Regulatory Terms and Conditions

Regulatory Terms and Conditions

The Community Care Foundation (“CCF”) is a Pennsylvania nonprofit corporation that is seeking federal tax-exempt status under IRC Section 501(c)(3). The Foundation’s charitable purposes will include administering a financial assistance grant program designed to fund up to 50% of out-of-pocket healthcare balances owed by patients who do not qualify for traditional charity care or financial assistance (or for whom charity care/financial assistance is insufficient) but who, based on objective measures of income, assets and other means/ability to pay, are unable to pay certain out-of-pocket expenses (as described above) for healthcare services. The Foundation’s primary focus will be on patients who opt out of needed care due to cost; however, patients with scheduled inpatient or outpatient procedures may also qualify. In addition to meeting income and asset thresholds/criteria, eligible patients will be required to be residents of the Southeastern Pennsylvania/New Jersey/Delaware region, and have qualifying out-of-pocket healthcare expenses.

The patient will also be required to meet certain other eligibility conditions (e.g., completion of Medicaid/other financial assistance applications, completion of financial education and counseling, ability to make the minimum down payment, and enrollment in an automated payment program for any balance remaining after the grant and down payment are applied, etc.). CCF uses a payment platform to maintain transaction histories for all grants issued to ensure that Foundation funds are only used for permissible purposes and to ensure compliance with all regulatory standards. CCF plans to solicit donations from a wide range of potential donors, including hospitals and other providers which may benefit from grants provided by CCF.

CCF has an exclusive partnership with FinPay to provide needed services to, and functions on behalf of CCF, including but not limited to certain management, personnel, compliance, and administrative services, including financial counseling services by FinPay payment specialists to grant applicants, automated payment software and support services, grant/payment processing and related services in connection with CCF’s grant programs. These services are designed to ensure the grants are used for proper charitable purposes and to assist patients in meeting their financial obligations. FinPay will also monitor all grant transactions in order to comply with regulatory requirements. All grantees will be required to establish a FinPay account so that the Foundation can validate that the grants are used for qualified healthcare expenses. All grantees will have complete “freedom of choice” to have their health care services provided by a provider of their choice, whether or not that provider has made a donation to the Foundation or has a contract with FinPay. Upon approval of a grant, the Foundation will transfer the grant funds to the grantee’s FinPay account and FinPay will then, at the appropriate time, transmit the necessary payment to the hospital or provider performing the services, including the grant funds and any required down payment from the patient. However, the provider will not be informed that the funds were provided by a grant from the Foundation and the provider will be unaware of whether the FinPay payment is being paid in whole or in part by the patient, a grant or otherwise.

More specifically, when CCF grant recipients choose to receive care from providers that have existing contracts with FinPay (“In-Network Providers”), grant payments will be processed in the same way that all other FinPay transactions (i.e., which do not involve CCF grant funds) are processed for such In-Network Providers’ patients with no indication as to whether the payments coming from FinPay accounts are comprised of patient funds, CCF grant funds or both. Fees for processing such FinPay account transfers (whether or not including grant funds) will be paid by the In-Network Providers to FinPay pursuant to their contracts with FinPay. FinPay will be responsible for processing, and will be compensated for processing, all patient payments for such In-Network Providers regardless of whether CCF grant funds are involved and will receive the same fees regardless of whether the transfer includes CCF grant funds. When CCF grant recipients choose to receive care from providers that do not have existing contracts with FinPay (“Out of Network Providers”), FinPay will contact such Out of Network Providers informing them that a patient would like to transfer funds to that provider from his/her FinPay account. The Out of Network Provider will be asked to undertake certain steps (e.g., establishing a merchant account with FinPay as it would for any commercial credit card company) to allow the transfer of such funds from the FinPay account. FinPay will not indicate to the Out of Network Providers whether the payments coming from FinPay accounts are comprised of patient funds, CCF grant funds or both, and we understand that there will be many other situations not involving CCF grant funds where FinPay will contact and set up a transfer with an Out of Network Provider in the exact same manner (i.e., the fact that FinPay contacts an Out of Network Provider will not necessarily indicate to that provider that the funds being transferred include CCF grant funds).

FinPay Platform Background FinPay, in conjunction with certain of its affiliates, contracts with hospitals and other healthcare providers to provide patient financial management solutions, including various financial services to increase the patients’ propensity to pay for the clinical services provided to them. FinPay does so by focusing on increasing the revenue capture rate of patient co-insurance, co-payments, deductibles and other out-of-pocket expenses related to those services. FinPay’s services include (i) the use of data analytics to identify common denominators of patients who may pose a higher financial risk to providers, (ii) development of financial clearance policies and processes for developing solutions for these high-risk patients, (iii) provision of on-site payment specialists to provide financial education & counseling and managing expectations on billing & claims to assist patients in understanding and meeting their financial obligations, as well as the availability of various grant programs to which they may apply, (iv) provision of more payment options (e.g., single payment, installment plan, credit/debit cards, bank/ACH transfers, and medical loans through a network of community banks), and (v) provision of a secure, cloud-based, automated platform to process those payments and pay the provider. FinPay’s platform will therefore be used to provide the patient financial management solutions outlined above, and then will serve as the conduit for transfer of payment for that portion of each patient’s payments through its automated system. FinPay’s platform also has integrated compliance tools that assist its hospital/ provider clients to be compliant with federal and state consumer protection laws, Internal Revenue Code (“IRC”) and other regulatory agencies.

Legal Requirements/ Guidelines. Under the federal Anti-Kickback Statute and the Civil Monetary Penalties Law (as described in more detail below), a hospital or other healthcare provider is generally prohibited from routinely waiving the payment of co-insurance, co-payments or deductibles by patients. The purpose of this restriction is to reduce the risk of inducing beneficiaries to over-utilize health care services covered under those government programs. A hospital/ provider is also prohibited from doing indirectly what it cannot do directly. Therefore, it is critical that the arrangements outlined above do not violate this proscription or other applicable laws. In general, the Anti-Kickback Statute, which is a criminal statute that includes significant penalties, including imprisonment, prohibits the payment of any “remuneration” to induce or in return for patient referrals or other business generated by the parties. The Civil Monetary Penalties Law6 prohibits offering certain remuneration/ inducements to patients to receive care from a particular provider. The outline below is based primarily on guidance from various advisory opinions issued by the OIG with respect to similar arrangements, and in particular, OIG Advisory Opinion #07-06 (re: the HealthWell Foundation), and OIG Advisory Opinions #15-06 and #15-14, as well as IRS guidelines.

I. Community Care Foundation Structure.

A. Organizational Structure

1. Nonprofit corporation organized under state law (Pennsylvania)

2. No members/shareholders; governed by self-perpetuating board of directors. 

3. Seek tax-exemption under Section 501(c)(3) of the IRC and non-private foundation status as a publically supported public charity

B. Basic 501(c)(3) Organizational/Operational Requirements

C. Other 501(c)(3) Standards/ OIG StandardsC. Other 501(c)(3) Standards/ OIG Standards

D. Independent Board of Directors

  • At least a majority of directors are independent (i.e., have no direct or indirect financial or employment relationship with Foundation, or affiliates, or any donor)
  • No direct or indirect healthcare donor representation on board of directors or on other decision-making bodies
  • Handles all policy-making functions for the Foundation

E. Independent Officers

  • Officers do not have financial or employment relationship with any affiliates 
  • Certain officers may be designated to serve as members of the governing board ex officio (e.g., Foundation CEO)
  • Compensation paid to officers must be reasonable and consistent with fair market value

F. Conflict of Interest Policy

  • No improper donor influence/control over Foundation or Program matters (e.g., selection of grantees, determination of eligibility criteria, charitable objectives, etc.)
  • Board members required to disclose potential conflicts of interest annually
  • Any board/committee members or other decision-makers must be recused from voting/discussion on matters with respect to which they have a conflict of interest

G. Charitable Beneficiary Class (for Grant-making)

  • Must define sufficiently broad “charitable class” of potential charitable recipients as to benefit public, and not private, interests
  • Beneficiaries may be limited to residents in a certain geographic area, who have certain healthcare needs, who do not have sufficient means to pay, etc.

H. Third-Party Management/Personnel and Administrative Services Agreements

1. Services provided must be commercially reasonable and compensation paid to third-parties must be consistent with fair market value of services provided9

2. Compensation should be fixed/objective and must not allow any sharing of Foundation net income/profits

3. Agreement between CCF and third-party service providers must be negotiated, terminated, renewed, overseen etc. by Foundation board (with recusal of any conflicted directors) or other independent/disinterested body (i.e., unrelated to  any donor)

4. Management and other personnel/operations must be segregated from third-party business operations (per OIG Advisory Opinion – HealthWell Foundation):

  • Ethical wall to maintain third-party segregation (i.e., confidentiality agreements, separate project teams/management/personnel, separate office space, separate IT systems and data/files, staff training, etc.)
  • Prohibition on third-party employees/agents soliciting donations to Foundation from healthcare donors (i.e., can solicit from other donors)11
  • Prohibition on third-party employees/agents proposing, developing or deciding upon eligibility criteria
  • Prohibition on Foundation tying, conditioning or connecting donations with third-party’s commercial business operations
  • Appointment of independent Compliance Auditor to oversee/audit above safeguards and report to Foundation board
  • Annual engagement of independent review organization to conduct independent audit of the above safeguards
  • Compensation paid to Foundation staff must be reasonable and consistent with fair market value and  not take into account any business generated for third-parties or donors

II. Program Design/AdministrationII. Program Design/AdministrationA. Objective, Uniform, Verifiable Eligibility Criteria

1. Eligibility for assistance based solely on documented financial need/inability to pay and other reasonable criteria (i.e., no consideration of healthcare provider identity, donors, referral sources, etc.)

2. Criteria must be verifiable and applied objectively and consistently 

3. All eligible patients receive assistance on a first-come, first-served basis to the extent funding is available

B. Community Outreach/Notice

1. CCF will make grant availability known to broader community in the geographic area served

2. CCF has implemented measures designed to reasonably publicize grant availability to members of the charitable class (e.g., website, brochures, advertisements, mailings, contact with and materials provided to providers, patients and community organizations/patient advocacy groups, etc.) given reasonable budgetary constraints

C. Foundation Independence from Healthcare Provider Donors

1. Donors may contribute effectively to support financially needy patients generally, including federal healthcare program beneficiaries, by contributing to independent, bone fide charitable assistance programs

2. Donors not permitted to exert any direct or indirect control or influence over Foundation, Program, grantee selection, eligibility criteria, allocation of funds, etc. 

3. No donor earmarks permitted for a particular treatment, procedure, service, disease/ condition, etc. that are unique to or only available from that specific donor (i.e., which might benefit a particular provider’s patients)

4. Foundation engages in broad charitable solicitations (i.e., not just from healthcare providers whose patients may receive grants)

5. No advantage/priority given to donors or patients of donors in the grant application and approval process

6. No reports or data provided to donors showing relationship between donated amounts and frequency of use of donors’ services or business generated for donors16

7. No individual grantee/patient information provided to any donor

8. Grants paid as to not identify to donor/provider that funds are coming from Foundation grants

9. Broad eligibility criteria 

D. No Improper Influence/Steering of Grant Recipients/PatientsD. 

1. Patients must have already consulted with physician or other healthcare provider and determined course of treatment prior to grant application

2. Patients must be notified that they are free to choose any provider and/or switch providers

3. Foundation must not refer, recommend or arrange for use of any particular provider, product, plan, etc.

4. Healthcare donors not identified, promoted or recommended to patients

 

 

    Etiam magna arcu, ullamcorper ut pulvinar et, ornare sit amet ligula. Aliquam vitae bibendum lorem. Cras id dui lectus. Pellentesque nec felis tristique urna lacinia sollicitudin ac ac ex. Maecenas mattis faucibus condimentum. Curabitur imperdiet felis at est posuere bibendum. Sed quis nulla tellus.

    ADDRESS

    63739 street lorem ipsum City, Country

    PHONE

    +12 (0) 345 678 9

    EMAIL

    info@company.com

    Cart