Financial Assistance at Longmont United Hospital

Longmont United Hospital provides financial assistance to patients in need of healthcare services. These same patients may not have the ability to pay for the services. If you think you need financial assistance, call the business office as early as possible, 303.485.4488. We can help find resources for you and start the process. A standard list of questions will be asked to determine what payment program will be best for you.

Patients may qualify for the following areas of assistance:

  • Payment plans that allow for regular monthly payments over time.
  • Discounts for self-pay patients at the time of service.
  • COBRA insurance premium help if a patient has recently stopped working.
  • Colorado Medicaid application assistance.
  • Colorado Indigent Care Program (CICP) application assistance. CICP is a state program that helps low income Colorado residents with their medical bills.
  • A Charity Care Program for patients who do not qualify for any of the above programs. Proof of Income must be provided in order to qualify.

Information regarding the Hospital Financial Assistance Program is available by calling 303.485.4488.


Who can apply for financial assistance?

Any patient with a combined account total over $500 can request Hospital Financial Assistance.

When can I apply for financial assistance?

You can apply before your procedure, when you come in to receive care, or when you receive your statement in the mail.

How do you apply for Hospital financial assistance?

To apply for financial assistance, mail a completed application (En Espanol) and all requested documents to Financial Assistance Program, Longmont United Hospital, 410 S. Sunset, Suite A, Longmont, CO 80501.

If you call the Business Office before mailing, we will review if you qualify for any government assistance programs. This includes Medicaid, Social Security and CICP, etc. If you qualify, we will send you the application. You will need to submit the application with all the requested documents. The application and other required information must be returned to Longmont United Hospital within 10 business days upon receipt of the application. It will need to be mailed to Financial Assistance Program, Longmont United Hospital, 410 S. Sunset, Suite A, Longmont, CO 80501.

How does the Hospital determine if a patient is eligible?

Eligibility will be determined by obtaining any or all of the following information:

  • Gross Income (Federal and State income tax for the most recent year)
  • Employment status (copy of current pay stubs for the last three months)
  • Letter of income source, if not employed
  • Self-employed patients may be required to provide additional information or documentation
  • Bank statements for the last three months
  • Family size
  • Child care/Day care expenses (three months of receipts)
  • Housing expenses
  • Outstanding medical obligations
  • Current medical status
  • Credit report

The financial assistance calculation will be determined by using of the Colorado Indigent Care Program Ability to Pay Scale (see below) and Longmont United Hospital Financial Assistance Guidelines. Previous payments made by the patient on the account will be taken into consideration.

What bills are covered under the Financial Assistance Program?

Only Longmont United Hospital services are covered by the Financial Assistance Program. You will need to contact all other providers to make arrangements with them.

What happens after I apply?

A determination will be based on information provided. You will be notified in writing of the determination.

Financial assistance may be denied if:
  • The application is missing information. Once all the information has been provided, it may be reviewed again.
  • The application has incomplete information. Once all the information has been provided, it may be reviewed again.
  • The applicant has savings, cash investments, or other assets in an amount sufficient to pay all or a portion of the account balance without placing financial hardship on the family.
  • A Credit Bureau review shows that the applicant has sufficient credit available to obtain a loan to repay the account. And if it shows a sufficient means to repay the loan without placing financial hardship on the family.
Financial Assistance Copayments

Patients approved for Financial Assistance are asked to pay a co-payment.

Insurance deductibles and copayments are disallowed, by State law, from being routinely written off. They may only be written off to Financial Assistance for medically and financially needy patients on a precisely documented and individual basis.

How long will I be eligible for Financial Assistance?

Six months from the date Financial Assistance has been approved. To remain qualified for Financial Assistance, a patient MUST apply for and continue to track all benefits they have received, or may receive, until they are either approved or denied. If a patient is denied benefits due to lack of cooperation, Financial Assistance will be canceled. Discounts will also be reversed. This results in all unpaid debts to Longmont United Hospital becoming the patient’s responsibility.

What if I receive a bill while I’m waiting to hear if I am approved?

You may receive statements during the Financial Assistance application process; we do ask that you attempt to make minimal payments during the application process.

If I have health insurance may I still qualify for any type of discount?

Yes, if approval is made any discount awarded would be applied to balances after insurance payment has been received.

What services are paid by Financial Assistance?

All necessary healthcare services at the Hospital. Healthcare services that are not necessary, as deemed by a doctor, will not qualify for the Financial Assistance Program. (For example, cosmetic procedures). Situations that are not covered by written policy may qualify a patient for Financial Assistance. Such situations will be precisely documented and require approval of the Financial Assistance Committee.


Colorado Indigent Care Program

Ability to Pay Scale
Effective April 1, 2012 - March 31, 2013

Annual Income Ranges for Each Ability-to-Pay Rate

Family
Size
Z N A B
1 $0-4,468 $0-4,468 $4,469-6,925 $6,926-9,048
2 $0-6,052 $0-6,052 $6,053-9,381 $9,382-12,255
3 $0-7,636 $0-7,636 $7,637-11,836 $11,837-15,463
4 $0-9,220 $0-9,220 $9,221-14,291 $14,292-18,671
5 $0-10,804 $0-10,804 $10,805-16,746 $16,747-21,878
6 $0-12,388 $0-12,388 $12,389-19,201 $19,202-25,086
7 $0-13,972 $0-13,972 $13,973-21,657 $21,658-28,293
8 $0-15,556 $0-15,556 $15,557-24,112 $24,113-31,501
9 $0-17,140 $0-17,140 $17,141-26,568 $26,569-34,708
10 $0-18,724 $0-18,724 $18,725-29,024 $29,025-37,915
11 $0-20,308 $0-20,308 $20,309-31,480 $31,481-41,122
12 $0-21,892 $0-21,892 $21,893-33,936 $33,937-44,329
13 $0-23,476 $0-23,476 $23,477-36,392 $36,393-47,536
14 $0-25,060 $0-25,060 $25,061-38,848 $38,849-50,743
15 $0-26,644 $0-26,644 $26,645-41,304 $41,305-53,950
16 $0-28,228 $0-28,228 $28,229-43,760 $43,761-57,157
Poverty
Level *
40% &
Homeless
40% 62% 81%

Family
Size
C D E F
1 $9,049-11,170 $11,171-13,069 $13,070-14,856 $14,857-17,760
2 $12,256-15,130 $15,131-17,702 $17,703-20,123 $20,124-24,057
3 $15,464-19,090 $19,091-22,335 $22,336-25,390 $25,391-30,353
4 $18,672-23,050 $23,051-26,969 $26,970-30,657 $30,658-36,650
5 $21,879-27,010 $27,011-31,602 $31,603-35,923 $35,924-42,946
6 $25,087-30,970 $30,971-36,235 $36,236-41,190 $41,191-49,242
7 $28,294-34,930 $34,931-40,868 $40,869-46,457 $46,458-55,539
8 $31,502-38,890 $38,891-45,501 $45,502-51,724 $51,725-61,835
9 $34,709-42,850 $42,851-50,134 $50,135-56,991 $56,992-68,132
10 $37,916-46,810 $46,811-54,767 $54,768-62,258 $62,259-74,429
11 $41,123-50,770 $50,771-59,400 $59,401-67,525 $67,526-80,726
12 $44,330-54,730 $54,731-64,033 $64,034-72,792 $72,793-87,023
13 $47,537-58,690 $58,691-68,666 $68,667-78,059 $78,060-93,320
14 $50,744-62,650 $62,651-73,299 $73,300-83,326 $83,327-99,617
15 $53,951-66,610 $66,611-77,932 $77,933-88,593 $88,594-105,914
16 $57,158-70,570 $70,571-82,565 $82,566-93,860 $93,861-112,211
Poverty
Level *
100% 117% 133% 159%

Family
Size
G H I
1 $17,761-20,665 $20,666-22,340 $22,341-27,925
2 $24,057-27,991 $27,992-30,260 $30,261-37,825
3 $30,354-35,317 $35,318-38,180 $38,181-47,725
4 $36,651-42,643 $42,644-46,100 $46,101-57,625
5 $42,947-49,969 $49,970-54,020 $54,021-67,525
6 $49,243-57,295 $57,296-61,940 $61,941-77,425
7 $55,540-64,621 $64.622-69,860 $69,861-87,325
8 $61,836-71,947 $71,948-77,780 $77,781-97,225
9 $68,133-79,273 $79,274-85,700 $85,701-107,125
10 $74,430-86,599 $86,600-93,620 $93,621-117,025
11 $80,727-93,925 $93,926-101,540 $101,541-126,925
12 $87,024-101,251 $101,252-109,460 $109,461-136,825
13 $93,321-108,577 $108,578-117,380 $117,381-146,725
14 $99,618-115,903 $115,904-125,300 $125,301-156,625
15 $105,915-123,229 $123,230-133,220 $133,221-166,525
16 $112,211-130,555 $130,556-141,400 $141,141-176,425
Poverty
Level *
185% 200% 250%

* Percent of Federal Poverty Level which corresponds to the upper limit of income in each rating level. Rev 2/2012



Longmont United Hospital Financial Assistance Guidelines
October 2012

Family Size J K L
1 27,926-28,930 28,931-31,835 31,836-33,510
2 37,826-39,187 39,188-43,121 43,122-45,390
3 47,726-49,443 49,444-54,407 54,408-57,270
4 57,626-59,700 59,701-65,693 65,694-69,150
5 67,526-69,956 69,957-76,979 76,980-81,030
6 77,426-80,212 80,213-88,265 88,266-92,910
7 87,326-90,469 90,470-99,551 99,552-104,790
8 97,226-100,725 100,726-110,837 110,838-116,670
Poverty Level 259% 285% 300%
       
Inpatient Copay $3,000.00 $4000.00 $5000.00
Outpatient Copay $300.00 $350.00 $400.00

* Day surgery patients incur an inpatient hospital copayment



Colorado Indigent Care Program Client Copayment Table

CICP
Rating
% of Federal
Poverty
Level
Copayment Category
Inpatient Facility &
Ambulatory Surgery
Inpatient &
Emergency Room
Physician
*N 40% $15 $7
A 62% $65 $35
B 81% $105 $55
C 100% $155 $80
D 117% $220 $110
E 133% $300 $150
F 159% $390 $195
G 185% $535 $270
H 200% $600 $300
I 250% $630 $315
**Z 40% $0 $0

CICP
Rating
Copayment Category
Outpatient
Clinic

Hospital
Emergency Room
Specialty Outpatient Clinic & Emergency Transportation

Prescription
& Laboratory
Services
*N $7 $15 $5
A $15 $25 $10
B $15 $25 $10
C $20 $30 $15
D $20 $30 $15
E $25 $35 $20
F $25 $35 $20
G $35 $45 $30
H $35 $45 $30
I $40 $50 $35
**Z $0 $0 $0

* Clients with an "N" CICP rating have an annual copayment cap of $120
** Homeless clients with a "Z" CICP rating are exempt from CICP copayments

The following information explains the different types of medical care charges:

  • The Hospital Inpatient Facility & Ambulatory Surgery copayment is required for charges related to non-physician (facility) services incurred while receiving care in a hospital for a continuous stay of 24 hours or longer and Ambulatory Surgery for operative procedures received by a client who is admitted to and discharged from the hospital setting on the same day.
  • The Inpatient and Emergency Room Physician copayment is required for charges related to services provided directly by the physician in the hospital setting, including emergency room care.
  • The Outpatient Clinic copayment is required for charges related to non-physician (facility) and physician services received in the outpatient clinic setting. This includes charges for primary and preventive medical care. Does not include charges for outpatient clinic setting. This includes charges for primary and preventive medical care. Does not include charges for outpatient services provided in a hospital (i.e., emergency room care, outpatient surgery, radiology).
  • The Hospital Emergency Room and Emergency Transportation copayment is required for charges related to non-physician (facility) services incurred while receiving care in the hospital setting for a continuous stay of less than 24 hours, including the Emergency Room.
  • The Specialty Outpatient Clinic copayment is required for charges related to non-physician (facility) and physician services received in the specialty outpatient clinic setting, but does not include charges for outpatient services provided in the hospital setting (i.e., emergency room physician, ambulatory surgery). Specialty outpatient charges include distinctive medical care (i.e., oncology, orthopedics, hematology, pulmonary) that is not normally available as primary and preventative medical care.
  • The Prescription copayment is required for prescription drugs received at a qualified CICP health care provider's pharmacy.
  • The Laboratory Services copayment is required for charges related to laboratory tests received by the client that are not associated with an inpatient facility or hospital outpatient charge during the same period.
  • Clients receiving a Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Positron Emission Tomography (PET), Sleep Studies or other Nuclear Medicine services in an Outpatient setting are responsible for the Hospital Inpatient Facility copayment in addition to the Outpatient Specialty Clinic copayment.
  • Clients receiving emergency transportation/ambulance services from CICP providers approved to discount such services are responsible for the Emergency Transportation copayment.