Application For Medicare Co-Insurance Waiver printable pdf download

Application For Medicare Co-Insurance Waiver

IMPORTANT NOTE:

All DMEPOS providers should seek legal counsel with regard to use of a financial hardship form.

Some attorneys suggest DMEPOS providers do NOT offer a financial hardship form to every

patient without secondary insurance. Provides should inform the patient of their payment

obligation, and to have the patient fill out the form ONLY if they indicate that they will be unable to

pay their portion. The patient should understand that they may or may not qualify for a hardship

waiver.

SAMPLE POLICY & PROCEDURE:

Policy:

Co-payment, deductible, or other owed amounts that are the patient’s responsibility under the

rules of the Medicare or Medicaid program or any other governmental or commercial third-party

payor may not be waived, except on a case-by-case basis upon a determination of financial need.

Routine waiver of co-payment, deductible, or other owed amounts may be a violation of federal

law and is a violation of

[Company]

policy.

Procedure:

Medicare/Medicaid and Federal Health Care Programs

Co-payment, deductible or other owed amounts may only be waived or reduced (including

"insurance only") if all three (3) of the following federal statutory requirements are met:

1. The waiver/discount was not advertised;

2. The waiver/discount is not routinely offered; and

3. The waiver/discount satisfies one of the following:

a. Is made after determining, in good faith, that the individual is in financial need, or

b. Is made after reasonable good-faith efforts to collect the co-payment or

deductible or other owed amounts from the patient have failed.

Application For Medicare Co-Insurance Waiver