Financial Assistance Policy & Application

Eaton Rapids Medical Center, in accordance with Section 501(r) of the Patient Protection and Affordable Care Act of 2010 has established a Financial Assistance Policy. The Financial Assistance Policy (FAP) applies to services provided by the ERMC facility, ERMC Emergency Department, ERMC Family Practice RHC and Springport Medical Clinic RHC. Information regarding our Financial Assistance Policy is available at all registration areas throughout the facilities.

It applies to Medically Necessary hospital and professional services only. It does not apply to cosmetic services or services provided by non-ERMC employed providers.

The Financial Assistance Policy explains the eligibility criteria, methods for applying, our method of determining eligibility and calculating discount amounts.

DEFINITIONS
AGB – Amount Generally Billed
ECA – Extraordinary Collection Actions
ERMC-Eaton Rapids Medical Center
FAA – Financial Assistance Application
FAP– Financial Assistance Policy
FPG – Federal Poverty Guidelines
RHC– Rural Health Clinics (ERMC Family Practice, “Redicare” and Springport Medical Clinic)
MDHHS– Michigan Department of Health and Human Services
Medically Necessary – services ordered by a physician to address medical conditions or are part of a preventative care plan. Cosmetic and Elective procedures are excluded.
Uninsured – those patients with no health insurance coverage.
Underinsured – those patients with health insurance coverage that does not cover medically necessary services that have been provided.

Eligibility Criteria:
Eligibility is based on family size and household gross income compared to the current Federal Poverty Guidelines (FPG). All patients must first apply for Michigan Medicaid and, if denied, provide a copy of the written denial (all pages) received from the Michigan Department of Health and Human Services (MDHHS). If zero income is reported, a patient must provide written explanation of how current needs are being met (for example: food, shelter, living expenses, etc.) or complete the Statement of Zero Income form available upon request.

Application Methods:
Information regarding our Financial Assistance Policy (FAP) is available at all registration areas throughout the facilities. The Financial Assistance Application (FAA) is attached to this policy. Complete instructions for completing the FAA are also attached to this policy as Exhibit B.
Financial Assistance Applications can be obtained in the following ways:

• Online at our website
• Calling our Financial Counselor at 517-663-9477.
• Calling our Business Office Payment Center at 517.663.9590.
• Visiting us in person at 1500 S. Main St., Eaton Rapids MI 48827 (Main Lobby Entrance A).

Eligibility Determinations:
All completed Financial Assistance Applications and supporting documentation will be reviewed by the Patient Accounts Manager and processed within 30 days of receipt. Written notification will be provided within 60 days. Incomplete applications will be returned for completion or required supporting documentation. The determination can be made before or after services are rendered. Accounts that have been turned to Bad Debt status may still be considered for financial assistance for an additional 120 days after the date the account was turned to bad debt or up to 240 days from the date the first statement was generated to the guarantor.

Amounts Generally Billed:
Eaton Rapids Medical Center calculates the Amounts Generally Billed (AGB) based on current cost of supplies and current fee schedules published by various insurance carriers. Charges are updated annually on July 1st.

Discounts Available:
Uninsured patients receive an automatic 20% discount applied prior to the initial billing. If approved for financial assistance, any additional discount will be based on the current published FPG. The maximum amount the patient is financially responsible for will not exceed the AGB for that service.
The following discounts will be applied based on family size and household gross income.

• No payment will be expected from patients whose income is below 133% of the FPG.
• Payment of 30% will be expected from patients whose income is between 133% and 175% of FPG.
• Payment of 50% will be expected from patients whose income is between 175% and 200% of FPG.
• Patients with income above 200% of FPG are not eligible for financial assistance.

Plain Language Summary:
A Plain Language Summary of Eaton Rapids Medical Center Financial Assistance Policy is attached as Exhibit A.

Financial Assistance Policy Publication:
Eaton Rapids Medical Center’s FAP is made available to the public in the following ways:

• Available at all registration areas within the facilities.
• Discussed with Inpatients prior to discharge.
• Referenced on the back of patient statements.
• Available on our website.
• Available upon request from our Business Office Payment Center or Financial Counselor.

Billing and Collections:
All patients will receive four (4) statements at 30-day intervals and at least one (1) phone call in an attempt to collect due balances prior to being referred for any Third-Party collection efforts. Collection activity will proceed based on a separate Collection Policy.

Confidentiality:
ERMC Staff will uphold the confidentiality and individual dignity of each patient. ERMC will meet all HIPAA requirements for handling of personal and protected health information.

EXHIBIT A
FAP PLAIN LANGUAGE SUMMARY:
Patients with balances owed to Eaton Rapids Medical Center may be eligible for Financial Assistance based on family size and household income in relation to the current United States Federal Poverty Guidelines. Uninsured/Underinsured patients may qualify for free care (100% discount) or discounted care (50%-70% discount). The maximum amount the patient is financially responsible for will not exceed the AGB for that service.
The complete Financial Assistance Policy (FAP) and application (FAA) can be viewed on our website. 
Individuals can also request a copy of the policy and an application from Eaton Rapids Medical Center, Financial Counselor:
By phone at: 517-663-9477
In person at: 1500 E. Main St., Eaton Rapids, MI 48827

EXHIBIT B
INSTRUCTIONS FOR COMPLETING FINANCIAL ASSISTANCE APPLICATION
The ERMC Financial Assistance Application (FAA) is a one-page form that collects the minimum amount of information needed to make a Financial Assistance eligibility determination. The required items are listed at the top of the application.
Patients can obtain a Financial Assistance Application in the following ways:

• Online.
• Calling our Financial Counselor at 517-663-9477.
• Calling our Business Office Payment Center at (855) 494-7968, or
• Visiting us in person at 1500 S. Main St, Eaton Rapids, MI 48827 (Main Lobby Entrance).

Completed applications can be submitted to us in the following ways:

• Mailing it to our Patient Financial Counselor at 1500 S. Main St, Eaton Rapids, MI 48827.
• Faxing it to our Patient Financial Counselor at 517-663-9411, or
• Returning it to us at 1500 S. Main St, Eaton Rapids, MI 48827 (Main Lobby Entrance).

EXHIBIT C
PROVIDERS COVERED UNDER THIS POLICY:
Eaton Rapids Medical Center Financial Assistance Policy only covers services provided by Eaton Rapids Medical Center facilities and all providers employed by Eaton Rapids Medical Center. Services which are separately billed by other healthcare providers (non-ERMC employed), even if services are provided in the Eaton Rapids Medical Center facilities, are not covered by this policy.

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Documents

PDF: Patient Financial Support Application

PDF: Patient Financial Assistance Policy