Financial Assistance Policy
Mission of the Hospital with Respect to Financial Assistance
Uninsured or underinsured patients may be eligible for financial assistance regardless of race, creed, color, national origin, sex, sexual orientation, or the presence of any sensory, mental, or physical disability or the use of a trained dog guide or service animal by the disabled person.
Financial assistance will be made publicly available in accordance with WAC 246-453-020(2).
Description of Eligibility Criteria
Financial Assistance is available to qualified uninsured or underinsured patients for appropriate hospital and clinic based medical services in accordance with WAC 246453 section 010 which states: "Those hospital services which are reasonably calculated to diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, or cause suffering or pain, or result in illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and there is no other equally effective more conservative or substantially less costly course of treatment available or suitable for the person requesting the service. For purpose of this section, "course of treatment" may include mere observation or, where appropriate, no treatment at all.
Eligible services include Emergency Room and Minor Care, Hospital Inpatient, Outpatient and Observation, Clinic services; including Family Practice, Internal Medicine, Rheumatology, Nephrology, Surgical Specialists, Urology, Pediatrics, Diabetes Education and Medical Nutrition Therapy, Hospital outpatient services; including Sleep Lab, Wound Care, Respiratory Therapy, Day Surgery, Endoscopy, Pain Clinic, Radiology, Dialysis, Laboratory and Interventional Pain Consultants; including outpatient surgical services.
Financial Assistance is generally secondary to all other financial resources available to the patient, including group or individual medical plans, worker's compensation, Medicare, Medicaid or medical assistance programs, other state, federal, or military programs, county aid, third party liability situations (e.g., auto accidents or personal injuries), or any other situation in which another person or entity may have a legal responsibility to pay for the costs of medical services.
Exclusions/Services not eligible for Financial Assistance: Office visit co-pays, elective services; such as sterilization procedures, Ideal Protein, Sports Physicals, Department of Transportation Physicals, contracted Occupational Health, elective circumcision, or any other service determined to be "not medically necessary" by the health insurance plan.
Uninsured or underinsured patients will have the opportunity to be considered for Financial Assistance under this Financial Assistance policy based upon the following criteria calculated upon the patient's financial documentation at the time of the request. Potential patient responsibility will be determined upon the sliding fee schedule and may have an expectation of payments set forth within Tri-State Memorial Hospital's collection policy:
A. The full patient balance for hospital charges will be evaluated to determine Financial Assistance eligibility for any patient whose gross family income is at or below 100% of the current federal poverty guidelines.
Patients whose gross family income are 101% to 200% of the current federal poverty guideline will be eligible for a discount of 75% to be applied to the patient account balance and will be determined as a Financial Assistance discount.
Patients whose gross family income is 201% to 300% of the current federal poverty guideline will qualify for a discount of 35% applied to the patient responsibility.
B. Prima Facie Write-offs: The hospital may choose to grant Financial Assistance based solely upon the initial determination. Any patients who are on state assistance, are unemployed, disabled, transient or incompetent may be valid "prima-facie" candidates. In such cases, the hospital may not complete full verification or documentation of any request.
C. Special Consideration Financial Assistance: Uninsured and underinsured Washington and Idaho patients may qualify for a discount. Determination will be made by TSMH Administration upon patient's completion of the Special Consideration Financial Assistance Application and the specified supporting documentation as proof of severe financial hardship or personal loss from time of request based on economic situation.
Process for Eligibility Determination
Initial Determination: The hospital will make an initial determination of eligibility based upon verbal or written application for Financial Assistance. In the event a patient cannot provide documentation supporting their application for Financial Assistance, Administrative discretion will apply.
A determination will be made upon the receipt of all requested information from the responsible party, including applications and supporting documentation within fourteen (14) days of receipt of a Financial Assistance application. No collection efforts will be made for parties during the determination process for Financial Assistance in accordance with WAC 246-553-010(1), WAC 246-453-020(1)(a), and WAC 246-453-020(1)(c).
The hospital will exercise the following options:
A. The hospital shall use an application process to determine qualification for Financial Assistance.
B. Requests to provide Financial Assistance will be accepted from sources such as physicians, community or religious groups, social services, financial services personnel or the patient/family. When the hospital becomes aware of factors which might qualify the patient for Financial Assistance under this policy, the patient will be advised of this potential and will make an initial determination that such account is to be treated as Financial Assistance.
Final Determinations: The hospital will exercise the following options in making the final determination for Financial Assistance:
Option 1: Financial Assistance may be granted based solely on the initial determination. In such cases, the hospital may not complete full verification or documentation of any request. This falls within the Prima Facie guidelines.
Option 2: When financial screening indicates potential need, Financial Assistance applications and instructions shall be furnished to patients. All applications, whether initiated by the patient or the hospital should be accompanied by documentation to verify income amounts indicated on the application form. Any one of the following documentation items may be acceptable for purposes of verifying income:
- Last year's 1040 Federal tax form.
- "W-2" withholding statement.
- Letters approving or denying Unemployment Compensation.
- Letters approving or denying Medicaid medical assistance.
- Pay stubs with year to date earnings from all household employment.
- Written statements from employers or welfare agents.
- Other acceptable documentation, should none of the above be accessible: Schedule C Federal tax form, current bank statements, student loans and/or grants, Social Security Awards Letter, other legal document showing dependent(s).
Option 3: During the initial request period, the hospital may pursue other sources of funding including Medicaid, Crime Victims, or County Aid for Idaho residents.
Option 4: Income shall be based on prior years Federal tax return and include documentation of current economic situation. Income will be calculated from the documentation provided by the patient or Medicaid. The process of calculation will be determined by the hospital and will take into consideration seasonal employment and temporary increases and/or decreases of income.
A. Time Frame for Final Determinations: The hospital shall provide final determination within fourteen (14) calendar days of receipt of a complete application.
B. In the event that a responsible party pays a portion or all of the charges related to appropriate medical services, and is subsequently found to have met the financial assistance criteria at the time that services were provided, any payments in excess of the amount determined to be appropriate in accordance with WAC 246-453-040 shall be refunded to the patient within thirty days of achieving the financial assistance designation.
C. Denial appeals: Denials will be written and include instructions for appeal or reconsideration as follows: The responsible party may appeal the determination of eligibility for Financial Assistance by correcting any deficiencies in documentation to the Patient Accounts Manager or designated representative. Upon the receipt of an appeal, there will be a thirty (30) day hold in the collection process. The Chief Financial Officer will review and respond to all appeals within fourteen (14) days of receipt. If this review affirms the previous denial of Financial Assistance, written notification will be sent to the patient/guarantor and the Department of Health, in accordance with state law. If the denial is reversed the patient shall immediately be declared an eligible candidate
- Collection efforts will cease if an appeal has been filed for Financial Assistance in accordance with WAC 246-453-020(9)(b).
Documentation and Records
A. Confidentiality: All information relating to the application will be kept confidential. Complete copies of documents that support the application will be kept with the application form.
B. Documents pertaining to Financial Assistance shall be retained for four (4) years.
Financial Assistance Application
Click here to download the Financial Assistance Application (also known as "Charity Care") at Tri-State Memorial Hospital & Medical Campus.
If you have any questions, please contact one of our Patient Financial Counselors at 509.758.4651 or 509.758.4653.
Effective: 07/2012 / Last Revised: 11/2016