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Financial assistance

We are committed to providing high quality rehabilitation care and services to our patients. Our hospital provides free or discounted emergency and other medically necessary care to patients who are uninsured or underinsured and who qualify for assistance under its Financial Assistance Policy. Learn about our financial assistance policy and how to apply for assistance.

Financial assistance policy

Purpose

This policy outlines the circumstances under which the hospital will provide free or discounted emergency or other medically necessary care to eligible patients who are unable to pay for their care, as determined by the hospital in accordance with the eligibility criteria and other terms specified in this policy. Patients are expected to cooperate with the hospital’s procedures for obtaining Financial Assistance, securing insurance or other forms of payment, and contributing to the cost of their care based on their ability to pay.

This policy applies to emergency or medically necessary care provided by the hospital. This policy does not apply to care delivered by physicians or other healthcare providers who bill “privately” (separate from the hospital). (See Attachment A for additional information about physicians and other healthcare providers providing care within the hospital.)
 
This policy does not apply to care that is not emergency or medically necessary care, including elective services or items that are solely for the comfort or convenience of a patient.

Financial Assistance does not apply to amounts that are covered by insurance, governmental programs or other funding sources (which may include, but are not limited to, workers’ compensation, automobile or other liability insurance, crime victims’ compensation funds, and litigation recoveries). To be eligible for Financial Assistance, a patient is expected to apply for and comply with all processes related to seeking assistance from other insurers and/or third-party sources of payment (including all applicable governmental programs) as requested by hospital staff. Patients who are noncompliant or uncooperative in attempting to obtain insurance coverage, qualification under governmental programs, or payment from third-party sources will not be eligible for Financial Assistance.
 
A patient will be ineligible for Financial Assistance if the patient, or his or her representative, provides false information or falsified documentation of household size, income, assets, or other pertinent information.

Definitions

Covered Services – emergency or medically necessary care provided by the hospital. Covered Services do not include services that are not emergency or medically necessary care, or care that is provided by physicians or other healthcare providers who bill “privately.”

Emergency or medically necessary care – services that are necessary and appropriate to sustain life or to prevent serious deterioration in the health of the patient from injury or disease. Medically necessary will be determined by the treating physician.

Family – includes spouse/domestic partner, children, and any other persons treated as “dependents” for federal income tax purposes.

Financial Assistance – reduction of an eligible patient’s account balance for Covered Services under the terms of this policy.

Patient – the individual receiving medical treatment and/or, in the case of an unemancipated minor or other dependent, the parent, legal guardian or other person (guarantor) who is financially responsible for the patient.
 
Uninsured – a patient who does not have health insurance coverage, is unable to obtain affordable coverage, and is ineligible for government healthcare programs or other third-party payment sources.
 
Underinsured – a patient who is not uninsured, but whose out-of-pocket medical expenses exceed his or her financial ability to pay.
 
Policy

Subject to the terms of this policy, Financial Assistance is provided to eligible patients who are uninsured 
or underinsured.

Eligibility for Financial Assistance, and the amount of Financial Assistance that will be provided, are based on an individualized assessment by the hospital of a patient’s financial need, generally determined by measuring the patient’s gross family income against the Federal Poverty Guidelines as specified in the Financial Assistance Discount Guidelines in Attachment B, provided that the patient does not have other financial resources that could be used to pay for his or her care. The Financial Assistance Discount Guidelines are adjusted annually to reflect changes in the Federal Poverty Guidelines.

Patients are presumed to be eligible for financial assistance, without completing an application, in the following circumstances:

Homelessness
Deceased with no estate
Mental incapacitation with no one to act on patient’s behalf
Recent Medicaid coverage, i.e. coverage within three (3) months of admission or discharge.

Presumptive financial assistance will be the most generous assistance available under the Financial Assistance Policy.

A patient determined to be eligible for Financial Assistance will not be billed more than the amount generally billed for emergency or other medically necessary care by hospital to individuals who have insurance covering such care. (See Attachment B for additional information about the “amount generally billed” limitation.)

If a patient is underinsured and is determined to be eligible for Financial Assistance, discounts will only apply to the balance due from the patient after insurance payments and other third-party payment sources have been applied to the account.


For purposes of this policy, “income” includes, but is not limited to, revenue from the following sources (before taxes):
 
Wages
Tips
Payments from Social Security
Retirement benefit payments
Unemployment compensation
Worker’s compensation
Veterans’ benefits
Public assistance
Alimony
Child support
Pensions
Regular insurance or annuity payments
Investment income
 
For purposes of this policy, “other financial resources” includes, but is not limited to the following:

Savings
Checking account
Medical savings account, healthcare savings account and/or flexible spending account
Trust fund
Retirement accounts
Investment assets
Other liquid assets
Equity value of real estate, other than the patient’s primary residence
Benefits from charity organizations
Pending litigation
 
To apply for Financial Assistance, a complete Financial Assistance Application is required. A complete Financial Assistance Application is inclusive of, but not limited to, disclosure of household size, employment information, income, assets and other financial resources, outstanding financial obligations, and supporting documents (such as recent tax returns, bank statements and pay stubs), as detailed in the Financial Assistance Application and the associated instructions.  If documentation proving household income is not available, patients may call the hospital finance department at the phone number listed above to discuss other evidence demonstrating eligibility. Undocumented residents (non-U.S. citizens living as residents in the U.S.) and patients who are without a home address may apply for Financial Assistance. Failure to provide the required information and documentation in a timely manner may result in ineligibility for Financial Assistance. 
 
Complete Financial Assistance Applications should be submitted to the hospital at the address listed above. A hospital finance representative will review the application for completeness. Financial Assistance determinations must be approved by the Facility Controller, and in certain circumstances, by the hospital CEO. The hospital will notify patients in writing of the decision on their eligibility under this policy.

Copies of this policy, a plain language summary of this policy, the Financial Assistance Application, and the associated instructions are available free of charge upon request by writing to the address above. These documents can be found in the admitting/registration areas of the hospital and may also be downloaded at hospital’s website.

All patients will be offered a plain language summary of the Financial Assistance Policy during discharge 
or intake. 

Billing statements will contain a written conspicuous notice informing patients about the availability of financial assistance, a telephone number where they may receive more information, as well as website address where the Financial Assistance Policy, application and plain language summary may be found.
 
Further information about this Financial Assistance Policy and assistance with the application process are available by calling Hospital Phone Number, or in person during normal business hours or by appointment from a hospital finance representative.

When a patient does not qualify for Financial Assistance under this policy but has special circumstances, other discounts may be available that are not part of this Financial Assistance Policy.  In these situations, hospital staff will review all available information (including documentation of income, liquid and illiquid assets, and other resources, amount of outstanding medical bills and other financial obligations) and make a case-by-case determination of the patient’s eligibility for other potential discounts.

Once a patient has been discharged and the patient’s balance due has been determined, the Billing Office will mail the patient monthly account statements and make phone calls in an attempt to collect the outstanding balance. If no payment has been received for 120 days, the account may be sent to a third-party collection agency.

The hospital, and any third parties acting on its behalf, do not engage in extraordinary collection actions such as lawsuits, liens, foreclosures, wage garnishment or reporting adverse information to credit agencies.

For additional information, please see the Billing and Collections Policy, which may be downloaded from hospital website. Copies are also available upon request, free of charge, by mail and in admitting/registration areas of the Hospital.
 
Nondiscrimination & emergency medical care

Hospital does not have a dedicated emergency department. The hospital will appraise emergencies, provide initial treatment, and refer or transfer an individual to another hospital/facility, when appropriate, without discrimination and without regard to whether the individual is eligible for Financial Assistance.

Hospital will not engage in actions that discourage individuals from seeking emergency medical care, such as demanding that an individual pay before receiving initial treatment for emergency medical conditions or permitting debt collection activities that interfere with hospital’s appraisal and provision, without discrimination, of such initial treatment.
 

Billing and collections

Amounts charged to a patient eligible for Financial Assistance under this policy will be based on the applicable discount stated in the table above multiplied by the gross charges otherwise billable to the patient, subject to the “AGB” limitation described below.

In accordance with Internal Revenue Code section 501(r), a patient eligible for Financial Assistance under this policy will not be charged more than the amount generally billed to individuals who have insurance covering such care (“AGB”).

Facility has initially elected to calculate AGB under the “prospective Medicare method” described in applicable Treasury Regulations, using the billing and coding process the Facility would use if the individual were a Medicare fee-for-service beneficiary and setting AGB for the care at the amount the Facility determines would be the total amount Medicare would allow for the care (including both the amounts that would be reimbursed by Medicare and the amount the beneficiary would be personally responsible for paying in the form of co-payments, co-insurance, and deductibles).

Financial assistance policy - Plain language summary

Our hospital provides free or discounted emergency and other medically necessary care to patients who are uninsured or underinsured and who qualify for assistance under its Financial Assistance Policy. Assistance does not apply to elective services or items that are solely for the comfort or convenience of a patient. This document is only a summary. Please refer to the Financial Assistance Policy for complete details.

Eligibility Requirements and Assistance Offered Under the Financial Assistance Policy

Patients who qualify for assistance are eligible for income/asset-based, sliding scale discounts for emergency and other medically necessary care. In general:

Patients whose family income is equal to or less than 200% of the Federal Poverty Guidelines are generally eligible for free emergency and medically necessary care. 
Patients whose family income is between 200% and 400% of the Federal Poverty Guidelines are generally eligible for a sliding scale discount ranging from 50% to 75% for emergency and other medically necessary care.

A patient who qualifies for assistance under the Financial Assistance Policy will not be charged more for emergency or medically necessary care than amounts generally billed to patients having insurance covering such care.

How to Obtain Copies of the Financial Assistance Policy and Financial Assistance Application

Copies of the Financial Assistance Policy, this plain language summary, and the Financial Assistance Application and associated instructions are available free of charge upon request by writing to the address above. Copies can also be found in the admitting/registration areas of the hospital. These documents may be found online at the website provided above. Translations of these documents to Spanish are available upon request from our hospital and also may be found online at website address above.  

How to Apply for Assistance Under the Financial Assistance Policy

To apply for financial assistance, please submit a complete Financial Assistance Application with supporting documents to the address above.  

Further information about the Financial Assistance Policy and assistance with the application process are available from the hospital controller via phone number listed above or in person at the address above.

Instructions - financial assistance application

Section A – patient and guarantor information 

Patient Name: Clearly print on the blank line the first name, middle initial, and last name of the patient.
Date: Clearly print on the blank line the date of the application.
Guarantor: Clearly print on the blank line the first name, middle initial, and last name of the patient’s parent, legal guardian or other responsible person (“guarantor”).
Relationship: Clearly print on the blank line the relationship to the patient of the guarantor.
Address: Clearly print on the blank line the address where the patient lives including the city, state and zip.
Phone: Clearly print on the blank line the patient’s phone number.
Patient’s Employer: Clearly print on the blank line the name of the company for which the patient works.
Title: Clearly print on the blank line the job title of the patient.
Years Employed: Clearly print on the blank line the start date of employment.
Spouse’s Name: Clearly print on the blank line the first name, middle initial, and last name of the patient/guarantor’s spouse.
Spouse’s Phone: Clearly print on the blank line the patient’s phone number.
Spouse’s Employer: Clearly print on the blank line the name of the company for which your spouse works.
Title: Clearly print on the blank line the job title of your spouse.
Years Employed: Clearly print on the blank line the start date of employment of your spouse.
Length of Time at Current Residence: Clearly print on the blank line the dates you have lived at the address provided on the application.
Total number of Dependents: Clearly print on the blank line the number of dependents in your household, including yourself. Dependents are those that generally qualify as your dependent for federal income tax purposes.
Health Insurance Provider: Clearly print on the blank line the name of your health insurance carrier (including Medicare, Medicaid or other governmental coverage you may have).
Policy number: Clearly print on the blank line the policy or account number of your insurance policy.

Section B – assets 

Total Household Income: Clearly print the assets of your household (yourself, your spouse, and dependents). You may attach additional sheets of paper if more space is needed. Provide the cash value as well as any loans or obligations you have on that asset

If your household has assets that you do not see listed, please indicate that amount on the line for “Other” and provide a description.
Assets include, but are not limited to savings and checking accounts, medical savings accounts, healthcare savings accounts, flexible spending accounts, trusts, retirement accounts, investment assets, other liquid assets, real estate (other than primary residence), benefits from charity organizations, pending or finalized litigation settlements, etc.
Years Employed: Clearly print on the blank line the start date of employment.
Spouse’s Name: Clearly print on the blank line the first name, middle initial, and last name of the patient/guarantor’s spouse.
Spouse’s Phone: Clearly print on the blank line the patient’s phone number.
Spouse’s Employer: Clearly print on the blank line the name of the company for which your spouse works.
Title: Clearly print on the blank line the job title of your spouse.
Years Employed: Clearly print on the blank line the start date of employment of your spouse.
Length of Time at Current Residence: Clearly print on the blank line the dates you have lived at the address provided on the application.
Total number of Dependents: Clearly print on the blank line the number of dependents in your household, including yourself. Dependents are those that generally qualify as your dependent for federal income tax purposes.
Health Insurance Provider: Clearly print on the blank line the name of your health insurance carrier (including Medicare, Medicaid or other governmental coverage you may have).
Policy number: Clearly print on the blank line the policy or account number of your insurance policy.

Section C – income 
Total Household Income: Clearly print the income your household (yourself, your spouse, and dependents) receives from all sources. You may attach additional sheets of paper if more space is needed. Provide the gross amounts and the amounts received after taxes and other deductions. 

If your household receives income from a source that you do not see listed, please indicate that amount on the line for “Other” and provide a description.
Sources of income include, but are not limited to wages, tips, social security payments, retirement benefits, unemployment, workers’ compensation, veteran benefits, public assistance, alimony, child support, pensions, insurance or annuity contracts, investment income, etc.

Section D – debts and obligations

Total Household Debts and Obligations: Clearly print the debts and obligations of your household (yourself, your spouse, and dependents). You may attach additional sheets of paper if more space is needed. Provide the total amount of the liability and the monthly payment amounts.

If your household has debts or obligations that you do not see listed, please indicate that amount on the line for “Other” and provide a description.
If your household has debts or obligations that are not paid by you every month, take the total amount due during the past 12 months, divide it by 12, and then indicate that amount on the application.
Sources of debts and obligations include, but are not limited to real estate mortgages, household utility bills, telephone, food, automobile loans, charge and credit accounts, other loans, etc.

Section E – required documentation
 
The documents listed in this section are needed to help us determine if you qualify for financial assistance under our Financial Assistance Policy. If you do not have, or cannot produce the items listed, please include an explanation as to why. Please note that additional information or documentation may be requested by a Hospital representative when processing your application.
 
Section F – Certification
 
Patient/Guarantor’s Signature: Carefully read the acknowledgement statement in this section and then sign and date the application.
 


Mailing Instructions/Contact Information 

Submit the completed Financial Assistance Application along with supporting documentation to the hospital’s address. 
   
Further information about the Financial Assistance Policy or assistance with the application process are available from the hospital controller via the hospital phone number, in person at the hospital address or online at the website address. Certain foreign language translations of the Financial Assistance Policy, Plain Language Summary, Financial Assistance Application and Instructions are available upon request. 

Provider/physician listing

Services may be provided in Fairlawn Rehabilitation Hospital, an affiliate of Encompass Health by the hospital as well as by other health care practitioners, who may or may not participate with the same health insurers or health maintenance organizations (HMOs) as Fairlawn Rehabilitation Hospital, an affiliate of Encompass Health and who may bill you separately. These providers are encouraged, but not required, to follow the financial assistance policy of Fairlawn Rehabilitation Hospital, an affiliate of Encompass Health. You should contact the health care practitioner who will provide services to you to determine which health insurers and HMOs the practitioner participates in as a network provider or preferred provider. Contact information for practitioners who may provide services to you during your stay at Fairlawn Rehabilitation Hospital, an affiliate of Encompass Health is provided below.

You may request from Fairlawn Rehabilitation Hospital, an affiliate of Encompass Health and other health care providers a personalized estimate of reasonably anticipated charges for the treatment of your specific condition.

This listing is updated quarterly and additional providers or physicians may be added and/or presented under an alternate name that may be different from what is listed below. Please call us directly at 508.791.6351 and ask to speak with Credentialing, so that we can assist you with the most current and accurate information.

03015600_Fairlawn
Last Name
First Name
Specialty
Address
City
St
ZIP
Phone

Abdullin

Marat

Nephrology

354 Birnie Ave 1st Fl

Springfield

MA

1107

413.733.0010

Abramov

Konstantin

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Ahmed

Wiaam

Physical Medicine & Rehab

189 May ST

Worcester

MA

1602

508.471.9302

Aiello

Paul

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Asghar

Irfan

Internal Medicine

4 Grove Meadow Lane

Shrewsbury

MA

1545

Awobuluyi

Marc

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Balla

Ashfaq

Neurology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Baumer

Joane

Radiology

3 Electronics Ave Ste 201

Danvers

MA

1923

978.750.0300

Baumer

Nathan

Modified Barium Swallow Study

1717 Rotary Dr

Humble

TX

77338

281.272.6277

Bertagnolli

Reono

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Bodziak

Kenneth

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Boots

Breta

Neurology

CNS 33 Lyman St

Westboro

MA

1581

Boulet

Christina

Nurse Practitioner

411 Chandler Street

Worcester

MA

1602

508.471.5600

Brand

Stephen

Modified Barium Swallow Study

3 Electronics Ave Ste 201

Danvers

MA

1923

978.750.0300

Brown

Trista

Physical Medicine & Rehab

189 May ST

Worcester

MA

1602

508.471.9302

Chaudhary

Saqib

Internal Medicine

475 Pleasant St Ste D

Worcester

MA

1609

Colon

Juffred

Nurse Practitioner

390 Main ST #509

Worcester

MA

1608

508.753.4151

Cournoyer

Russell

Podiatry

135 Gold Star BLVD

Worcester

MA

1606

Deb

Anindita

Neurology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

DelRosario

Maria

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Deliso

Kathryn

Optometry

10 Lincoln Square

Worcester

MA

1608

Donahue

John

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Donepudi

Ramesh

Pulmonology

1 Hospital drive

Lowell

MA

1852

774.267.1226

Eisenstock

Jordan

Neurology

CNS 33 Lyman St

Westboro

MA

1581

508.898.0055

Esper

Paula

Nurse Practitioner

189 May ST

Worcester

MA

1602

508.471.9302

Estes

Sheree

Psychology/Neuropsychology

189 May ST

Worcester

MA

1602

508.791.6351

Fajana

Adekunle

Internal Medicine

390 Main ST #509

Worcester

MA

1608

508.753.4151

Fan

Pang

Neurology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Foster

Ruth

Nurse Practitioner

475 Pleasant St Ste D

Worcester

MA

1609

Garg

Kabul

TeleCardiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Grassi

Clement

Radiology

3 Electronics Ave Ste 201

Danvers

MA

1923

978.750.0300

Gyawali

Smita

Physician Assistant

22 Old Canal Drive

Lowell

MA

1851

Hakim

Faiyaz

Internal Medicine

390 Main ST #509

Worcester

MA

1608

508.753.4151

Hakim

Farah

Physician Assistant

475 Pleasant St Ste D

Worcester

MA

1609

Hanson

Natasha

Physician Assistant

390 Main St

Worcester

MA

1608

Holick

Emily

Physical Medicine & Rehab

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Iida

Eric

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Iyer

Suhasini

Internal Medicine

475 Pleasant St Ste D

Worcester

MA

1609

Katzen

Marshall

Orthopaedics

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Kent

David

Psychology/Neuropsychology

189 May ST

Worcester

MA

1602

508.471.9302

Kent

Sandra

Psychology/Neuropsychology

189 May ST

Worcester

MA

1602

508.471.9302

Kershaw

Glenn

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Ketchum

Jonathan

Podiatry

1378 Main ST

Worcester

MA

1603

508.755.9573

Klinger

Dagmar

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Klink

Arlene

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Kurella

Sarvalakshmi

Internal Medicine

291 Lincoln St

Worcester

MA

1605

Kurland

Jason

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Larios

Roberto

Internal Medicine

60 Hospital Road

Leominster

MA

1453

978.466.4169

MacGinnis

Christine

Internal Medicine

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Magoo

Hemant

Nephrology

100 Wason Ave Ste 200

Springfield

MA

1107

413.750.3440

Marino

Anthony

TeleCardiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Montague

Jahan

Optometry

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Niemi

Matthew

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Nowell

David

Psychology/Neuropsychology

189 May ST

Worcester

MA

1602

508.471.9302

Quarshie

Nicholas

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Ralto

Kenneth

Nephrology

119 Belmont ST

Worcester

MA

1605

508.791.6351

Riccio

Gioia

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Russo

Gregory

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Saikewicz

Olena

Radiology

3 Electronics Ave Ste 201

Danvers

MA

1923

978.750.0300

Seth

Priyanka

Physician Assistant

390 Main St

Worcester

MA

1608

Simh

Deetu

Nephrology

100 Wason Ave Ste 200

Springfield

MA

1107

413.750.3440

Smith

Kara

Neurology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Steigman

Daniel

Pulmonology

123 Summer ST

Worcester

MA

1608

508)795.1400

Stevens

Michael

Modified Barium Swallow Study

3 Electronics Ave Ste 201

Danvers

MA

1923

978.750.0300

Stoff

Jeffrey

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Sullivan

John

Neurology

60 Fenwood Rd

Boston

MA

2115

617.732.6753

Szabo

Felix

Internal Medicine

119 Belmont ST

Worcester

MA

1605

508.791.6351

Tanenbaum

Daniel

Physical Medicine & Rehab

189 May ST

Worcester

MA

1602

508.471.9302

Thamel

Brian

Optometry

335 Park Ave

Worcester

MA

1610

508.753.5103

Timerding

Beverly

Modified Barium Swallow Study

3 Electronics Ave Ste 201

Danvers

MA

1923

978.750.0300

Trainor

Matthew

Nephrology

55 Lake Ave North

Worcester

MA

1655

508.856.3590

Twehous

Debra

Physical Medicine & Rehab

119 Belmont ST

Worcester

MA

1605

508.791.6351

Veridiano

Valerie

Internal Medicine

189 May ST

Worcester

MA

1602

508.471.9302

Verma

Ashish

Nephrology

100 Wason Ave Ste 200

Springfield

MA

1107

413.750.3440

Vittimberga

Frank

Modified Barium Swallow Study

3 Electronics Ave Ste 201

Danvers

MA

1923

978.750.0300

Woodruff

Charles

TeleRadiology

1620 Northwest Blvd Ste 202

Coeur d'Alene

ID

83814

208.292.4323

Attachment B – 2019 Financial Assistance Discount Guidelines

Amounts charged to a patient eligible for Financial Assistance under this policy will be based on the applicable discount stated in the table above multiplied by the gross charges otherwise billable to the patient, subject to the “AGB” limitation described below.

In accordance with Internal Revenue Code section 501(r), a patient eligible for Financial Assistance under this policy will not be charged more than the amount generally billed to individuals who have insurance covering such care (“AGB”).

Facility has initially elected to calculate AGB under the “prospective Medicare method” described in applicable Treasury Regulations, using the billing and coding process the Facility would use if the individual were a Medicare fee-for-service beneficiary and setting AGB for the care at the amount the Facility determines would be the total amount Medicare would allow for the care (including both the amounts that would be reimbursed by Medicare and the amount the beneficiary would be personally responsible for paying in the form of co-payments, co-insurance, and deductibles).

Discount provided 100% discount 75% discount 50% discount
Family size Federal poverty guideline* Income less than or equal to 200% of FPG Income of 201%-300% of FPG Income of 301%-400% of FPG
1 $12,490 $0 - $24,980 $24,981 - $37,470 $37,471 - $48,560
2 $16,910 $0 - $33,820 $33,821 - $50,730 $50,731 - $65,840
3 $21,330 $0 - $42,660 $42,661 - $63,990 $63,991 - $83,120
4 $25,750 $0 - $51,500 $51,501 - $77,250 $77,251 - $100,400
5 $30,170 $0 - $60,340 $60,341 - $90,510 $90,511 - $117,680
6 $34,590 $0 - $69,180 $69,181 - $103,770 $103,771 - $134,960
7 $39,010 $0 - $78,020 $78,021 - $117,030 $117,031 - $152,240
8 $43,430 $0 - $86,860 $86,861 - $130,290 $130,291 - $169,520

* For family units with more than 8 persons, add $4,420 for each additional person.