A. To specify the criteria for identifying those populations which shall not be subject to collection action by setting a minimum financial assistance eligibility standard.
B. Patients qualifying for financial assistance will be exempt from any liability for their hospital visit. 

A. All financial assistance provided shall be accompanied by a signed application for financial assistance by the patient, relative, or legal guardian, POA, or hospital consultant with authorization from the patient.
B. There shall be no residency requirement for patients applying for financial assistance.
C. The hospital or it’s agents shall not pursue collection actions against patients qualifying for financial assistance.
D. Applicants may qualify for financial assistance under the following circumstances. 

1. The patient’s and/or guarantor’s income is equal to or less than the currently approved Springfield Hospital’s income poverty guidelines (found as attachment 1 of this policy) and there are no other assets available to the patient which could be used in settlement of hospital charges.  Principal residence generally would not be considered an available asset in this regard.  
2. A patient who has been declared a Medicaid recipient and who’s income is less or equal to federal poverty guidelines .  Where as we have billed Medicaid and Medicaid has processed leaving a balance.  These balances of $50.00 and under will be billed to the patient under our normal  billing cycle system.  After four months of billing if a balance of a Medicaid recipient is still outstanding the patient will be exempt from collection efforts or collection agencies outside of the hospital.  The hospital will grant full assistance on all balances after Medicaid has paid.  The hospital guidelines are above federal poverty guidelines.  The patient and/or guarantor has demonstrated extreme financial hardship.  Accounts that fall outside of the hospital guidelines are approved by the Director of Patient Financial Services. 

E. A patient who applies for financial assistance must receive a written  notice of the hospital’s decision within 45 days of submission of written application and necessary documentation.  
F. Once the hospital determines the patient to be eligible for financial assistance, this determination MAY be in effect for 6 months from the data of the initial determination.
G. The hospital shall not discriminate on the basis of race, color, national origin, alienage, religion, creed, sex, age for persons beyond the age of majority, or handicap on its policies, or in its application of policies, concerning the acquisition and verification of financial information, and eligibility for financial assistance.  
H. Patient and/or guarantor must be willing to work with the hospital to explore and obtain all possible alternative insurance coverage, ie: Medicaid, car insurance settlements, SSI, etc.

A. If the hospital provides inpatient, outpatient, swing, or psychiatric services to a patient whose income and family size are equal to or less than one hundred percent (100%) of the Springfield Hospital’s approved poverty income guidelines, such patient shall be exempt from collection action.

B. If the hospital provides inpatient, outpatient, swing, or psychiatric services to a patient whose income and family size are equal to or less than one hundred and fifty percent (150%) of the Springfield Hospital’s approved poverty income guidelines, such patient shall be eligible for reduced fee financial assistance.

1. If the income is at 110% the patient will receive 90% of the bill as financial assistance ands will be responsible for paying 10% of the bill.
2. If the income is at 120% the patient will receive 80% of the bill as financial assistance ands will be responsible for paying 20% of the bill.
3. If the income is at 130% the patient will receive 70% of the bill as financial assistance ands will be responsible for paying 30% of the bill.
4. If the income is at 140% the patient will receive 60% of the bill as financial assistance ands will be responsible for paying 40% of the bill.
5. If the income is at 150% the patient will receive 50% of the bill as financial assistance ands will be responsible for paying 50% of the bill.

C. If the patient demonstrates extreme financial hardship that falls outside  of the above guidelines, the Director of Patient Financial Services and Director of Finance may approve the financial assistance eligibility. 

A. NOTIFICATION:

1. The hospital shall post signs in Inpatient, Outpatient, Swing, Psychiatric, and Emergency Registration areas and in the Patient Financial Services areas that are customarily used by the patients, that conspicuously inform patients of the availability of the financial assistance and where to apply for such care.
2. The hospital shall provide individual notice of the availability og financial assistance when the hospital has been given an indication that a patient will incur charges that may not be paid in full by third party coverage.  The individual notice shall specify the income and resource criteria the hospital uses in order to determine patient eligibility for financial assistance ands the time it takes the hospital to make such a determination and include also information where patients can apply for financial assistance.  The notification will be given to the patient at the time of registration.  
3. On and inpatient admission that occur after the registration department closes each night, the admitting office will be responsible for delivering the notice of the availability of financial assistance to the patient they following day or as soon as possible.  
4. The Director of Public Relations will attempt to inform the public though the use of public announcement paid advertising, etc. of the existence of financial assistance at the hospital.

B. ASSISTANCE:   

1. The Patient Financial Services department will be responsible for providing assistance to patients desiring to apply for financial assistance.  Assistance will consist of supplying the appropriate application forms and instructions for their completion, and receipt and processing of such forms to determine eligibility.
2. In certain instances where the patient is physically or mentally unable to complete the application for financial assistance, the hospital may take a determination of eligibility on its own. 

V. DOCUMENTATION AND AUDIT: FINANCIAL ASSISTANCE:

1. Each financial assistance application shall be accompanied by patient documentation of all efforts made by the hospital to determine eligibility.
2. Financial Assistance application documentation shall be kept on file for a period of 5 years. 

VI. DECISION OF ELIGIBILITY FOR FINANCIAL ASSISTANCE:

1. Patient Financial Services will make initial determination of eligibility for financial assistance using the above policy.  This information will be recorded in writing in the appropriate section of the application forms.
2. Patient Financial Services will submit any applications for extreme hardship that fall outside the guidelines to the Director of Patient Financial Services and/or with the Director of Finance will make the final determination on eligibility.  
3. In the instance where a patient is physically or mentally unable to complete an application for financial assistance the Patient Financial Services Department, or a case manager, will obtain all available information and complete the application for the patient to the best or their ability.  Patient Financial Services will then submit the application to the Director of Patient Financial Services for final determination.  
4. Patient Financial Services will then issue the Notice of Eligibility Decision letter to the applicant, no later than 45 days from the date of the application for financial assistance. 

VII. NOTICE OF AVAILABILITY OF FINANCIAL ASSISTANCE

SPRINGFIELD HOSPITAL is aware of the high cost of medical services, and the financial burden that this can cause.

SPRINGFIELD HOSPITAL offers Financial Assistance program which is intended to help those people who find their medical expenses to be an extreme financial burden as a result of low to no income, lack or insurance coverage or temporary financial hardship.  

If you feel you may qualify for Financial Assistance or would like to know more about this program, please contact our Patient Financial Services Department at 802-885-7630 or 802-885-7631.

Attachment 1: Federal poverty guidelines & Springfield Hospital’s Charity guidelines