Santa Clara County
Ability to Pay Determination Program
751 S. Bascom Avenue
San Jose, CA 95128
ABILITY TO PAY DETERMINATION (APD) PROGRAM MANUAL & FINANCIAL
ASSISTANCE APPLICATION GUIDANCE
This manual has been updated to reflect certain changes in the APD program and reflects the
program requirements as of June 20, 2012.
SECTION
INDEX
DESCRIPTION
PAGE
I
Introduction
II
General Description
APD Eligibility
Interviewing & Documentation
Program Organization
Requests for Review of APD
III
Program Definitions
What is a Family
What is Income
What are Liquid Assets
IV
APD Program Administration
Determining Family Size
Determining Gross Income
Determining APD Financial Status
V
APD Program Questions & Answers
VI
Appendix A
Revised by:
Santa Clara Valley Health & Hospital System
SCVHHS Administration
September 2012
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ABILITY TO PAY DETERMINATION PROGRAM
Program Guidelines & Procedures
2012
1 Introduction:
The Ability to Pay Determination (APD) Program was developed by Santa Clara County
pursuant to and in connection with the 1983 transfer of the Medi-Cal Medically Indigent Adult
(MIA) Program to County responsibility. The APD program has been designed to provide
services from or arranged through SCVMC or its affiliated clinics (known as the Valley Health
Centers) to certain indigent residents of Santa Clara County in accordance with their ability to
pay for these services.
Each year since 1983, the State of California has allocated monies to counties to help offset the
cost of providing care for this population of patients. However, this allocation is insufficient to
pay for all possible services, and therefore, monitoring and utilization controls have been put in
place to help contain medical cost in Santa Clara County. The program has also been designed
to be as administratively efficient and as cost effective as possible so that the County of Santa
Clara can employ its limited resources in direct patient care.
The APD program is intended for County residents who currently have no third party coverage
(such as Medicare, full scope Medi-Cal, Healthy Families, Health Kids, Valley Care, or
commercial insurance). Through the financial screening process, the Santa Clara Valley Health
& Hospital System’s (SCVHHS) Patient Access staff will review the applicant’s eligibility for
all publicly-sponsored insurance and coverage programs; there are currently 16 such programs.
Once a patient is determined not to be eligible for any of the 16 programs through the initial
screening, they will be screened for APD eligibility.
Where patients appear to qualify for other government sponsored health care programs (such as
Medi-Cal or Breast Cancer Early Detection Program), they will be required to apply for these
programs before and be denied as ineligible before they may participate in the APD program.
Thus, for patients who appear eligible for another program, they must apply for the other
program and be denied before having their application reviewed for APD eligibility. If the
applicant does not appear to be eligible for another program through the initial financial
screening process, the Financial Assistance (APD) Application is the only application required to
be completed.
Additionally, when patients are eligible for other programs which have coverage for specific
conditions or diagnosis or episodes of care, the patient may be covered by APD for only those
conditions, diagnosis or episodes of care which are not covered by other third parties or
coverage. Examples of this include but are not limited to:
 Access for Infants and Mothers Program (AIM) - covering pregnancy and 60 days Post
Natal Care
 IMProving Access, Counseling and Treatment for Californians with Prostate Cancer
(IMPACT) -covers only prostate diagnosis and care
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

Breast and Cervical Cancer Treatment Program (BCCTP) – covers Breast and Cervical
Cancer Treatment only
Family Planning, Access, Care, Treatment Program (FPACT) – covers family planning
and STD-related services only.
Patients who are County residents and whose income meets APD guidelines may participate in
the APD program for outpatient services for a period of twelve calendar months, after which they
must reapply for APD. They must also answer a series of questions (see APD Determination
Period, below) upon each inpatient admission. These patients will be billed for services
received during this time period based on the applicable fee schedule (inpatient or outpatient)
which is based on income.
Looking forward to full implementation of the Patient Protection and Affordable Care Act (also
known as Health Care Reform) in 2014, it is the intent of Santa Clara Valley Medical Center to
move APD patients into a managed care environment within SCVHHS. This would assist
SCVHHS in improving the health of the community by moving APD patients from episodic to
managed care. As demonstrated through Valley Care and other coverage programs, moving
patients into managed care improves health and health outcomes while reducing hospital stays.
2 General Description:
2.1 APD Eligibility – In order for a County resident to enroll in any coverage program,
including APD, the applicant must submit a completed Financial Assistance Application and
required documentation to the Patient Access Department.
Financial Assistance Applications are available online at www.scvmed.org/valleycare as well as
at:
 Patient Access Department – 770 S. Bascom, San Jose
 SCVMC Admitting Department – 751 S. Bascom, San Jose
 VHC East Valley – 1993 McKee Rd, San Jose
 VHC Gilroy – 7475 Camino Arroyo, Gilroy
 VHC Milpitas – 143 N. Main, Milpitas
 VHC Sunnyvale – 660 S. Fair Oaks, Sunnyvale
The signed, completed Financial Assistance Application and all required documentation may be
faxed to Patient Access at 408-494-7848, or, scanned and emailed to:
[email protected]. Alternatively, the completed form and documents may be
dropped off in person at the Patient Access Department, located at 770 S. Bascom, San Jose.
Application forms will be considered complete only when submitted with all required
documentation. Incomplete applications will not be accepted and incomplete sets of
documentation will not be processed. If needed, a patient of SCVMC may request in writing a
14-day extension to provide the required documentation, recognizing that inpatients may not
have ready access to required documentation.
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2.2 Required Documentation – Applicants for publicly sponsored programs, as well as APD,
are required to provide proof of identity, income and residency. The applicant should bring
copies of the required documents. However, some programs require proof of US citizenship or
legal status. If the applicant is eligible for one of the programs requiring proof of citizenship or
status (including Medi-Cal and Valley Care), the applicant must bring the original document as
proof of citizenship or status, as required by the federal government.
2.3 Proof of Identity – all applicants must provide a photo ID and any one of the following:
 Driver’s license
 Passport
 Government issued ID card
 Work or school ID card.
2.4 Proof of Income – applicant must provide copies of all that apply:
 Paystubs (2 consecutive pay-stubs not older than 45 days from application date)
 Tax return (Current or previous year Federal Tax Forms. Current year if after April 15th
unless extension document provided)
 Military benefit statement
 Rental income receipts
 Cash income statements
 Award letter (Social Security, Disability, Unemployment, Worker’s Comp)
 Signed affidavit of no income.
 Bank statements and/or investment statements, only necessary when considering liquid
assets.
2.5 Proof of Residency in Santa Clara County - applicant must provide one of the following:
 Current rental contract/lease
 Mortgage statement
 Current utility bill (water, electric, gas, garbage. Cell phone bill is not accepted)
 Or affidavit of homelessness.
2.6 Proof of US Citizenship or legal status, if required:
 US Passport
 US birth certificate
 US Permanent Residency (green) card
 Visa
 Certificate of Naturalization (N-550 or N-570)
 Certificate of US Citizenship (N-560 or N-561).
2.7 APD Applications – Applications to participate in the APD program may be made at the
time of services, or up to three calendar months after the month of service. The interviewer or
applicant will complete the Financial Assistance Application form. This form lists several
questions that will allow Patient Access to determine if the patient should be referred to another
program such as Medi-Cal, or if other coverage may be present (such as litigation in accident
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cases). The applicant must supply all required documentation (identity, citizenship if applicable,
residency, income). A determination by Patient Access as to the patient’s APD status shall be
made within 30 days of the completion of the Financial Assistance Application form and the
provision of all required documents, and, is retroactive for services provided at SCVMC three
months prior to the application’s completion if services were rendered during that time.
2.8 Determining Ability to Pay – The patient’s ability to pay is based upon family size and
family income. Using the APD Determination Chart (Appendix A), the patient’s ability to pay
status is determined. The patient may have a co-payment depending on income level, due at the
time that the services are provided, for each outpatient visit or inpatient admission. The copayment applies to the patient Each adult family member must complete a separate application
and be responsible for their individual co-payment. The APD income scale used in determining a
patient’s APD status is updated annually based upon Federal medical care poverty guidelines.
All APD applications or reviews are, therefore, processed under the income scale in effect at the
time services were received.
2.9 APD Determination Period – . When a Financial Assistance Application is completed and
the applicant is determined to be eligible for APD, the eligibility determination will be good for
one year. Should the APD patient require inpatient or diagnostic services that generally require
authorization during that one year period, the patient will be asked for:
 New onset or new diagnosis of a medical condition that would link the recipient to
eligibility for Medi-Cal or another payer source.
 Changes in family size
 Changes in source or amount of income
 Changes in residence.
These questions help determine whether the patient might have become eligible for another
insurance or coverage program and if so, the patient will be assisted in completing an application
for full-scope Medi-Cal, etc.
Upon each inpatient admission to SCVMC, the patient’s APD status will be re-evaluated and the
inpatient APD determination chart utilized. If the medical bill is in excess of $250,000 in one
calendar year, liquid assets would be considered and continued eligibility determined,
At the expiration of the one year APD determination period, a renewal request for APD must be
made. The APD patient will be asked to confirm income, residency, family size and whether
there have been any changes in medical condition that could make him/her eligible for another
insurance program. If no changes have occurred, the patient will have an additional one year
determination period granted.
2.10 Timing of Applications – It shall be the policy of SCVMC to conduct financial screening
for all patients requesting a routine medical visit (primary or specialty care). If patients are not
insured and are not able to pre-pay for the visit, they are encouraged to complete a Financial
Assistance Application and be screened for coverage eligibility. If applications are not
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completed in advance of routine care visits, SCVMC will provide information about financial
screening at the visit and will send follow up information. Requests must be made no later than
three calendar months from the month of service for emergency or inpatient care provided.
2.11 Interviewing & Documentation – APD determinations may be made based upon an
interview with the patient or the patient’s representative or upon the completion of an application
which includes all required documentation..
Applications may be initiated by the patient, the patient’s representative, by SCVMC or its
affiliated clinics.
Potential program participants will be required to provide reasonable proof of identity, income
and residency in Santa Clara County. The interviewer may require additional documentation in
situations where the information provided appears unreasonable or contradictory. If SCVMC
receives information that the patient is not eligible for the program, or if the patient fails to
provide eligibility documentation, the application will be denied.
2.12 Program Organization – Applications for Financial Assistance programs, including APD,
may be made at emergency room registration area, in the Admitting Department, at Patient
Access; applications are also available at Patient Business Services. All APD determinations
shall be made or approved by Patient Access, which is also responsible for the appropriate
processing of the accounts of APD patients and issuing APD determination notices to patients.
2.13 Requests for Review of APD – Patients may request, within 30 days of the receipt of their
“Notice of APD Determination”, a review and explanation by contacting Patient Access. The
Patient Access staff will review the determination and notify the patient within 30 days as to
their findings. Should the patient remain unsatisfied as to their APD determination, the patient
may request, within 30 days, a review by the APD Review Committee. The Director of Patient
Access shall determine the membership of this committee. Actions of the APD Review
Committee may be appealed within 30 days to the Chief Financial Officer for a final review and
decision.
Patients who have any concerns over their care and treatment may also request a review by
contacting SCVMC’s Customer Service Department.
3 Program Definitions:
3.1 What is a “Family”?
For the APD Program, a family includes:
 Applicant
 Spouse (if any)
 Dependent children under age 21 (if any).
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3.2 What is “Income”?
Income is defined as gross income received by any family membe.r For persons 18 years and
older, the spouse and dependent children under 21 years of age (whether living at home or
not) are included in income and family size calculation.
This is income before any mandatory deductions (such as Federal taxes, State taxes, Social
Security) or voluntary deductions (such as credit unions, union dues, insurance premiums)
and includes overtime and tips. Income includes monies received or available from labor or
public assistance programs.
Examples of income would include:






Hourly wages
 interest or dividend
Retirement checks
 rental income
 Unemployment benefits
Disability insurance
 monies received from a trust fund
Temporary Assistance to Needy Families
 Child Support
Social Security (though Medicaid disregards Social Security)
Tips, bonuses, commissions.
Examples of non-income would include:
 Money received from sale of personal property
 School loans
 Any in-kind income, such as free rent, food or utilities.
3.3 What are liquid assets?
Liquid assets consist of cash or assets that can be easily and readily converted to cash.
Examples of liquid assets:
 Savings accounts
 Money market funds
 Stocks
 Checking accounts
 Bonds
 Cash on hand
4 APD Program Administration
4.1 APD Co-Payment
Patients who meet all APD program requirements are expected to pay the applicable co-payment
for each outpatient visit or inpatient admission at the time of service (see page….). If payment is
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not made at time of service for inpatient and/or Emergency Department visits (following the
medical screening exam), the patient will be billed the co-pay amount. Payment must be made at
time of service for non-emergency services.
4.2 Determining Family Size
From information received during the interview or from other documents, Patient Access staff
will determine the size of the family.
The patient’s declaration of whether there is a spouse, children or other persons counted for tax
filing purposes and APD will be accepted unless the information provded seems unreasonable or
contradictory. . In such situations, the issue must be resolved with the patient through the
request of documentation and/or other source such as a credit check before the APD request can
be finalized.
4.3 Determination of Gross Income
The applicant’s gross income will be determined by the Financial Counselor based on the
information provided by the applicant. Acceptable documents verifying the current monthly
income are described in Section 2.4 (above). Sections 3.2 describes what is considered income
and who is counted as part of the family, both are taken into consideration.
4.4 Determination of APD Financial Status
Table A will be used to determine a patient’s APD financial status (to participate in APD, factors
in addition to financial, such as residency, also apply).
4.5 Determination of liquid assets
The liquid assets of a family are the sum of those assets belonging to each family member that
are in the form of cash or can be easily converted to cash. Liquid assets will be divided by 12
and added to the monthly income used in determining a patient’s APD status, in cases when
medical bills are in excess of $250,000 in one calendar year.
5 APD Program Questions & Answers
5. 1Who may request an APD determination?




Patients
Individuals authorized by the patient to act in their behalf
Patient’s guarantor or guardian
In those situations where the patient is unable to apply for APD, SCVMC or other County
staff may make a request for the patient
5.2 When must the patient make a request for APD?
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
No later than three calendar months from the month of service.
5.3 Are non-county residents able to participate in the APD program?

No.
5.4 How is County residency defined?


For the APD program, residency is defined as the place where the person is currently
living with the intent to remain. There is no minimum period of residency.
A valid driver’s license, current rental agreement or current utility bill can demonstrate
residency.
5.5 What is the APD period?

The APD enrollment period is twelve months.
5.6 May the patient’s APD status be redetermined during this period?


Yes. Upon every inpatient admission or at the option of SCVMC, the patient’s APD
status can be redetermined.
The patient may also request a redetermination should their income or family size change
during the APD period. This request must be made within 90 days of the end of the APD
period.
5.7 Are welfare cash payments considered income?

Yes.
5.8 Do persons on General Assistance qualify for APD?

Yes
5.9 What is not considered income?

Any in-kind support such as free rent, utilities or food.
5.10 Are there any deductions to income such as taxes or child support?

No. The formula is based on gross income.
5.11 Do people in a household have to be related by blood or marriage to be considered a
family?
Generally yes. Family member means the following persons living in the home:
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(1) A child or sibling children.
(2) The parents married or unmarried of the sibling children.
(3) The stepparents of the sibling children.
(4) The separate children of either unmarried parent or of the parent or stepparent.
(b) If there are no children, family member means a single person or a married couple.
5.12 What if a household includes a cousin or grandparent?

The cousin or grandparent would not be included in the family determination.
5.13 Can people with insurance, full scope Medi-Cal or Medicare participate in APD?


No. However, in those situations where the services are not covered by these programs
or where coverage is insignificant, the patients may request an APD review.
Persons on full scope Medi-Cal, Valley Care, Healthy Families, Healthy Kids or
Medicare may not participate in APD.
5.14 Can a person in custody participate in APD?

No.
5.15 What about patients who may qualify for other health care programs (such as MediCal)?

Patients who appear to qualify for another health care program based on initial screening
must apply and have a determination rendered for that program before their APD
application can be acted upon. If the patient fails to cooperate or complete the
application process of such a program, their APD application will be denied.
5.16 Are services received at other providers covered under APD?

Only services provided by or arranged through SCVMC or its affiliated clinics are
covered under APD.
5.17 What if the patient cannot be located or mail is returned?

It is the patient’s responsibility to follow through in completing an application for APD.
Financial Assistance Applications must be completed in full and any additional
documents requested provided. When a patient cannot be reached due to the patient
moving or having given incorrect information, the application shall be denied and the
account processed as an unsponsored patient’s account.
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5.18 Is the APD program participant actually forgiven the obligation of ever paying for the
services received?

The obligation is not forgiven, although no effort will be made by the County to collect
for such services unless sufficient surplus assets and or property (after meeting the
support needs of the patient and family) is received in the future, such as the settlement of
an outstanding medical cost related litigation.
5.19 What if a patient makes a payment or deposit on an account and later is determined to
have APD, will a refund be made?

No. The patient is still responsible for the charges incurred so any payments merely
reduce their liability. However, in unique situations where this has created an extreme
financial hardship for the patient, the situation should be referred to the APD Review
Committee for resolution.
5.20 What if the patient disagrees with their APD determination?

Patients may request a review within 30 days from the date of the initial determination.
Such requests should be made directly to the Patient Access Department at (408)4947863.
5.21 How are patients informed about the APD program?

Signs are posted at all registration points, advising patients about the APD program. On
all bills sent to unsponsored patients, messages also advise patients about APD.
5.22 May patients visiting the United States with an active Visitor’s Visa in their passports
qualify for APD?
 No. However, if the Visa has expired, the patient may qualify if all other requirements
are met.
5.23 May patients with a foreign passport but no Visa qualify for APD?
 Yes, if the patient has already established residency and meets all other requirements.
5.24 May a person with a Consular ID be considered a resident?
 Yes. A Consular ID is a picture ID issued by the Mexican Consulate and does not
preclude a patient from establishing residency.
5.25 When does a person need to provide documentation of liquid assets?
 When a patient has medical bills in excess of $250,000 in a calendar year, the patient will
be required to provide documentation regarding liquid assets in order to re-determine
eligibility.
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5.26 Additional questions about APD?

Contact Patient Access at (408)494-7863..
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APPENDIX A
APD DETERMINATION CHART
INCOME
PATIENT OBLIGATION
Required Co-Payment
Federal
Poverty Level
0 – 75%
Outpatient
Visits
$10 per visit
$0 if homeless*
Ambulatory
Surgery
$25 per surgery
$0 if homeless
Emergency
Dept
$25 per visit
$0 if homeless
76 – 100%
$10 per visit
$0 if homeless*
$25 per surgery
$0 if homeless
$25 per visit
$0 if homeless
101 – 133%
$25 per visit
$50 per surgery
$50 per visit
134 – 150%
$25 per visit
$50 per surgery
$50 per visit
151 – 200%
$25 per visit
$50 per surgery
$50 per visit
201 – 250%
$35 per visit
$75 per surgery
$75 per visit
251 – 300%
$40 per visit
$100 per surgery
$100 per visit
$40 per visit
$100 per surgery
$100 per visit
301 – 350%
Inpatient
$50 per day
(cap at $100)
$0 if homeless
$50 per day
(cap at $100)
$0 if homeless
$100 per day
(cap at $200)
$100 per day
(cap at $200)
$100 per day
(cap at $200)
$200 per day
(cap at $400)
$300 per day
(cap at $600)
$300 per day
(cap at $600)
Pharmacy Payment – Non-emergency prescriptions will be mailed, as will all refills (except
Class II and drugs requiring refrigeration), otherwise a $5 per prescription fee will be assessed.
Homeless APD patients excepted from pharmacy pick up fee.
* Applicants who are homeless attest to this fact when completing the application, or, notifying
Patient Access of the change in situation.
Program Notes:

Payment is expected to be made at the time of service. If payment is not collected at the
time of service, the co-payment will be billed.
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