How do I apply? List the names and birth dates for each family member applying for the program. If you do not list them on the form, they will not be included. If your spouse is also applying for this program, both of you must sign the form. Your family includes a spouse, dependent children and any person for whom you have legal guardianship. A copy of your most recent Federal Income Tax form. Do not include W2 forms. Records of income are to include copies of the two most recent payroll stubs.
Example: pay stubs that show your year-to-date earnings. Copies of bank statements for all checking and savings accounts for the last 30 days. Include the last statement for any CDs Certificates of Deposit. Records of all retirement savings: employee pension plans, K plans, b plans, annuities, IRAs. Record of current balances in all health savings accounts HSA. Optional: a letter explaining any recent events that might affect your ability to pay your medical bills.
If your insurance has paid part of the bill but you need help in paying your balance, you can apply for Charity Care. First, you should request help from a Minnesota Health Care program. If the county denies you help, we will review the denial. We may be able to help you with one of our Charity Care programs. What is the amount generally billed AGB? The law covers eligibility, determination of assets and more. The Affordable Care Act created a new Section r for hospitals to maintain Section c 3 status.
Requirements cover financial assistance, limitation on charges, and billing and collections. Enhance your organization's efforts to develop effective, patient-friendly billing policies through resources developed for hospital leaders.
Every year, Illinois non-profit hospitals must report to the state Attorney General the amount of community benefits they provide, including charity care, language services, education and research. Some or all of the financial documentation listed below will be required for consideration. The Patient may be required to submit some or all of the financial documentation listed below:. The financial resources of a parent or guardian may be considered in determining the eligibility of a patient who is dependent on the parent or guardian for financial support.
There are instances where a patient may appear eligible for charity care, but supporting documentation is lacking or unavailable. In such event Main Line Health will use other appropriate 3rd party resources to estimate an individual's income. A patient meeting the criteria for presumptive financial assistance will have all charges waived.
Presumptive eligibility may be determined on the basis of individual life circumstances that may include:. When the Application for Charity Care and Financial Assistance is received, the staff will review and determine through the use of the Charity Care and Financial Assistance Table, Schedule A if the application is complete and whether the documentation supports the individual's eligibility for charity care or financial assistance. Individuals will be notified of the determination within 30 days.
Your payments to Main Line Health under this policy will be available to you in accordance with financial need, as determined in reference to Federal Poverty Levels FPL in effect at the time of the determination. Once a patient has been determined by Main Line Health to be eligible for charity care or financial assistance, that patient shall not receive any future bills based on undiscounted gross charges.
The basis for the amounts Main Line Health will charge patients qualifying for charity care or financial assistance is as follows:. Main Line Health does, however, offer such patients a discount off of gross charges for such care. The self pay discount is based on the following guidelines:. Notifications about the availability of charity care and financial assistance from Main Line Health, will be disseminated by Main Line Health by various means which may include, but are not limited to, the publication of notices in patient bills and by posting notices in emergency rooms, in the Conditions of Admissions form, admitting and registration departments, and patient financial services offices that are located on facility campuses, and at other public places as Main Line Health may elect.
These documents and notices will all include a contact phone number for further information. Main Line Health will also publish and widely publicize a summary of this financial assistance policy on facility websites, in brochures available in patient access sites and other places within the community served by the hospital as Main Line Health may elect.
Such notices and summary information will be provided in the primary languages spoken by the population serviced by Main Line Health. Referral for charity care and financial assistance may be made by any member of the Main Line Health staff or medical staff, including physicians, nurses, financial counselors, social workers, case managers, chaplains, and religious sponsors. A request for charity care and financial assistance may be made by the patient or a family member, close friend, or associate of the patient, subject to applicable privacy laws.
In implementing this policy Main Line Health management and facilities shall comply with all other federal, state and local laws, rules and regulations that may apply to activities conducted pursuant to this policy. Individuals may contact the Main Line Health Business office at Please download and view the PDF of the complete charity care and financial assistance policy for access to the following schedules:.
Working together to serve the community Main Line Health is committed to providing charity care and financial assistance to persons who are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay, for medically necessary care based on their individual financial situation.
Financial assistance Financial assistance is provided to patients who are uninsured for the relevant service and who are ineligible for governmental or other insurance coverage, and who have family incomes in excess of percent, but not exceeding percent, of the Federal Poverty Level. Uninsured patient An uninsured patient that has no health insurance from any source for specific services, inpatient or outpatient, furnished by any provider.
Commercial insurance Commercial insurance means coverage for medical expenses from any of the following: Commercial health insurance plans such as Blue Cross, Aetna and United Health Care Federal health care insurance programs such as Medicare, Medicaid, SCHIP State Children's Health Insurance Program and TRICARE Health insurance program available to military personnel and their families Workers' Compensation is insurance that may be used if a patient is injured at work or on the job Automobile insurance may be used if a patient's health care needs are related to an automobile accident Family Using the Census Bureau definition, a group of two or more people who reside together and who are related by birth, marriage, or adoption.
Family income Family income is determined using the Census Bureau definition, which uses the following income when computing federal poverty guidelines: Includes pre-tax earnings, unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household and other miscellaneous sources Excludes capital gains or losses and noncash benefits such as food stamps and housing subsidies do not count Excludes the income of non-relatives, e.
Federal Health Care Program Any health care program operated or financed at least in part by the federal, state or local government is a federal health care program.
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