Financial Assistance

1. ELIGIBILITY REQUIREMENTS
   

   The patient/guarantor must meet the following criteria established by the Wayne County Hospital Board of Trustees for consideration for charity care.

   1. The patient/guarantor must show a clear need for charity consideration as determined by Wayne County Hospital.
2. FACTORS USED IN DETERMINATION OF CHARITY
   1. The patient/guarantor must complete an application requesting consideration for charity. This application requests information on the patient’s/guarantor’s financial status.
   2. The application is reviewed by the Administration and the Board of Directors.
      1. The patient/guarantor may be asked to provide proof of income–this may be paycheck stubs from the current month, income tax return, bank statements indicating deposits for self-employed individuals or other documentation verifying the patient’s or guarantor’s income. Wayne County Hospital reserves the right to contact the employer, public welfare agencies or any other third party as may be necessary to verify the patient’s/family’s income.
      2. The patient/guarantor may be asked to provide proof of financial responsibility for any dependents claimed on the application–this may include income tax returns, divorce decrees, or other documentation.
   3. The U.S. Department of Health and Human Services Poverty Guidelines will also be used in determining eligibility for charity. This policy will be updated automatically as changes are made to the HHS Guidelines.  (Per Board amendment 3-21-2005).
3. PROCEDURES FOR DETERMINING ELIGIBILITY
   1. Review application for charity care as to completeness. Contact patient/guarantor for any missing information.
   2. Compare the patient’s/guarantor’s income to the Poverty Guidelines based on the family’s size.
   3. The Charity Care allowance is determined by the percentage of income the family has above the Poverty Guidelines as listed in the Charity Percentages Table.
   4. This allowance can then be adjusted up or down based on the information provided by the patient/guarantor on their application.
   5. All applications must be forwarded to Business Office Director for determination of financial need.
   6. Final determination of a Charity Care allowance will be made by the Administration and/or the Board of Directors and is binding.
4. ANNUAL LIMIT ON CHARITY PROVISION
   1. An annual limit on the amount of charity care to be provided during the next fiscal year shall be determined by the Budget Committee of the Board of Directors during the Hospital Budget process.
   2. The patient must seek to apply for Medicaid assistance. A proof of denial must be provided to the Financial Counselor/Business Office Manager.

GLOSSARY

Charity Care – Services provided to a patient with a demonstrated inability to pay.  This may include a charity determination before or after services are provided.  It may consist of a complete write-off of the charges for the service or a partial write-off of the charges.

Guarantor – The person responsible for payment of the charges incurred for services provided by Wayne County Hospital.

Financial Resources – Financial resources means available cash on hand and in financial institutions, and assets that can be readily converted to cash without upsetting day-to-day household operations.  Assets exempt from this consideration are household furnishings, tools and equipment used for self-support, household vehicles used for gainful employment and homestead used as a principal place of residence.

Charity Policy & Application