1. Purpose.

Cherry County Hospital is committed to provide reasonable amounts of financial assistance to persons unable to pay for its services. This Policy is intended to provide direction and consistency to ensure a fair and comprehensive system of providing such financial assistance. This policy addresses:

• Scope of services;
• Eligibility criteria for financial assistance;
• The extent to which charity care will include free or discounted care;
• The basis for calculating amoµnts charged to the patient;
• The method for applying for financial assistance;
• Decision making process;
• Length of time .covered by determination; and
• Measures to widely publicize the policy.

2. Scope.

This Policy applies to all medically necessary Hospital services, regardless of location or type of service, subject to the following:

A. Emergency medical treatment will be provided without regard. to ability to pay and regardless of whether the patient qualifies for finandal assistance under this policy. Emergency medical treatment will be provided in accordance with the requirements of the Emergency Medical Treatment and Active Labor At ("EMTALA"). There will be no discrimination against patients based on ability to pay in the provision of emergency medical treatment.

B. Financial assistance is not available for elective services otherwise classified as non-covered or not-medically-necessary by . Medicare or Medicaid.

C. Financial assistance is not available for services provided to individuals not legally residing in the United States, except for services that are necessary for the treatment of an emergency medical condition, includingf;emergency labor and delivery.

3. Eligibility for Financial Assistance.

Financial assistance is a resource of last resort. The Hospital reserves the ri@ht to allow or disallow financial assistance based on the patient's or guarantor's ability to pay as determined in the financial investigation process as set forth herein. Furthermore, the Hospital reserves the right to deny financial assistance for the failure of patients to take reasonable steps in making application for Medicare, Medicaid and other governmental medical assistance programs in which they

may be entitled to participate, and for a failure to comply with the terms and conditions of this Policy.

The Hospital will evaluate all factors in determining whether a person qualifies for financial assistance. This includes:

1. Assets.
2. Income.
3. Liabilities.
4. Health status - current and future.
5. Spending history and habits.
6. Federal Poverty Guidelines will be considered.
7. Residency located in Cherry County or a county in the hospital's service area.
8. Eligibility for other financial resources.
9. Working, actively seeking employment, or responsible for care of another person/s.
10. Need for medical services.

4. Procedure.

A. . The patient must submit a Financial Assistance Application on the form used by the Hospital. Upon request, the patient will be provided with the Application. Upon request for the Application, no further collection actions will be taken until the Hospital has determined the patient's eligibility. If an application is not received within ten days of the Application being provided to the patient, collection actions may resume. The applicant must provide copies of their previous year income tax return, pay stubs (or billed invoices and expense records in case of the self-employed) covering their previous three months of earned income. Copies of other supporting evidence may be required to substantiate information. The Hospital may request additional financial information. Applications should be filled out in their entirety. Incomplete applications will not be considered and will be returned to the applicant for completion. Assistance with the completion of the application will be provided by hospital staff if requested.

B. Upon receipt of a completed application the application will be reviewed by the hospital administrative staff for any additional information prior to review by the Administrative Committee or the Board of Trustees.

C. Action taken by the Administrative Committee or the Board of Trustees may include but is not limited to the approval of financial assistance in the form of free or discounted care.

5. Determination of Eligibility for Financial Assistance.

The determination of eligibility for financial assistance/charity care shall be made either of two ways. Less complex applications will be processed by an Administrative Committee of three including the Administrator, Chief Financial Officer, and one other individual from the Business

Office. A listing of those decisions will be submitted to the Board of Trustees. More complex or difficult applications involving any of the previously stated· factors for eligibility or as specified by the Board of Trustees will be forwarded by the Administrative Committee to the Board of Trustees for consideration. The Hospital will promptly notify the patient of its decision. Missing or false information on the application may result in
- denial or revocation of any approved financial assistance, in which case all collection actions may resume.

When possible, the Hospital will attempt to determine eligibility to charity care in advance of billing for services; however, the Hospital may make a determination of eligibility ·at any stage of the process. The Hospital reserves the right to provide financial assistance even though an Application has not been submitted, in which case eligibility for charity care may be determined based on information from other sources. The determination of eligibility will be made without regard to age, sex, national origin, color, religion or handicap.

6. Limits on Amount of Financial Assistance.

The Hospital Board of Trustees may annually determine reasonable financial caps that must be placed on the amount of financial assistance that can be provided in the year, or may limit the types of services eligible for financial assistance.

7. Application for Other Medical Assistance Programs.

The Hospital may assist patients in applying for or obtaining Medicare, Medicaid, other governmental medical assistance, and private medical insurance or assistance programs, and reserves the right to deny financial assistance under this Policy for failure of patients to take reasonable steps in making application for any such programs or assistance:

8. Financial Assistance Over the Course of Treatment.

The financial assistance determination may extend for up to 90 days over the course of treatment for which financial assistance was originally sought. Any other services or procedures that do not relate to the original course of treatment will not be included in the financial assistance determination. A new application is necessary for any other services.

9. Dissemination of Policy.

The Policy will be made widely available to patients, including the following:

A. A notice of the availability of charity care and availability of this Policy will be posted in the admission area of the Hospital informing the public that charity care applications are available upon request from the receptionist or the accounts receivable clerk. This notice will be made available in patient rooms.

B. The Policy will be provided to patients on request.