St. Mary’s Health Center defines charitable or financial assistance care as that care rendered to customers unable to pay due to personal lack of finances. It would also include catastrophic health issues with requirements that preclude the ability of the individual to pay the rendered services, regardless of income bracket. Charitable or financial assistance care also includes non-covered services for public aid programs (Medicaid/Medicaid out of state and other programs for the indigent).
Charges that will be excluded from the free care apply to outpatient pharmacy and supplies and equipment for home use.
Persons eligible for free care will have the following "factors for consideration" applied before a final determination will be made:
1. Available financial resources will be evaluated before determining financial assistance eligibility. All information obtained from patients and family members will be treated as confidential. Availability of funds include but not limited to:
- Saving
- Investment
- Credit availability
- Other family member
- Income from Wage
- Income from self-employment
- Alimony
- Public Assistance
- Social Security
- Strike Benefit
- Unemployment Compensation
- Workers Compensation
- Veteran Benefits
- Pension
- Child Support
- Military family allotment
- Other sources, such as income from dividends, interest or rental property
2. Other assets, including the ability to borrow on insurance or property
3. Potential change(s) in financial capability in the near future
4. Type of care (costs) e.g. voluntary surgery versus true emergency
Any insurance benefit must be assigned to the hospital prior to application for charitable or financial assistance.
In order to evaluate and process the application for assistance the guarantor/obligator may be required to provide:
- Most recently filed federal income tax form
- Copies of current paycheck stubs
- W2’s
- Social Security Checks
- Bank Statement
Financial Assistance Application Form