone: 718-334-3690
Gouverneur Health Care Services 227 Madison Street, New York, NY 10002 General Information: 212-238-7000
Patient Relations: Anu Iyer, Director Phone: 212-318-6054
- 61 -
Harlem Hospital Center 506 Lenox Avenue, New York, NY 10037 General Information: 212-939-1000
Patient Relations: Elizabeth Tate, Director Phone: 212-939-1976
Kings County Hospital Center 541 Clarkson Avenue, Brooklyn, NY 11203 General Information: 718-245-3131
Patient Relations: Ed Taylor, Director Phone: 718-245-7418
Lincoln Medical and Mental Health Center 234 Eugenio Maria de Hostos (149th St.), Bronx, NY 10451 General Information: 718-579-5000
Patient Relations: Gina Tull, Director 718-579-5937/38
Metropolitan Hospital Center 1901 First Avenue, New York, NY 10029 General Information: 212-423-6262
Patient Relations: Morgan Ranezani, Director Phone: 212-423-8105
Queens Hospital Center 82-68 164th Street, Jamaica, NY 11432 General Information: 718-883-3000
Patient Relations: Terry Flexer, Director Phone: 718-883-2222
Sea View Hospital Rehabilitation Center & Home 460 Brielle Avenue, Staten Island, NY 10314 General Information: 718-317-3000
Patient Resident: Jamie Langan, Director Phone: 718-317-3621
- 62 -
Woodhull Medical and Mental Health Center 760 Broadway, Broadway, Brooklyn, NY 11206 General Information: 718-963-8000
Patient Relations: Ivelesse Mendez, Director Phone: 718-963-8465
Current as of: October 22, 2002
- 63 -
- 64 -
SUPPLEMENT III – C
- 65 -
- 66 -
SUPPLEMENT III – D ADULT FEE SCALE FOR OUTPATIENT SERVICES
- 67 -
- 68 -
SUPPLEMENT III – E FEE SCALE FOR AMBULATORY SURGERY
- 69 -
- 70 -
Supplement III - F FEE SCALE FOR INPATIENT SERVICES
.
- 71 -
- 72 -
- 73 -
- 74 -
- 75 -
- 76 -
- 77 -
- 78 -
- 79 -
- 80 -
SUPPLEMENT III-G NEW YORK STATE PATIENTS’ BILL OF RIGHTS136
As a patient in a hospital in New York State, you have the right, consistent with law, to: (1) Understand and use these rights. If for any reason you do not understand or you need help, the hospital must provide assistance, including an interpreter. (2) Receive treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation, or source of payment. (3) Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints. (4) Receive emergency care if you need it. (5) Be informed of the name and position of the doctor who will be in charge of your care in the hospital. (6) Know the names, positions, and functions of any hospital staff involved in your care and refuse their treatment, examination or observation. (7) A no smoking room. (8) Receive complete information about your diagnosis, treatment and prognosis. (9) Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment. (10) Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet. Do Not Resuscitate Orders--A Guide for Patients and Families. (11) Refuse treatment and be told what effect this may have on your health. (12) Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation. (13) Privacy while in the hospital and confidentiality of all information and records regarding your care. (14) Participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge. (15) Review your medical record without charge and obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay. (16) Receive an itemized bill and explanation of all charges. (17) Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response. If you are not satisfied with the hospital's response, you can complain to the New York State Health Department. The hospital must provide you with the Health Department telephone number.
- 81 -
- 82 -
SUPPLEMENT III – H EXECUTIVE ORDER NO. 29
- 83 -
- 84 -
SUPPLEMENT III – I
- 85 -
- 86 -
CHAPTER IV
The Hill-Burton Act: Patients’ Rights at Facilities in Receipt of Hill-Burton Funding
In 1946, Congress enacted Title VI of the Public Health Service Act, commonly known as the Hill-Burton Act, which has as its purpose: “to assist the several states… to furnish adequate hospital, clinic, or similar services to all their people.”137
The law offered states federal grants and loans to build and modernize hospitals, provided the states developed plans to assure that the facilities: 1) “[would] be made available to all persons residing in the territorial area of the [facilities]”; and 2) that “a reasonable volume of services” would be made available to persons unable to pay.138 These two requirements are known respectively as the community service and uncompensated care obligations.139 From 1947 through 1976, the Hill-Burton program awarded over 12,000 grants and loans to 6,643 medical facilities totaling $4.6 billion in grants and $1.5 billion in loans.140
In 1974, Congress enacted replacement legislation known as Title XVI of the Public Health Services Act.141 This new law imposes requirements on Hill- Burton facilities nearly identical to the original. There are two principal differences between the two versions, however: 1) under the new law, facilities that receive Hill-Burton funds are bound by the uncompensated care requirement forever, not just for the 20 years required under the original version; and 2) only a small number of facilities nationwide received funding under the most recent program. From 1976 to 1997, the Hill-Burton program awarded approximately $116 million in grants to 197 projects under Title XVI.142 There are 12 facilities in New York City that received this funding.143
In recent years, Congress has continued the trend of allocating fewer funds for Hill-Burton grants and loans. Still, facilities that received Hill-Burton funds in the past are bound to adhere to the requirements as follows:
• Uncompensated Care: The uncompensated care obligation requires facilities to provide free or below-cost services to low-income individuals. Facilities that received funds under the original program are obligated to provide this free or below-cost care for twenty years. (See Supplement IV-A.) Facilities that received funds after 1976 are obligated to provide uncompensated services forever. (See Supplement IV-B.)
- 87 -
• Community Service: The community service obligation requires facilities to make services available to individuals without discrimination on the basis of race, color, national origin, creed, or any other ground unrelated to the individual’s need for the service or the availability of the needed service in the facility. The community service obligation also requires facilities to make available emergency services without regard to a patient’s ability to pay. Under the Act, facilities may not discriminate against participants in the Medicaid program. But note that the community service obligation does not require facilities to make non-emergency services available to people unable to pay for them. Whereas the duration of the uncompensated care obligation varies depending on whether the facility received funds under the original or the most recent law, all Hill-Burton facilities are bound by the community service obligations forever.
Uncompensated Care Obligations
What facilities must provide uncompensated services under the Hill-Burton Act and for how long?
The Hill-Burton Act requires any facility that received assistance under the Act to construct, modernize, or convert the facility, to provide a reasonable volume of services to indigent patients.144 Supplement IV-A contains a list of facilities that received grants in the early years of the program and thus are obligated to provide uncompensated care for 20 years from the facility’s opening date.145 Supplement IV-B contains a list of facilities that received funding since 1975 and thus are obligated to provide uncompensated services indefinitely.146 (Please note that all of the facilities listed in Supplements A and B are also required to fulfill the community service requirement, which binds forever any facility that received Hill-Burton funds. A discussion of the community service requirement follows this section.)
Certain facilities are permitted to operate their own programs of discounted health services instead of operating under the general Hill-Burton uncompensated care requirements. These facilities are noted in Supplements A and B with an asterisk. Their programs may be called either a free care, a charity care, a discounted services, or an indigent care program. These programs may have different eligibility and financial criteria. There are four categories of facilities that may operate under a compliance alternative:
• Public Health Facility Compliance Alternative: publicly or quasi-publicly owned and operated facilities. Eligible facilities must receive over a three-year period an average of 10 percent of their revenues from state and local governments.147
- 88 -
• Small Annual Obligation Compliance Alternative: facilities with annual compliance level of not more than $10,000.148 • Community Health Centers, Migrant Health Centers, and certain National Health Service Corps Sites Compliance Alternative: Eligible facilities must be current recipients of funds under the Public Health Service Act.149 • Charitable Facility Compliance Alternative: facilities whose mission and purpose are substantially supported by charitable and state and local governmental entities at an average level for the past three years equal to 10 percent of total revenues.150
Facilities that qualify under any of these compliance alternatives have reduced procedural and reporting requirements, thus allowing them to operate their own discounted health services programs.151
What are uncompensated services and how much do they cost?
Each facility chooses what services it will provide under the Hill-Burton uncompensated care requirements.152 Facilities must publish a list of these covered services and provide this notice to all persons seeking services in the facility.153 Services fully covered by third-party insurance or a government program (e.g., Medicare and Medicaid) are not eligible for Hill-Burton coverage.154 However, Hill-Burton may cover services not covered by the government programs.
Private pharmacy and private physician fees are not covered by the Hill- Burton uncompensated care requirement.155
“Uncompensated services” refers to services provided both without cost and at a reduced cost.156 A Hill-Burton facility may charge the patient a partial fee for providing “uncompensated” services.
What level of uncompensated services does a facility have to provide?
Under federal law, facilities must provide a “reasonable volume” of uncompensated services to low-income patients who cannot afford such services.157 What constitutes a “reasonable volume” of services is the lesser of: 1) 10 percent of the Federal assistance received, adjusted for inflation; or 2) 3 percent of the facility’s annual operating costs, minus Medicare or Medicaid reimbursement.158 If in the fiscal year a facility does not meet its annual compliance level, it must provide uncompensated services in an amount sufficient to make up the deficit in subsequent years until the deficit is made up.159 If a facility provides uncompensated services exceeding the annual compliance level in a fiscal year, it may apply the amount of excesses to reduce its annual compliance level in any subsequent fiscal year.160
- 89 -
Who is eligible for uncompensated care?
A patient’s eligibility for uncompensated services is based solely on the income figures in the Federal Poverty Guidelines. See Appendix B, in Chapter seven at the rear of the manual. Persons eligible for uncompensated care fall into one of three categories:
Category A: Facilities are required to provide uncompensated services to patients with incomes up to the poverty level free of charge.161
Category B: Facilities may, but are not required to, provide free or reduced-cost services to persons with incomes up to two times the Poverty Guidelines.162
Category C: Facilities may, but are not required to, provide free or reduced-cost nursing home services to individuals with incomes up to three times the Poverty Guidelines.163 Category C applies to nursing homes only.
How can patients find out if a facility is obligated under the Act?
Whenever uncompensated care is available, facilities must give all patients an individual written notice that explains how to obtain free services, and must make a written eligibility determination for each patient.164 The facility is responsible for making reasonable efforts to communicate the contents of the notice to persons who cannot read it.165 The notice must be provided before service provision, except in cases of emergency, when this may not be practical.166
Before the beginning of the fiscal year, the facility is required to publish notice of its uncompensated services obligation in a newspaper of general circulation in its area.167 This notice should include a plan of how services will be allocated, the amount of uncompensated services available, and if the amount of uncompensated services falls below the compliance level, an explanation.168
Advocacy Tip: Ask each hospital for a copy of the published notice detailing the facility’s uncompensated services obligation.
The facility must post notices supplied by HHS in English and Spanish in appropriate areas of the facility such as admissions areas and business offices.169 These notices should be translated into languages other than English and Spanish if the facility is in a service area where that language is the “usual language of households” of ten percent or more of the population according to the Census Bureau.170 According to an official with HHS, the service area of a New York City facility is the borough in which it is located.171
- 90 -
Advocacy Tip: Go to the hospital and make sure notices are posted.
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 against you 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.172
What must be in the written determinations of eligibility?
A written copy of the determination of eligibility must be provided to the applicant promptly.173 If the patient is eligible, the determination must indicate the following: • that the facility will provide uncompensated services at no charge or a reduced charge; • the date on which services were requested; • the date on which the determination was made; • the applicant’s individual or family income, and family size; and • date of service provision.174
Note: The facility can grant a conditional determination which allows it to do the following as a condition to providing uncompensated services: require information from the applicant to substantiate eligibility; and require the applicant to apply for any benefits under third party insurer or governmental programs to which she could be entitled.175 Conditional determinations must state the conditions under which the applicant will be found eligible.176
A facility must provide to each applicant denied the uncompensated services requested a dated statement of the reasons for denial.177
How long should a determination of eligibility take?
For a determination request made before services are received, facilities other than nursing homes must make a determination of eligibility within two working days following the applicant’s request.178 Nursing homes must make a determination of eligibility within ten working days following a request, but no later than two working days following the date of an applicant’s admission.179
For a determination request made after services are received, all facilities are required to make a determination of eligibility no later than the end of the first full billing cycle following an applicant request made after the
- 91 -
receipt of outpatient services, discharge of inpatient services, or admission for nursing homes.180
What is a facility’s allocation plan and how is it determined?
Facilities obligated to provide uncompensated services under Hill-Burton must adopt a plan that sets out the method by which the facility will distribute its uncompensated services for persons unable to pay.181 The plan must also do the following:
• State the type of available services. • Specify the method for distributing those services in different periods of the year. • State whether Category B, or in the case of nursing homes, Category C persons will be provided uncompensated services, and whether it will be without charge or at a reduced rate. • If reduced-rate services will be made available to persons in Category B, specify the method for reducing charges. • For nursing home facilities only, if services are made available to persons in Category C at a reduced charge, specify the method for reducing charges, provided that it will not result in greater reductions than those for persons in Category B. • Provide that the facility provides uncompensated services to all persons eligible under the plan who request uncompensated services.182
The allocation plan must be published in a newspaper of general circulation in the facility’s service area (in New York City, borough)183 and meet the notice requirements described above. The plan may not take effect earlier than 60 days following the date of publication.184
Under what circumstances may a facility cease providing uncompensated care?
When a facility maintains proper records and determines based on them that it has met its annual compliance level for the fiscal year, it may then cease providing uncompensated services, stop providing individual notices and remove posted notices. The facility may also post an additional notice stating that it has satisfied its obligation for the fiscal year, and when additional uncompensated services will be available.185
How does a patient make a complaint?
Any person may file a complaint with the Secretary of Health and Human Services against a facility that he or she believes has failed to meet its uncompensated care requirements.186 A complaint is considered to be filed with the Secretary on the date that it is received in the Regional Office of the
- 92 -
Center for Medicare and Medicaid Services (CMS).187 (See Supplement IV-C for the address for New York Residents.)
The complaint should include the following information:
• Name and address of complainant or person on whose behalf the complaint is made. • Name and location of the facility. • Date or approximate date on which event occurred. • Statement of actions alleged to have violated the requirements.188
It bears mentioning that the Secretary of HHS is supposed to periodically investigate and assess facilities to determine whether they are complying with the Hill-Burton uncompensated care requirements. 189 By filing a complaint with HHS, patients and advocates can help notify HHS of problem facilities that should be further investigated.
What happens to the complaint once it is filed?
HHS promptly provides a copy of the complaint to the facility.190 When HHS investigates a facility, the facility must provide upon request any information relating to the uncompensated care requirements.191 A facility will be assumed to be out of compliance unless it supplies appropriate documentation.192
HHS will evaluate a number of factors to determine whether the facility was in compliance with its uncompensated care requirements, including the ratio of revenues to expenses and the occupancy rate.193
What happens if HHS finds that the facility is out of compliance?
If HHS finds that a facility is out of compliance, HHS may take any action authorized by the law to secure compliance, including negotiating an agreement or sending a request to the Attorney General to bring an action to compel the facility to comply.194
A facility that is found to be out of compliance must take whatever remedial steps are necessary.195 Remedial actions include provision of uncompensated services to applicants improperly denied, repayment of improperly collected money and other corrective actions ordered by HHS.196 If HHS finds that the facility is in substantial noncompliance, it may disallow all of the uncompensated services claimed in a fiscal year.197 This means that the facility will have to provide a higher level of uncompensated services in the future.
- 93 -
Is there a private right of action for the complainant?
If HHS dismisses a complaint or the Attorney General has not brought an action for compliance within six months from filing, the complainant may bring a private action in court to enforce a facility’s compliance with its obligations under the Hill-Burton Act.198 If HHS determines that it will be unable to issue a decision on a complaint or otherwise take appropriate action, within the six- month period, it may dismiss the complaint without a finding as early as 45 days after the filing of a complaint.199
Can a plaintiff pursue money damages under the Act?
It is unclear. One federal district court has held that private plaintiffs who sue under the Hill-Burton Act may not recover for personal relief or damages, such as relief from hospital bills, and that any relief that may be granted must be prospective in nature.200 Another court has held, however, that retrospective relief is available to plaintiffs who were eligible for, but denied Hill-Burton uncompensated care by a facility.201 The federal courts in New York have not addressed this issue, and thus it is an open question how these courts would rule.
Hill-Burton Community Service Regulations
In addition to the uncompensated care requirements, any facility that has received Hill-Burton funding must abide by the community service regulations. These regulations bind facilities to provide medical care to individuals in the community without regard to “race, color, national origin, creed, or any other ground unrelated to an individual’s need for the service or the availability of the needed service in the facility.”202 They also prohibit discrimination against participants in a governmental third-party payor program such as Medicaid or Medicare.
Although this may not mean the hospital has to treat Medicaid patients in exactly the same way as privately insured patients, it does mean that a facility would need a legitimate reason for any differences in treatment. So, for example, it may be legal for a hospital to create a special high-cost unit with special benefits, though Medicaid patients would be excluded, but it might run afoul of the law to separate Medicaid patients on particular wards, unless the hospital has a persuasive legitimate reason for the differences in treatment.
- 94 -
What is the difference between the uncompensated care obligation and the community service obligation under the Hill-Burton Act?
The Hill-Burton uncompensated care requirement provides the right to free or discounted medical care. It lasts for twenty years for Title VI facilities or indefinitely for Title XVI facilities. The community service obligation establishes the right to treatment, but does not pay patients’ bills. It lasts forever for all Hill-Burton facilities.
What facilities are subject to the community service regulations?
The community service regulations apply to any recipient of Federal assistance under Title VI or XVI of the Public Health Service Act (Hill-Burton funding).203 See Supplement IV-D for a list of such obligated facilities in New York City.
A Hill-Burton facility must post notices in English and Spanish informing the public of its community service obligations. If ten percent or more of the households in the service area (in New York City, borough)204 usually speak a language other than English or Spanish, the facility must translate the notice into that language and post it as well.205
How long does the community service obligation last?
Obligated facilities are forever bound to fulfill the community service regulations, unless they request a waiver from CMS.
Who is entitled to nondiscriminatory treatment under the community service requirements?
Facilities are obligated to provide this nondiscriminatory treatment only to individuals who reside (and in some cases, work) in the facility’s service area.206 In New York City, the service area of a facility is the borough in which it is located.207
What do the community service obligations require of facilities?
Obligated facilities must make available the services provided in the facility to all persons in the service area “without discrimination on the ground of race, color, national origin, creed, or any other ground unrelated to an individual’s need for the service or the availability of the needed service in the facility.”208
- 95 -
The regulations also specify that facilities may not discriminate because an individual receives Medicare, Medicaid, or a state health insurance program.209
Facilities also are prohibited from adopting admissions policies that have the effect of excluding persons on prohibited grounds. For example, if a facility implemented a policy or practice of admitting only those patients who are referred by physicians with staff privileges at the facility and this had the effect of excluding from the facility persons who reside in the community since they did not have a private family doctor with staff privileges at the facility, the facility would be violating its community service obligations. Such a facility could abolish the staff physician admissions policy or make other arrangements, such as:
(i) Authorizing the individual’s physician, if licensed and otherwise qualified, to treat the patient at the facility even though the physician does not have staff privileges at the facility; (ii) For those patients who have no physician, obtaining the voluntary agreement of physicians with staff privileges at the facility to accept referrals of such patients, perhaps on a rotating basis.210
Advocacy Tip: This last provision may provide community groups concerned about lack of access to a neighborhood facility a point of leverage. If a barrier to access for community residents can be identified, it might be challenged as violating the community service obligation.
Are facilities required under the Hill-Burton community service obligations to provide services to individuals who cannot pay for them?
It depends. Facilities must provide emergency services to all individuals within the community without regard to ability to pay.211 However, in most cases, facilities may deny non-emergency services to individuals who cannot pay for them.212 The only exception to this rule is when the facility continues to be bound by the uncompensated care requirements and the individual is required to be provided this uncompensated care.213
Once having provided emergency services, a facility is under no obligation to keep a patient whose medical condition has improved. A facility may discharge such a person or may transfer him or her to another facility when the appropriate medical personnel determine that discharge or transfer will not subject the person to a substantial risk of deterioration.214
- 96 -
How can a patient make a complaint about a facility’s failure to abide by the community service requirements?
Individuals have two options for filing complaints about violations of the community service requirements:
1. Follow the procedures described above for complaining about breaches of the uncompensated care requirements.215 2. File a complaint with the Office of Civil Rights (OCR). OCR has jurisdiction to investigate complaints alleging that a Hill-Burton facility has failed to comply with the community service requirements. (But note that OCR is not responsible for investigating complaints under the uncompensated care requirements).
How do I file a complaint with OCR?
Any person may file a complaint with OCR against a facility that she or he believes has failed to comply with the community service requirements.216 See Appendix D for a copy of an OCR discrimination complaint form.
The complaint should include the following information:
• Your name, address and telephone number. You must sign your name. (If you are filing a complaint on someone’s behalf, include your name, address, telephone number, and statement of your relationship to the individual, e.g., spouse, attorney, friend). • Name and address of the facility you believe discriminated against you. • How, why and when you believe you were discriminated against. • Any other relevant information.
You can send your complaint or completed complaint form to the OCR Regional Office (see Supplement IV-C) or to the Washington, D.C. headquarters at:
Director Office for Civil Rights U.S. Department of Health and Human Services Room 509 F HHH Building 200 Independence Avenue S.S. Washington, D.C. 20201
What happens to the complaint once it is filed with OCR?
OCR staff will review the complaint to determine whether it raises issues covered by the community service provisions of the Hill-Burton Act. If your
- 97 -
complaint raises covered issues, OCR will conduct an investigation. If discrimination is found, OCR will negotiate with the institution to voluntarily correct the discriminatory action. If negotiations are unsuccessful, OCR may initiate enforcement proceedings to assure nondiscrimination.217
Is a private right of action available under the community service requirements?
If the Secretary of HHS dismisses a complaint or the Attorney General has not brought an action for compliance within six months from filing, the complainant may bring a private action to effectuate compliance with the community service obligations.218 If the Secretary determines that she will be unable to issue a decision on a complaint or otherwise take appropriate action within the six-month period, she may dismiss the complaint without a finding as early as 45 days after the filing of a complaint.219
Can a plaintiff pursue money damages under the Act?
It is unclear. No court has reached the issue of whether personal relief is available pursuant to a private suit under Hill-Burton’s community service requirements. An individual can, however, go to court to seek injunctive relief—that is, to ask a court to require that a facility change a policy or practice so it will be in compliance with the law.
- 98 -
SUPPLEMENT IV-A List of New York City Facilities With a Continuing Obligation to Provide Uncompensated Care under Hill- Burton for 20 Years (Title VI facilities)220
Bronx 1. Calvary Hospital 1740 Eastchester Road Bronx, NY 10461 (212) 863-6900 General Hospital
2. Claremont Family CC 264 East 174th Street Bronx, NY 10457 (718) 299-6910 Outpatient Facility
Brooklyn 1. Catholic MC/St. Mary’s Hospital 170 Buffalo Avenue Brooklyn, NY 11213 (718) 774-3600 General Hospital
2. Interfaith Medical Center # 1545 Atlantic Avenue Brooklyn, NY 11213 (718) 935-7000
3. Wyckoff Heights Medical Center 374 Stockholm Street Brooklyn, NY 11237 (718) 963-7102 General Hospital
Note: # The facility includes multiple medical buildings.
- 99 -
- 100 -
SUPPLEMENT IV-B List of New York City Facilities Obligated to Provide Uncompensated Care under Hill-Burton in Perpetuity (Title XVI facilities)221
Bronx (212) 848-6027 1. Bronx-Lebanon Hospital Center 1265 Fulton Avenue 2. Goldwater Memorial Hospital * Bronx, NY 10456 Franklin D. Roosevelt Island (718) 590-1800 New York, NY 10044 Nursing Home (212) 750-5980 Nursing Home 2. Morris Heights Health Center * 85 West Burnside Avenue 3. Harlem Hospital Center * Bronx, NY 10453 506 Lenox Avenue Outpatient Facility New York, NY 10037 (212) 939-1000 Brooklyn General Hospital 1. Bushwick Clinic 1149 Myrtle Avenue 4. Highbridge-Woodycrest Brooklyn, NY 11210 936 Woodycrest Avenue (718) 260-2968 Bronx, NY 10452 Outpatient Facility (718) 293-3200 Nursing Home 2. Kings County Hospital Center 451 Clarkson Avenue 5. Rivington Health Care Facility Brooklyn, NY 11203 45 Rivington Street (718) 245-3131 New York, NY 10002 (212) 539-6450 3. Lutheran Medical Center Nursing Home 150 – 55th Street Brooklyn, NY 11220 6. St. Luke’s/Roosevelt Hospital # (718) 630-7000 1111 Amsterdam Avenue General Hospital New York, NY 10025 (212) 523-4000 4. Sunset Park Family HC * General Hospital 150 55th Street Notes: Brooklyn, NY 11220 * These facilities are certified under a compliance alternative. Their programs (718) 630-7000 may be called either a free care, a charity Outpatient Facility care, a discounted services, or an indigent care program, etc. These programs may Manhattan have different eligibility and financial 1. Coler Memorial Hospital * criteria.
Franklin D. Roosevelt Island # The facility includes multiple New York, NY 10044 medical buildings.
- 101 -
- 102 -
SUPPLEMENT IV-C WHERE TO SEND HILL-BURTON COMPLAINTS
Address to which complaints regarding the Uncompensated Care Obligation of the Hill-Burton Act should be sent:
Center for Medicare and Medicaid Services (CMS) Regional Administrator 26 Federal Plaza, Room 3811 New York, NY 10278 (212) 264-4488
Source: http://www.hcfa.gov/regions/roinfo.htm
Address to which complaints regarding the Community Service Obligation of the Hill-Burton Act should be sent:
Office for Civil Rights U.S. Department of Health and Human Services Region II Michael Carter, Regional Manager Jacob Javits Federal Building 26 Federal Plaza—Suite 3312 New York, NY 10278 Voice Phone (212) 264-3313 FAX (212) 264-3039 TDD (212) 264-2355
See Appendix D for a copy of an OCR discrimination complaint form.
- 103 -
- 104 -
SUPPLEMENT IV-D List of New York City Facilities Obligated to Provide Community Service under Hill-Burton222
Bronx 11. Morris Heights Health Center 1. Altro Workshops 85 West Burnside Avenue 3600 Jerome Ave. Bronx, NY 10453 Bronx, NY 10467 Outpatient Facility
2. Beth Abraham Home 12. Our Lady of Mercy Medical 612 Allerton Ave. Center Bronx, NY 10467 600 East 233rd St. New York, NY 10466 3. Bronx Lebanon Hospital 1265 Fulton Ave. 13. St. Patricks Home Bronx, NY 10456 66 Van Cortland Place New York, NY 10462 4. Bronx Municipal Hospital Pelham Parkway Brooklyn New York, NY 10461 1. Brooklyn Caledonian Hospital 121 DeKalb St. 5. Calvary Hospital Brooklyn, NY 11201 1740 Eastchester Rd. Bronx, NY 10461 2. Bushwick Clinic 1149 Myrtle Ave. 6. Claremont Family Center Brooklyn, NY 11210 195-199 Mt. Eden Pk. Bronx, NY 10417 3. Catholic Medical Center/St. Mary’s Hospital 7. Einstein-Weiler Hospital 170 Buffalo Ave. 1825 Eastchester Rd. Brooklyn, NY 11213 New York, NY 10461 4. Interfaith Medical Center 8. Highbridge-Woodycrest 1545 Atlantic Ave. 936 Woodycrest Ave. Brooklyn, NY 11213 Bronx, NY 10452 5. Jewish Hospital Medical Center 9. Lincoln Medical Center 555 Prospect Ave. 234 East 149th St. Brooklyn, NY 11238 Bronx, NY 10453 6. Kings County Hospital Center 10. Montefiore Hospital/Moses 451 Clarkson Ave. 111 East 210th St. Brooklyn, NY 11203 Bronx, NY 10467
- 105 -
7. League School 6. Harlem Hospital Center 567 Kingston Ave. 506 Lenox Ave. Brooklyn, NY 11203 New York, NY 10037
8. Lutheran Medical Center 7. ICD International Center 150-55th St. Disabled Brooklyn, NY 11220 340 E. 24th St. New York, NY 10010 9. Maimonides Medical Center 4802 Tenth Ave. 8. Lenox Hill Hospital Brooklyn, NY 11219 100 East 77th St. New York, NY 10021 10. Methodist Hospital 506-6th Ave. 9. Mount Sinai Hospital Brooklyn, NY 11215 100th Street & New York, NY 10029 11. Sunset Park Family Health Clinic 150 55th Street 10. New York University Medical Brooklyn, NY 11220 Center 560 First Ave. 12. Wyckoff Heights Medical Center New York, NY 10016 374 Stockholm St. Brooklyn, NY 11237 11. Northern Disp City NY 165 Waverly Place Manhattan New York, NY 10014 1. Bailey House 178-180 Christopher St. 12. Presbyterian Hospital New York, NY 10014 622 W. 168th St. New York, NY 10032 2. Beth Israel Medical Center 10 Nathan D. Perlm 13. Rivington Health Care Facility New York, NY 10003 49 Rivington St. New York, NY 10002 3. Cabrini Medical Care/Support 215 E. 21st St. 14. Roosevelt Hospital New York, NY 10003 428 W. 59th St. New York, NY 10019 4. Coler Memorial Hospital Franklin D. Roosevelt Island 15. St. Luke’s/Roosevelt Hospital New York, NY 10044 1111 Amsterdam Avenue New York, NY 10025 5. Goldwater Memorial Hospital Franklin D. Roosevelt Island 16. St. Vincent’s New York, NY 10044 153 W. 11th Street New York, NY 10011
- 106 -
17. T.C. Cooke Health Care Center 2. Staten Island University Hospital 1249 Fifth Ave. North New York, NY 10029 475 Seaview Ave. Staten Island, NY 10305 Queens 1. Catholic Medical Center St. 3. Staten Island University Hospital Johns South 90 02 Queens Blvd. 375 Sequine Ave. Elmhurst, NY 11373 Staten Island, NY 10309
2. Flushing Hospital Medical Center 45th Avenue Flushing, NY 11355
3. Jamaica Hospital Van Wyck Expressway Jamaica, NY 11418
4. Mary Immaculate Hospital 152-11 89th Ave. Jamaica, NY 11432
5. N.Y. Hospital Medical Center- Queens Main St. and Booth Flushing, NY 11355
6. Peninsula General Hospital 51-15 Beach Channel Rockaway Beach, NY 11691
7. Queens General Hospital 82-68 164th St. Jamaica, NY 11432
8. St. Joseph’s Hospital 327 Beach 19th St. Far Rockaway, NY 11691
Staten Island 1. St. Vincent’s Medical Center 355 Bard Ave. Staten Island, NY 10310
- 107 -
- 108 -
CHAPTER V
CIVIL RIGHTS AT PUBLIC AND PRIVATE HEALTH CARE FACILITIES
Various federal, state, and local laws prohibit discrimination by health care facilities—whether public or private—on the basis of race, color, ethnicity, national origin, sex, religion, sexual orientation, disability, and/or source of payment. These civil rights laws also require medical facilities to provide interpreters to non-English speakers and patients with disabilities. This section provides basic information about these civil rights.
Do I have the right to an interpreter at a healthcare facility?
Yes. Under New York State’s Patients’ Bill of Rights, individuals have the right to “treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation, or source of payment” at both public and private medical facilities, including hospitals, health centers, diagnostic centers, treatment centers, dental clinics, rehabilitation centers, and nursing homes.223 Please refer to Supplement III-G for specific provisions of the Patients’ Bill of Rights.
These facilities must “manage a resource of skilled interpreters and persons skilled in communicating with vision and hearing impaired individuals and shall provide translations/transcriptions of significant hospital forms, instructions and information in order to provide effective visual, oral and written communication with all persons receiving treatment.”224 In general, interpreters for individuals with hearing and visual impairments must be available to patients in inpatient and outpatient settings within 20 minutes, and within 10 minutes for patients in emergency settings.225
Interpreter services must also be “regularly available” for non-English speaking groups comprising more than one percent of the total hospital service area population.226
Advocacy Tip: Community organizations may have to set up meetings with hospital administrators to ensure that these requirements are being met.
Interpreters should be made available to ensure effective communication with both patients and family members. In addition, hospital forms must be available for non-English speaking groups. If interpreters are needed, but the facility does not make them available, see the social worker or
- 109 -
hospital administrators and complaints can also be made to hospital administrators. As detailed below, patients and their families can also consider filing a complaint with the Federal Office for Civil Rights, the New York State Department of Health, the Health Bureau of the state Attorney General’s office or with other administrative agencies.
Various federal laws also obligate medical facilities to provide interpreters to non-English speakers and patients with disabilities. Title VI of the Civil Rights Act of 1964 states that “[n]o person in the United States shall on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”227 Title VI has been interpreted to require health care facilities that receive Federal funds to provide “meaningful access” to health care programs and services.228 The Office for Civil Rights (“OCR”), which enforces Title VI, has not established specific requirements for when a facility must provide an interpreter and translate written materials, but rather makes case-by-case determinations as to whether a facility has complied with Title VI.229 OCR encourages medical facilities to: 1) assess their language needs; 2) develop a comprehensive written policy on language access; 3) train staff to carry out the facility’s policy; and 4) monitor the language program to ensure that non-English speakers have meaningful access to hospital services.230
In addition, New York City requires the “provision of interpretation services for non-English speaking residents in all hospital emergency rooms located in New York City.”231
Advocacy Tip: If a patient believes s/he has been denied an interpreter and/or translated materials in violation of Title VI or the Rehabilitation Act, the patient or advocate can file a complaint with OCR. See Appendix D for a copy of an OCR discrimination complaint form.
Complaints should be sent to: Office for Civil Rights U.S. Department of Health and Human Services Region II Michael Carter, Regional Manager Jacob Javits Federal Building 26 Federal Plaza-Suite 3312 New York, NY 10278 Voice Phone: (212) 264-3313 FAX: (212) 264-3039 TDD: (212) 264-2355
Complaints can also be sent to:
- 110 -
New York State Department of Health Metropolitan Region
New York City Office 5 Penn Plaza New York, NY 10001-1803 (212) 268-6477
Do individuals with disabilities also have the right to effective communication?
Yes. The federal Americans with Disabilities Act (ADA) and other federal laws provide similar prohibitions against discrimination on the basis of disability and require entities to provide language assistance such as sign language interpreters for people with hearing impairments and alternative format publications for individuals with visual impairments.232 Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the basis of disability by recipients of federal financial assistance, including hospitals.233 Facilities have an obligation to ensure effective communication with both patients and family members.
Furthermore, in addition to sending complaints to the office for Civil Rights and the New York State Department of Health, individuals who feel their rights have been violated under the ADA can contact the Department of Justice:
Disability Rights Section Civil Rights Division U.S. Department of Justice P.O. Box 66738 Washington, D.C. 20035-6738 Voice: (800) 514-0301 TDD: (800) 514-0383
New York Lawyers for the Public Interest, Inc. 151 West 30th Street 11th Floor New York, NY 10001 (212) 244-4664
Puerto Rican Legal Defense & Education Fund 99 Hudson Street New York, NY 10013 (212) 219-3360
- 111 - Asian American Legal Defense & Education Fund 99 Hudson Street New York, NY 10013 (212) 966-5932
How do I complain about the care or service I have received at a public or private healthcare facility?
The New York State Patients’ Bill of Rights describes grievance procedures that apply to both public and private medical facilities, including hospitals, health centers, diagnostic centers, treatment centers, dental clinics, rehabilitation centers, and nursing homes.234 (See Supplement III-G.) Under the Patients’ Bill of Rights, if an individual is dissatisfied with the care and/or services s/he has received, s/he has the right to complain to the facility.235
The hospital must investigate the complaint and, if requested by the patient, provide a written response.236 If the patient is not satisfied with the facility’s response, the patient may complain to the New York State Department of Health’s Office of Health Systems Management.237 The local area office of the Health Department is (212) 268-6476.
Patients may complain to the Health Department orally or in writing. Either way, patients will receive written acknowledgment of their complaint. The Health Department will make an investigation of all complaints. At the completion of the investigation, the Health Department will inform the complainant whether it has found any “deficiencies.” If the Department determines that the medical facility has not been deficient, the patient has the right to appeal by filing another complaint. The Health Department will then take a second look at the complaint. If the Health Department responds with a second no deficiency finding, the patient may appeal again. The Health Department will hire an independent consultant to perform this third review.238
In addition to filing complaints with the Health Department, patients may also contact the New York State Attorney General’s Health Care Bureau. They can be reached at (518) 474-8376. Patients and advocates may also call the Attorney General’s Consumer Complaint Hotline at (800) 771-7755. (Be warned that it may be difficult to reach a human being using the (800) number. Patients and advocates are likely to have better luck calling the Albany number.)
Please note that patients in a long-term care facility should direct complaints to the state long-term care ombudsman.239 The address is:
- 112 -
Faith E. Fish FAX: (518) 474-7761 State Long-Term Care Ombudsman OFFICE FOR THE AGING 2 Empire State Plaza, Agency Bldg. #2 Albany, NY 12223-0001 (518) 474-0108
- 113 -
- 114 -
CHAPTER VI
APPENDIX A NEW YORK DISTRICT ATTORNEYS’ OFFICES
1. Bronx County District Attorney’s Office 198 East 161st Street Bronx, NY 10451 (718) 590-2000
2. Kings County District Attorney’s Office 350 Jay Street Brooklyn, NY 11201 (718) 250-2000
3. Manhattan County District Attorney’s Office 1 Hogan Place New York, NY 10013-4311 (212) 335-9000
4. Queens County District Attorney’s Office 125-01 Queens Boulevard Kew Gardens, NY 11415 (718) 286-6000
5. Richmond County District Attorney’s Office 36 Richmond Terrace Staten Island, NY 10301 (718) 876-6300
- 115 -
- 116 -
APPENDIX B 2002 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
Size of family unit Poverty Guideline 1 $ 8,860 2 11,940 3 15,020 4 18,100 5 21,180 6 24,260 7 27,340 8 30,420
For family units with more than 8 members, add $3,080 for each additional member. (The same increment applies to smaller family sizes also, as can be seen in the figures above.)
Source: http://www.nhelp.org/pubs/povertyguidelines2002.html
- 117 -
- 118 -
APPENDIX C MEDICAID FINANCIAL ELIGIBILITY LEVELS FOR NEW YORK EFFECTIVE JANUARY 1, 2001240
All figures are net income levels per month after exemptions and disregards. Resources are counted as of the first of the month.
PUBLIC ASSISTANCE (PA) STANDARD OF NEED Use this section for Low Income Families with Children (LIF) and Single Individuals and Childless Couples (S/CC) Categories
1 2 3 4 5 6 7 8 FOR EA. ADD’L FAMILY SIZE MEMBER ADD:
1. MAX. GROSS $566 $776 $936 $1127 $1326 $1474 $1628 $1811 INCOME TEST (185% OF PA STANDARD ) 2. MAX. PA GRANT $306 $419 $506 $609 $717 $797 $ 880 $979 72.50 (STANDARD OF NEED)
3. RESOURCE TESTS FOR LIF LOW INCOME FAMILIES $3,000 AND ______S /CC CATEGORIES SINGLE INDIVIDUALS AND CHILDLESS COUPLES $2,000 60 YEARS AND OVER $3,000
REGULAR MEDICAID ELIGIBILITY INCOME AND RESOURCE LEVELS Use this section for ADC-related families and SSI related individuals
INCOME 625 900 909 917 992 1,134 1,275 1,417 142 RESOURCES 3,750 5,400 5,450 5,500 5,950 6,800 7,650 8,500 850
- 119 -
EXPANDED MEDICAID INCOME ELIGIBILITY LEVELS (No Resource Test)
200% 2001 FPL for pregnant women* limited 1,424 1,927 2,430 2,834 3,437 3,940 4,444 4,947 504 perinatal; children under 1 133% 2001 FPL 947 1,282 1,616 1,951 2,286 2,621 2,955 3,290 335 for children 1-5 100% 2001 FPL 712 964 1,215 1,467 1,719 1,970 2,222 2,474 252 for pregnant women* full coverage; children 6-19
* A pregnant woman’s family size begins with two.
- 120 -
APPENDIX D OFFICE OF CIVIL RIGHTS DISCRIMINATION COMPLAINT FORM
- 121 -
- 122 -
- 123 -
- 124 -
- 125 -
- 126 -
- 127 -
- 128 -
- 129 -
- 130 -
- 131 -
- 132 -
APPENDIX E COMMUNITY HEALTH CENTERS
What is a community health center?
Community health centers (CHC’s) are federally funded clinics that have a MISSION to provide access to health services without regard for a person’s ability to pay.241 They are primary care clinics located in medically underserved communities that provide services for reimbursement from insurers (such as Medicaid and Medicare) and on a sliding fee scale for people who are underinsured and uninsured. Patients who have no insurance are billed in accordance with the schedule of discounts based on income and family size. Community health centers that receive federal funds, Federally Qualified Health Centers (FQHC), may not turn anyone away. The centers develop their own billing policies and programs for reducing the fees for the uninsured.
There are different types of FQHC’s. There are community health centers that are established to serve a diverse underserved population in a neighborhood. There are health centers that are set up to serve special populations: migratory and seasonal farm workers and their families; homeless people and their families; and those serving residents of public housing. There are also school-based health centers that are funded through the Healthy Schools, Healthy Communities program.
What are the services provided by health centers?
Health Centers are required to provide directly, contract for or set up, cooperative agreements for a certain set of services. These basic services include: • primary care; • preventive services including prenatal and perinatal services; • well child services; • nutrition; • immunizations and vaccines against preventable diseases; • screening for elevated blood lead levels, communicable diseases and cholesterol; • eye, ear, and dental screening for children; • family planning services; • preventive dental services; • emergency medical and dental services; • diagnostic laboratory and radiologic services; and • pharmacy services.
Health centers are also required to provide “enabling” services to help ensure access to services for patients, including:
• case management; • services to assist patients gain financial support for health and social services; • referrals to other services, including substance abuse and mental health services;
- 133 -
• services that assist patients in accessing health care such as outreach, transportation, interpreting, and education of patients and the community about the availability of health services. Health Centers must have arrangements with one or more hospitals to provide the full range of medical care services.
“Health centers must assess the needs of underserved populations and design programs and services which are culturally and linguistically appropriate to those populations.”242 This means that health centers are expected to eliminate barriers, such as limited English-speaking ability, to access to health services; including hiring culturally and linguistically appropriate staff.
Health centers, with a few exceptions, are required to have a governing board with a majority of consumers of services. The board must also be representative of the patients being served by the center in terms of race, ethnicity, and gender. This board sets policies for the center, must approve the hiring and firing of the Executive Director, and engages in a planning process.
Health centers are required to engage in a planning process. Part of this process includes the development of health care goals and objectives.
Who is eligible to receive services at health centers?
Low income, high-risk and underserved populations are served by community health centers. Health centers provide care for patients who have health insurance (including public insurance: Medicaid and Medicare) and services for the under- and uninsured. For uninsured patients, there is a sliding fee scale, with reductions of the cost of care based on the person’s ability to pay.
Which providers are community health centers?
See the attached list of centers in four of the five New York City boroughs. Call the included telephone number, or visit the health center to learn about that clinic’s specific fee scale. When you call the health centers, ask the following questions: What is the fee scale? What services does the fee scale cover? Does the center have a pharmacy and is there an additional charge for medications?
Contacts: Organization Phone Number Type of Information Community Health (212) 870-2273 Referrals to area community health centers Care Association of New York (212) 279-9686 State (CHCANYS) http://www.chcanys.org
- 134 -
APPENDIX F DHHS-HEALTH RESOURCES & SERVICES ADMINISTRATION FEDERALLY FUNDED PROGRAMS & FEDERALLY QUALIFIED HEALTH CENTER (FQHC) LOOK-ALIKES
Bronx Health Centers 1276 Fulton Avenue Bronx Community Health Network, Inc. Bronx, New York 10456 Montefiore Family Health Center 360 East 193 Street Martin Luther King, Jr. Health Center Bronx, New York 10451 3674 Third Avenue 718-579-2500 Bronx, New York 10456 718-681-3400 Montefiore Medical Group 305 East 161 Street Mid-Bronx Desperados Bronx, New York 10451 1690 Bryant Avenue 718-579-2500 Bronx, New York 10460 718-893-8850 Montefiore Medical Group - Morris Park 1621 Eastchester Road Poe Medical & Dental Services Center Bronx, New York 10461 2432 Grand Concourse 718-405-8040 Bronx, New York 10458
Promesa, Inc. Medical Unit Tiffany Practice Care Center 1776 Clay Avenue 853 Tiffany Street Bronx, New York 10457 Bronx, New York 10459
Promesa, Inc. Hunts Point Multi-Service Center Claremont Family Health Center 630 Jackson Avenue 262-66 East 174 Street Bronx, New York 10455 Bronx, New York 10457 718-402-8241
South Bronx High School Governor Juan Ponce de Leon Clinic 701 St. Ann’s Avenue 1675 Westchester Avenue Bronx, New York 10455 Bronx, New York 10472 718-402-7618 The Health Center Bronx Lebanon Integrated Services 66 Cauldwell Avenue Crotona Park Family Practice Bronx, New York 10451 1591 Fulton Avenue Bronx, New York 10457 Morris Heights Health Center 718-633-0800 Urban Health Plan 85 West Burnside Avenue General Medicine & Family Practice Bronx, New York 10453 718-716-4400 - 135 -
Bronx, New York 10460 183rd Street Health Center 25 East 183rd Street I.S. 201 Bronx, New York 10453 730 Bryant Avenue Bronx, New York 10459 The Women’s Center 718-328-8833 70 West Burnside Avenue Bronx, New York 10453 Jane Adams Vocational High School 900 Tinton Avenue Middle School 319/399 Bronx, New York 10456 120 East 184 Street 718-292-4513 Bronx, New York 10468 P.S. 98 Soundview Health Center 1290 Spofford Avenue 731 White Plains Road Bronx, New York 10474 Bronx, New York 10473 718-589-8324 Institute for Urban Family Health 212-633-0800 Allerton Health Center 2722 White Plains Road Mt. Hope Family Practice Bronx, New York 10467 130 West Tremont Avenue Bronx, New York 10453 Burnside Health Center Tremont Crotona Urban Horizon Family Practice 165 E. Burnside Avenue 50 East 168 Street Bronx, New York 10453 Bronx, New York 10452 718-293-3900 Castle Hill Health Center 615 Castle Hill Avenue Morris Park Medical Center Bronx, New York 10473 1800 White Plains Road Bronx, New York 10462 Children’s Medical Center 1733 East 172 Street Brooklyn Health Centers Bronx, New York 10472 Bedford Stuyvesant Family Health Morris Park Medical Center 1413 Fulton Street 1800 White Plains Road Brooklyn, New York 11216 Bronx, New York 10462 718-636-4500
Urban Health Plan Brooklyn Plaza Medical Center 1070 Southern Boulevard 650 Fulton Street Bronx, New York Brooklyn, New York 11217 718-589-2440 718-596-9800
Bella Vista Health Center Benjamin Bannekeer Academy 890 Hunts Point Avenue 27 Clinton Avenue Bronx, New York 10474 Brooklyn, New York 11205
Plaza del Castillo Health Center 1515 Southern Boulevard - 136 -
Brooklyn, New York 11220
Brownsville Community Development P.S. 10 592 Rockaway Avenue 511 7th Avenue Brooklyn, New York 11212 Brooklyn, New York 11215 718-345-5000 Community Healthcare Network Lyndon Baines Johnson Health Complex CABS - Community Action of Bedford 276 Nostrand Avenue Stuyvesant Brooklyn, New York 11205 94 Manhattan Avenue 718-636-2200 Brooklyn, New York 11206
ODA Primary Care Health Center Manhattan Health Centers 14-16 Heyward Street Brooklyn, New York 11211 Betances Health Unit 718-260-4600 280 Henry Street New York, New York 10002 Sunset Park Family Health Center th 212-227-8401 150 — 55 Street Brooklyn, New York 11220 Boriken Neighborhood Health Center 718-630-7047 2253 Third Avenue — 3rd Floor New York, New York 10035 Asian Health Center th 212-289-6650 812 54 Street Brooklyn, New York 11220 Homeless Health Care Care for the Homeless Caribbean-American Family Health Administrative Office 3414 Church Avenue 12 West 21st Street - 8th Floor Brooklyn, New York 11203 New York, New York 10010 212-366-4459 Family Physician Health Center 5616 Sixth Avenue Community Healthcare Network Brooklyn, New York 11220 Administrative Office 718-438-5440 184 Fifth Avenue New York, New York 10010 Park Ridge Family Health Center 212-366-4500 6314 Fourth Avenue Brooklyn, New York 111209 Helen B. Atkinson Center 81 West 115th Street Park Slope Family Health Center th New York, New York 10026 220 13 Street Brooklyn, New York 11215 Council’s Ambulatory Care Center 718-832-5980 1727 Amsterdam Avenue New York, New York 10031 Shore Road Family Health Center 212-862-0054 9000 Shore Road Brooklyn, New York 11209 Council Health Center of Heritage Health & Housing Sunset Terrace Family Health Center 3333 Broadway 514 49th Street - 137 -
New York, New York 10031
P.S. 192 Settlement Health & Medical Services 500 West 138th Street 212 East 106 Street New York, New York 10031 New York, New York 10029 212-360-2681 Covenant House/Under 21 460 West 41 Street - Room 717 Chinatown Health Clinic New York, New York 10036 125 Walker Street - 2nd Floor 212-330-0542 New York, New York 10013
Convenant House/Moms & Babies Canal Street Health Center 427 West 52 Street 268 Canal Street New York, New York 10019 New York, New York 10013
Institute for Urban Family Health Queens Health Centers Sidney Hillman Family Practice 16 East 16 Street Joseph P. Addabbo Family Health New York, New York 10003 Center 212-633-0800 67-10 Rockaway Beach Boulevard
th Arverne, New York 11692 East 13 Street Family Practice 718-945-7150 113 East 13 Street New York, New York 10003 Site 2 1288 Central Avenue William F. Ryan Community Health Far Rockaway, New York 11691 Center 110 West 97 Street Community Healthcare Network New York, New York 10025 Queens Health Center 212-749-1820 97-04 Sutphin Boulevard Jamaica, New York 11435 NENA Comprehensive Health Center 279 East Third Street New York, New York 10009 212-477-8500
Ryan Chelsea/Clinton Health Center 645 Tenth Avenue New York, New York 10036
P.S. 64/Earth School 600 East 6 Street New York, New York 10009
P.S. 196/Island School 444 East Houston Street New York, New York 10002
- 138 -
APPENDIX G CHILD HEALTH PLUS (CHPLUS)243
What is CHPlus?
• Developed in 1990, Child Health Plus is a New York State health insurance plan for children. CHPlus subsidizes private health insurance coverage for children using state and federal funding.
What are the benefits under CHPlus?
• CHPlus benefits can be grouped into two categories: 1) primary and preventive health care services; and 2) inpatient services. The following are covered primary and preventive health care services: “the services of physicians, optometrists, nurses, nurse practitioners, midwives, and other related professional personnel which are provided on an outpatient basis, including routine well-child visits; diagnosis and treatment of illness and injury; laboratory tests; diagnostic x-rays; prescription drugs; radiation therapy; chemotherapy; hemodialysis; emergency room services; and outpatient alcohol and substance abuse services.”244 The following are covered inpatient services: “inpatient hospital services provided by a general hospital, . . . excluding mental health services, substance abuse services, and alcohol treatment services; and services provided by physicians and other professional personnel on an inpatient basis for covered inpatient service.”245
Who is eligible for CHPlus?
• Effective March 31, 2001, children under the age of 19 who reside in a household with a net income at or below 185% FPL or its gross equivalent are eligible.246 (See Appendix B for the 2001 Federal Poverty Guidelines) • Child must not be eligible for Medicaid or have other equivalent health care coverage.247 • Child must not have been covered by a group health plan based upon a family member’s employment during the six month period prior to the date of application, except in limited circumstances.248 • Child must be New York state resident.249 A social security number is not required—the child does not have to be a U.S. citizen to be eligible.
What are the costs?
• There are no co-payments or deductibles for CHPlus services. Instead, families pay monthly premiums based on family income and family size. • Families with a net income at or below 133% FPL or its gross equivalent do not have to pay any premiums.250 • For families with net income between 133% and 185% FPL, the premium is $9 per child, per month, up to a family maximum of $27 per month.251 • For example, the premium for a family with income between 133% and 185% of the Federal poverty level is currently $9 per child per month up to a family maximum of $27 per month. Families whose incomes exceed 192% of the federal poverty level may enroll - 139 -
their child or children in CHPlus, but must pay the full premium, which varies depending on the insurer selected.
How to Apply:
There are two ways to apply for the Child Health Plus program:
• Interested persons can contact the NYS Child Health Plus Resource Hotline (see below) directly to get information on the program and to find out if they are eligible.
• Interested persons can also contact Facilitated Enrollers in their communities (see Appendix H). These agencies are representatives for CHPlus and can help complete and process applications. In order to reach a Facilitated Enroller in one’s community, first contact one of the lead agencies listed below in Appendix H which will direct you to a facilitated enroller in your immediate area.
Contact: Organization Phone Number/Web Site Type of information NYS Child (800) 698-4543 general CHPlus program Health Plus http://www.health.state.ny.us/nysdoh/chplus/cp information; can provide lus-1.htm Resource referrals to health care Hotline providers Legal Services (212) 431-7200 Neighborhood offices can for NYC assist in benefits applications; call the main # for a referral Legal Aid (212) 577-3575 Health law unit provides Society legal services for health consumers. See Appendix H for list of Facilitated Enrollers
- 140 -
APPENDIX H NEW YORK CITY FACILITATED ENROLLMENT LEAD AGENCIES
These agencies can help enroll people in Medicaid, Child Health Plus and Family Health Plus.
Manhattan Denise West 30 Third Avenue, Room 618 Children's Aid Society Brooklyn, NY 11217 Kate Lawler (718) 643-8258 x21 (p) 150 East 45 Street, 2nd Floor (718) 797-1254 (f) New York, NY 10017 (212) 503-6801 (p) Southern Brooklyn (212) 681-6315 (f) Met Council Lisa Gaon UPPER MANHATTAN 80 Maiden Lane, 21st Floor Alianza Dominicana, Inc. New York, NY 10038 Miriam Mejia (212) 453-9532, (212) 453-9595 (p) 2410 Amsterdam Avenue, First Floor New York, NY 10033 Bushwick (212) 740-1960 x124 (p) Ridgewood-Bushwick Senior Citizens (212) 740-1967 (f) Council Maria Viera LOWER MANHATTAN & SOUTH 217 Wyckoff Avenue BRONX Brooklyn, NY 11237 Hispanic Federation (718) 366-3800 x145/146 (p) Nancy Conde (718) 366-8740 (f) 130 Williams Street, 9th Floor New York, NY 10038 Queens (212) 233-8955 (p) (212) 233-8996 (f) Northern and Southern Queens Safe Space Bronx Brunilda Clermont 96-01 43rd Avenue, 2nd Floor Morris Heights Health Center Corona, NY 11368 Judith Fairweather (718) 205-9294 (p) 85 W. Burnside Avenue (718) 205-9353 (f) Bronx, NY 10453 (718) 716-4400 (p) Far Rockaway (718) 294-6912 (f) Joseph P. Addabbo Family Health Center Brooklyn Miguel Jiminez 1288 Central Avenue Northern Brooklyn Far Rockaway, NY 11691 Brooklyn Perinatal Network, Inc. (718) 868-8291 (p)
- 141 -
(718) 868-0752 (f) 475 Victory Boulevard Staten Island, NY 10301 Staten Island (718) 981-1500 (p) (718) 720-5058 (f) Jewish Community Center Liz Windle
- 142 -
APPENDIX I FAMILY HEALTH PLUS (FHPLUS)252
What is FHPlus?
Family Health Plus makes comprehensive health insurance available at no cost to lower-income uninsured adults who do not have employer-sponsored coverage and are not eligible for Medicaid or Medicare. FHPlus is modeled on Child Health Plus (see Appendix G above). It became available in New York City on February 1, 2002.
Who is eligible for FHPlus?
Adults between the ages of 19 and 64 who do not have employer- sponsored coverage and are not eligible for other public health insurance programs such as Medicaid or Medicare are eligible for coverage. The applicant does not have to be a U.S. citizen to be eligible. Applicants may not drop their existing employer-sponsored health insurance to join FHPlus.
Individuals must also meet the following income requirements to qualify for FHPlus. The chart below shows the maximum annual amount adults can earn and still qualify for FHPlus.
Yearly Income (Maximum Gross Annual Income) Family Single or Parent (living with Parent (living with Size Childless Couples at least one child at least one child under 21) as of under 21) as of 10/1/01 10/1/02 1 $ 8,860 N/A N/A 2 $11,940 $15,880 $17,910 3 N/A $19,977 $22,530 4 N/A $24,073 $27,150 5 N/A $28,170 $31,770 Chart is effective 2/1/2002 and subject to annual income updates.
What are the benefits under FHPlus?
All benefits are provided through managed care plans. While less comprehensive than Medicaid, the benefits package generally includes:
o physician services; o inpatient and outpatient health care; o prescription drugs;
- 143 -
o lab tests and x-rays; o vision, speech and hearing services; o durable medical equipment; o emergency room and emergency ambulance services; o drug, alcohol and mental health treatment; o diabetic supplies and equipment; o radiation therapy, chemotherapy and hemodialysis, and o dental services to the extent offered by the managed care plan.
What are the costs?
• There are no co-payments, premiums or other types of cost sharing under FHPlus.
Contact:
Organization Phone Number/Web Site Type of information FHPlus Hotline (877) 934-7587 General information; to http://www.health.state request an application ny.us/nysdoh/fhplus/index.htm Legal Aid (212) 577-3575 Health law unit provides Society legal services for health consumers. New Yorkers for (212) 367-1240 General Accessible information/advocacy Health organization Coverage See Appendix H for List of Facilitated Enrollers that can help enroll people in Family Health Plus, Child Health Plus and Medicaid.
- 144 -
APPENDIX J MEDICAID253
What is Medicaid?
• Medicaid is a joint federal and state program that helps pay medical costs for some people with low incomes and limited resources. Medicaid is a means-tested program that requires applicants to prove their financial need to be eligible.
What are the benefits under Medicaid?
• Medicaid services in New York generally include: hospital inpatient and outpatient services; prenatal care; vaccines for children; physician services; nursing facility services for persons aged 21 or older; family planning services and supplies; home health care for persons eligible for skilled-nursing services; laboratory and x-ray services; pediatric and family nurse practitioner services; nurse-midwife services; federally qualified health-center (FQHC) services; and early and periodic screening, diagnostic, and treatment services for children under age 21.
Who is eligible for Medicaid?
• States have some discretion, within broad federal guidelines, in determining whom to cover under their Medicaid program. The following are some of the major categories of people who are eligible for Medicaid in New York State: • People who are disabled, aged or blind who meet income and resource requirements; • Children in foster care homes or institutions run by public agencies or voluntary organizations contracted through the government; • Low-income families (LIF) who meet income and resource requirements; • Single individuals and childless couples who meet income and resource requirements; • Families not eligible under the LIF standard who meet the Aid to Dependent Children (ADC) requirements of deprivation of support and the presence of child(ren) under the age of 21; • Pregnant women and children under one with income up to 185% of the Federal Poverty Level [note that these women may receive only limited perinatal services]; • Children ages 1-5 with family income up to 133% Federal poverty level; and
- 145 -
• Pregnant women and children between ages 6 and 19 with income up to 100% Federal poverty level (note that these women may receive full Medicaid coverage). • See chart on Medicaid Financial Eligibility Levels for New York, effective January 1, 2001, Appendix C.
What are the costs?
• Some Medicaid recipients are responsible for co-payments for certain services. There is a $100 annual co-payment cap per recipient. The groups exempt from co-payments include: children under 18; pregnant women; and individuals in certain nursing homes and intermediate care facilities. The services that are exempt from co-payments include: all emergency services and family planning services. Recipients enrolled in managed care plans are exempt from co-payments.
Contacts:
Organization Phone Number/Web Site Type of information New York City (718) 291-1900; or How to apply for Human (877) 472-8411 Medicaid in New York Resources City. Administration New York State (212) 417-6550 To request a fair hearing Office of if dissatisfied with Temporary and benefits determination. Disability Assistance New York State (800) 541-2831 General program Medicaid information; to report Hotline fraud. Brookdale (212) 481-4433 Telephone consultations Center on Aging with advocates who work of Hunter with the elderly on College Institute Medicaid, Medicare and on Law and SSI. They are unable to Rights of Older take calls from Adults consumers due to limited staff. HICAP (Health (800) 334-4114 Free counseling to help Insurance older New Yorkers with Counseling Medicare, Medicaid and Assistance supplemental insurance Program) policies.
- 146 -
Legal Aid (212) 577-3575 Health law unit provides Society legal services for health consumers. Managed Care (212) 614-5400 Counseling and Consumer assistance. Assistance Program (MCCAP) MCCAP Public (212) 614-5552 General information, Benefits counseling, assistance, Resource Center eligibility. (Community Service Society)
- 147 -
- 148 -
APPENDIX K MEDICAID MANAGED CARE254
What is Medicaid Managed Care? How is Medicaid Managed Care different than Medicaid?
• Medicaid Managed Care is another way for consumers to receive Medicaid services. Under traditional Medicaid, consumers may visit any doctor or facility who accepts Medicaid and the State reimburses health care professionals on a fee-for-service basis. Under Medicaid Managed Care, patients enroll in a managed care plan and receive all of their health care services from physicians, pharmacies, hospitals and clinics that are members of a plan’s network. The State pays for Medicaid services through various prepayment arrangements with managed care providers, such as health maintenance organizations (HMOs).
What are the benefits under Medicaid Managed Care?
• Medicaid Managed Care plans generally provide the same services available under fee-for-service Medicaid. If a managed care plan does not cover a particular service that is covered by fee-for-service Medicaid, consumers may still receive that service on a fee-for-service basis. In other words, Medicaid will pay for the consumer to receive the service outside of his or her managed care plan.
Who is eligible for Medicaid Managed Care?
• New York State has received federal approval to require all Medicaid beneficiaries in New York City (with some limited exceptions) to join a Medicaid Managed Care plan. Thus, with limited exceptions, any individual eligible for Medicaid will eventually be required to choose a Managed Care plan. (See the Medicaid eligibility requirements discussed earlier.) Consumers living in the north Bronx, lower Manhattan, parts of Brooklyn, northeast and central Queens and all of Staten Island must now enroll in Medicaid Managed Care Plans. Consumers in other parts of the City will be required to enroll at a later date. • Some individuals are excluded from joining a Medicaid Managed Care plan. These individuals may not join a plan even if they want to. These excluded individuals include: Medicare/Medicaid dually eligibles who are enrolled in a Medicare HMO and residents of nursing facilities, institutional long-term care facilities, child care facilities or hospice. • Some individuals are exempt from joining a Medicaid Managed Care plan. These individuals may join a plan if they desire, but are not required to do so. Some commonly exempted groups include: HIV positive individuals who are under the care of a physician; seriously mentally ill
- 149 -
or emotionally disturbed individuals; SSI recipients; individuals who are homeless; individuals who do not have a geographically accessible managed care provider; and pregnant women who are already receiving prenatal care from a prenatal primary care provider who is not participating in any managed care plan.
Contacts:
Organization Phone Number/Web Site Type of information New York City (800) 505-5678 Information about Managed Care (888) 329-1541 (TDD) different managed care Helpline plans, member rights, workshops for recipients, filing a grievance and expedited enrollments. New York State (800) 206-8125 To complain about Dept. of Health quality of care provided Office of by a managed care plan. Managed Care Brookdale (212) 481-4433 Telephone consultations Center on Aging with advocates who work of Hunter with the elderly on College Institute Medicaid, Medicare and on Law and SSI. They are unable to Rights of Older take calls from Adults consumers due to limited staff. Legal Aid (212) 577-3575 Health law unit provides Society Program legal services for health consumers. Managed Care (212) 614-5400 Information and Consumer assistance regarding Assistance manage care issues, Program including one-on-one counseling.
- 150 -
Below please find a list of the agencies providing information and assistance on managed care questions for the Managed Care Consumer Assistance Program (MCCAP).
MCCAP Agencies for Information & Assistance on Managed Care Questions
AIDS Service Center of Lower Asian Americans for Equality Manhattan 277 Grand Street 80 Fifth Avenue., 3rd Floor New York, NY 10002 New York, NY 10011 (212) 964-6023 (212) 645-0875 English, Chinese, Bengali English, Spanish
Black Veterans for Social Justice Center for Independence of the 665 Willoughby Avenue Disabled of New York (CIDNY)* Brooklyn, NY 11206 841 Broadway, Room 205 (718) 852-6004 New York, NY 10003 English, Spanish, Creole, Chinese (212) 674-2300 English, Spanish, ASL
Citizen’s Advice Bureau Community Association of 1477 Townsend Avenue Progressive Dominicans Bronx, NY 10452 3940 Broadway, 2nd Floor (718) 588-3836 New York, NY 10011 English, Spanish (212) 781-5500 English, Spanish
Community Service Society (CSS)* El Puente 105 E. 22nd Street 211 South Fourth Street New York, NY 10010 Brooklyn, NY 11211 (212) 614-5400 (718) 387-0404 English, Spanish English, Spanish
Gay Men’s Health Crisis (GMHC)* Haitian Americans United for Advocacy Unit, 7th Fl. Progress 119 West 24th Street 221-05 Linden Boulevard New York, NY 10011 Cambria Heights, NY 11411 (212) 367-1125 (718) 527-3776 English, Spanish English, French, Haitian-Creole
*Specialist Agency ** These Agencies only provide Outreach & Consumer Education
- 151 -
JCC of Staten Island JCC of the Rockaway Peninsula 475 Victory Blvd. 1911 Nameoke Street Staten Island, NY 10301 Far Rockaway, NY 11691-4926 (718) 981-1500 (718) 327-7867, ext. 16 English, Spanish English, Russian
Korean Community Services of Latin American Integration Center Metropolitan NY 49-06 Skillman Avenue 149 W. 24th St. 6th Floor Woodside, NY 11377 New York, NY 10011 (718) 565-8500 Korean, English English, Spanish
Legal Aid Society* Medicare Rights Center* Civil Division 1460 Broadway, 11th Floor 166 Montague Street New York, NY 10036 Brooklyn, NY 10007 (212) 869-3850 (718) 422-2777 English English, Spanish, Haitian-Creole
Medicare Rights Center* New York Legal Assistance Group 1460 Broadway, 11th Floor 130 East 59th St. New York, NY 10036 New York, NY 10022 (212) 869-3850 (212) 750-0800 English English, Spanish, Russian
Northern Manhattan Perinatal Northern Queens Health Coalition* Partnership 39-01 Main Street, Suite 611 127 West 127th St. Flushing, NY 11354 New York, NY 10027 (718) 661-9313/670-0334 (212) 665-2600 English, Haitian-Creole, Farsi English, Spanish, French
Westside Campaign Against Hunger Women’s Housing and Economic Church of St. Paul and St. Andrew Development Corp. (WHEDCO) 263 W. 86th Street 50 E. 168th Street New York, NY 10021 Bronx, NY 10452 (212) 362-3662 (800) 400-3917 English, Spanish English, Spanish
*Specialist Agency ** These Agencies only provide Outreach & Consumer Education
- 152 -
United Jewish Organizations of Urban Justice Center* Williamsburg 666 Broadway, 10th Floor 32 Penn St. New York, NY 10012 Brooklyn, NY 11211 (646) 602-5675 (718) 643-9700 English, Spanish Yiddish, English
YM/YWHA Washington Heights and Inwood 54 Nagle Ave. New York, NY 10040 (212) 569-6200 Russian, Spanish, English
*Specialist Agency ** These Agencies only provide Outreach & Consumer Education
- 153 -
- 154 -
APPENDIX L MEDICARE255
What is Medicare?
• Medicare is a federal program that provides health insurance for people over 65 years of age and some people with disabilities under 65. Unlike Medicaid, Medicare does not have any income or resource eligibility criteria.
What are the benefits under Medicare?
• Medicare Part A is hospital insurance. It helps pay for: care in hospitals, some skilled nursing facilities, hospice and some home health care. • Medicare Part B is medical insurance. It helps pay for: doctors, outpatient hospital care and other services not covered under Part A, including physical and occupational therapy and some home health services. Medicare Part B does NOT cover routine physical exams, eyeglasses, dental care or cosmetic surgery, among other things.
Who is eligible for Medicare?
• People over 65 years of age; • Some people with disabilities under 65 who have received Social Security or Railroad Retirement Board disability benefits for 24 months; and • People with End-Stage Renal Disease (permanent kidney failure). • Note that to be eligible for Medicare, individuals must be: 1) U.S. citizens; or 2) aliens lawfully admitted for permanent residence who have lived in the United States for five years.256
What are the costs?
• Most Medicare beneficiaries do not have to pay a premium for Part A services because they (or a spouse) paid Medicare taxes while they were working. All beneficiaries are responsible for deductible and coinsurance costs under Part A. The 2001 deductible is $792.00 per benefit period. • Medicare beneficiaries must pay a premium to receive Part B coverage. The 2001 premium is $50.00 per month. There is also a $100.00 per year deductible for Part B coverage.
- 155 -
What is Medigap Insurance?257
• Medigap, also known as supplemental insurance, provides reimbursement for the out-of-pocket costs that are not covered by Medicare and which are the beneficiary’s share of health care costs. Medigap may also pay for certain services not covered by Medicare. In New York State, when you are enrolled in Medicare, you can purchase a Medigap policy at any time. Medigap policies are available with different benefit plans and at various monthly premiums.
What is a Medicare HMO?
• A Medicare HMO is a different way to receive Medicare services. Traditional Medicare is provided on a fee-for-service basis; beneficiaries may receive services from any medical provider who accepts Medicare reimbursement. Under a Medicare HMO, beneficiaries receive all of their medical care through a network of physicians, hospitals and other health care providers, who receive payment directly from Medicare. Many HMOs offer additional benefits not covered under traditional Medicare. Individuals who enroll in a Medicare-contracting HMO must continue to pay their Part B monthly premium. The HMO may also require small co-payments and a monthly premium. Individuals who join a Medicare HMO do not need a Medigap policy.
Contacts:
Organization Phone Number Type of information Social Security (800) 772-1213 Information about signing up for Administration TTY: (800) 325- Medicare Parts A and B 0778 New York State (800) 333-4114 Information regarding Medicare Health Insurance payment denials or appeals, Medicare Assistance rights and protections, help with Program complaints about care or treatment, help choosing a Medicare health plan and help with Medicare bills Center for (212) 264-3657 To report a complaint Medicare and Medicaid Services (CMS) Regional Offices Dept. Health and (800) 447-8477 To report Medicare fraud or abuse Human Services TTY: (800) 377- Office of 4950 Inspector General
- 156 -
Medicare Rights (212) 869-3850 Provide telephone consultations with Center Medicare beneficiaries and their families. Represent Medicare beneficiaries through the appeals process. Brookdale Center (212) 481-4433 Provide telephone consultations with on Aging of advocates who work with the elderly Hunter College on Medicaid, Medicare and SSI. They Institute on Law are unable to take calls from and Rights of consumers due to limited staff. Older Adults HICAP (Health (800) 334-4114 Free counseling to help older New Insurance Yorkers with Medicare, Medicaid and Counseling supplemental insurance policies. Assistance Program)
- 157 -
- 158 -
APPENDIX M MEDICARE BUY-IN258
What are Medicare Buy-In Programs?
• Congress enacted a law in 1988 that required each state’s Medicaid program to “buy-in” to Medicare for low-income beneficiaries and persons with disabilities by paying for their Medicare premiums, deductibles and coinsurance. This buy-in program was subsequently expanded to help more low-income Medicare beneficiaries shoulder the Medicare program’s cost-sharing requirements.
Who is eligible and what are the benefits?
• The Qualified Medicare Beneficiary Program (QMB) pays for all premiums, deductible and coinsurance under Medicare Parts A and B for: o Medicare beneficiaries with incomes at or below 100% of the federal poverty level (FPL) who have limited financial resources. • The Specified Low Income Medicare Beneficiary Program (SLIMB) pays Medicare’s monthly Part B premiums for: o Medicare beneficiaries whose incomes are between 100-120% federal poverty level and who have limited financial resources. • Qualifying Individuals receive either partial or full assistance with their monthly Part B premiums, depending on income. o Medicare beneficiaries whose incomes are between 120-135% federal poverty level who have limited financial resources qualify for full coverage of Part B premiums. o Medicare beneficiaries whose incomes are between 130-175% federal poverty level who have limited financial resources qualify for partial assistance with Part B premiums. • Under the Qualified Disabled and Working Individuals Program (QDWI) the state pays a portion of Medicare’s Part A premiums. In order to be eligible: o Individuals must be either disabled, over age 65, or must have lost their Medicare Part A insurance because they returned to work. o Persons must not have resources worth more than $4000 for individuals and $6000 for couples. o Individuals cannot be eligible for Medicaid
Contacts:
Organization Phone Number Type of information New York City (718) 291-1900; or To receive Medicare Buy-In eligibility Human Resources (877) 472-8411 information and application Administration materials.
- 159 -
New York Lawyers (212) 244-4664 Assistance with applying for benefits for the Public programs. Interest MFY Legal (212) 417-3700 Assistance with applying for benefits Services, Inc. http://www.mfy.org programs.
Hunter College On Medicaid, Medicare and SSI. They Institute on Law are unable to take calls from and Rights of consumers due to limited staff. Older Adults
HICAP (Health (800) 334-4114 Free counseling to help older New Insurance Yorkers with Medicare, Medicaid and Counseling supplemental insurance policies. Assistance Program
- 160 -
APPENDIX N SCHOOL-BASED HEALTH CENTERS259
What are school-based health centers?
• School-based health centers provide age-appropriate primary health, mental health, social and health education services. Some services are provided at health centers that are located on a school campus, while other services are available by referral.
What are the services provided by school-based health centers?
• Services provided by school-based health centers, either on-site or by referral, include: comprehensive health assessments; limited laboratory tests; age-appropriate reproductive health care; health education; mental health services; social services; dental care; nutrition education and counseling; and well-child care of students’ children.
Who is eligible to receive services at school-based health centers?
• Any student who attends a school where a school-based health center is located may receive services there. School-based health centers will not turn any student away because of insurance status, health status or because a student has an existing primary care provider. Students under the age of 18 must receive parental consent to enroll in a center. If a student has a primary care provider, centers will try to coordinate with him or her to avoid duplication of services.
What are the costs?
• There are no out-of-pocket costs for students to receive services at school-based health centers.
Contacts:
Organization Phone Number Type of information New York State (518) 486-4966 information re: school-based health Department of (212) 268-7889 centers and referrals. Health, Family Health Services
- 161 -
- 162 -
APPENDIX O COBRA (CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT)260
What is COBRA?
• COBRA is a program that assists eligible persons in maintaining their health insurance coverage after a loss or reduction in employment. The federal government requires employers with 20 or more employees to provide this continuation coverage. New York State also requires small employers with fewer than 20 employees to provide continuation coverage.
What are the benefits available under COBRA? How long are they available?
• Individuals who are qualified under COBRA must receive the same insurance that similarly situated employees who are not eligible for COBRA receive under the employer’s group health plan. • Most employees and their dependents may receive continuation coverage for 18 months. Certain qualifying events, such as the death of the covered employee, enable beneficiaries to receive 36 months of continuation coverage. Individuals who are or become disabled in the first 60 days of continuation coverage are eligible for 29 months of coverage.
Who is eligible to receive COBRA (or its equivalent under New York State law)?
• The following people are eligible for COBRA in the event of a “qualifying event”: o a covered employee; and o the employee’s spouse and dependents. • The following are “qualifying events”: o the death of the covered employee; o the termination (other than because of an employee’s gross misconduct), or reduction of hours of the covered employee; o the divorce or legal separation of the covered employee from the employee’s spouse; o a covered employee becoming entitled to Medicare benefits; o a dependent child ceasing to be a dependent child of the covered employee under the terms of the group health plan; or o with respect to certain retirees and their dependents, bankruptcy proceedings of an employer.
- 163 -
What are the costs?
• Employees may have to pay their share and the employer’s share of the premium. The amount charged may not exceed 102% of the applicable premium for that period.
How to apply?
• Qualified beneficiaries have at least 60 days from: a) the date on which they are notified of their eligibility for COBRA; or b) the date on which they would lose group health coverage; whichever is later, to determine whether to elect continuation coverage.
Contacts:
Organization Phone Number Type of information U.S. Dep’t of (202) 219-8776 COBRA information for employees Labor (212) 637-0600 whose employers have more than 20 employees New York State (212) 480-6400 COBRA information for employees Dep’t of (800) 342-3736 whose employers have fewer than 20 Insurance employees. Consumer Services Bureau New York State (212) 352-6000 COBRA information for employees Dep’t Labor whose employers have fewer than 20 employees.
- 164 -
APPENDIX P ELDERLY PHARMACEUTICAL INSURANCE COVERAGE (EPIC) PROGRAM261
What is EPIC?
• EPIC is a New York State sponsored prescription plan for senior citizens who need help paying for their prescriptions. As of September 30, 1999, more than 100,000 New York State seniors are enrolled in the program.
What are the benefits under EPIC? What are the costs?
• EPIC helps low and moderate income seniors purchase their prescription drugs, including insulin, insulin syringes and insulin needles. The program does not cover the cost of any drugs generally available without a prescription, such as eyeglasses and vitamins. EPIC prescriptions may be dispensed in a thirty-day supply or one hundred units, whichever is greater.262
• EPIC is a cost-sharing program. Depending on their annual income, seniors may join EPIC by enrolling in the Fee Plan or the Deductible Plan.
• Fee Plan:
o Seniors with incomes up to $20,000 if single or $26,000 if married are eligible to participate in EPIC through the Fee Plan only. They pay an annual fee based on annual income. The fee can be paid in quarterly installments. For example, unmarried individuals with annual income of $6,000 or less pay a yearly fee of $8. Seniors with income between $19,001 and $20,000 pay a yearly fee of $230.263 Married individuals with joint annual income of $6,000 or less pay a yearly fee of $8. Married individuals with joint income between $25,001 and $26,000 pay an annual fee of $300.264 o In addition to the yearly fee, seniors pay a co-payment when they purchase their prescriptions. For example, co-payments are $3 for a prescription costing up to $15 and $20 for a prescription costing more than $55. o Once an EPIC participant has paid a certain co-payment amount, determined by income level, EPIC will pay 100% of all future prescription drug costs for the remainder of the enrollment year. For example, unmarried individuals with incomes of $5,000 or less do not have to pay more than $340 per year in co- payments. Individuals with incomes between $19,000 and
- 165 -
$20,000 do not have to pay more than $1,160 per year in co- payments. A married individual with a joint income of $5,000 or less does not have to pay more than $291 per year in co-payments. A married individual with a joint income between $25,000 and $26,000 does not have to pay more than $1,150 per year in co- payments.
• Deductible Plan
o Seniors with income between $20,001 and $35,000 if single, or between $26,001 and $50,000 if married are eligible to participate in EPIC through the Deductible Plan only. With the Deductible Plan, the senior pays no fee to join. Instead, the participant pays the full price of his or her prescription costs until the deductible amount, which is based on income, has been spent.265 For example, the yearly deductible for a single individual with income between $20,001 and $21,000 is $530. The yearly deductible for a single individual with income between $34,001 and $35,000 is $1,230.266 The yearly deductible for a married individual with joint income between $26,001 and $27,000 is $650. The yearly deductible for a married individual with joint income between $49,001 and $50,000 is $1,715.267 o After the deductible is met, enrollees pay a co-payment when they purchase their prescription drugs and EPIC covers the rest. The co- payments are the same as under the Fee Plan.268 o As for the Fee Plan, once an enrollee has paid a certain co-payment amount, determined by income level, EPIC will pay 100% of all future prescription drug costs for the remainder of the enrollment year.269
Who is eligible for EPIC?
• As of January 1, 2001, New York State residents can join EPIC if they are 65 years of age or older, and have an annual income of $35,000 or less if single, or $50,000 or less if married. EPIC does not have an asset test.270
• Seniors who received Medicaid benefits or have other prescription coverage that is equivalent to or better than EPIC are not eligible for EPIC benefits.271 Individuals whose prescription costs are covered in part by any public or private plan may qualify for reduced assistance under EPIC.272
• The fact that an individual’s prescription drug expenses are paid or reimbursable under Medicare does not disqualify him or her from receiving assistance under EPIC.273
- 166 -
Contact:
Organization Phone Number/Web Site Type of information EPIC Helpline (800) 332-3742; General program email: [email protected] information; to request an application Legal Services (212) 431-7200 Neighborhood offices can for NYC assist in benefits applications; call the main # for a referral Legal Aid (212) 577-3575 Health law unit provides Society legal services for health consumers.
- 167 -
- 168 -
- 169 -
- 170 -
APPENDIX Q HIV UNINSURED CARE PROGRAMS: ADAP, ADAP PLUS, HOME CARE AND INSURANCE CONTINUATION274
What are the HIV Uninsured Care Programs?
• There are four HIV Uninsured Care Programs jointly funded by the federal government and the state to provide free medical services to HIV-infected New York State residents who are uninsured, underinsured or unable to pay for existing insurance coverage. The four programs are: o ADAP: prescription drugs o ADAP Plus: primary care/outpatient services o Home Care: skilled nursing and personal care o Insurance Continuation: payment of existing health insurance costs.
What are the benefits under the HIV Uninsured Care Programs?
• AIDS Drug Assistance Program (ADAP): Covers many FDA-approved prescription medications to treat HIV/AIDS and associated illnesses, including prophylaxis for Pneumocystis carinii pneumonia (PCP), anti- retroviral therapy and protease inhibitors.
• ADAP Plus: Covers a full range of HIV Primary Care services, provided on an outpatient ambulatory basis at enrolled hospitals, diagnostic and treatment centers, community-based health centers, laboratory vendors or through enrolled office based physicians. Covered services include an annual comprehensive medical evaluation, clinical HIV disease monitoring, drug and immunotherapy administration, ambulatory surgery and the treatment of both HIV related and non-HIV related illness.
• Home Care Program: Covers skilled nursing, personal care, homemaker and home health aid services, intravenous medications and supplies and durable medical equipment. There is a lifetime limit of $35,000 for services and equipment provided through the Home Care program.
• Insurance Continuation Program: Covers health insurance costs for individuals with existing coverage who cannot afford to pay. The program pays for health insurance for people who: o Have lost their job and are eligible to keep their insurance under COBRA; o Are employed, but for whom the cost of insurance is too high; and o Have self-pay insurance, but for whom the cost is too high.
- 171 -
Who is eligible for the HIV Uninsured Care Programs?
• To enroll in any of the HIV Uninsured Care Programs, applicants must meet all of the following criteria: o be a resident of New York State; o have a diagnosis of HIV or AIDS (asymptomatics are eligible); o for Home Care only, applicants must be chronically medically dependent; o be otherwise uninsured or underinsured; o have liquid assets less than $25,000 (resource calculation excludes the value of an applicant’s car and home); and o have income less than $44,000/year for a household of one; $59,200 for two, and $74,000 for three or more. o For Insurance Continuation only, are paying for or will need to pay for existing, cost effective insurance premiums and cannot afford them. o Individuals enrolled in Medicaid are NOT eligible for the programs. Because of Medicaid’s broader range of covered services, Medicaid is the preferred medical coverage for individuals who meet their eligibility requirements. o Note that individuals do not have to be U.S. citizens to be eligible for the HIV Uninsured Care Program.
What are the costs?
• ADAP Plus services are provided at no cost to eligible individuals.
Contact:
Organization Phone Number/Web Site Type of information HIV Uninsured (800) 542-2437 General program Care Programs TDD: (518) 459-0121 information; to request Hotline Relay operator: (800) 421-1240 an application. Brooklyn Legal (718) 237-5546 Represents HIV-infected Services HIV individuals throughout Project Brooklyn. General advocacy. HIV Law Project (212) 674-7590 Represents HIV-infected individuals regarding denial of entitlements and other legal matters. Gay Men’s (212) 807-6655 Health care and Health Crisis http://www.gmhc.org entitlement advocacy. HIV/AIDS Hotline (GMHC)
- 172 -
Bronx AIDS (718) 295-5605 Case management and Services http://www.basnyc.org counseling services for HIV-positive residents of the Bronx. AIDS Center of (718) 896-2500 Case management and Queens County http://www.acqc.homestead.com counseling services for HIV-positive residents of Queens. Staten Island (718) HIV-CALL (448-2255) Case management and AIDS Task Force http://www.siatf.org counseling for HIV- positive Staten Island residents. Project (718) 448-1544 Legal services to HIV- Hospitality http://www.projecthospitality.org positive Staten Island residents including estate planning and health care proxies.
- 173 -
- 174 -
APPENDIX R NEW YORK STATE PARTNERSHIP FOR LONG-TERM CARE275
What is the New York State Partnership for Long Term Care?
• The New York State Partnership for Long-Term Care is a public-private partnership that links Medicaid and private long-term care insurance. The program allows New Yorkers to protect their assets while remaining eligible for Medicaid if their long-term care needs exceed the period covered by their private insurance policy.
How does the Partnership work?
• Individuals must first purchase private long-term health care insurance. The policy must cover at least three years of nursing home care, six years of home care or an equivalent combination of both. This is the “minimum benefit duration.”
• Once the minimum benefit duration is reached, regardless of whether the policy’s benefits have been exhausted, the policy holder, if income eligible, will be eligible for Medicaid extended coverage for the remainder of his or her life without consideration of his or her assets. In other words, a person who has purchased and used a qualified Partnership long-term care insurance policy may then qualify for Medicaid without exhausting his or her assets. Whereas most Medicaid enrollees must satisfy both income and asset requirements, Partnership enrollees must only meet the income requirements.
What are the costs?
• The cost of premiums for Partnership policies will depend on an individual’s age and the policy and coverage options he or she chooses. Whatever the cost, the premiums will not change based on changes in health status or your advancing age.
How do I purchase a Partnership policy?
• The State does not sell Partnership insurance. To purchase a Partnership policy, contact your financial adviser, insurance agent, insurance broker or attorney. Not all long-term care insurance policies are qualified as Partnership policies.
- 175 -
Contact:
Organization Phone Number/Web Site Type of information New York State (888) NYS-PLTC [697-7582] or General program Partnership for (518) 473-8083 information; questions Long-Term Care about policies. Hotline
APPENDIX S
- 176 -
- 177 -
- 178 -
CHAPTER VII
GLOSSARY
-A-
Acute Care Facilities – Facilities operated by public and private hospitals that provide both inpatient and outpatient care.
ADAP – AIDS Drug Assistance Program. A federally and state-funded program that covers FDA-approved medications to treat HIV/AIDS and related illnesses.
Americans with Disabilities Act (ADA) – A federal law that prohibits discrimination on the basis of disability. The ADA also requires health care facilities to provide interpreters for persons with hearing and/or visual impairments.
Attorney General – The Attorney General (AG) serves as chief law enforcement officer of the state of New York. The AG represents the state of New York and its citizens in legal matters.
-C-
Center for Medicare and Medicaid Services (CMS) – Previously known as the Health Care Financing Administration (HCFA), CMS is the federal agency that administers and provides funding for Medicare, Medicaid, and the children’s health program. CMS is an agency within the U.S. Department of Health and Human Services.
Child Health Clinic – These clinics are facilities operated by Health and Hospitals Corporation (HHC), under contract with the New York City Health Department, that provide primary and preventive care to children and teenagers. Services are free of charge if the child is uninsured.
Child Health Plus (CHPlus) – A New York state health insurance plan that subsidizes health insurance coverage for children using state and federal funding.
Co-Payment – A portion of the cost of medical services that is not covered by insurance and must be paid by the patient.
- 179 -
COBRA – Consolidated Omnibus Budget Reconciliation Act. A federal program that assists eligible persons in maintaining health insurance coverage after a loss or reduction in employment.
Commission on the Public’s Health System – CPHS was organized in 1991 to fight the privatization of the public hospitals and to work to strengthen the public health system. Its work includes support of community and labor efforts to continue services and provide resources for needed health care services, particularly for the under- and uninsured. Membership is comprised of consumers, community organizations, health professionals, health advocates, health care workers, and unions.
Communicare Center – Community based facilities run by Health and Hospitals Corporation that provide preventive, primary care, and some specialty care for all members of the family.
Community Health Center (FQHC) – Federally funded clinics that have a mission to provide access to health services without regard for a person’s ability to pay. These clinics provide primary care services and some specialty care in medically underserved communities.
Community Service Obligation – An obligation under the Hill-Burton Act which requires facilities to make health care services available to individuals without discrimination on the basis of race, color, national origin, or creed. This obligation also requires facilities to make emergency services available without regard to a patient’s ability to pay, and prohibits discrimination against participants in Medicaid, Medicare or other government insurance programs.
-D-
Deductible – A predetermined monetary amount that must be paid by an individual before her insurance benefits will begin covering any medical expenses.
Department of Health (DOH) – A New York State government office with the mission of protecting and promoting the health of New Yorkers. The person who runs the DOH is called the Commissioner. There is also a New York City Department of Health.
Department of Justice (DOJ) – The DOJ is the law enforcement office of the federal government. It represents the citizens of the United States and the federal government in legal matters.
- 180 -
Diagnostic & Treatment Center (D&TC) – D&TCs are community clinics that provide routine, preventive, and primary care services. Some centers also provide specialty services.
District Attorney – An attorney that represents the people and state of New York in prosecuting criminal cases.
Diversion – Diversion refers to the practice of hospitals informing EMS that their emergency rooms are closed and they cannot accept a certain category of patients (e.g., obstetric, psychiatric, etc.) because of inadequate facilities, overcrowding, or temporary understaffing.
Dumping – The practice of denying emergency services and prematurely transferring patients from one hospital to another because the person is uninsured or otherwise cannot guarantee payment to the health facility.
-E-
EMS – Emergency Medical Services.
EMSRA – The Emergency Medical Services Reform Act. A New York law enacted to prevent hospitals from dumping patients or inappropriately transferring them.
EMT – Emergency Medical Technician.
EMTALA – The Emergency Medical Treatment and Active Labor Act. A federal law that prevents hospitals from dumping patients or making inappropriate transfers.
EPIC – Elderly Pharmaceutical Insurance Coverage. A New York state sponsored insurance program for senior citizens (65 years or older) that provides assistance paying for prescriptions.
-F-
Facilitated Enroller – Community agencies that serve as representatives for the New York Child Health Plus program. These agencies assist persons applying for CHPlus benefits.
- 181 -
Family Health Plus (FHPlus) – A New York state health insurance program funded by both state and federal sources that is targeted at uninsured, working poor adults in New York State.
Federal Poverty Level – Income level, which varies with family size, set by the federal government and used to determine eligibility for some government benefits programs such as Medicaid.
Federally Qualified Health Centers (FQHC) – A community health center that receives federal funds.
Fiscal Year – The twelve-month period used by corporations, non-profits, and other businesses to mark time for budgeting and fundraising purposes. The beginning and end points of this twelve-month period vary from business to business.
-H-
Health and Hospitals Corporation (HHC) – Established under New York State law to operate New York City’s public health and hospital system. HHC facilities are located in all 5 boroughs and provide a wide range of medical services. HHC facilities are required to provide medical care regardless of a patient’s ability to pay.
Health and Human Services Department (HHS) – An agency of the federal government that is responsible for protecting the health of all residents and providing essential human services, especially to those who are least able to help themselves. The person who runs HHS is called the Secretary.
Hill-Burton Act – Title VI of the Public Health Services Act, first enacted by Congress in 1946. This legislation was later replaced with Title XVI of the Public Health Services Act in 1974. The Act offered states federal grants and loans to build and modernize hospitals provided that the facilities met community service and/or uncompensated care obligations.
HMO – Health Maintenance Organization. Sometimes used interchangeably with Managed Care Organization (MCO). HMO’s arrange for and pay for health services for enrolled members.
-L-
Long-Term Care Facility – Facilities that provide extended care for individuals who require ongoing medical attention.
- 182 -
-M-
MCO – Managed Care Organization. A health insurance carrier that regulates the provision of health services, sometimes by coordinating a network of health care providers (e.g., Oxford, Cigna, U.S. Healthcare, etc.), and sometimes by providing the services itself (e.g., HIP).
Medicaid – A joint federal, state, and locally funded program that helps pay medical costs for people with low income and limited resources. Individuals must meet New York state financial eligibility levels and other criteria to receive Medicaid services.
Medicaid Managed Care – Another way that individuals can receive Medicaid services. Patients enroll in a managed care program and then receive medical services from physicians, pharmacies, and medical facilities within the plan’s network. In the future, almost all individuals eligible for Medicaid may be required to join a managed care plan.
Medicare – A federal program that provides health insurance for people with disabilities or people over the age of 65 years. There is no income criteria.
Medicare Buy-In – A federal law which requires each state’s Medicaid program to “buy-in” to Medicare coverage for low-income individuals eligible for Medicare by paying for their Medicare premiums, deductible, and coinsurance. Individuals must be eligible through specific benefits programs.
Medicare HMO – A different way to receive Medicare services. Individuals receive medical care through a network of physicians, pharmacies, and other medical facilities.
Medigap – Also known as Medicare Supplemental Insurance. This plan is specifically designed to supplement Medicare’s benefits by paying some of the costs that Medicare does not pay for covered services and may even pay for certain benefits not covered by Medicare. Individuals purchase Medigap insurance plans.
-N-
New York Lawyers for the Public Interest – NYLPI was created in 1976 to address the unmet legal needs of disadvantaged New Yorkers. NYLPI’s lawyers, community organizers and paralegals find unique ways to tackle the problems facing low-income and underrepresented people throughout New York City using two related approaches: an in-house legal program focusing on access to health care, disability law, and environmental justice and a pro bono
- 183 -
clearinghouse, which draws upon the resources of more than eighty of the city’s private law firms.
New York Public Health Council – In New York State, the New York Public Health Council has responsibility for reviewing all applications for the establishment or construction of a hospital.
New York Court of Appeals – The highest state court in New York.
-O-
Office for Civil Rights (OCR) – OCR exists within the U.S. Department of Health and Human Services (HHS). OCR is responsible for promoting and ensuring that people have equal access to and opportunity to participate in all HHS programs without unlawful discrimination.
Office for the Aging – A New York state agency. It is the designated state unit on aging as required under the Older Americans Act. The office serves as advocate for New Yorkers age 60 and older.
Oral Health Clinic – Facilities that provide children and adults with routine dental examinations, care and treatment for gum and tooth disease.
-P-
Patient Advocate – An employee at a hospital or other medical facility that works with patients to protect their rights and serves as a liaison with hospital administration and medical staff.
Premium – A monetary amount that a person must pay in order to get insurance coverage.
-R-
Rehabilitation Act of 1973 – A federal law that prohibits discrimination on the basis of disability by agencies, organizations, or businesses that receive federal financial assistance.
-S-
School–Based Health Center – Provides age-appropriate primary health, mental health, social, and education services. Any child who attends a school
- 184 -
where a school-based health center is located may receive services there. There is no fee for services at these centers.
Steering – When a patient is taken to a particular hospital by an ambulance based on her ability to pay, not which hospital is closest or most appropriate for the patient’s medical condition.
-T-
TDD/TTY – Devices that allows persons with hearing impairments to communicate over telephone lines by typing.
Trauma Center – An emergency room that is equipped to provide high level care for patients who are acutely ill or victims of serious sudden injury.
-U-
Uncompensated Care Obligation – An obligation under the Hill-Burton Act that requires facilities to provide free or below-cost services to low-income individuals for a specified period of time.
- 185 -
- 186 -
CHAPTER VIII
Endnotes
1 N.Y. PUB. HEALTH LAW § 3000 (McKinney 1993 & Supp. 1999-2000). 2 FDNY EMSC OGP 106-02 On-Scene Operations: General Regulations (Sept. 15, 1999). 3 N.Y. GEN. MUN. LAW § 122(1) (McKinney 1999); FDNY EMSC OGP 106-02 § 3.1.3 (Sept. 15, 1999). 4 N.Y. GEN. MUN. LAW § 122(2) (McKinney 1999). 5 A “911 Ambulance Destination” is a hospital emergency department that meets the New York City Regional 911 Emergency Department standards and has been approved as such by the New York City Regional 911 Ambulance Destination Committee (ADAC) and the Regional Emergency Medical Advisory Committee (REMAC). 6 FDNY EMSC OGP 115-01 Emergency Department Ambulance Diversion §§ 3.8, 4.9 (Sept. 15, 1999). 7 N.Y. PUB. HEALTH LAW § 2805-b(3) (McKinney 1993 & Supp 1999-2000). 8 FDNY EMSC OGP 115-01 Emergency Department Ambulance Diversion § 4.5 (Sept. 15, 1999). 9 Id. § 4.9. 10 Id. §§ 3.2, 3.4. 11 N.Y. PUB. HEALTH LAW § 2805-b(3) (McKinney 1993 & Supp. 1999-2000). 12 FDNY EMSC OGP 115-01 Emergency Department Ambulance Diversion § 4.3 (Sept. 15, 1999). 13 Id. § 3.5. 14 Id. § 3.6. 15 Id. § 3.7. 16 Id. § 4.11. 17 Id. § 5.1.1. 18 Id. § 5.1.2. 19 Id. § 5.1.5. 20 Id. §§ 5.2–5.4. 21 Procedures are mandated by the operating Guideline, EMSC OGP 115-01. 22 Id. §§ 5.5–5.11. 23 N.Y. PUB. HEALTH LAW § 3012(2) (McKinney 1993 & Supp. 1999-2000). 24 N.Y. PUB. HEALTH LAW § 3012(1) (McKinney 1993 & Supp. 1999-2000). 25 Lakeland Fire Dep’t v. DeBuono, 673 N.Y.S.2d 244, 246 (N.Y. App. Div. 1998) 26 Id. at 246. 27 N.Y. GEN. MUN. LAW § 122(1)(b). 28 42 U.S.C.A. § 1395dd (West Supp. 1993-1999). 29 Ballachino v. Anders, 811 F. Supp. 121, 123 (W.D.N.Y. 1993) (EMTALA’s protections are not limited to those who are indigent); Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1040 (D.C. Cir. 1991) (EMTALA extends its protections to “any individual” who seeks emergency room assistance, and thus, covers individuals whose claim has nothing to do with insurance, inability to pay or other economic factors); Correa v. Hospital San Francisco, 69 F.3d 1184, 1193-94 (1st Cir. 1995), cert. denied, 517 U.S. 1136, 116 S. Ct. 1423 (1996) (EMTALA, by its terms, covers all patients who come to a hospital’s emergency department, and requires appropriate screening, regardless of insurance status or ability to pay); Tolton v. American Biodyne, Inc., 48 F.3d 937, 944 (6th Cir. 1995) (EMTALA not limited to those who are indigent or uninsured); Jones v. Wake County Hosp. Sys., Inc., 786 F. Supp. 538, 543 (E.D.N.C. 1991) (EMTALA not limited to acts of patient dumping for economic reasons). 30 42 U.S.C.A. § 1395dd(a)(2000); 42 C.F.R. § 489.24(a)(2000). 31 42 U.S.C.A. § 1395cc(a)(2000)(1)(I). 32 42 C.F.R. § 489.24 (b)(2000). 33 42 U.S.C.A. § 1395dd(d)(1)(B). (2000) 34 42 U.S.C.A. § 1395dd(a). (2000)
- 187 -
35 Campbell v. Westchester County, 96 Civ. 0467 1998 U.S. Dist. LEXIS 17757, at *8 (S.D.N.Y. Nov. 9, 1998) (patient who presented via the outpatient department did not present in the emergency room, as required by § 1395dd(a)). 36 Vazquez v. New York City Health and Hosp. Corp., 98 Civ. 7922 2000 U.S. Dist. LEXIS 5614, at *9 (S.D.N.Y. Feb. 3, 2000) (medical screening requirement only applies to patients who seek treatment from an emergency department, and thus, patient who was brought directly to hospital’s intensive care rather than emergency room, was not covered). 37 Baber v. Hospital Corp. of Am., 977 F.2d 872, 884 (4th Cir. 1992) (EMTALA does not apply to patient who was not screened upon admittance to psychiatric unit). 38 “Comes to the emergency department means, with respect to an individual requesting examination or treatment, that the individual is on the hospital property. For purposes of this section, “property” means the entire main hospital campus as defined in § 413.65(b) of this chapter, including the parking lot, sidewalk, and driveway, as well as any facility or organization that is located off the main hospital campus but has been determined under § 413.65 of this chapter to be a department of the hospital. . . .Property also includes ambulances owned and operated by the hospital even if the ambulance is not on hospital grounds. An individual in a non hospital-owned ambulance on hospital property is considered to have come to the hospital’s emergency department. An individual in a non hospital-owned ambulance off hospital property is not considered to have come to the hospital’s emergency department, even if a member of the ambulance staff contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. In such situations, the hospital may deny access if it is in ‘diversionary status,’ that is, it does not have the staff or facilities to accept any additional emergency patients. If, however, the ambulance staff disregards the hospital's instructions and transports the individual on to hospital property, the individual is considered to have come to the emergency department.” 42 C.F.R. § 489.24(b)(2000). 39 42 U.S.C.A. § 1395dd(h). 40 Correa v. Hospital San Francisco, 69 F.3d 1184, 1190 (1st Cir. 1995) (§ 1395dd(a) does not require that a patient show that she in fact suffered from an emergency medical condition when she arrived at the emergency room; the failure to appropriately screen, by itself, is sufficient to ground liability as long as the other elements are met); Power v. Arlington Hosp. Ass’n, 42 F.3d 851, 859 (4th Cir. 1994) (§ 1395dd(a) not limited to screening situations when hospital has actual knowledge of an emergency medical condition). 41 See e.g., Power v. Arlington Hosp. Ass’n., 42 F.3d 851, 857 (4th Cir. 1994)(threshold requirement of EMTALA claim is that screening provided by hospital. deviated from that given to other patients); Baber v. Hospital Corp. of America, 977 F.2d 872, 878-80 (4th Cir. 1992); Vazquez v. New York City Health and Hosp. Corp., 98 Civ. 7922 2000 U.S. Dist. LEXIS 5614, at *9 (S.D.N.Y.Feb. 3, 2000) (EMTALA’s screening requirement covers patients who received disparate treatment from other patients with the same or similar conditions). 42 Vickers v. Nash Gen. Hosp., 78 F.3d 139, 144 (4th Cir. 1996). 43 Fisher v. New York City Health and Hosp. Corp., 989 F. Supp. 444, 449 (E.D.N.Y. 1998) (EMTALA only requires Hospitals to apply their standard screening procedures for identification of an emergency medical condition uniformly to all patients and, thus, does not impose a national standard of care in screening patients) 44 Summers v. Baptist Med. Ctr. Arkadelphia, 91 F.3d 1132, 1138 (8th Cir. 1996) (en banc) (where the doctor treated the patient similarly to any other patient in the same condition, district court was correct to dismiss EMTALA case; no improper motive required); Gatewood, 933 F.2d at 1040 (Hospital meets “appropriate medical screening” requirement when it conforms its treatment of a particular patient to its standard screening procedures); Repp v. Anadarko Mun. Hosp., 43 F.3d 519, 522 (10th Cir. 1994) (a hospital violates § 1395dd(a) when it does not follow its own standard procedures). 45 42 U.S.C.A. § 1395dd(e)(1) (emphasis added). 46 Slabik v. Sorrentino, 891 F. Supp. 235, 237 (E.D. Pa. 1995), aff’d, 82 F.3d 406 (3d Cir. 1996) (appropriate medical screening requirement does not cover failure to instruct how to obtain
- 188 -
care if condition failed to improve; once standard screening procedure determines no emergency medical condition, §1395dd(a) imposes no further obligations); Green v. Reddy, 918 F. Supp. 329, 334 (D. Kan. 1996) (where hospital found emergency medical condition and treated patient in ICU, there was no claim of improper screening). 47 42 U.S.C.A. § 1395dd(b)(1). 48 42 U.S.C.A. § 1395dd(e)(3)(A); see also 42 C.F.R. § 489.24(b). The assurance of whether material deterioration is likely to result in judged by a standard of “reasonable medical probability.” 42 U.S.C.A. § 1395dd(e)(3)(A). 49 Campbell v. Westchester County, 96 Civ 0467 1997 U.S. Dist. LEXIS 19750, at *9 (S.D.N.Y. Nov. 9, 1998) (§ 1395dd(b) does not require presentment at emergency room; instead, patient need only arrive at the hospital in an emergency condition, the hospital find the condition, and the hospital discharged patient prior to stabilizing him). 50 Lopez-Soto v. Hawayek, 175 F.3d 170, 177 (1st Cir. 1999)(where infant presented emergency condition in the operating room, hospital’s stabilization and transfer obligations under 42 U.S.C.A. § 1395dd(b) &(c) were triggered). 51 Reynolds v. Mercy Hosp., 861 F. Supp. 214, 222 (W.D.N.Y. 1994). 52 Slaven v. Mee Noodle Shop & Grill, 96 Civ. 0374 1998, U.S. Dist. LEXIS 15049, at *15-16 (S.D.N.Y. Sept. 24, 1998) (where hospital discharged patient without detecting hip fracture, EMTALA’s stabilization requirement did not apply to allegation that hospital failed to stabilize his fracture); Vickers v. Nash Gen. Hosp., 78 F.3d 139, 145 (4th Cir. 1996) (EMTALA does not hold hospitals accountable for failing to stabilize conditions of which they are not aware, or even conditions of which they should have been aware); Scott v. Hutchinson Hosp., 959 F. Supp. 1351, 1357-58 (D. Kan. 1997)(hospital’s duty to provide appropriate treatment arises once the hospital determines that an emergency condition exists; thus, where hospital never determined that patient had aneurysm, no duty to provide treatment for condition arose). 53 Holcomb v. Monahan, 30 F.3d 116, 117 (11th Cir. 1994) (to succeed on a § 1395dd(b) claim, a plaintiff must present evidence that the patient had an emergency medical condition, the hospital knew of the conditions, the patient was not stabilized before being transferred, and the hospital neither obtained the patient’s consent to transfer nor completed a certificate indicating the transfer would be beneficial to the patient and was appropriate); Jones v. Wake County Hosp. Sys., Inc., 786 F. Supp. 538, 543-44 (E.D.N.Y. 1991) (§ 1395dd(b)(1) requires stabilizing treatment for “emergency medical conditions” that a hospital has determined to exist, and thus, no claim stated where hospital did not treat undiagnosed sepsis); Anadumaka v. Edgewater Operating Co., 823 F. Supp. 507, 510 (N.D. Ill. 1993) (where plaintiff alleged misdiagnosis rather than failure to treat diagnosed emergency medical condition, hospital cannot be in violation of stabilization requirement). 54 Campbell v. Westchester County, 96 Civ. 0467 1998, U.S. Dist. LEXIS 17757, at *8 (S.D.N.Y. 1998) (where patient arrived for a scheduled appointment complaining of severe head pain, but only significant problem detected was high cholesterol, plaintiff was not in an “emergency condition” for the purposes of § 13955dd(b) stabilization requirement). 55 In the matter of Baby “K”, 16 F.3d 590 (4th Cir. 1994), cert. denied, 513 U.S. 825, 115 S. Ct. 91 (1994). 56 Id. at 597. 57 42 U.S.C.A. § 1395dd(b)(2). 58 Id. 59 Roberts v. Galen of Virginia, Inc., 525 U.S. 249, 253 (1999) (Court of Appeals erred in ruling that EMTALA stabilization suit required showing of improper motive such as indigence, race or sex of the patient, expressly in contrast with Cleland on this point for § 1395dd(b)). 60 See Bryan v. Rectors & Visitors of the Univ. of Virginia, 95 F.3d 349, 352 (4th Cir. 1996) (finding that hospital satisfied EMTALA’s stabilization requirement by treating patient for twelve days, after which the hospital entered a “Do Not Resuscitate” order and the patient died eight days later). 61 42 U.S.C.A. § 1395dd(e)(4); see also 42 C.F.R. § 489.24(b). 62 42 U.S.C.A. § 1395dd(c)(1); see also 42 C.F.R. § 489.24(c).
- 189 -
63 42 U.S.C.A. § 1395dd(c)(2); see also, 42 C.F.R. § 489.24(d) (the regulations do not contain any requirements that are not contained in the statute). 64 Urban By and Through Urban v. King, 43 F.3d 523, 526 (10th Cir. 1994) (a claim for improper transfer requires that hospital had actual knowledge of emergency condition); Summers v. Baptist Med. Ctr. Arkadelphia, 91 F.3d 1132, 1140 (8th Cir. 1996) (where the hospital believed that plaintiff was suffering from only muscle spasms, not an emergency medical condition, the duty to stabilize never arose); Baber v. Hospital Corp. of America, 977 F.2d 872, 883 (4th Cir. 1992) (EMTALA’s transfer requirements do not apply unless the hospital actually determines that the patient suffers from an emergency medical condition); Green v. Reddy, 918 F. Supp. 329, 335 (D. Kan. 1996) (where hospital did not find emergency medical condition of which plaintiff complained, there was no duty of stabilization or proper transfer); Gerber v. Northwest Hosp. Ctr., Inc., 943 F. Supp. 571, 577 (D. Md. 1996) (failure to stabilize only applies to emergency medical conditions they actually detect, not for conditions they were not aware or should have been aware of); Scott v. Hutchinson Hosp., 959 F. Supp. 1351, 1358 (D. Kan. 1997) (once a hospital determines that emergency medical condition exists, that is sufficient to trigger § 1395dd(c) obligations discharging or transferring patient, even if hospital is not aware of all of patients’ emergency conditions; duty under § 1395dd(c) arose where hospital was aware of emergency cardiac condition, even when it was not aware of the emergency bleeding condition; however, the duty to stabilize a condition only applies to the known condition). 65 Reynolds v. Mercy Hosp., 861 F. Supp. 214 (W.D.N.Y. 1994) (where plaintiff did not submit any evidence that he was in an “emergency medical condition” that was not stabilized at the time of transfer, plaintiff’s cause of action failed); Taylor v. Dallas County Hosp. Dist., 959 F. Supp. 373, 378 (N.D. Tex. 1996) (where plaintiff never suffered from severe pain and was never at risk of seriously impairing his bodily functions or organs, plaintiff did not suffer from emergency medical condition requiring stabilization prior to discharge under 1395dd(c)); see also Huckaby v. East Alabama Med. Ctr., 830 F. Supp. 1399, 1402 (M.D. Ala. 1993) (where plaintiff alleged that she came to the hospital suffering from a stroke and that she was transferred before being stabilized, plaintiff made out a claim under EMTALA). 66 42 USCS § 1395dd (b)(3). 67 Id. 68 42 U.S.C.A. § 1395dd(g). 69 42 U.S.C.A. § 1395dd(i). 70 42 U.S.C.A. § 1395dd(i)(1)(A). 71 42 U.S.C.A. § 1395dd(i)(1)(B). 72 42 C.F.R. § 489.53(b). 73 42 U.S.C.A. § 1395dd(d)(1)(B)(ii). 74 42 U.S.C.A. § 1395dd(d)(2)(A). 75 42 U.S.C.A. § 1395dd(d)(2)(B). 76 Teresa A. Williams, Recent Case Law Decisions and Interpretive Guidelines Expand the Scope of EMTALA Obligations, in HEALTH LAW HANDBOOK 305 (Alice G. Gosfield ed., 2000). 77 42 U.S.C.A. § 1395dd(d)(1). 78 42 C.F.R. § 489.53(c). 79 42 U.S.C.A. § 1395dd(d)(1)(B). 80 42 U.S.C.A. § 1395dd(d)(1)(B)(ii). 81 42 U.S.C.A. § 1395dd(d)(2)(A); Baber v. Hospital Corp. of America, 977 F.2d 872, 878 (4th Cir. 1992); Fisher v. New York Health and Hosp. Corp., 989 F. Supp. 444, 448 (E.D.N.Y. 1998) (EMTALA does not create a private cause of action against individual physicians); Jones v. Wake County Hosp. Sys., Inc., 786 F. Supp. 538, 545 (E.D.N.C. 1991) (§ 1395dd(d)(2) only provides private cause of action against participating hospitals, not individual physicians); Lane v. Calhoun-Liberty County Hosp. Ass’n, Inc., 846 F. Supp. 1543, 1548-49 (N.D. Fla. 1994); Smith v. Janes, 895 F. Supp. 875, 879 (S.D. Miss. 1995) (EMTALA does not allow private right of action against individual treating physicians); Reynolds v. Mercy Hosp., 861 F. Supp. 214, 220 (W.D.N.Y. 1994). 82 Lane v. Calhoun-Liberty County Hosp. Ass’n, Inc., 846 F. Supp. 1543. 1552 (N.D. Fla. 1994).
- 190 -
83 42 U.S.C.A. § 1395dd(d)(2)(B). 84 42 C.F.R. §489.20(m). 85 Assemblyman Hevesi in support of Law of 1983, chapter 787. 1983, ch. 787, 86 N.Y. PUB. HEALTH LAW § 2805-a (McKinney 1993 & Supp. 1999-2000). 87 N.Y. PUB. HEALTH LAW § 2805-b(2) 88 N.Y. PUB. HEALTH Law §2801(10) 89 N.Y. PUB. HEALTH LAW § 2805-b 90 N.Y. PUB. HEALTH LAW § 2805-b(2). Note that the requirement under EMSRA to provide emergency treatment to people in need only extends to cities with a population greater than one million. As discussed below, all New York cities, regardless of size, are bound by EMSRA’s requirement to admit patients in need of immediate hospitalization. 91 People v. Anyakora, 162 Misc. 2d 47, 55 (N.Y. Gen. Term 1993). 92 Id. 93 Palmieri v. Cuomo, 566 N.Y.S.2d 14 (N.Y. App. Div. 1991). 94 N.Y. PUB. HEALTH LAW § 2805-b(2)(b). 95 N.Y. PUB. HEALTH LAW § 2805-b(2)(C). 96 N.Y. PUB. HEALTH LAW § 2805-b(3). 97 N.Y. PUB. HEALTH LAW § 2805-b(1). 98 Id. 99 Id. 100 N.Y. PUB. HEALTH LAW § 2805-b(1). 101 Id. 102 N.Y. PUB. HEALTH LAW § 2805-b(2)(a)–(b). 103 N.Y. PUB. HEALTH LAW § 12-b. 104 N.Y. PUB. HEALTH LAW § 2805-b(2). 105 See People v. Anyakora, 162 Misc. 2d 47 (N.Y. Sup. Ct. 1993) and People v. Flushing Hosp. Med. Ctr., 471 N.Y.S.2d 745 (N.Y. Crim. Ct. 1983) 106 N.Y. PUB. HEALTH LAW § 2801-(c). 107 Quijije v Lutheran Med. Ctr., 460 N.Y.S.2d 600 (N.Y. App. Div. 1983). 108 See People v. Flushing Hosp. Med. Ctr., 471 N.Y.S.2d 745 (1983). 109 People v. Anyakora, 616 N.Y.S.2d 149 (1993). See also People v. Flushing Hosp. Med. Ctr., (N.Y. Crim. Ct. 1983) 471 N.Y.S.2d 745 (1983) (interpreting EMSRA in conjunction with § 12-b of the Public Health Law, which declares that a “willful” violation of any provision of the Public Health law is a misdemeanor, but stating that “willful” in the EMSRA context requires only that the denial was a deliberate and voluntary act of a person acting as an agent of the hospital.). 110 N.Y. PUB. HEALTH LAW § 2801-(c). 111 See Operating Agreement, Preamble. See also N.Y. UNCONSOL. LAW § 7382 (McKinney 2000). 112 N.Y. UNCONSOL. LAW § 7383(13). 113 See also HHC: Frequently Asked Questions, http://www.ci.nyc.ny.us/html/hhc/faq.html (accessed July 20, 2000). 114 Council of City of New York v. Giuliani, 662 N.Y.S.2d 516 (N.Y. App. Div. 1997), leave to appeal granted, 92 N.Y.2d 801, 677 N.Y.S.2d 71, 699 N.E.2d 431, aff’d 93 N.Y.2d 60, 687 N.Y.S.2d 609, 710 N.E.2d 255 (N.Y. 1999) 115 Council of City of New York v. Giuliani, 687 N.Y.S.2d 609, 614 (N.Y. 1999). 116 See Council of City of New York, 662 N.Y.S.2d at 519. But see Hamburg v. McBarnette, 83 N.Y.2d 726, 635 N.E.2d 1225 (N.Y. 1994) (holding that state Department of Health's denial of reimbursement to city agencies including HHC might be incorrect, since those agencies were not “legally responsible” for providing the health services in question). 117 N.Y. UNCONSOL. LAW § 7382. 118 N.Y. PUB. HEALTH LAW § 2805-b(1); 42 U.S.C.A. § 1395dd 119 N.Y. UNCONSOL. LAW § 7382. 120 N.Y. PUB. HEALTH LAW § 2805-b(1); 42 U.S.C.A. § 1395dd. 121 42 U.S.C.A. § 291c(e).
- 191 -
122 Letter from Jacqueline Huey, New York City Health and Hospitals Corporation Revenue Management Department, to Jill Lebwohl (October 31, 2000). 123 The facilities obligated to abide by the New York State Patients’ Bill of Rights include the following: general hospitals, public health centers, diagnostic centers, treatment centers, dental clinics, dental dispensaries, rehabilitation centers (other than centers used solely for vocational rehabilitation), nursing homes, tuberculosis hospitals, chronic disease hospitals, maternity hospitals, lying-in-asylums, out-patient departments, out-patient lodges, dispensaries and some laboratories. N.Y. PUB. HEALTH LAW § 2801(1). 124 Telephone Interview with Jacqueline Huey, New York City Health and Hospitals Corporation, Revenue Management Department (Apr. 11, 2001). 125 Executive Order No. 29, “Individual Self-Pay Ambulatory Fee Adjustment”, HHC (Jan. 1, 1985). 126 Letter from Jacqueline Huey, New York City Health and Hospitals Corporation Revenue Management Department, to Jill Lebwohl (Oct. 31, 2000). 127 HHC Home Page, Multi-Cultural Services, at http://www.ci.nys.ny.us/html/hhc/html/multi.html (last visited April 4, 2001). 128 N.Y. UNCONSOL. LAW § 7401(2). 129 N.Y. UNCONSOL. LAW § 7401(2). 130 N.Y. UNCONSOL. LAW § 7401(1). 131 N.Y. PUB. AUTH. LAW § 2980. 132 N.Y. PUB. AUTH. LAW § 2981. 133 N.Y. UNCONSOL. LAW § 7401(1). 134 The Green Book 2000-2001: Official Directory of the City of New York 168-72 (Krishna Kirk ed., 2000); Fax from DeJares Gantt, HHC Office of Child Health, (212) 442-4818, (Jan. 5, 2001). 135 Please note that facilities listed in italics are obligated under Hill-Burton to provide uncompensated care 136 10 N.Y. COMP. CODES R. & REGS. tit. 10 § 405.7 (2000). 137 42 U.S.C.A. Section 291(a) (emphasis added). 138 42 U.S.C.A. Section 291c(e). 139 42 C.F.R. § 124, Subparts F and G. 140 See “The Fiscal Year 1999 Hill-Burton Profile”, at http://www.hrsa.gov/osp/dfcr/about/dfcrpub.htm (accessed May 3, 2001). 141 42 U.S.C.A. §§ 300q–300t (West 1991). 142 See “The Fiscal Year 1999 Hill-Burton Profile”, at http://www.hrsa.gov/osp/dfcr/about/dfcrpub.htm (accessed May 3, 2001). 143 Fax from Eulas C. Dorch, Director, Health Resources and Services Administration, Division of Facilities Compliance and Recovery, (301) 443-8007 (May 7, 2001). 144 42 C.F.R. § 124.501. 145 Id. 146 Id. 147 42 C.F.R. § 124.513. 148 42 C.F.R. § 124.514. 149 42 C.F.R. § 124.515. 150 42 C.F.R. § 124.516. 151 See “The Fiscal Year 1999 Hill-Burton Profile”, at http://www.hrsa.gov/osp/dfcr/about/dfcrpub.htm (accessed May 3, 2001). 152 42 C.F.R. § 124.506(a)(1)(i). 153 See “Frequently Asked Questions by Consumers about Receiving Hill-Burton Free or Reduced Cost Care”, at http://www.hrsa.dhhs.gov/osp/dfcr/obtain/consfaq.htm (accessed Nov. 3, 2000). 154 42 C.F.R. § 124.505(a)(1). 155 See “Frequently Asked Questions by Consumers about Receiving Hill-Burton Free or Reduced Cost Care”, http://www.hrsa.dhhs.gov/osp/dfcr/obtain/consfaq.htm (accessed Nov. 3, 2000). 156 42 C.F.R. § 124.506.
- 192 -
157 42 C.F.R. § 124.503(a). 158 Id. 159 42 C.F.R. § 124.503(b). According to Michelle Kanner, Chief, Policy Information Branch, Health Resources and Service Administration, Office of Special Programs, most of the facilities listed in Supplement A as obligated to provide uncompensated care failed to meet their compliance levels in past years and are making up these deficits. Telephone Interview with Michelle Kanner, (301) 443-1022 (Nov. 3, 2000). 160 42 C.F.R. S.124.503(c). 161 42 C.F.R. § 124.505(a)(2)(i). 162 42 C.F.R. § 124.505(a)(2)(ii). 163 42 C.F.R. § 124.505(a)(2)(iii). 164 42 C.F.R. § 124.504(c). 165 Id. 166 Id. 167 42 C.F.R. § 124.504(a). 168 Id. 169 42 C.F.R. § 124.504(b). 170 Id. 171 Telephone Interview with Eulas C. Dortch, Director, Health Resources and Services Administration, Division of Facilities Compliance and Recovery, (301) 443-8007 (May 4, 2001). 172 See “Frequently Asked Questions by Consumers about Receiving Hill-Burton Free or Reduced Cost Care”, at http://www.hrsa.dhhs.gov/osp/dfcr/obtain/consfaq.htm (accessed May 2, 2001). 173 42 C.F.R. § 124.507(a). 174 42 C.F.R. § 124.507(b)(1). 175 42 C.F.R. § 124.507(b)(2). 176 Id. 177 42 C.F.R. § 124.507(b)(3). 178 42 C.F.R. § 124.507(c)(1)(i). 179 42 C.F.R. § 124.507(c)(1)(ii). 180 42 C.F.R. §.124.507(c)(2). 181 42 C.F.R. § 124.506(a)(1). 182 Id. 183 Telephone Interview with Eulas C. Dortch, supra note 171. 184 42 C.F.R. § 124.506(a)(2). 185 42 C.F.R. § 124.508. 186 42 C.F.R. § 124.511(a). 187 42 C.F.R. § 124.511(a)(1). 188 Id. 189 42 C.F.R. § 124.511(b). 190 42 C.F.R. § 124.511(a)(2). 191 42 C.F.R. § 124.511(a)(3). 192 Id. 193 42 C.F.R. § 124.511(c). 194 42 C.F.R. § 124.512(a). 195 42 C.F.R. § 124.512(b). 196 Id. 197 42 C.F.R. § 124.512(c). 198 42 U.S.C.A. § 300s-6 (1999). 199 42 C.F.R. § 124.511(a)(4); See Gordon v. Forsyth County Hosp. Authority, Inc. 409 F. Supp. 708 (D.C.N.C. 1976), aff’d in part and vacated in part on other grounds, 544 F.2d 748 (4th Cir. 1976).
- 193 -
200 White v. Moses Taylor Hosp., 763 F. Supp. 776 (M.D. Penn. 1991), plaintiff’s summary judgment motion denied, 841 F. Supp. 629 (M.D. Penn. 1992) (denying relief where plaintiff sought to be relieved of her debt to a hospital). 201 Flagstaff Med. Ctr. v. Sullivan, 962 F.2d 879 (9th Cir. 1992) (affirming lower court order requiring hospital to reimburse Hill-Burton eligible plaintiffs who were denied uncompensated care and to cease collection actions against them). 202 42 C.F.R. § 124.603(a)(1). 203 42 C.F.R. § 124.601. 204 Telephone Interview with Eulas C. Dortch, supra note 171. 205 42 C.F.R. §.124.604. 206 42 C.F.R. § 124.603(a)(2), (b)(1). 207 Telephone Interview with Eulas C. Dortch, supra note 171. 208 Id. 209 42 C.F.R. § 124.603(c)(2). 210 42 C.F.R. § 124.603(a)(1), (d)(1). 211 42 C.F.R. § 124.603(b)(1). Note that federal law and New York state law compliment this requirement with additional provisions. See Chapter Two. 212 42 C.F.R. § 124.603(a)(1). 213 Id. 214 42 C.F.R. § 124.603(b)(2). 215 See 42 C.F.R. § 124.606 for a description of the procedures to follow in filing a complaint. Note that the filing procedures are identical under the uncompensated care and community service regulations. 216 See “How to File a Complaint with OCR”, at http://www.hhs.gov/ocr/hbfile.html (accessed May 3, 2001). 217 Id. 218 42 C.F.R. § 124.606(a)(4). 219 Id. 220 Fax from Eulas C. Dortch, supra note 143; HRSA website, at http://www.hrsa.dhhs.gov/osp/dfcr/obtain/hbstates.htm. (Users of this manual should check with individual facilities for the most current information about Hill-Burton obligations as many of these facilities may be nearing the end of their 20-year obligation.) Please note that these facilities also are obligated by the community care requirement. See Supplement D for a list of New York City facilities obligated by the community care requirement only. 221 Fax from Eulas C. Dortch, supra note 143; HRSA website, at http://www.hrsa.dhhs.gov/osp/dfcr/obtain/hbstates.htm. Please note that these facilities also are obligated by the community care requirement. See Supplement D for a list of New York City facilities obligated by the community care requirement only. 222 Source: E-mail communication from Brenda Brown, Office of Civil Rights. This list includes all the facilities listed under Supplements A and B (facilities obligated by both the uncompensated care and community service requirements) as well as facilities obligated only by the community service requirement. Facilities obligated by BOTH requirements are listed in italics. 223 N.Y. COMP. CODES R. & REGS. tit. 10, § 405.7(b)(2) (2000) (emphasis added). 224 N.Y. COMP. CODES R. & REGS. tit. 10, § 405.7(a)(7) (2000). 225 N.Y. COMP. CODES R. & REGS. tit. 10, § 405.7(a)(7)(ii) (2000). 226 N.Y. COMP. CODES R. & REGS. tit. 10, § 405.7(a)(7)(i) (2000). 227 42 U.S.C.A. § 2000d et seq. 228 Id.; Policy Guidance on the Prohibition Against National Origin Discrimination as it Affects Persons with Limited English Proficiency, 65 Fed. Reg. 52762 (Aug. 30, 2000). 229 Id. 230 Id. 231 New York City Code § 17-174 (2001) 232 42 U.S.C.A. § 12101 et seq.
- 194 -
233 29 U.S.C.A. § 794. 234 N.Y. COMP. CODES R. & REGS. tit. 10, § 405.7(b)(23) (2000). 235 Id. 236 Id. 237 Id. 238 Telephone Interview with Mary Stevens, Coordinator for Hospital Complaints, New York State Department of Health (April 11, 2001). 239 N.Y. EXEC. LAW § 544-a(3)(c) (McKinney 199 & Supp. 1999-2000). 240 Medicaid Financial Eligibility Levels for New York, at http://www.nls.org/medichrt.htm (accessed on May 7, 2001). 241 Section 330 of the Public Health Service Act as amended by the Health Centers Consolidation Act of 1996. 242 Marilyn H. Gaston, M.D. Bureau of Primary Health Care, Health Resources & Services Administration, U.S. Department of Health and Human Services. Health Center Program Expectations. 98-23. August 17, 1998. Page 7. 243 Child Health Plus website, at http://www.health.state.ny.us/nysdoh/chplus/cplus-1.htm 244 N.Y. PUB. HEALTH LAW § 2510(7)(a) (McKinney 2000). 245 N.Y. PUB. HEALTH LAW § 2510(11) (McKinney 2000). 246 N.Y. PUB. HEALTH LAW § 2511(2)(a) (McKinney 2000). 247 N.Y. PUB. HEALTH LAW § 2511(2)(b), (c) (McKinney 2000). 248 N.Y. PUB. HEALTH LAW § 2511(2)(d) (McKinney 2000). 249 N.Y. PUB. HEALTH LAW § 2511(2)(e) (McKinney 2000). 250 2000 N.Y. Laws 419, § 61. 251 N.Y. PUB. HEALTH LAW § 2510(9)(c)(ii) (McKinney 2000). 252 Family Health Plus website, at http://www.health.state.ny.us/nysdoh/search/index.htm; Conversation with Mary Cherubin, State Dep’t. of Health, (518) 473-5330. 253 Health Care Financing Administration websites, at http://www.hcfa.gov/medicaid/medicaid.htm, and http://www.hcfa.gov/pubforms/actuary/ormedmed/default4.htm. 254 New York State Dep’t. Health website, at http://www.health.state.ny.us/nysdoh/commish/99/nyc1115.htm; http://www.medicare.gov; New York Lawyers for the Public Interest, “Advocates’ Manual on the Basics of New York State’s Medicaid Managed Care Program” (1999); Public Benefits Resource Manual, J10, p. 27- 31 (1998). 255 “2000 Guide to Health Insurance for People with Medicare,” Health Care Financing Administration (2000). 256 42 U.S.C.A. §§ 1395i-2, 1305o (2000). 257 New York State Health Insurance Information, Counseling and Assistance Program website, at http://www.hiicap.state.ny.us. 258 NYLPI Training Manual, unpublished; “Medicare Savings for Qualified Beneficiaries,” Health Care Financing Administration (March 2000); Public Benefits Resource Manual, J9, p. 1-3 (1998). 259 New York State Dep’t Health website at http://www.health.state.ny.us/nysdoh/school/skserv.htm; Conversation with Sandra Rivers, New York State Dep’t Health, Family Health Services, (212) 268-7889. 260 “2000 Guide to Health Insurance for People with Medicare,” Health Care Financing Administration at 70-72 (2000); 29 U.S.C.A. §§ 1162-63, 1165 (West 1999). 261 General information about EPIC was culled from the EPIC website, at http://www.health.state.ny.us/nysdoh/epic/faq.htm. The figures used in this program description refer to 2001 eligibility requirements. Citations to specific statutes also follow. 262 N.Y. EXEC. LAW § 547-a(1) (McKinney 2000). 263 N.Y. EXEC. LAW § 547-g(2). 264 N.Y. Exec. Law § 547-g(2). 265 N.Y. EXEC. LAW § 547-h(1)-(2).
- 195 -
266 N.Y. EXEC. LAW § 547-h(2)(i). 267 N.Y. EXEC. LAW § 547-h(2)(ii). 268 N.Y. EXEC. LAW § 547-h(3). 269 N.Y. EXEC. LAW § 547-h(4). 270 N.Y. EXEC. LAW § 547-b. Prior to January 1, 2001, the income eligibility limits were significantly lower--$18,500 for singles and $24,400 for people who are married. The state legislature passed legislation in May 2000 to raise these limits. 271 N.Y. EXEC. LAW § 547-b(3)(a). 272 N.Y. EXEC. LAW § 547-b(3)(b). 273 N.Y. EXEC. LAW § 547-b(c). 274 N.Y. COMP. CODES R. & REGS. tit. 10, § 43-2.5 (1995) (regulation cover drug prescription program only); New York State Dep’t of Health, HIV Uninsured Care Programs Descriptions, received from Christine Rivera, Deputy Director, HIV Uninsured Care Programs, (800) 542-2437 or (518) 459-1641. 275 New York State Health Insurance Information, Counseling and Assistance Program website: http://hiicap.state.ny.us and New York State Partnership for Long-Term Care website: http://www.nyspltc.org
- 196 -
- 197 -