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Financial Assistance... for those who qualify.

As a not-for-profit organization, Longmont United Hospital can provide payment help to those who qualify. By contacting us as early as possible, we can help find resources for you. To 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.

Or call 303.485.4110 for more on what payment help is offered.

Our Charity Policy

Purpose

To provide financial assistance for qualifying patients in order to better serve their health care needs.

Policy

Longmont United Hospital provides a uniform charge structure that applies to all patients regardless of their ability to pay. Information on the hospital-based Charity Care Program and other known programs of financial assistance are easily accessible to the public. Longmont United Hospital will communicate this information to patients in a way that is easy to understand, culturally appropriate, and in other languages prevalent in our community.

Procedures

1. A patient, any employee, physician or interested party on behalf of the patient, can initiate a need for assistance on a combined account total over $500.

2. A charity application will be mailed or given to the patient. The account will be documented that the application was sent or given to the patient.

3. Attach to the application a list of information needed to complete it along with a notice that all completed forms need to be returned in 10 business days upon receipt. Collection activity will resume on the account if the forms are not returned or there has been no communication on the account within 14 business days.

4. The completed application will be returned to the business office.

5. Eligibility shall be determined by obtaining any or all of the following information in a confidential manner:

• Gross Income
• Employment status
• Family Size
• Child care/Day Care expenses
• Housing Expenses
• Outstanding Medical Obligations
• Current medical status
• Credit Report

6. Upon receipt, review the Financial Disclosure Statement and supporting documentation to insure that the financial documentation includes any or all of the following:

• Patient or Patient Representative Signature
• Federal and State income tax for the most recent year
• Copy of current pay stubs (employer) for last three months
• Letter of income source, if not employed.
• Bank statements for last three months
• Three months of child care/day care receipts
• Self-employed patients may be required to provide additional information or documentation

7. Document account that completed forms have been received, and charity is pending review.

Charity Adjustment Calculation

1. Calculate the patient’s gross income.
2. Establish the charity discount level by analyzing the gross income and number of dependents on the Colorado Indigent Care Program Ability-to-Pay Scale.
3. Determine the adjusted patient responsibility. All previous payments will be taken into consideration and subtracted from the patient’s co-pay amount due.

Charity Approvals Levels

Special Programs Coordinator	$10,000 and under
Business Services Manager	$10,001 to $50,000
Charity Committee	$50,001 and above

For individuals who have applied for public benefits no adjustments will be done until patient can provide final determination.

Counseling of Charity Care Patients

The Account Representative or the Special Programs Coordinator will call/meet/visit the patient and inform the patient of:

• Eligibility for program
• Eligible charity amount
• Remaining patient responsibility
• Establish acceptable payment arrangements for remaining patient liability if balance can not be paid in full.

Completion Process

The Account Representative or Special Programs Coordinator will:

• Document the account
• Send follow-up letter to patient with the amount of adjustment and, if applicable payment agreement
• • Applications will be stored by year and alpha in the Special Programs Coordinator office for audit purposes. Applications will be stored for a period of two years then retained in an accessible storage area for another five years.

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

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.