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For questions regarding your Financial Disclosure Worksheet, please call:
- If your last name begins with the letter A - K, Karen at 815.756.1521 x153546
- If your last name begins with the letter L - Z, Kristy at 815.748.8338
Fax your completed Financial Disclosure Worksheet to 815.748.8354.
As a charitable institution, KishHealth System and its hospitals and other affiliates recognize the importance of providing Charity Services to the community and its obligation to provide medically necessary care to its patients.
Based on current Illinois and Federal laws, KishHealth System has an obligation to provide emergency and/or trauma services to the best of its ability before determining the source of payment for such services. Medically necessary care is provided to uninsured, low-income and medically indigent patients based on the actual policy.
KishHealth System communicates the availability of Charity Services and provides Charity Services within reasonable guidelines to eligible low-income, uninsured and medically indigent patients in the community, and in a fair and consistent manner. This is done through publication, brochures, posters, and other modes of communication.
Charity Services are medically necessary services essential to a patient's health that are provided to a patient meeting eligibility criteria for reduced or waived fees under this Policy; Charity Services shall exclude services that are not medically necessary reasonably determined by KishHealth System from time to time not to be subject to this Policy.Communication of Availability of Charity Services
- KishHealth System shall request general financial information from a patient as soon as possible upon the patient's presenting for services. This request will occur after medical screening and/or stabilizing treatment in the case of emergency services.
- KishHealth System shall communicate the availability of Charity Services to patients by providing patients who present for services with general written or oral information regarding the availability of financial assistance.
- Upon a patient's request, KishHealth System shall provide such patient with eligibility paperwork (the "Financial Disclosure Worksheet") for Charity Services and assist patients in completing such worksheet.
- KishHealth System shall communicate to patients the availability of general financial assistance, including community aid, Medicaid, Medicare, welfare and other community resources of which KishHealth System is aware, and shall assist patients in completing applications for such assistance.Patients Meeting the Following Criteria will be
Eligible for Charity Services
- Low Income Individuals: KishHealth System will bill third party payors for medically necessary services provided to low income individuals. With respect to any amounts not covered by a responsible third party payor, a patient meeting a Federal Poverty Level income category may be eligible to receive a Charity Services discount off from the KishHealth System standard charges.
- Uninsured or Medically Indigent Individuals: A patient failing to meet the criteria in section IV.B.1. may be eligible for Charity Services in an amount determined by KishHealth System based on the following criteria:
- Family size and other related pertinent factors including financial obligations, family living expenses or the like.
- Employment status, including but not limited to future earning capacity and allowing for the likelihood of a financial capacity sufficient to meet his or her financial obligations in an acceptable time period.
- Future and current ability to pay.
- Amount and frequency of medical bills in relation to the above factors.
- Catastrophic medical costs that may make the patient medically indigent, even if the patient does not initially meet the criteria established under this Policy.
- Other factors deemed appropriate by KishHealth System from time to time.
- Special Consideration of Assets. In determining a patient's eligibility for Charity Services under this Policy, KishHealth System shall not consider the value of a patient's personal or real property and shall not attach or force the pledge or use of such assets; provided, however, that if a patient is self-employed, and therefore uninsured, and the patient holds substantial assets while reporting minimal income on the Financial Disclosure Worksheet, KishHealth System may consider the patient's assets in determining the patient's reasonable ability to pay his or her medical expenses.Granting of Charity Services
The determination of a patient's eligibility for Charity Services under this Policy shall be made as close as possible to the time of admission or the provision of services, assuming that adequate eligibility information is readily available.
- The determination of a patient's eligibility for Charity Services under this policy shall be made in a non-discriminatory manner.
- KishHealth System shall ask patients who seek Charity Services to complete a Financial Disclosure Worksheet. The Financial Disclosure Worksheet will be used to assist KishHealth System in determining whether the patient qualifies for Charity Services. KishHealth System shall assist patients in completing the Financial Disclosure Worksheet.
- KishHealth System's determinations whether Charity Services are to be provided shall be made only after a complete and accurate Financial Disclosure Worksheet is obtained.
- A patient applying for Charity Services must update their Financial Disclosure Worksheet upon each inpatient admission, regardless of past receipt of Charity Services. KishHealth System shall require patients to update their Financial Disclosure Worksheet on a periodic basis to ensure their financial circumstances have not changed.
- Before an application for Charity Services is reviewed for eligibility, KishHealth System shall assist the patient in determining whether other resources, including community aid, Medicaid and Medicare, welfare or other community resources, may be available. To assist in this process, KishHealth System shall refer a patient to enrollment personnel or, as appropriate, directly assist any patient in applying for Medicaid or other community assistance.
- Following exhaustion of available community resources, if a patient meets the Charity Services eligibility criteria and the services qualify as Charity Services, KishHealth System shall grant Charity Services.Payment Policies Applicable to Charity Services
- Before beginning collection proceedings relating to Charity Services, KishHealth System shall attempt to assist a patient and exhaust all available community resources, including community aid, Medicaid and Medicare, welfare and other community resources.
- KishHealth System may classify a portion of a patient account as Charity Service, if a patient is able to pay for only a portion, but not all, of the services KishHealth System provides.
- Once KishHealth System has classified a patient's services as Charity Services that determination will be final unless KishHealth System finds the determination is based on erroneous information.
- Payments made by self-pay patients prior to the determination of eligibility for Charity Services will not be refunded or considered against outstanding balances for purposes of applying for or determining eligibility for Charity Services.
- KishHealth System may write off inactive outstanding Bad Debt balances for services provided before a patient was eligible for or failed to complete an application for Charity Services.
- KishHealth System will not pursue or attach any patient's personal or real property during collection.
Seniors: Confused about your health insurance?
The Senior Health Insurance Program, SHIP, helps Medicare recipients understand benefits, supplementary insurance programs and the prescription drug plan Medicare Part D. For information call 815.756.1521 x153344