It is the policy of Carroll County Memorial Hospital to render care to patients irrespective of their ability to pay. Patients who qualify for full or partial charity care will be identified as soon as possible and will be treated with the same courtesy as all other patients. Annually, the CEO and Board Members will establish the amount of charity services to be budgeted.

Who Qualifies?
Patients who have been reviewed or interviewed by the Carroll County Memorial Hospital Financial Counselor, or Case Manager, and who upon initial review appear to be financially or medically indigent and may need financial assistance to cover all or part of the patient’s hospital bill including:
    • Patients whose income is at or below 200% the percentage of the federal poverty guidelines
    • Catastrophic Medical cases where a patient/guarantor who has suffered a catastrophic medical incident resulting in medical bills that
        exceed one’s annual income, or, if in any given three (3) month consecutive window, whose medical bills exceed 20% of their gross
        income plus assets for the year; thereby concluding that one’s unpaid hospital charges exceed their ability to pay. The balance owed
        of these patients will be subject to a sliding scale and partial charity may be applied.
    • Patients who are uninsured or underinsured
    • Patients with a current Missouri Medicaid card or on a Missouri Medicaid Spend Down plan
    • Patients who have very limited financial resources and where payment of the entire bill would prove an undue hardship.
    • Patients whose stay exceeds the current Medicaid benefits limit.

Patients who qualify presently, or have qualified previously for this program, will not be disqualified from future consideration.  The specific circumstance will be reviewed for each date of service and determination of special need made at that time. Charity care qualification will apply retroactively to all open accounts in a ‘Final Bill’ status and remain in effect for 12 months after the first service date applied.  After the twelve-month period, all information may need to be resubmitted and re-reviewed.

Assistance is generally secondary to all other financial resources available to the patient including:

• Insurance 
• Government programs such as but not limited to VA benefits, Medicare, Medicaid, Missouri Crippled Children Services
• Third party liability
• Personal assets including existing liquid assets and open lines of credit

 
Uninsured Patient Discount Eligibility Criteria
An uninsured patient who does not qualify as financially or medically indigent shall receive a discount of 15% of the total balance.

Application Process: 
Financial Assistance applications can be obtained through the Business Office. Completed applications must be submitted to the Business Office within 10 days of receipt. Completed applications are legible, signed, dated, and will include applicable and requested attachments. If married, the patient must provide the requested information for both the patient and spouse. Applications not meeting these conditions may be returned to applicant or considered denied. An incomplete application that has been returned or considered denied may be resubmitted one time within 30 days for additional review. 
 
Upon receipt of a completed application, collection activity will cease until a determination has been made.

Verification of Income, Expenses, Liabilities, and Assets:
Verification of income and asset documentation is required for any charity care request and may increase depending on the quantity and dollar value of the account(s).
 
Attachments:

1. Proof of Identity: 
       • Photo copy of drivers’ license or government issued state id 
2. Proof of Residency
       a. Copy of utility bill
   Note: If the applicant is living with a friend or relative, a signed letter confirming the patient’s residence must be submitted along with a copy of the friend or relatives photo id (which must have a signature).  We may request that the letter be notarized.
3. Proof of Income: 
       • If you are employed: Last 3 pay stubs 
       • If you are self-employed (includes farming income): A copy of your monthly income statement for self-employment or a copy of your general business ledger/business checking account summary 
       • If you are not employed: 
           a)   A copy of benefit confirmation from Social Security, disability, pension, public assistance, workers compensation,trust fund, unemployment, military support, child support, and alimony.
           b)   Public assistance checks
           c)   Retirement checks
       • If you are employed and divorced: Last 3 pay stubs and proof of child support and alimony paid or received.  If you do not receive
            child support or alimony, please enclose a copy of the divorce decree where such is stated that it is not required.
   4. Conditional Attachments: (If requested)
   
   • A copy of your bank statement(s)
   • Dividends, interest or estate trusts
   • Rent or lease income
   • A copy of your Medicaid denial.
   • Copies of the previous years W-2
   • Copies of the previous years Federal Income Tax return if required to file
   • Copies of Medical expenses including outstanding bills
   • Other:_________________________________________________
                  __________________________________________________________

Determination
Upon receipt of completed application, the financial representative will review the completed Request Form Worksheet and submit to the Supervisor for approval. The Financial Assistance Worksheet determines the percentage of charity care for which the guarantor is eligible. The Financial Counselors must confirm that all figures used to calculate eligibility are correct, and if needed, they have the authority to seek additional verification before submitting for approval. The Supervisor will evaluate the Financial Counselor recommendations, verify calculations and documentation and, either approve or deny.

    • Consideration: When reviewing an application, the following considerations are reviewed: 
    • Source of income, for employed patients and unemployed where the patient/guarantor is not working, but has income. 
    • Assets 
    • Bank Account Balances (including name of bank) 
    • Alimony 
    • Child Support 
    • Credit report, obtained through Transunion w/open lines of credit indicative of resources to pay the bill. 
    • Resident of service area 
    • Pt does not have insurance or qualify for Medicaid or any other government program 
    • Statements for non-retirement accounts for the past three (3) months. We will “spend down” these account balances to pay the open
        accounts. 
    • Evidence that all possible third party payers have been exhausted and the balance is due from the patient/responsible party
 
Carroll County  may utilize discretion to make exceptions to the above procedures based on specific extraordinary circumstances.

In the event of extenuating or catastrophic circumstances where the income exceeds the poverty guidelines, but medical bills are excessive, partial charity may be offered per the ‘Sliding Scale’.
 
When the patient has been approved under the charity care policy for a partial discount, Carroll County will work with the patient or the responsible party to establish mutually agreeable payment option which will settle the balance in house within 24 months.

Financial Assistance calculation:
To be eligible for a 100 percent reduction from the patient portion of billed charges (i.e. full write-off) the patient’s household income must be at or below 200 percent of the current Federal Poverty Guidelines.  Patients with household income between 150 percent and 200 percent of the Federal Poverty Guidelines will be eligible for a sliding scale discount of the patient portion of billed charges.  (See attachment B) 
 
Notification:
Carroll County’s decision to provide financial assistance in no way affects the patients/guarantors financial obligation to their physician or other health care providers. 
    • All applicants will be notified of their approval or denial in writing.  
    • Appeal: Patients/guarantors may appeal a financial assistance determination by providing additional information such as income
        verification or an explanation of extenuating circumstances to the Financial Counselor Supervisor within 10 days of receiving
        notification of determination. The Financial Counselor Supervisor and Director will review all appeals. 
 
The patient/guarantor will be notified of the appeals outcome. Collection follow up will be pended during the appeal process.
 
For all patients identified Full Charity Care Patients, Carroll County:
    • Will not use forced court appearance to require the charity care patient or responsible party to appear in court.
    • Will not garnish wages.
 
For all patients who have received Partial Charity, Carroll County: 
    • Will not pursue collection action against a patient who has clearly demonstrated that he or she does not have sufficient income or assets to meet any part of their financial obligation to the Medical Center. 
    • Will re-review a patient’s determination if the patient agreed to a repayment plan that was reasonable in relation to his or her circumstances at the time, but the patient subsequently lost his or her job and became unable to pay under the plan, the original charity determination may be re-reviewed.

 
Note: If Carroll County has sufficient reason to believe that patient has income or assets to meet his or her partial obligation but continues with non-payment, the charity discount will be removed and the account will be referred to our outside collection agency.