Exhibit A: Financial Aid and Charity Care Policy CHECKLIST
Exhibit B1: 2021 Federal Poverty Guidelines (effective 3/1/2021)
Exhibit C1: Eligibility Table Based on Type of Service Provided and Application of Categories Based on Federal Poverty Guidelines (effective 4/1/2021)
Use the following to determine the patient’s financial responsibility:
• Determine the annual household income and family size.
• Use the Federal Poverty Guidelines Table (Exhibit B1) to determine the eligibility of patient.
• Locate the family size and determine what percentage of Federal Guidelines corresponds to patient’s income, i.e., Column 1, 2, 3, or 4.
• For Inpatient or High Cost Outpatient Services, go to the Eligibility Table (Exhibit C1) and (a) multiply the applicable patient responsibility percentage by the charges for those services, including the applicable HCRA surcharge for self-pay patients to determine the amount that the patient should be billed for each discharge or outpatient visit.
• For General Outpatient Services, go to the Eligibility Table (Exhibit C1) and use the co-pay amount set forth in the applicable column, based on the patient’s income and family size, i.e., Row F, G, H, I, J, K or L, to determine the patient financial responsibility which should be billed for each outpatient visit.
• Determine whether patient is eligible for an extended payment plan based on income and resources.
• Determine if other factors should be considered in further adjusting the amount of Charity Care or Financial Aid that the patient may receive. The appropriate member of Administration must approve any such exceptions in accordance with this Policy.