PAWNEE VALLEY COMMUNITY HOSPITAL FINANCIAL ASSISTANCE POLICY (FAP) SUMMARY

In compliance with section 501(r)(6) of the Internal Revenue Code (IRC), the hospital will inform their patient(s)/guarantor(s) of the financial assistance policy (FAP) and will make reasonable efforts to determine a patient’s/guarantor’s eligibility for financial assistance.  The patient(s)/guarantor(s) will be notified in writing of the determination.  If the determination is made that an individual is eligible for assistance, the hospital will reverse, when possible, adverse results of any collection efforts and will refund any over-paid amounts to the individual.  The hospital will also issue a new billing statement which represents the amount generally billed (AGB) to individuals with insurance.  This amount will be calculated using the “look-back” method, based on actual past claims paid to the hospital by Medicare and by other private insurers.

Financial Assistance Application

APPLICATION PROCESS

1. A patient/guarantor may apply for financial assistance by completing our financial assistance application and submitting it, along with other required documents, to Pawnee Valley Community Hospital, 923 Carroll, Larned, KS 67550 or HaysMed, 2220 Canterbury, Hays, KS 67601.
2. An application may be requested from the Registration Departments at either location shown above or by calling the HaysMed Customer Service Department at 785-623-5100.
3. The completed application, along with the supporting documents listed on the application, may be sent to HaysMed at 2220 Canterbury Dr. (or P.O. Box 8110) Hays, Ks 67601, or it may be delivered to the Registration Department at Pawnee Valley Community Hospital at 923 Carroll Avenue, Larned, or to the Registration Department at HaysMed at 2220 Canterbury Dr., Hays.
4. In the event of non-payment of any amount determined to be the responsibility of the patient/guarantor and the absence of an application for assistance, the hospital may refer the account(s) to an outside collection agency. Such action may result in an adverse entry on the patient’s/guarantor’s credit rating.

ELIGIBILITY CRITERIA

1. Applicant will be screened for eligibility for any third party payor sources, such as Medicaid, and payment from any such source(s) must be exhausted before applicant will be eligible for hospital financial assistance.
2. The applicant must also meet other eligibility criteria which are included in the full financial assistance policy. This policy may be requested and/or viewed by accessing the addresses, locations, or telephone numbers shown in section A (above).  Additionally, the policy can be viewed on public display at the hospitals or on the hospitals’ websites.  (see A., 3 above)
3. Once the applicant is deemed eligible for assistance, the actual level of assistance will be determined, in part, by comparing the applicant’s family income to the Federal Poverty Guidelines (FPG), as follows:

100% discount if income is 0% to 130% of FPG

50% discount if income is 131% to 200% of FPG

30% discount if income is 201% to 300% of FPG

4. Catastrophic medical expenses will also be a factor in determining eligibility for financial assistance.
5. INFORMATION

For additional information on financial assistance or to ask questions, inquirers may call HaysMed at 785-623-5100 or visit in person at 2220 Canterbury Rd, Hays, KS.

Qualifications for Financial Assistance

We, at Pawnee Valley Community Hospital, realize that financial concerns can add to the stress of any medical situation. Financial assistance will be made available to any eligible patient. Each case is handled individually, based on the following eligibility guidelines:

• *Applicant must agree to participate in a review for qualification for coverage through any applicable public program such as Medicaid or Medikan
• *Payment from all other sources must be exhausted
• *Assistance is applied only to the self-pay portions of a patient’s bill
• *Patient must reside in our service area and meet residency requirements
• *Financial need is based on income guidelines established by the Federal Government
• *Financial assistance will be provided only for those procedures considered to be medically necessary
• *Applicant must provide copies of income tax return and prior three months pay stubs; additional information may be requested
• *Applicant must complete Pawnee Valley Community Hospital’s Financial Assistance Application form
• *For clinic accounts, only income and family size will be used for determining eligibility.

If you feel you may qualify for financial assistance, or if you have any questions, please contact one of our Financial Counselors at the following number:

785-623-5100.