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Geary Community Hospital Financial Assistance Policy & Application

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Geary Community Hospital Financial Assistance Policy & Application Geary Community Hospital Financial Assistance Policy & Application This policy and application is for patients who do not have any available resources for making payments towards the services they received while at Geary Community Hospital or GCH-owned entities. This policy and application will apply towards any current outstanding patient bills for: Geary Community Hospital (GCH) Services GCH-owned and operated Clinics Home Health Services Hospice Services Home Medical Equipment GEARY COMMUNITY HOSPITAL (GCH) FINANCIAL ASSISTANCE POLICY The GCH financial assistance program is designed to offer discounts to patients who do not have the financial resources to pay for their healthcare. This policy does meet the qualifications of the proposed Federal Patient Protection and Affordable Care Act (PPACA) of 2010 which state that individuals (uninsured and under-insured) who qualify for assistance under this policy will not be charged more than the amount generally billed to insured patients for emergency or medically necessary care. Eligibility for assistance is based on ability to pay regardless of age, sex, race, creed, disability or national origin. Financial assistance is available to Geary County residents and/or individuals whose primary care provider (PCP) is a member of the Geary Community Hospital medical staff. Primary care providers are doctors, physician assistants, nurse practitioners who are considered family or general practitioners, internal medicine, OB/GYN or pediatricians. Surgeons or specialists are not considered primary care providers. GCH will use the annual Federal poverty limits established by the U.S. Department of Health and Human Services (DHHS) for determining eligibility (http: //asep.hhs.gov/poverty) and will provide a discount for patients whose household income are at or below 200% of the Federal poverty guidelines. The discounts determined for 2019 are as follows: Household Income Discount % 0% - 125% of Federal poverty guidelines: 100% discount 126%-150% of Federal poverty guidelines: 79% discount 151%-175% of Federal poverty guidelines: 50% discount 176%-200% of Federal poverty guidelines: 25% discount Individuals who apply for financial assistance must cooperate with Hospital staff and other representatives who will attempt to enroll the patient for healthcare benefits through Medicaid /Kancare or other programs. Individuals must also provide proof of residence and proof of income (12 months) as well as complete the Financial Assistance Application. The program policies and application form are available through the Hospital’s website, at registration, the hospital business office, the hospital-owned physician clinics, home health, hospice and home medical equipment. Copies of the policy and application can also be obtained by calling (785) 210-3405. GEARY COMMUNITY HOSPITAL FINANCIAL ASSISTANCE APPLICATION Please complete all the requested information. Please use the “What Does This Mean?” tool located on the back of this application for help in completing this form. Any false information could lead to automatic denial of this application. Guarantor: ______________________________________________ Date of Birth: ________________________ Dependents: ______________________________________ ___________________________________________ ______________________________________ ___________________________________________ Current Address*: ____________________________________ Daytime Telephone Number (____) _____________ ____________________________________ * Proof of residence will be required with this application If your current residence is not located in Geary County, please provide your Primary Care Provider on the line below. Otherwise, you may leave blank. Primary Care Provider: ___________________________________________________________________________ Have you talked to someone recently about whether you may qualify for medical benefits such as Medicaid, MediKan, Crime Victims, SOBRA, etc.? _______ Yes ________ No If you have not been recently screened for medical benefits, this application may be denied. Please contact 1-877-803-6675 and request a financial screening. If you elect to be screened by another agency, please provide proof with this application that you have been denied access to other medical benefits. Income Information*: Wages: $_____________ per week/month/year {Circle the time frame that applies} Disability: $___________ per week/month approved for _____ months Child Support: $__________ per week/month/year {Circle the time frame that applies} Unemployment: $__________ Other Income: $___________ * Please provide proof of income for the past 12 months. Additional Comments: ______________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Checklist of additional documents to include with completed application: __________________________________________ □ Proof of residence Signature □ Medical benefit screening information (if ______________________________ applicable) Date □ Proof of income (for past 12-months) □ Signed and dated application FINANCIAL ASSISTANCE APPLICATION WHAT DOES THIS MEAN? A Guide to Assist in Completing the GCH Financial Assistance Application GUARANTOR This is the person who is responsible for paying the bill for healthcare services at Geary Community Hospital (GCH). This could be the patient, the parent of a child or someone who is claiming responsibility for an outstanding bill. DEPENDENTS Dependents are any individual who can be considered a dependent on an IRS income tax form. A dependent includes the patient, a spouse, a child, etc. CURRENT We need to know your current address so we can send a written response to you once your ADDRESS application has been processed. To qualify for GCH financial assistance, this address must be located in Geary County (including Fort Riley) or your primary care provider is a GCH provider. PROOF OF Proof of your current residence will be required and may include: address listed on tax forms, CURRENT paycheck stubs, disability letter and/or a utility bill. RESIDENCE PRIMARY CARE A doctor, usually a family or general practitioner, internist or pediatrician, who is chosen by an PROVIDER individual to provide or coordinate that entire person's health care needs. A specialist, consultant or surgeon is not considered a primary care provider. If you do not currently live in Geary County, your primary care provider must be on the Geary Community Hospital medical staff. MEDICAL The GCH Financial Assistance program is a last resort program when all avenues to attempt to find BENEFITS coverage and/or payment for services have been exhausted. If you or your family has not completed a screening for possible medical coverage, your application could be denied. INCOME GCH requires at least 12-month’s worth of income documentation. This documentation should be complete and demonstrate your current financial situation. Documents may include: Prior year’s income tax forms, W-2 forms, pay check stubs showing at least 12-month’s worth of income, bank statements, child support forms, disability letters, unemployment letters, etc. For individuals who have not worked during the past year and did not file a tax return, you will be asked to sign a 4506-T IRS form to request any transcripts from the IRS to document your financial status. FINANCIAL FINANCIAL ASSISTANCE: 100% discount (0%-125% Federal guidelines) DISCOUNTS DEFINED LOW INCOME DISCOUNT: 79% discount (126%-150% Federal guidelines) SLIDING SCALE DISCOUNT: 50% discount (Income 151%-175% of Poverty Guideline) 25% discount (Income 176%-200% of Poverty Guideline) The Federal poverty guideline used for determining financial assistance is provided in the table below: 2021 Poverty Guidelines Poverty Household/Family Guideline 125% of Poverty 150% of Poverty 175% of Poverty 200% of Poverty Size 100% Guidelne Guideline Guideline Guideline 1 $12,880 $16,100 $19,320 $22,540 $25,760 2 $17,420 $21,775 $26,130 $30,485 $34,840 3 $21,960 $27,450 $32,940 $38,430 $43,920 4 $26,500 $33,125 $39,750 $46,375 $53,000 5 $31,040 $38,800 $46,560 $54,320 $62,080 6 $35,580 $44,475 $53,370 $62,265 $71,160 7 $40,120 $50,150 $60,180 $70,210 $80,240 8 $44,660 $55,825 $66,990 $78,155 $89,320 For each additional person add $4,540 each.
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