greenville health system policy and procedures · 2 | page 4. medicare look-back methodology-...
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GREENVILLEHEALTHSYSTEMPOLICYANDPROCEDURESManualofPolicyDirectives
POLICYNAME:FinancialArrangementsandAssistance POLICYNUMBER:S-020-08
EFFECTIVEDATE:October1,2016 SUPERSEDES:October1,2013 Revised:January31,2017
January 14, 2019
POLICYSTATEMENT:Inkeepingwithourmissiontohealcompassionately,teachinnovativelyandimproveconstantly,GreenvilleHealthSystem(GHS)iscommittedtoprovidingfinancialassistancetopatientswhocannotpayforallorapartoftheirbill.
AfurtherresponsibilityofGreenvilleHealthSystemrequiresittogeneratesufficientrevenuesinordertoprovidehighqualitypatientcareandtomaintainasoundfinancialposition.BecausetheprimarysourceofoperatingrevenueforGreenvilleHealthSystemconsistsofcollectionsforservicesrenderedtopatients,itisimperativethatreimbursementfrompatientsorotherresponsiblepartiesbeoptimized.Inordertoprovidefinancialassistanceresponsivetothecommunitiesservedandkeephospitalizationcostsataminimumforthecommunity,GreenvilleHealthSystemhasadoptedthispolicy.
AllfacilitiesoftheGreenvilleHealthSystemareavailabletopatientswithoutregardtorace,color,religion,age,sexornationaloriginoranyotherdiscriminatorydifferentiatingfactor.Emergencyserviceswillnotbedeniedbecauseofaninabilitytopay.Satisfactoryfinancialarrangementsarerequiredbeforeelectiveservicesarerendered.Electivecaseswithoutsatisfactoryfinancialarrangementsmaybedeferredwithphysicianconsent.
ThispolicyappliestothefollowingGHShospitals:
GHSGreenvilleMemorialHospitalandrelatedhospitalsandclinicsGHSGreerMemorialHospitalGHSHillcrestMemorialHospitalGHSLaurensCountyMemorialHospitalGHSNorthGreenvilleLongTermAcuteCareHospitalGHSPatewoodMemorialHospitalandrelatedhospitalsandclinicsGHSOconeeMemorialHospital
DEFINITIONS:
1. AGB-Amountsgenerallybilledforemergencyorothermedicallynecessarycaretoindividualswhohaveinsurancecoverage
2. ExtraordinaryCollectionActions(ECAs)-Actionstakentocollectadebt,includesbutnotlimitedtoreportingdebtstocreditbureaus,sellingdebttoathirdpartyandpursuingliens,garnishmentsandotherlegalactions.
3. FPG-FederalPovertyGuideline(publishedbytheU.S.DepartmentofHealthandHumanServices).
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4. MedicareLook-BackMethodology-calculationbasedonactualpastclaimspaidtothehospitalfacilitybyeitherMedicarefee-for-servicealoneorMedicarefee-for-servicetogetherwithallprivatehealthinsurerspayingclaimstothehospitalfacility(including,ineachcase,anyassociatedportionsoftheseclaimspaidbyMedicarebeneficiariesorinsuredindividuals).
5. ServiceCatchmentArea-Ageographicregionthatthehospitalserves.6. TertiaryCareFacility-Ahospitalthatprovidesspecializedcarebyspecialistsinalargehospital
afterareferralfromprimarycareandsecondarycare.Tertiarycentersusuallyincludethefollowing:
• Amajorhospitalthatusuallyhasafullcomplementofservicesincludingpediatrics,obstetrics,generalmedicine,gynecology,variousbranchesofsurgeryandpsychiatryor
• Aspecialtyhospitaldedicatedtospecificsub-specialtycare(pediatriccenters,oncologycenters,psychiatrichospitals).Patientswilloftenbereferredfromsmallerhospitalstoatertiaryhospitalformajoroperations,consultationswithsub-specialistsandwhensophisticatedintensivecarefacilitiesarerequire.
PROCEDURE:
SatisfactoryFinancialArrangements:Allfinancialarrangementswillbemadeusingthefollowingguidelinesafterthepatient’sstatusisdeterminedbythephysician:
1. EmergencyPatients:Assoonaspracticalafterstabilizingcareisrendered.2. UrgentPatients:Priortoadmissionorassoonaspracticalafterstabilizingcareisrendered.3. ElectivePatients:Priortorenderingservice.
Satisfactoryfinancialarrangementsmustbemadepriortodischargeinallinstances.Satisfactoryfinancialarrangementsmayconsistofanyoneoracombinationofthefollowing:
1. Paymentinfullofallestimatedchargesismadeinadvanceofservicesbeingrendered.2. Adequatehospitalizationinsurancebenefitsexistwhichthepatientiswillingtoassignto
GreenvilleHealthSystemforthepaymentofservices.Automobileliabilitycoveragealoneisnotconsideredadequatehospitalizationinsurance.
3. Sponsorshipbyathirdparty,suchasMedicare,Medicaid,orotheragenciescontractingwithGreenvilleHealthSystemforpaymentofcarerenderedtopatientsuponverificationofeligibility.
4. IfGreenvilleHealthSystemdeterminesthatthepatienthasnoavailablemeansforpayingtheservices.ApatientwillthenbedeclaredeligibleforhospitalcharityorhospitalsponsorshipundertheFinancialAssistancePolicyaccordingtocriteriaoutlinedinthispolicy.TheMedicallyIndigentAssistanceProgram(MIAP)criteriaareusedasaguidelineforhospitalcharity.Hospitalsponsorshipguidelinesaredefinedbythehospital.
Thespecificpercentagediscountsforincomegreaterthan200%upto400%ofFPGareupdatedannuallyandtheslidingscaleadjustmentisbasedonMedicarelook-backmethodology.ThisisdeterminedfromactualpastclaimspaidtothehospitalfacilitybyMedicarefee-for-servicetogetherwithallprivatehealthinsurerspayingclaimstothehospitalfacility(including,ineachcase,anyassociatedportionsoftheseclaimspaidbyMedicarebeneficiariesorinsuredindividuals).
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NopersoneligibleforfinancialassistanceunderthispolicywillbechargedmoreforemergencyorothermedicallynecessarycarethanAmountsGenerallyBilled(AGB)toindividualswithinsurancecoveringsuchcare.Thisappliestoallpatientsifthecareisemergencyormedicallynecessary,regardlessofcountyofresidency.HospitalcharityorhospitalsponsorshipisnotavailableforelectivecareunlessapprovedbyChiefFinancialOfficer(CFO),ExecutiveDirector,RevenueCycle,Director,PatientAccessorDirector,PatientFinancialServices.
RequestsforindigentcareofpatientsresidinginaforeigncountryandnotaUnitedStatescitizenwhowishtoreceivetertiaryservicesatGHSmustbepriorapprovedbytheChiefOperatingOfficer(COO)andChiefFinancialOfficer(CFO).
METHODFORAPPLYINGFORFINANCIALASSISTANCE:
Allpatientswhobelievetheymayqualifyforfinancialassistanceareurgedtofillout,signandsubmitaFinancialAssistanceApplication.Theapplicationcanbeobtainedthesefourways:
1. VisitGHSwebsiteathttp://www.ghs.org/financial-assistance.2. ContactGHSPatientFinancialServicesat(864)454-9604or1-844-302-8298(tollfree).3. MailarequesttoGreenvilleHealthSystem,255EnterpriseBlvd.,Ste.250,Greenville,SC
29615Attn:FinancialCounseling.4. SeeaPatientAccessRepresentativeataGHSfacility.Representativesareavailableto
provideacopyoftheFinancialAssistanceApplicationorassistthepatient/guarantorincompletingandsubmittingtheapplication.
Documentationtobesubmittedwiththeapplicationisarecentpaystubandstatementsforinvestmentsorothersourcesofincome.Individualswhoareself-employedarerequiredtosubmitthemostrecentyears’businessandpersonaltaxreturn.FailuretosubmitrequireddocumentationmayresultindenialoftheFinancialAssistanceApplication.
EXTRAORDINARYCOLLECTIONACTIONS(ECAs):
GreenvilleHealthSystemwillnotengageinECAsagainstanindividualtoobtainpaymentforcarebeforemakingreasonableeffortstodeterminewhethertheindividualiseligibleforfinancialassistanceunderthisFinancialArrangementsandAssistancePolicy.
GreenvilleHealthSystemoffershospitalpatientstwooptionsforpaymentwhenhospitalcharity,hospitalsponsorshiporinsuranceisnotavailable:
A. In-houseinterestfreepaymentsforuptotwelve(12)monthsinduration.B. Ifpaymentsareneededbeyondtwelve(12)months,reasonablepaymentarrangements
withinterestareavailablewithanoutsideagencyforpatientswhohavenootherresourcesormeanstopayanddonotqualifyforhospitalcharityorhospitalsponsorship.
Patientbalancesthatdonotqualifyforhospitalsponsorshiporhospitalcharityandareunpaidmaybeplacedwithacollectionagencyorattorneyorfiledasalienagainstrealestateorpersonalproperty.TheseactionsarefurtherdescribedintheBillingandCollectionsPolicy.MembersofthepublicmayobtainafreecopyofthisseparatepolicyfromGHSasindicatedinthecontactlistattheendofthispolicy.
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FinancialAssistance/CharityEligibilityCriteria:
ThefollowingiscriteriaestablishedforHospitalCharity:
1. ApplicantsmustcompleteandsigntheFinancialAssistanceApplication.Thisrequirementmaybewaivedintheeventthatthetotalityofthecircumstancesindicatesthatthepatientwouldqualifyforcharitybutisdeceased,homeless,transientorasaresultofphysicalormentalincapacityisunabletoprovidetherequiredinformation.ThesecircumstancesmustbedocumentedandreviewedbyRevenueCycleManagementbeforethepatient’saccountmaybeconsideredforcharity.
2. Applicantsmustmeetthefollowingcriteria:A. Stateresidence(intenttoliveinSouthCarolina;migrantsareconsideredstateResidents
unlesstheymaintainadomicileinanotherstate);B. U.S.citizenorlegallyadmittedalienforpermanentresidence;C. Institutionalstatus(coverscountyinmatesawaitingtrial,butnotinmatesorresidentsof
othergovernmentalinstitutions);D. Grossfamilyincomecannotexceed200%oftheCommunityServicesAdministrative
(CSA)guidelines,alsoknownasFederalPovertyGuidelines(FPG),referenceAttachment“A”;
3. ResourceLimits:A. Primaryresidenceincludesoneprimaryplaceofresidencewithataxassessedvalueof
twohundredthousanddollars($200,000)orless;withanequityvalueoflessthanthirty-fivethousanddollars($35,000).
B. OtherResourcesincludesotherrealestateorliquidassetsorotherrealestateconvertibletocashandunnecessaryforthepatient’sdailyliving;nottoexceedacombinedtotalvalueoftenthousanddollars($10,000).Recreationalvehiclesareincludedinthetotalvalueofliquidassets.Vehiclesnecessaryfordaytodaylivingareexcludedfromotherresources.
4. Householdcompositionisusedtocalculatethelevelofcharityandisbasedonincomeandthenumberofpersonsinthefamilythattheguarantorisfinanciallyresponsiblefor.Theseareperson(s)claimedonanindividual’staxreturn.Householdcompositionisdefinedasfollows:
A. Adult-apersonatleasteighteen(18)yearsofageorayoungerpersonwhoisorhasbeenmarriedorhashadthedisabilitiesofminorityremovedforgeneralpurposes.
B. Unmarriedcouples-adultswholivetogetherandfiletaxesjointlyand/orownpropertytogether.
C. Managingconservator-apersondesignatedbyacourttohavelegalresponsibilityforaminor.
D. Minorchild-apersonuptoandincludingthemonthofthenineteenth(19th)birthday(orthetwenty-sixth(26th)birthday)andisclaimedasadependentonanadult’sFederaltaxreturn.Apersonovertheageofeighteen(18)yearsoldisconsideredhis/herownguarantorandtheparentsincomeisnotconsideredwhendeterminingcharityforthatindividual.Ifanapplicationissubmittedandapersonovertheageofeighteen(18)yearsoldisclaimedonaperson’staxreturnasadependent,thispersoncountsinthehouseholdcompositionbutnotintheincome.
5. FilingtimelineforHospitalCharityisamaximumofeight(8)monthsfromthedateofservice.Durationofeligibilitywillbeone(1)yearfromdateofapplication.Exceptionsareasfollows:
A. AccountspendingMedicaid,SSI,andSocialSecurityDisabilityformorethaneight(8)monthsandhavebeendeniedbenefitsandqualifyforhospitalcharity.Durationofthe
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applicationinthisinstancetocoveranyoutstandingbalancesatthetimeofdeterminationforMedicaid,SupplementalSocialSecurityIncome(SSI)orSocialSecurityDisability.
B. Accountswhichhaveliabilitycoverageandhavebeeninlitigationformorethaneight(8)monthsandhavebeendeniedamedicalsettlement,orreceivedalimitedmedicalsettlementandqualifyforhospitalcharity.
C. Accountsthathavehadanestateinprobatemorethaneight(8)monthswithnoassetsandqualifyforhospitalcharity.
D. Accountswhereinsurancewasfiledandtherewasadelayofmorethan(8)monthsregardingpaymentfrominsurance.
6. Income,asset,residencyinformation,etc.providedbythepatientwillbeverifiedthroughanelectronicvendorinquiry.Incomediscrepanciesinexcessoffivethousanddollars($5,000),betweeninformationprovidedbythepatient/patientrepresentativeandtheelectronicinquiry,willrequireanattestationsignedbythepatient/patientrepresentative;orotherprooftobedeterminedatthetimeofprocessing.Intheeventadditionaldocumentationisrequestedbutnotreceived(exampleincludesbutnotlimitedto:onemostrecentpaystub,realestateequityletter,bankstatements,mostrecentyears’taxreturnorotherfinancialdocuments)theaccountwillbedispositionedfourteendaysaftertherequestandmaybedeniedforfailuretosubmitrequesteddocumentation.
ShouldtheapplicantfailtomeetthecriteriaforHospitalCharitybutmeritsconsiderationforassistance,theapplicantwillbeassessedforHospitalSponsorshipbasedoncriteriaoutlinedinthispolicy.
Ifduringthecollectionprocessitappearsapatienthasnoavailablemeanstopayforservices,doesnotmeetguidelinesforHospitalCharityandisdeclaredeligibleforHospitalSponsorship,chargeswillbeadjustedaccordingtothelevelofsponsorshipdocumentedonthepatient’saccount.Hospitalrelatedgrouppracticesmayalsousethesecriteriatodeterminehospitalsponsorshipofpatientswithintheirpractices.HospitalSponsorshipconstitutesasatisfactoryfinancialarrangement.
TheVicePresidentandCFOFinancialServiceswilldeterminethepercentageoftheguidelinesutilizedforsponsorshiponanannualbasis.TheHospitalSystemreservestherighttodefinemaximumcharitableexpenditures,servicecatchmentareas,prevailingcharges,excludedservices,feereductionschedules,patientresponsibilities,andotherbusinesspracticeparametersconsistentwiththeprudentmanagementoftheGreenvilleHealthSystem.
FinancialAssistance/HospitalSponsorshipEligibilityCriteria:
ThefollowingiscriteriaestablishedforHospitalSponsorship:
1. Incomeandresourcelimitsareoutlinedasfollows:A. Income:
i. Grossfamilyincomecannotexceed400%oftheCommunityServicesAdministration(CSA)PovertyGuidelines,alsoknownasFederalPovertyGuidelines(FPG),referenceAttachment“A”.Levelofsponsorshipisbasedonannualincomeandtotalbalanceduefromthepatientonalloutstandingaccountsatthetimeeligibilityforhospitalsponsorshipisdetermined.
B. PrimaryResidence:
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i. Oneprimaryplaceofresidencewithataxappraisedvalueoftwohundredthousanddollars($200,000)orless;withanequityvalueoflessthanonehundredthousand($100,000).Patientswhohaveonehundredthousand($100,000)ormoreequityintheirprimaryresidenceandcannotborrowagainsttheequitywillbeconsideredforsponsorshipiftheyprovidealetterfromamortgagelenderstatingthepatient/guarantorisnoteligibletoborrow.
C. OtherResources:i. Otherrealestateorliquidassetsconvertibletocashandunnecessaryfor
thepatient’sdailyliving;nottoexceedacombinedtotalvalueoftenthousanddollars($10,000).Recreationalvehiclesareincludedinthetotalvalueofliquidassets.Vehiclesnecessaryfordaytodaylivingareexcludedfromotherresources.
ii. Ifthepatient,spouseorparent(s)ifpatientisachild,ownsabusiness,acopyofthemostrecentyear’spersonalandbusinesstaxreturnmustbesubmittedinitsentirety.Thevalueofthebusinessisconsideredaresource.
2. Householdcompositionisusedtocalculatethelevelofsponsorshipandisbasedonincomeandthenumberofpersonsinthefamilythattheguarantorisfinanciallyresponsiblefor.Theseareperson(s)claimedonanindividual’staxreturn.
A. Adult-apersonatleasteighteen(18)yearsofageorayoungerpersonwhoisorhasbeenmarriedorhashadthedisabilitiesofminorityremovedforgeneralpurposes.
B. Unmarriedcouples-adultswholivetogetherandfiletaxesjointlyand/orownpropertytogether.Intheeventthereisadiscrepancyininformationprovidedontheapplicationandsupportingdocumentation,additionaldocumentationmayberequested(e.g.taxreturn)/
C. Managingconservator-apersondesignatedbyacourttohavelegalresponsibilityforaminor.
D. Minorchild-apersonuptoandincludingthemonthofthenineteenth(19th)birthday(orthetwenty-sixth(26th)birthday)andisclaimedasadependentonanadult’sFederaltaxreturn.Apersonovertheageofeighteen(18)yearsoldisconsideredhis/herownguarantorandtheparentsincomeisnotconsideredwhendeterminingcharityforthatindividual.Ifanapplicationissubmittedandapersonovertheageofeighteen(18)yearsoldisclaimedonaperson’staxreturnasadependent,thispersoncountsinthehouseholdcompositionbutnotintheincome.
3. Filingtimelineforhospitalsponsorshipisamaximumofeight(8)monthsfromthedateofservice.Iftheapplicationisnotdated,the“Received”stampdateontheapplicationwillbeused.Durationofeligibilitywillbeone(1)yearfromdateofapplication.Exceptionsareasfollows:
A. AccountspendingMedicaid,SupplementalSocialSecurityIncome(SSI)andSocialSecurityDisabilityformorethaneightmonthsandhavebeendeniedbenefitsandqualifyforhospitalsponsorship.DurationoftheapplicationinthisinstancetocoveranyoutstandingbalancesatthetimeofdeterminationforMedicaid,SupplementalSocialSecurityIncome(SSI)orSocialSecurityDisability.
B. Accountswhichhaveliabilitycoverageandhavebeeninlitigationforkorethaneight(8)monthsandhavebeendeniedamedicalsettlement,orreceivedalimitedmedicalsettlementandqualifyforhospitalsponsorship.
C. Accountsthathavehadanestateinprobatemorethaneight(8)monthswithnoassetsandqualifyforhospitalsponsorship.
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D. Accountswhereinsurancewasfiledandtherewasadelayofmorethan(8)monthsregardingpaymentfrominsurance.
E. Recentlossofincome/employmentwillbeconsideredforoutstandingaccounts.Ifapprovedforassistance,sponsorshipwillonlyapplytooutstandingaccountsmeetingallothercriteriaatthetimeofapproval.Charity/Sponsorshipwillnotbeaddedtothepatient’srecordforfuturedatesofservicebutmayreapplywhenadditionalservicesarereceived.
4. Ifthepatientisdeceasedandthereisnoestate,thepatient’saccount(s)willbeadjustedtohospitalsponsorship.
5. CatastrophicEvent:A. Whenthepatient’shospitalaccount(s)exceedtwo(2)timesthehouseholdannual
grossincomethefollowingcriteriawillbeconsideredwhendeterminingsponsorshipeligibility:
i. Thetaxappraisedvalueoftheprimaryplaceofresidencemayexceedthetwohundredthousanddollars($200,000).
ii. Equityvalueoftheprimaryplaceofresidencemayexceedthirty-fivethousand($35,000)dollars.
iii. Liquidassetsmaybeconsideredwhendeterminingsponsorship.iv. Sponsorshipforacatastrophiceventmaybeapprovedforoutstanding
accountsfordatesofservicewithineight(8)monthsfromthedateofapplication.Charity/Sponsorshipwillnotbeaddedtothepatient’srecordforfuturedatesofservicebutmayreapplywhenadditionalservicesarereceived.
6. Income,asset,residencyinformation,etc.providedbythepatientwillbeverifiedthroughanelectronicvendorinquiry.Incomediscrepanciesinexcessoffivethousanddollars($5,000),betweeninformationprovidedbythepatient/patientrepresentativeandtheelectronicinquiry,willrequireanattestationsignedbythepatient/patientrepresentative;orotherprooftobedeterminedatthetimeofprocessing.Intheeventadditionaldocumentationisrequested(example:onemostrecentpaystub)theaccountwillbedispositionedthirtydaysafterrequestandmaybedeniedforfailuretosubmitrequesteddocumentation.
GreenvilleHealthSystemaccommodatesallsignificantpopulationsservedwhohavelimitedproficiencyinEnglishbytranslatingcopiesofourFinancialArrangementsandAssistancePolicy,FinancialAssistanceApplicationForm,andthissummaryintheprimarylanguagesspokenbythosepopulations.
TheFinancialArrangementsandAssistancePolicy,FinancialAssistanceApplicationForm,BillingandCollectionsPolicy,aswellasinformationaboutthefinancialassistanceapplicationprocessesarewidelypublicized.Informationcanbeobtainedbythefollowingmethods:
1. VisittheGHSwebsiteathttp://www.ghs.org/financial-assistance.2. CallGHSPatientFinancialServicesat(864)454-9604or1-844-302-8298(tollfree).3. MailarequesttoGreenvilleHealthSystem,255EnterpriseBlvd.,Ste.250,Greenville,SC
29615Attn:FinancialCounseling.4. SeeaPatientAccessRepresentativeataGHSfacility.
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IfitisdeterminedthatapatienthasnoavailablemeanstopayforservicesandisdeclaredeligibleforHospitalCharityorHospitalSponsorship,chargeswillbeadjustedaccordingtothelevelofcharityorsponsorshipdocumentedonthepatient’saccount.SpecifictopatientsseenatcomponentsoftheGreenvilleMemorialHospitalprovider,andforpurposesofthe340Bdrugprogram,theContractPharmacieswillextenddiscountstopatientsundertheHospitalSponsorshipprogram.HospitalCharityandHospitalSponsorshipconstitutesasatisfactoryfinancialarrangement.
TheVicePresidentandCFOwilldeterminethepercentageoftheguidelinesutilizedforcharityandsponsorshiponanannualbasis.TheGreenvilleHealthSystemreservestherighttodefinemaximumcharitableexpenditures,servicecatchmentareas,prevailingcharges,excludedservices,feereductionschedules,patientresponsibilities,andotherbusinesspracticeparametersconsistentwiththeprudentmanagementoftheGreenvilleHealthSystemandpracticegroupswithinitscommitmenttothecommunity.
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AttachmentA
TableforDeterminationofFinancialAssistanceAllowanceEffective1/30/2016
TABLEFORDETERMINATIONOFFINANCIALASSISTANCEHOSPITALCHARITY
#ofPersonsinFamily IncomeLevel*
1 $23,7602 $32,0403 $40,3204 $48,6005 $56,8806 $65,1607 $73,4608 $81,780
Forfamiliesof9ormoreadd $8,320Allowancetogive 100%
*200%ofPovertyGuidelines
TABLEFORDETERMINATIONOFFINANCIALASSISTANCEHOSPITALSPONSORSHIP
#ofPersonsinFamily
IncomeLevel*0-200%
IncomeLevelCap201-400%
1 $23,760 $47,5202 $32,040 $64,0803 $40,320 $80,6404 $48,600 $97,2005 $56,880 $113,7606 $65,160 $130,3207 $73,460 $146,9208 $81,780 $163,560
Forfamiliesof9ormoreadd
$8,320 $16,640
Allowancetogive 100% 76%
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AttachmentB
TableforDeterminationofFinancialAssistanceAllowanceEffective1/31/2017
TABLEFORDETERMINATIONOFFINANCIALASSISTANCEHOSPITALCHARITY
#ofPersonsinFamily IncomeLevel*
1 $24,120.2 $32,480.3 $40,840.4 $49,200.5 $57,560.6 $65,920.7 $74,280.8 $82,640.
Forfamiliesof9ormoreadd $8,360.Allowancetogive 100%
*200%ofPovertyGuidelines
TABLEFORDETERMINATIONOFFINANCIALASSISTANCEHOSPITALSPONSORSHIP
#ofPersonsinFamily
IncomeLevel*0-200%
IncomeLevelCap201-400%
1 $24,120. $48,240.2 $32,480. $64,960.3 $40,840. $81,680.4 $49,200. $98,400.5 $57,560. $115,120.6 $65,920. $131,840.7 $74,280. $148,560.8 $82,640. $165,280.
Forfamiliesof9ormoreadd
$8,360. $16,720.
Allowancetogive 100% 76%
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Attachment C
Table for Determination of Financial Assistance Allowance Effective 1/31/2018
TABLE FOR DETERMINATION OF FINANCIAL ASSISTANCE HOSPITAL CHARITY
# of Persons in Family Income Level*
1 $ 24,280
2 $ 32,920
3 $ 41,560
4 $ 50,200
5 $ 58,840
6 $ 67,480
7 $ 76,120
8 $ 84,760
For families of 9 or more add $ 8,640
Allowance to give 100%
*200% of Poverty Guidelines
TABLE FOR DETERMINATION OF FINANCIAL ASSISTANCE HOSPITAL SPONSORSHIP
# of Persons in Family
Income Level* 0-200%
Income Level Cap 201-400%
1 $ 24,280 $ 48,560
2 $ 32,920 $ 65,840
3 $ 41,560 $ 83,120
4 $ 50,200 $ 100,400
5 $ 58,840 $ 117,680
6 $ 67,480 $ 134,960
7 $76,120 $ 152,240
8 $ 84,760 $ 169,520
For families of 9 or more add
$ 8,640 $ 17,280
Allowance to give 100% 76%
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Attachment D
Table for Determination of Financial Assistance Allowance Effective 1/31/2019
TABLE FOR DETERMINATION OF FINANCIAL ASSISTANCE HOSPITAL CHARITY
# of Persons in Family Income Level*
1 $ 24,980
2 $ 33,820
3 $ 42,660
4 $ 51,500
5 $ 60,340
6 $ 69,180
7 $ 78,020
8 $ 86,860
For families of 9 or more add $ 8,840
Allowance to give 100%
*200% of Poverty Guidelines
TABLE FOR DETERMINATION OF FINANCIAL ASSISTANCE HOSPITAL SPONSORSHIP
# of Persons in Family
Income Level* 0-200%
Income Level Cap 201-400%
1 $ 24,980 $ 49,960
2 $ 33,820 $ 67,640
3 $ 42,660 $ 85,320
4 $ 51,500 $ 103,000
5 $ 60,340 $ 120,680
6 $ 69,180 $ 138,360
7 $ 78,020 $ 156,040
8 $ 86,860 $ 173,720
For families of 9 or more add
$ 8,840 $ 17,680
Allowance to give 100% 76%