POLICY and / or PROCEDURE TITLE: Financial Assistance ... · Ohio or any patient who has come to...

POLICY and / or PROCEDURE

TITLE: Financial Assistance Policy (“FAP”) NUMBER: F-300.300

ISSUE DATE: 7/1/2016 EFFECTIVE DATE: 7/1/2016 DEVELOPED / REVISED BY: Revenue Cycle Leadership

REVIEWED BY: Sr. VP and CFO; Office of the General Counsel

DATE REVIEWED: March 2019

APPROVED BY: OhioHealth Board

Board of Trustees

SCOPE:

This policy is in effect for all OhioHealth member hospitals and employed physician practices, OhioHealth Urgent Care Centers and OhioHealth Home Care (collectively “OhioHealth facilities”).

STATEMENT OF PURPOSE:

The mission of OhioHealth is to extend the healing ministry by providing high quality and cost effective service responsive to the needs of the community. OhioHealth’s commitment includes providing access to health care for persons regardless of their ability to pay. This policy establishes OhioHealth’s guidelines for providing financial assistance to patients who are eligible for partially or fully discounted services.

POLICY: FINANCIAL ASSISTANCE PROGRAMS

OhioHealth provides free or discounted services to eligible patients for emergency or medically necessary services. OhioHealth’s Financial Assistance Programs include the following:

A. Hospital Care Assurance Program (HCAP). The HCAP program is the Ohio Department of Job and Family Services’ (ODJFS) mechanism for meeting the federal requirement to provide additional payments to hospitals which provide a disproportionate share of uncompensated services to the indigent and uninsured.

B. OhioHealth Charity Program. The OhioHealth Charity Program provides assistance for emergency and other medically necessary care provided to eligible patients for whom other payment resources are not available. The OhioHealth Charity Program will provide:

a 100% discount off of the patient’s payment responsibility to patients whose income is at or below 200% of the Federal Poverty Guidelines;

a 80% discount off of the patient’s payment responsibility to patients whose income is at or below 300% of the Federal Poverty Guidelines; or

a 65% discount off the patient’s payment responsibility to patients whose income is at or below 400% of the Federal Poverty Guidelines.

C. OhioHealth Hardship Program. Where none of the above programs apply, OhioHealth reserves the right to also consider a Hardship application on a case-by-case basis for patients who otherwise demonstrate that a financial hardship is catastrophic, unusual, or extraordinary. Both the OhioHealth Charity Program and the Hardship Program are programs of last resort, meaning that if another state or federal program is available to provide assistance, or if another resource is available to pay for a patient’s care or reimburse the patient for charges relating to that care, that program or resource must be exhausted before the patient becomes eligible for the OhioHealth programs.

PROCEDURE:

1. Eligibility Requirements for Financial Assistance Programs: OhioHealth uses the following guidelines to establish eligibility for its various Financial Assistance Programs. Eligibility for a Financial Assistance Program requires both that the service and the patient be eligible for the Financial Assistance Program.

A. ELIGIBLE SERVICES: The OhioHealth Financial Assistance Programs are applicable only to emergency or other

medically necessary healthcare services provided by an OhioHealth hospital, OhioHealth employed physician practice, OhioHealth Urgent Care Center, and OhioHealth Home Care, as listed above. Determinations as to whether care is medically necessary are based upon the generally accepted standards of medicine in the community served by OhioHealth.

Services which are separately billed by other healthcare providers, even if provided in an OhioHealth hospital, are not covered by this policy. A hospital-specific list of providers who provide services in the hospital, and indicating whether the services each provides are covered by this policy, is attached to this policy as Attachment 1.

B. OHIOHEALTH CHARITY PROGRAM: The OhioHealth Charity Program is available to OhioHealth’s patients who are not otherwise eligible for a financial assistance program provided by a third party and who do not have another source of payment or reimbursement for the charges related to their care. Other sources of payment that must be exhausted before a patient is eligible for financial assistance could include but are not limited to health insurance, HCAP, various other government programs, other insurance such as automobile, homeowner, or liability insurance, or third parties who may be responsible for the patient’s care. Patients must complete a Financial Assistance Application and meet the following income-based eligibility requirements:

1. Patients whose income is less than 200% of the current Federal Poverty Income Guidelines can be eligible for a 100% charity discount off of the patient’s payment responsibility.

2. Patients whose income is between 201% and 300% of the current Federal Poverty Income Guidelines can be eligible for an 80% charity discount off of the patient’s payment responsibility.

3. Patients whose income is between 301% and 400% of the current Federal Poverty Income Guidelines can be eligible for a 65% charity discount off of the patient’s payment responsibility.

These discounts are applied via the Charity Discount Worksheet (Attachment 2). Due to the Federal Poverty Income Guidelines changing annually, OhioHealth routinely updates this worksheet. Family size includes the patient, the patient's spouse (regardless of whether they live in the home), and all of the patient's children, natural or adoptive, under the age of eighteen who live in the home. If the patient is under the age of eighteen, the "family" shall include the patient, the patient's natural or adoptive parent(s) (regardless of whether they live in the home), and the parent(s)' children, natural or adoptive, under the age of eighteen who live in the home. If the patient is the child of a minor parent who still resides in the home of the patient's grandparents, the "family" shall include only the parent(s) and any of the parent(s)' children, natural or adoptive, who reside in the home. For patients who are not initially eligible because they have another source of payment, the amounts that the patient is responsible for may be eligible for the OhioHealth Charity Program after all other payment sources are exhausted, subject to applicable legal limitations for Medicaid and other State and Federal Beneficiaries. In addition, where no other financial assistance programs apply, including the OhioHealth Charity Program, OhioHealth reserves the right to consider a Hardship application on a case-by-case basis for patients whom the OhioHealth Hardship Committee determines to be eligible on the basis of a demonstrated financial hardship being catastrophic, unusual, or extraordinary.

C. HCAP: The Hospital Care Assurance Program is administered by the Ohio Department of Job and Family Services (ODJFS) and is governed by state and federal requirements. OhioHealth applies the HCAP eligibility requirements per instructions from ODJFS and OhioHealth does not have discretion to change them. This policy summarizes these requirements.

1. Residency Requirement - The patient must be voluntarily living in the state of Ohio. This includes temporary residents such as students or migrant workers and patients who are temporarily residing with in-state relatives. This does not include patients who reside in another state and are merely traveling through or vacationing in Ohio or any patient who has come to Ohio solely to receive medical care.

2. Financial Need Requirement - The patient must meet the income guidelines of at or below 100% of the current Federal Poverty Income Guidelines at the time of service for the patient’s family size. Family size includes the patient, the patient's spouse (regardless of whether they live in the home), and all of the patient's children, natural or adoptive, under the age of eighteen who live in the home. If the patient is under the age of eighteen, the "family" shall include the patient, the patient's natural or adoptive parent(s) (regardless of whether they live in the home), and the parent(s)' children, natural or adoptive, under the age of eighteen who live in the home. If the patient is the child of a minor parent who still resides in the home of the patient's grandparents, the "family" shall include only the parent(s) and any of the parent(s)' children, natural or adoptive, who reside in the home. The patient cannot be a recipient of Medicaid or any other state Medicaid program.

3. Services Requirement - Services must be a medically covered service per ODJFS guidelines. 4. Signed Application – A signed application is required for eligibility for the HCAP program.

D. COMMUNITY PROGRAMS: OhioHealth recognizes and cooperates with a number of other charity programs, such as various pharmaceutical industry charitable programs. Each such program is governed by its own eligibility requirements and eligibility for such programs will not constitute eligibility for an OhioHealth Financial Assistance Program. However, OhioHealth also participates in the Physicians Free Clinic program. Patients participating in the Physicians Free Clinic program and who receive emergent or other medically necessary care at an OhioHealth facility as part of the Free Clinic program, are eligible to receive that care for free from the OhioHealth facility.

2. HOW TO APPLY FOR FINANCIAL ASSISTANCE PROGRAMS:

A. To Inquire about Financial Assistance: Patients can apply for Financial Assistance Programs at any time from pre-registration until the patient’s account is closed. For information on how to apply, and for any questions related to the application, the patient can call the Customer Call Center or contact the Customer Call Center via email or visit the registration desk or cashier’s office of any OhioHealth facility (the physical address for each OhioHealth facility is set forth on Attachment 3 to this FAP) and ask to speak to a Financial Counselor. All patients at an OhioHealth facility can ask to speak with a Financial Counselor at any time.

B. To Obtain a Financial Assistance Application Form: Application forms are available during registration at all OhioHealth locations, are available via mail at the patient’s request, and can be found online at: https://ohiohealth.com/financialassistance/

C. To Complete a Financial Assistance Application Form: To be considered complete:

1. The application must be fully completed according to the instructions on the form;

2. The application must be signed by the patient, the patient’s guardian, or the financially responsible person as

applicable;

3. The application must enclose appropriate documentation of income, including: a. Payroll stubs covering either the three month period prior to the date of service or date of application, or

the twelve month period prior to the date of service or application, whichever the patient chooses. If pay stubs are not available, a letter from the applicant’s employer (on company letterhead) verifying applicant’s gross income for the three months prior to the date of service (or application) may be accepted. The company letter must be signed by a company official and a contact name must be referenced as well as telephone number of a contact person for the company.

b. Spouse’s income regardless of whether he/she lives in the patient’s home. c. Bank statements if used for payroll or Social Security Income direct deposits, in which case, the applicant

must indicate whether health insurance or other payments are deducted – and if so, how much. d. Depending on the circumstances, OhioHealth may, from time to time, accept W2’s or tax returns for the

most recently completed tax year as evidence of a patient’s income. e. Documentation of child support and/or alimony payments received, provided, however, that, child support

is not considered income unless it is for the patient/child that the support is being paid. f. Documentation of unemployment compensation, workers compensation, tips, interest, rental income,

retirement income, investment income, inheritance or any other type of income or compensation received during the twelve (12) month period preceding the date of service or application date.

4. The application includes a statement authorizing OhioHealth to obtain financial information from other sources

such as the patient’s credit report, a property search and/or information from a collection agency if needed;

5. The application must be returned to the address located on Attachment 3.

6. In exceptional circumstances, OhioHealth Customer Call Center representatives are authorized to take Financial Assistance Applications via the phone.

D. Benefits of Financial Assistance Applications for Patients Who are Not Eligible for Financial Assistance Programs:

https://ohiohealth.com/financialassistance/

Completing a Financial Assistance Application can provide benefits even for patients who are not eligible for financial assistance.

1. Medicaid or Other Government Programs: Upon receipt of a Financial Assistance Application where it is indicated that the patient may be eligible for Medicaid, the Medicaid eligible patients will be referred to a Medicaid eligibility specialist to assist the patient with applying for Medicaid or any other relevant government program. The Medicaid eligibility specialist will assist the patient/family through the application process, including assisting in obtaining all necessary documentation required by the governmental program.

2. Installment Plans: All applicants are eligible for the organization’s installment payment plan. This arrangement provides interest free loans with a minimum monthly payment amount.

3. Uninsured or Self Pay Discount: Uninsured applicants who do not qualify for HCAP, an OhioHealth Charity discount or a hardship discount, and, therefore, do not qualify as an eligible patient under this policy, are eligible for the Uninsured Discount for emergent or other medically necessary services such applicants receive. The Uninsured Discount is 35% off of the charges for such emergent or medically necessary services.

E. Other Eligibility Considerations in the Event Documentation of Income or a Complete Application Cannot be Produced: Recognizing that some patients are unable to produce some or all of the requested documentation or information necessary to prepare and submit a complete application in accordance with the requirements of this policy or may otherwise be unable to furnish an application at all, OhioHealth reserves the right to determine a patient’s eligibility for Financial Assistance Programs based upon the totality of information available. Relevant factors include, but are not limited to, the following circumstances:

1. Patient is deceased with no known estate; 2. Patient is homeless and /or has given a shelter address during the registration process, or mail returned as

homeless; 3. Family/friend declares information supporting patient’s inability to pay; 4. Patient states that he or she is a victim of crime. In these cases, patient must apply for financial assistance

prior to being awarded coverage through the Victims of Crime program; 5. Patient was incarcerated during the 3 or 12 months prior to the date of service; 6. In exceptional cases, verbal application/attestation by a patient may be deemed acceptable after 30 days of

due diligence on efforts to obtain a patient’s signature; 7. Patient has Out of State Medicaid and OhioHealth does not have a provider number for this state; 8. Patient was Medicaid recipient either before or after date of service; 9. Catastrophic case approved for partial charity due to high outstanding balance(s); 10. Patient was HCAP/Charity eligible either before or after date of service; 11. Patient’s current income and family size qualifies the patient for charity care under this policy and, therefore,

may be determined eligible for prior dates of service, inpatient and outpatient; or 12. Patient is covered under the Medicaid Family Planning program.

F. Hardship Application: After a patient has completed a Financial Assistance Application and has been determined to be not eligible for other Financial Assistance Programs, or has not satisfied the other criteria for eligibility set forth in Section E above, OhioHealth reserves the right to consider a Hardship application on a case-by-case basis for patients who the OhioHealth Hardship Committee determines to be eligible on the basis of an unusual financial situation or a religious or cultural belief that creates a demonstrably catastrophic, unusual, or extraordinary situation. To apply for the Hardship program, the patient must send a letter describing the unusual circumstances and requesting consideration along with any supporting documentation to: OhioHealth CBO, P.O. Box 7527, Dublin, Ohio 43016. Consideration of a Hardship application does require that the patient declare all assets, including investments or other property of significant value, stocks, bonds, any settlements that have been received, and all other sources of assets or income.

3. ELIGIBILITY DETERMINATIONS: Financial Assistance Program eligibility determinations are good for the following periods of time:

A. For inpatient services, eligibility determinations with respect to HCAP are made separately for each admission, unless the patient is readmitted within 45 days for the same underlying condition, in which case the eligibility determination shall apply to such readmission.

B. For outpatient services, eligibility determinations for HCAP are good for 90 days.

C. Eligibility determinations for the OhioHealth Charity Program (inpatient and outpatient) are good for 180 days. In

addition, eligibility determinations may be applied to a patient’s existing past-due accounts that are unrelated to the care for which an application for financial assistance has been submitted. If eligibility determinations are applied to a patient’s existing past-due accounts, any amount the patient has personally paid on such past-due accounts in excess of the amount for which the patient would be personally responsible using the AGB percentage described in paragraph 5 below, shall be returned to the patient.

D. If, at any time, a patient is presumed eligible for financial assistance for an episode of care based upon a prior eligibility determination and the assistance for which the patient is determined eligible is less than the most generous assistance provided under this policy, the patient will be notified that he/she may apply for more generous assistance.

4. NOTIFICATION OF FINANCIAL ASSISTANCE: Signs are posted in conspicuous locations stating OhioHealth’s compliance with the State of Ohio’s Hospital Care Assurance Program (HCAP) and informing patients about the OhioHealth Charity Program. Information materials, including copies of this policy, a plain language summary of this policy, and the application are available at registration, via mail without charge to the patient, and online at https://www.ohiohealth.com/financialassistance/, and are available in each of the primary languages spoken in the community. Interpretive services can also be arranged if the patient/guarantor does not speak English. Also, billing statements notify patients of the availability of Financial Assistance Programs and how to get more information.

5. AMOUNTS GENERALLY BILLED: For patients who are determined to be eligible for a Financial Assistance Program, OhioHealth will not hold the patient responsible for more than the “amount generally billed” (or AGB) by the hospital. The AGB percentage is calculated using the “Look-Back” method, as defined in federal regulations. Each OhioHealth hospital calculates its AGB percentage based on all claims allowed by Medicare and private health insurers over a 12 month period, divided by the applicable hospital’s associated gross charges for those claims. The AGB percentage varies by hospital, but for all OhioHealth hospitals it equals no more than a 65% discount off gross charges. This calculation is updated annually. Members of the public may obtain a written copy of any OhioHealth hospital’s specific AGB percentage free of charge by calling the Customer Call Center or writing to OhioHealth, PO Box 7527, Columbus, Ohio 43016.

6. BILLING AND COLLECTION OF PATIENT RESPONSIBILITIES: OhioHealth will use diligent efforts to protect its charitable resources by appropriately billing and pursuing collections for services provided by OhioHealth. OhioHealth maintains a separate Billing and Collection Policy with a full description of this process. Members of the public may readily obtain a free copy of this separate policy by calling the Customer Call Center.

RECISION: SPP F-300-R effective August 19, 2003 is hereby rescinded.

https://www.ohiohealth.com/financialassistance/

LIST OF SPECIALITIES AT: BERGER HOSPITAL

As of: 03/2020

Providers covered by the OhioHealth Financial Assistance Policy

Berger Hospital

OhioHealth Physician Group (primary and specialty care)

Providers not covered by the OhioHealth Financial Assistance Policy:

Physician services provided in Radiology (Riverside Radiology and Interventional Associates, Inc.)

Physician services provided in Pathology (Diagnostic Pathology Associates, Inc.)

Physician services provided by Hospitalists (Sound Physicians)

Physician services provided in Emergency Room (Circleville Emergency Physicians)

Anesthesiology services provided by Capital Anesthesia Solutions

Physician services provided at the hospital in any of the following departments are not covered unless provided by an

OhioHealth Physician Group provider.

Wound Care

Pain Center

Surgery

Medicine

Orthopedics

Podiatry

LIST OF SPECIALTIES AT: DOCTORS HOSPITAL

As of: 3/2020


Doctors Hospital



Nationwide Children’s Hospital Neonatal Intensive Care Unit


Physician services provided in Pathology (CORPath)

Physician services provided in Emergency Room (USACS- US Acute Care Services)

Anesthesiology services provided by West Broad Anesthesiology

Physician services provided at the hospital in any of the following departments are not covered unless provided by an OhioHealth Physician Group provider.

Cardiothoracic

Hematology/Oncology

Medicine

Obstetrics/Gynecology

Orthopedics

Pediatrics

Podiatric Medicine and Surgery

Surgery

LIST OF SPECIALTIES AT: DUBLIN METHODIST HOSPITAL

As of: 3/2020


Dublin Methodist Hospital





Physician services provided in Pathology (Corpath, Ltd.)

Physician services provided in Emergency Room (Team Health)

Anesthesiology services provided by MidWest Anesthesia


Cardiology Obstetrics/Gynecology Surgery Medicine Pediatrics

LIST OF SPECIALTIES AT: GRANT MEDICAL CENTER

As of: 3/2020


Grant Medical Center


OhioHealth Urgent Care



Physician services provided in Radiology (Columbus Radiology and Interventional Associates, Inc.)

Physician services provided in Radiology (Riverside Radiology and Interventional Associates) – Free-standing EDs


Physician services provided in Emergency Room (Mid-Ohio Emergency Services)

Physician services provided in Emergency Room (United States Acute Care Solutions) at Grove City Methodist Hospital

Anesthesiology services provided by Doctors Anesthesia at Grove City Methodist Hospital


Cardiothoracic

Family Medicine

Medicine


Orthopedics

Surgery

LIST OF SPECIALTIES AT: GRADY MEMORIAL HOSPITAL

As of: 4/2020


Grady Memorial Hospital


Grady Memorial Hospital Professional Services

Marion Area Physicians





Physician services provided in Emergency Room (Premier Health Services, Inc)


Cardiology

Medicine


Orthopedics

Pediatrics

Podiatry

Psychology

Surgery H

Hospitalists

Anesthesiology

LIST OF SPECIALTIES AT: GROVE CITY METHODIST HOSPITAL

As of: 3/2020


Grove City Methodist Hospital





Physician services provided by Hospitalists (HMS)

Physician services provided in Emergency Room (ACS)

Anesthesiology services provided by DASC

Orthopedic services provided by OrthoNeuro


Medicine

Surgery

Urology

Orthopedics

LIST OF SPECIALTIES AT: HARDIN MEMORIAL HOSPITAL

As of: 04/2020


Hardin Memorial Hospital





Physician services provided in Pathology (Corepath)

Physician services provided by Hospitalists (Central Ohio Primary Care; MedOne)

Access Medical - Dr. Bekkam

Independent physicians i.e. Dr. Deshmukh

Physician services provided in Emergency Room (Schumacher Group)

Anesthesiology services provided by (Marion Anesthesia)

Urgent Care Providers (Meritra)


Cardiology

Medicine


Orthopedics

Pediatrics

Podiatry Surgery U Uro

LIST OF SPECIALTIES AT: MARION GENERAL HOSPITAL

As of: 04/2020


Marion General Hospital





Physician services provided in Pathology (Corepath)

Physician services provided by Hospitalists (Central Ohio Primary Care; MedOne; Access Medical Group)

Physician services provided in Emergency Room (Team Health (Premier))

Anesthesiology services provided by Medac


Cardiothoracic

Medicine


Orthopedics

Pediatrics

Surgery

LIST OF SPECIALTIES AT: MANSFIELD HOSPITAL

As of: 4/2020


Mansfield Hospital


Med Central Professional Foundation


Physician services provided in Emergency Department (Mid-Ohio Emergency Physicians, LLP)

Physician services provided in Pathology (APS Medical Billing)

Physician services provided by Hospitalists (Mid-State Physicians, LLP and NES Healthcare Group)

Anesthesiology services provided by Malabar Anesthesia and Anesthesiologists Associates

Physician services provided at the hospital in any of the following departments are not covered unless provided by an OhioHealth Physician Group provider or MedCentral Professional Foundation provider.

Cardiothoracic

Medicine


Orthopedics

Pediatrics

Podiatry

Psychiatry

Surgery

LIST OF SPECIALTIES AT: O’BLENESS HOSPITAL

As of: 4/2020


OhioHealth O’Bleness Hospital




Physician services provided in Emergency Room (OVP Health)


Cardiology

Hospital Medicine


Orthopedics

Pediatrics

Podiatry

Surgery

LIST OF SPECIALTIES AT: RIVERSIDE METHODIST HOSPITAL

As of April, 2020


Riverside Methodist Hospital






Physician services provided by Hospitalists (Central Ohio Primary Care; MedOne)

Physician services provided in Emergency Room (MidOhio Emergency Services)

Anesthesiology services provided by MidWest Physician Anesthesia Services


Family Medicine

Medicine


Pediatrics

Psychiatry

Surgery

LIST OF SPECIALTIES AT: SHELBY HOSPITAL

As of: 4/20


Shelby Hospital


MedCentral Professional Foundation


Physician services provided in Emergency Department (Mid-Ohio Emergency Physicians, LLP)

Physician services provided in Pathology (APS Medical Billing)

Physician services provided by Hospitalists (Mid-State Physicians, LLP and NES Healthcare Group)

Anesthesiology services provided by Malabar Anesthesia and Anesthesiologists Associates

Physician services provided at the hospital in any of the following departments are not covered unless provided by an OhioHealth Physician Group provider or MedCentral Professional Foundation provider.

Medicine


Orthopedics

Pediatrics

Podiatry

Surgery

CHARITY DISCOUNT WORKSHEET - BASED ON 2020 FEDERAL INCOME GUIDELINES

ANNUAL INCOME

HCAP Expanded Medicaid Charity Charity Charity

Family Size 100% FPL 138% FPL 101% - 200% FPL 201% - 300% FPL 301% - 400% FPL

100% Discount 100% Discount 80% Discount 65% Discount

1 $ 12,760 $ 17,609 $ 12,761 $ 25,520 $ 25,521 $ 38,280 $ 38,281 $ 51,040

2 $ 17,240 $ 23,791 $ 17,241 $ 34,480 $ 34,481 $ 51,720 $ 51,721 $ 68,960

3 $ 21,720 $ 29,974 $ 21,721 $ 43,440 $ 43,441 $ 65,160 $ 65,161 $ 86,880

4 $ 26,200 $ 36,156 $ 26,201 $ 52,400 $ 52,401 $ 78,600 $ 78,601 $ 104,800

5 $ 30,680 $ 42,338 $ 30,681 $ 61,360 $ 61,361 $ 92,040 $ 92,041 $ 122,720

6 $ 35,160 $ 48,521 $ 35,161 $ 70,320 $ 70,321 $ 105,480 $ 105,481 $ 140,640

7 $ 39,640 $ 54,703 $ 39,641 $ 79,280 $ 79,281 $ 118,920 $ 118,921 $ 158,560

8 $ 44,120 $ 60,886 $ 44,121 $ 88,240 $ 88,241 $ 132,360 $ 132,361 $ 176,480

9 $ 48,600 $ 67,068 $ 48,601 $ 97,200 $ 97,201 $ 145,800 $ 145,801 $ 194,400

10 $ 53,080 $ 73,250 $ 53,081 $ 106,160 $ 106,161 $ 159,240 $ 159,241 $ 212,320

11 $ 57,560 $ 79,433 $ 57,561 $ 115,120 $ 115,121 $ 172,680 $ 172,681 $ 230,240

12 $ 62,040 $ 85,615 $ 62,041 $ 124,080 $ 124,081 $ 186,120 $ 186,121 $ 248,160

13 $ 66,520 $ 91,798 $ 66,521 $ 133,040 $ 133,041 $ 199,560 $ 199,561 $ 266,080

14 $ 71,000 $ 97,980 $ 71,001 $ 142,000 $ 142,001 $ 213,000 $ 213,001 $ 284,000

15 $ 75,480 $ 104,162 $ 75,481 $ 150,960 $ 150,961 $ 226,440 $ 226,441 $ 301,920

Effective for dates of service January 15, 2020 and after

OhioHealth Financial Assistance Policy for Medical Needs The mission of OhioHealth is to improve the health of those we serve. We are pleased to offer The OhioHealth Financial Assistance Program (FAP),

which provides free or discounted services to eligible patients for emergency or medically necessary services. Patients seeking financial assistance

must apply for the program.

Eligibility To be eligible for the program, patients must complete a Financial Assistance Application and meet specified income-based eligibility requirements or otherwise be able to show a significant financial hardship that precludes a patient from paying for care received. Generally, patients who are eligible have a family income at or below 400% of the federal poverty guidelines and do not have another source of payment of reimbursement for the cost of care. Based upon income level, discounts range from 65% -100% off of the patient’s responsibility for the care received. In no event will a patient determined to be eligible for assistance under the FAP be charged more than the amounts generally billed by the hospital for care provided to insured patients. The FAP applies only to services billed by OhioHealth and physician services received by a patient at the hospital from an OhioHealth-employed physician. To apply Free Copies of the Financial Assistance Policy and Applications for Financial Assistance may be obtained by:

Visiting an OhioHealth hospital’s main registration or emergency department desk (addresses on back)

Calling OhioHealth’s Customer Call Centers (phone numbers on back)

Writing to addresses on back

Downloading it from www.OhioHealth.com/patients-and-visitors/paying-for-your-care/financial-assistance/

Mail completed applications to address on the back of this page or deliver it to the main registration desk at an OhioHealth hospital.

Questions regarding the Financial Assistance Policy or the Application form (including assistance completing the form) may be addressed by calling

or going to one of the OhioHealth hospitals financial counselor’s office (listed on the back of this page)

Translations

Translated copies of the Financial Assistance Policy, this summary of the policy and the application form are available in Arabic, French, German,

Japanese, Korean, Mandarin, Nepali, Russian, Somali, Spanish, and Vietnamese.

http://www.ohiohealth.com/patients-and-visitors/paying-for-your-care/financial

OhioHealth Facility

Where to call with questions regarding the

FAP and application

Where to obtain a free copy of the FAP and financial assistance applications

and send completed application

Where to go with questions or help with the financial assistance application

Riverside Methodist Hospital

614-566-1505 OhioHealth

P.O. Box 7527 Dublin, Ohio 43016

OhioHealth Riverside Methodist Hospital 3535 Olentangy River Road

Columbus, Ohio 43214

Grant Medical Center 614-566-1505 OhioHealth


OhioHealth Grant Medical Center 111 South Grant Avenue Columbus, Ohio 43215

Doctors Hospital 614-566-1505 OhioHealth


OhioHealth Doctors Hospital 5100 West Broad Street Columbus, Ohio 43228

Grady Memorial Hospital 614-566-1505 OhioHealth


OhioHealth Grady Memorial Hospital 561 W. Central Avenue Delaware, Ohio 43015

Dublin Methodist Hospital



OhioHealth Dublin Methodist Hospital 7500 Hospital Drive Dublin, Ohio 43016

Grove City Methodist Hospital



Grove City Methodist Hospital 1375 Stringtown Road Grove City, Ohio 43123

Hardin Memorial Hospital



OhioHealth Hardin Memorial Hospital 921 East Franklin Street

Kenton, Ohio 43326

Marion General Hospital 614-566-1505 OhioHealth


OhioHealth Marion General Hospital 1000 McKinley Park Drive

Marion, Ohio 43302

O'Bleness Hospital 740-566-4803 OhioHealth - Patient Financial Services

55 Hospital Drive Athens, Ohio 45701

OhioHealth O’Bleness Hospital 55 Hospital Drive

Athens, Ohio 45701

Mansfield Hospital 419-526-8428 OhioHealth - Mansfield Business Office

335 Glessner Avenue Mansfield, Ohio 44903

OhioHealth Mansfield Hospital 335 Glessner Avenue

Mansfield, Ohio 44903

Shelby Hospital 419-526-8428 OhioHealth - Mansfield Business Office

335 Glessner Avenue Mansfield, Ohio 44903

OhioHealth Shelby Hospital 199 W. Main Street Shelby, Ohio 44875

Berger Hospital 740-420-8020 OhioHealth – Patient Financial Services

600 N. Pickaway Street Circleville, Ohio 43113

OhioHealth-Patient Financial Services 1180 N. Court St.

Circleville, Ohio 43113

Westerville Medical Campus



OhioHealth Westerville Medical Campus 260-300 Polaris Parkway Westerville, Ohio 43082

Pickerington Medical Campus



OhioHealth Pickerington Medical Campus 1010-1030 Refugee Road

Columbus, Ohio 43147

Freestanding Emergency Department Facilities

614-566-1505

OhioHealth P.O. Box 7527

Dublin, Ohio 43016 Go to any of the locations on this list

Physician Group (OPG) 614-566-1505 OhioHealth


Go to any of the locations on this list

Urgent Care Centers 614-566-1505 OhioHealth



Marion Area Physicians 614-566-1505 OhioHealth



Home Health Care 614-566-1505

OhioHealth P.O. Box 7527

Dublin, Ohio 43016 Go to any of the locations on this list

POLICY and / or PROCEDURE TITLE: Financial Assistance ... · Ohio or any patient who has come to...

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