Charitable Care Policy
POLICY STATEMENT: It is the policy of Elliot Hospital to offer medical care to all who may have difficulty in paying for services due to limited income without regard to their race, religion, sex, or age.
Generally, individuals whose income falls below 400% of the federal poverty guidelines qualify for some level of assistance for medically necessary services. The charitable care provided can range from the patient having no financial obligation, to a percentage of their hospital charges.
PURPOSE: This policy defines the income eligibility criteria. The policy also sets forth the procedure by which a patient shall apply for charitable care.
All patients who qualify for Charitable Care will be responsible to pay a Community Co-Payment. The Community Co-Payment is per encounter.
| Inpatient | $100.00 per episode | |
| Emergency Department | $25.00 per visit | |
| Ambulatory Surgery | $25.00 per visit | |
| Series (Recurring) | $15.00 per 30 day period | |
| Behavioral Health (Recurring) | $15.00 per 30 day period | |
| Urgent Care | $10.00 per visit | |
| Out Patient Visit | $10.00 per visit |
Charitable Care recipients who do not pay their Community Co-Payment after being approved for Charitable Care will not be eligible to re-qualify for Charitable Care.
PROCEDURE:
If a patient believes that they may qualify for charitable care, they should call 866-890-8689 (8:00-4:30) to schedule an appointment with the charitable care coordinator.
The patient must complete a formal application for charitable care within 120 days of receiving medically necessary services from the hospital. The following documentation must be submitted with each application in order to most accurately determine eligibility.
- Complete copy of most current tax return including all schedules. Copy of 3 most recent pay stubs from each income earner. (If more than one employer within the calendar year, proof of gross income earned at each employer, with corresponding dates of employment will be required.)
- If social security income: copy of check or a copy of bank statement showing most recent social security check deposit.
- If unemployed: verification of any compensation received. Example: unemployment compensation, workers compensation, etc.
- If unemployed and receive no income: a letter of support written by the person or persons who are providing financial support.
- If assistance from City Welfare: vouchers from each program that provides assistance to the individual. Example: food stamps, rental subsidy, fuel assistance, etc.
- If child support and/or alimony are provided: copies of checks.
The application with requested information should be returned to:
Elliot Hospital Patient Financial Services
Attn: Charitable Care Coordinator
One Elliot Way
Manchester, New Hampshire 03103
Application for charitable care will not be processed until all insurance benefits and/or financial aid from third party; state and federal assistance programs, charitable or endowment funds have been exhausted.
Charitable care will be available only for medical services that are reasonable and necessary for the diagnosis and treatment of illness or injury. Non-medically necessary services will not be considered. Services that are considered cosmetic or patient convenience would not qualify for charitable care. Also any services that are elective and are not medically urgent or emergent do not qualify for charitable care.
Patient Financial Services will render determination of eligibility in writing within fourteen days of receipt of the complete application.
Patients denied charitable care might appeal the decision in writing to the Charitable Care Appeal Committee. The Committee shall include the Director of Patient Financial Services, Director of Social Work/Case Management/Pastoral Care, Vice President of Finance, and Associate Medical Director for Resource Management. The Committee will review the appeal and render a written decision within 30 days of receipt.
The approval of charitable care services will remain in effect for six months from the date approved.
All questions concerning this policy should be directed to the Director of Patient Financial Services
ELLIOT HOSPITAL CHARITABLE CARE GUIDELINES JULY 1, 2012 to JUNE 30, 2013
If your family size is: And your annual income is less than:
1 $43,560.00 38,115.00 32,670.00 27,225.00 21,780.00
2 56,680.00 49,595.00 42,510.00 35,425.00 28,340.00
3 74,120.00 64,855.00 55,590.00 46,325.00 37,060.00
4 89,400.00 78,225.00 67,050.00 55,875.00 44,700.00
5 104,680.00 91,595.00 78,510.00 65,425.00 52,340.00
6 119,960.00 104,965.00 89,970.00 74,975.00 59,980.00
7 135,240.00 118,335.00 101,430.00 84,525.00 67,620.00
8 150,520.00 131,705.00 112,890.00 94,075.00 75,260.00
You may qualify for a discount of:
20% 40% 60% 80% 100%