Financial Assistance Policy

Financial Assistance Program Full Charity and Partial Discount Programs

Click HERE to download the Policy in a PDF format

Kaweah Delta Health Care District (KDHCD) serves all persons within District boundaries and the surrounding region. As a regional hospital provider, KDHCD is dedicated to providing high-quality, customer-oriented, and financially strong healthcare services that meet the needs of those we serve. Providing patients with opportunities for Financial Assistance for healthcare services is therefore an essential element of fulfilling the KDHCD mission. KDHCD is committed to providing access to Financial Assistance programs when patients are uninsured, underinsured, or may need help paying their hospital bill. These programs include government sponsored coverage programs, charity care, and partial charity care as defined herein. This policy defines the KDHCD Financial Assistance Program, its criteria, systems, and methods.

KDHCD, like all California acute care hospitals, must comply with Health & Safety Code Sections 127400 et seq., including requirements for written policies providing charity care to financially-qualified patients. KDHCD operates a non-profit hospital and, therefore, KDHCD must also comply with 26 U.S.C. § 501(r) and its implementation regulations, 26 C.F.R. § 1.501(r), et seq., including requirements related to billing and collections practices for financially-qualified patients. This policy is intended to meet such legal obligations and provides for charity care to patients who financially qualify under the terms and conditions of the KDHCD Financial Assistance Program.

KDHCD affirms and maintains its commitment to serve the community in a manner consistent with the philosophy of the Board of Directors. This philosophy emphasizes the provision of optimal health care services to aid all persons regardless of age, sex, race, creed, disability, national origin, sexual orientation, gender identity, or financial status. These beliefs have led KDHCD to develop a policy for providing charity care for the less fortunate.

Definitions:

• Charity care is defined as health care services provided at no charge to patients who do not have or cannot obtain adequate financial resources or other means to pay for this care and who qualify for free care under the eligibility guidelines specified in this policy. Charity care is in contrast to bad debt, which is defined as a patient and/or guarantor who, having the requisite financial resources to pay for health care services, has demonstrated by his/her actions an unwillingness to comply with the obligation to resolve an account.

• Partial Charity Care is defined as health care services provided at a reduced charge to patients who do not have adequate financial resources or other means to pay for this care and who qualify for discounted care under the eligibility guidelines specified in this policy, but do not qualify for free care.

• Community Care Rate means the amount KDHCD would receive for services under its contract with Blue Cross.

• Essential living expenses means, for purposes of this policy, expenses for all of the following, as applicable to the patient’s individual circumstances: rent or house payment and maintenance, food and household supplies, utilities and telephone, clothing, medical and dental payments, insurance, school or child care, child or spousal support, transportation and auto expenses, including insurance, gas, and repairs, installment payments, laundry and cleaning, and other extraordinary expenses.

• Financially Qualified Patients are eligible for assistance under this policy for care covered by the policy without regard to whether the patient has applied for assistance under the policy and includes any of the following:

  • i) Self-Pay Patients are:

    • Patients who do not have third party insurance, Medi-Cal, or Medicare, and who do not have a compensable injury for purposes of worker’s compensation, automobile insurance, or other insurance as determined and documented by KDHCD.

  • ii)Under-insured Patients include:

    • Patients with high medical cost who have insurance or health coverage but have a remaining patient responsibility balance that they are unable to pay. Remaining patient responsibility balances include out-of-pocket costs, deductibles, and coinsurance that constitute high medical costs as defined below.

    • Patients who are eligible for Medi-Cal, Medicare, California Children’s Services and any other applicable state or local low-income programs who do not receive coverage or payment for all services or for the entire stay.

    • Patients with third-party insurance whose benefits under insurance have been exhausted prior to admission or whose insurance has denied stays, denied days of care, or refused payment for medically necessary services.

  • iii) High Medical Cost Patients are patients:

    • Whose family income is at or below 350% of the Federal Poverty Guidelines;

    • Who do not otherwise qualify for full charity care under this policy;

    • Who have high medical costs as defined below.

• High medical costs are defined as out-of-pocket medical costs incurred by the patient that exceed 10 percent of the Patient’s Family Income in the prior 12 months, or annual out-of-pocket medical expenses incurred in the prior twelve (12) months that exceed 10% of Patient’s Family income.

• Patient’s Family is defined as follows:

  • For persons 18 years of age and older, the family includes the patient’s spouse, registered domestic partner, and dependent children under 21 years of age, whether living at home or not.

  • For patients under 18 years of age, the family includes the patient’s parent, caretaker relatives, and other children under 21 years of age of the parent or caretaker relative.

Policy and Procedures:

KDHCD recognizes that the need for charity is a sensitive and deeply personal issue for recipients. Confidentiality of information and individual dignity will be maintained for all who seek charitable services. Training of staff and the selection of personnel who will implement these policies and procedures are guided by these values. Providing charity care (financial assistance) to low-income families along with other community benefit services are important evidence of KDHCD’s mission fulfillment. It is imperative that the determination, reporting, and tracking of charity care are in concert with our not-for-profit mission and community obligation and in compliance with Assembly Bill No. 774, Hospital Fair Pricing Policies and Senate Bill 1276 (Chapter 758, statutes or 2014) and applicable IRS laws and regulations.

Charity care will not be abridged on the basis of age, sex, race, creed, disability, national origin, sexual orientation, gender identity, or financial status. Medically necessary available health care services, inpatient or outpatient, shall be available to all individuals under this policy. Confidentiality of information and individual dignity will be maintained for all that seek charitable services. The handling of personal health information will meet all HIPAA requirements.

Charity care will be based on income and family size as defined by Federal Poverty Income Guidelines and the attached sliding scales. KDHCD will also actively assist an individual in pursuing alternate sources of payment from third parties. Those individuals or families who qualify for alternative programs and services within the community but refuse to take advantage of them will not be covered by this policy. These actions are intended to allow KDHCD to provide the maximum level of necessary charity services within the limits of respective resources.

Charity care provided by this policy are available for medically necessary care. Charity is generally not available for non-medically necessary procedures. However, in certain cases an exception may be made. Exceptions require approval by administration. Specialized, high-cost services (i.e., experimental procedures, etc.) requiring charity care are also subject to the review of administration prior to the provision of service.

Identification of Applicant

KDHCD makes reasonable efforts to presumptively determine whether a patient is eligible for Financial Assistance based on prior eligibility for Financial Assistance or the use of third party data to identify Financially Qualified Patients.

Any member of the medical staff, any employee, the patient or his/her family and any other responsible party may request charity care from KDHCD. Any member of the Patient Financial Services team, other hospital staff, or community advocates may identify possible charity recipients during any portion of the business cycle.

How to Apply

Patients may request an application for assistance in person from the Acequia Lobby at the corner of Floral and Acequia, 305 West Acequia Avenue in Visalia, California 93291, over the phone by calling Patient

Financial Services at (559) 470-0016 or (559) 624-4200 option 5, or may obtain an application from KDHCD’s website at kaweahhealth.org/financialassistance. Documentation required to determine eligibility is included on the application. KDHCD does not require any documentation not listed on the application form.

The KDHCD standardized application form will be available in both English and Spanish, and any other language deemed necessary by the methods discussed in Section VIII, below, and shall be available in any Registration or Patient Accounting area, as well as on the KDHCD website. For patients who speak a language other than English or Spanish, or who need other accessibility accommodations, KDHCD will provide appropriate accommodations, language assistance services, and application assistance free of charge.

Full Charity Care

A full write-off of all balances due from a patient, whether the patient is insured, underinsured or self-pay, shall be granted to those financially qualified patients whose family income is up to 200% of the most recent Federal Poverty Guidelines.

KDHCD presumes qualified for full charity care any patient who can provide proof that they are eligible for or in a public benefits program such as CalWORKS, CalFresh, SSI/SSP, Medicare Savings Program, WIC, or general assistance/general relief.

Patients who are covered by Medi-Cal are eligible for charity write-offs. This includes patients that have Medi-Cal with a Share of Cost. It also includes charges related to Medi-Cal denied stays or denied days of care, non-covered medically necessary Medi-Cal services received on a Medi-Cal remittance advice, or when otherwise required by law. Treatment Authorization Request (TAR) denials and any lack of payment for non-covered services provided to Medi-Cal patients are to be classified as charity.

Partial Charity Care

Partial Charity Care will be granted to Financially Qualified Patients earning between 201% and 600% of the Federal Poverty Level based on the most recent Federal Poverty Guidelines. For these patients, expected payment for services will be limited to the amount KDHCD would have received from Medicare and then adjusted by the percentages defined on the attached sliding scales.

In determining what if any payment is due from a patient with insurance, the expected payment amount, defined as the amount equal to the KDHCD community rate, will be compared to the amount paid by their third party insurance. If the amount paid by the third party insurance is greater than the expected payment, no payment will be sought from the patient. If the expected payment is greater than the payment received from the third party insurance, and the patient has a remaining patient responsibility amount, the difference in payment will be sought from the patient subject to a determination of eligibility for financial assistance.

Governmental Assistance

KDHCD makes all reasonable efforts to determine whether medical care would be either fully or partially paid for under other private or public health insurance. Consideration will be given to coverage offered through private health insurance, Medi-Cal, Medicare, California Children’s Services, the California Health Benefit Exchange (Covered California), or other state- or county-funded programs designed to provide health coverage.

KDHCD provides an application for the Medi-Cal program or other state- or county-funded health coverage programs to patients identified as being potentially eligible for Medi-Cal or any other third party coverage. This application is provided prior to discharge if the patient has been admitted or to patients receiving emergency or outpatient care.

If a patient applies or has a pending application or related appeal for another health coverage program, or for coverage under their health plan at the time an application for charity or discounted care is submitted, neither application shall preclude eligibility for the other program. KDHCD will hold any charity care eligibility determinations until the final disposition of the application or appeal of the health coverage program, if the patient makes a reasonable effort to communicate with KDHCD about the progress of any pending appeals.

Eligibility Criteria:

General Guidelines:

• KDHCD determines eligibility for financially qualified patients in accordance with this policy and applicable state and federal laws.

• KDHCD will not defer, deny, or require payment before providing medically necessary care because of an individual's nonpayment of one or more bills for previously provided care covered under KDHCD's Financial Assistance Policy.

• 3. Financially Qualified Patients, as defined above, or any patient who indicates the financial inability to pay a bill for a medically necessary service is screened for charity care.

• Information obtained during the application process for financial assistance may not be used in the collection process, either by KDHCD, or by any collection agency engaged by KDHCD, except that such information, if independently obtained, may be used by KDHCD or any collection agency engaged by KDHCD independently of the eligibility process for charity care.

• A patient’s status or claims with respect to worker’s compensation, automobile insurance, or other insurance, including potential payments from pending litigation or third party liens related to the incident of care, may be taken into consideration when evaluating the patient’s eligibility for charity care or discount payments.

• Emergency physicians providing emergency services in KDHCD are required to provide discounts to financially qualified patients whose family incomes are at or below 350 percent of the Federal Poverty Guidelines. At the patient’s request, KDHCD will advise patients to apply for charity care to the physician’s billing company upon the patient’s receipt of a bill for services from that billing company. This statement shall not be construed to impose any additional responsibilities upon KDHCD.

Eligibility Guidelines

The following factors are used in the determination of financially qualified recipients and the amount of charity extended.

• Patient Income

  • The Federal Poverty Guidelines as established by Health and Human Services will be used to determine annual income guidelines and limits.

To determine the patient’s eligibility for financial assistance, KDHCD considers the patient’s family size and family income. KDHCD considers annual family earnings and cash benefits from all sources before taxes, less payments made for alimony and child support.

Earnings for the purposes of determining eligibility will be based on the lower of either the patient’s projected annual family income or the patient’s family current income level at the time of application for financial assistance.

The applicant may be asked to provide acceptable income verification, such as recent payroll stubs, tax returns, or other items or verification. If the patient is unemployed or does not receive payroll stubs, a written statement of need must be provided by the patient or the patient’s representative attesting to their income and employment status as part of their financial assistance application.

Patient Assets

Only certain assets and resources may be considered when determining eligibility for charity care. Retirement or deferred compensation plans qualified under the Internal Revenue Code, or nonqualified deferred compensation plans will not be considered as available resources to pay KDHCD bills. Furthermore, the first ten thousand dollars ($10,000) of a patient’s monetary assets shall not be counted in determining eligibility, nor shall 50 percent of a patient’s monetary assets over the first ten thousand dollars ($10,000) be counted in determining eligibility.

Other Sources of Payment for Services Rendered

The appropriate amount of charity care is determined in relation to the amounts due after applying all other sources of payment. KDHCD provides applications for other sources of payment, such as Medi-Cal, if requested by the patient, or if the patient does not indicate coverage by a third-party payor or requests a discounted price or charity care.

Homeless Patients

Patients without a residence, source of family income, and mailing address will be classified as charity care eligible. Consideration for charity care must also given to emergency department patients who do not provide adequate information as to their financial status. In many instances, these patients are homeless and have few resources to cover the cost of care.

Special Circumstances

Charity care may be granted in special circumstances to those who would not otherwise qualify for assistance under this policy. KDHCD will document why the decision was made and why the patient did not meet the regular criteria. Special circumstances may include:

• Deceased patients without an estate or third party coverage.

• Patients who are in bankruptcy or recently completed bankruptcy.

• On rare occasions, a patient’s individual circumstances may be such that while they do not meet the regular charity care criteria in this policy, they do not have the ability to pay their KDHCD bill. In these situations, with the approval of management (see subsection VII, below), part or all of their cost of care may be written off as charity care.

Timelines

Eligibility Period

Eligibility for charity care may be determined at any time KDHCD is in receipt of information regarding a patient’s family income and financial situation. While it is preferred that such patients be screened upon admission, they may be screened at any time, including throughout any third-party collections process.
Once granted charity care, services the patient receives in the 6-month period following that approval will also remain eligible for such charity care. However, if over the course of that 6-month period the patient’s family income or insurance status changes to such an extent that the patient may be ineligible for free or discounted care, the patient has an obligation to report those changes to KDHCD. Such subsequent services would require a new charity care application. Any patient may be required to re-apply for charity care after their 6-month eligibility period has expired. Nothing shall limit the number of times a person may request charity care or discounted payments.

Time Requirements for Charity Care Eligibility Determination

Every effort is made to determine a patient’s eligibility for charity care as soon as possible. While it is desirable to determine the amount of charity care for which the patient is eligible as close to the time of service as possible, there is no limit on the time when an application or the eligibility determination is made. A determination will be postponed while insurance or other sources of payment are still pending.

The timeframe to make a decision on an application will be extended if the patient has a pending appeal for coverage of the services, until a final determination of that appeal is made. The patient shall make a reasonable effort to communicate with KDHCD about the progress of any pending appeals.

For purposes of this section, “pending appeal” includes any of the following:

1. (1) A grievance or appeal against a health plan;

2. (2) An independent medical review;

3. (3) A fair hearing for a review of Medi-Cal eligibility or claims;

4. (4) An appeal regarding Medicare coverage consistent with federal law and regulations.

The timeframe to make a decision on an application may also be extended if a patient is attempting to qualify for coverage under any third-party insurance, Medi-Cal, or Medicare, or if the patient has a pending claim with respect to worker’s compensation, automobile insurance, or other insurance, including potential payments from pending litigation or third party liens related to the incident of care.

In some cases, a patient eligible for charity care may not have been identified prior to initiating external collection action. Accordingly, KDHCD requires its collection agencies to comply fully with all pertinent state and federal laws and regulations, with this policy on charity care, and with KDHCD’s Credit and Collection Policy. This will allow the agency to report amounts that they have determined to be uncollectible due to the inability to pay in accordance with KDHCD’s charity care eligibility guidelines.

Partial Charity Care Discount Payment Plans

KDHCD will make available reasonable, no-interest payment plans for patients qualifying for Partial Charity Care under this policy.30 The plan will be individually negotiated between the patient and KDHCD based on the rates outlined in Section III.D. (“Partial Charity Care”), above. reasonable payment plan means monthly payments cannot exceed more than ten percent of a patient’s family income for a month after deductions for essential living expenses, as defined in Section II above.

In the event a Financially Qualified Patient still has a remaining balance after payment has been received from third-party payers and an application for financial assistance has been processed, expected payment for services will be based on the attached sliding scales.

Any patient who inquires about a payment plan for an outstanding balance who has not already applied for assistance will be informed of the availability of financial assistance and screened for eligibility under this policy.

If a patient defaults making regular payments, KDHCD makes reasonable efforts to contact the patient by phone and in writing, giving notice that the extended payment plan may become inoperative. An attempt at renegotiating the payment plan will be done at the request of the patient or their guarantor. KDHCD initiates collection efforts only after reasonable efforts to contact the patient have failed and after 90 days of non-payment. KDHCD does not report adverse information to a credit-reporting bureau until the extended payment plan has been declared inoperative.

Patient Finance Processes

Who can grant Charity Care Eligibility

KDHCD provides personnel who have been trained to review Financial Assistance applications for completeness and accuracy. Application reviews are completed as quickly as possible considering the patient’s need for a timely response.

A Financial Assistance determination will be made only by approved KDHCD personnel according to the following levels of authority:

• Account Specialist, Patient Financial Services: Accounts less than$5,000

• Supervisor, Patient Financial Services: Accounts less than $25,000

• Manager, Patient Financial Services: Accounts less than $50,000

• Director of Patent Financial Services: Accounts less than $100,000

• Chief Financial Officer: Accounts greater than $100,000

Review of Decision

Once a determination has been made, a notification letter will be sent to each applicant advising them of KDHCD’s decision.

In the event of a dispute prior to an eligibility determination, a patient may seek review from the Patient Accounting Supervisor, Revenue Cycle Manager or Director of Revenue Cycle.
If a patient’s application for assistance is denied, the patient has the right to an appeal and review of that decision. A patient may request further review by contacting the Patient Accounting Department. The patient shall include with the appeal an explanation of the dispute and rationale for reconsideration. The patient shall also include any additional relevant documentation to support the patient’s appeal.

The review process shall consist of these level of management:

1. First Level: Revenue Cycle Manager

2. Second Level: Director of Revenue Cycle

External Collections

Accounts will not be sent to a collection agency if the patient is in the process of applying for charity care or discounted payment. If the patient does not comply with requests for information or refuses to provide KDHCD with information, the account can be sent for collections no sooner than 150 days after initial billing. Prior to sending the account to collections, a notice must be provided to the patient as specified in the KDHCD Credit and Collection Policy.

KDHCD will only send patient accounts to a collection agency when the collection agency agrees to adhere to all state and federal laws pertaining to fair collection of debt, as well as to those pertaining to charity and discount care.34 That includes the KDHCD Financial Assistance Policy, the KDHCD Credit and Collection Policy, the California Hospital Fair Pricing Act, the Rosenthal Fair Debt Collection Practices Act, the federal Fair Debt Collection Practices Act, and the tax regulations at 26 C.F.R. §§ 1.501(r)-1, et seq.

An account that has been placed with an outside collection agency can be considered for charity care at any time in accordance with KDHCD’s charity care policy. When, during the collection process, a patient asserts they cannot afford to pay the debt, has failed to make previously agreed upon extended payments, or is otherwise identified by the collection agency as meeting KDHCD’s charity care eligibility criteria, the collection agency will refer the account to KDHCD to screen for charity care eligibility. KDHCD will undertake reasonable efforts to gather eligibility information from the patient. If, after such reasonable efforts, the patient fails or refuses to provide required information, the account will be referred back to the collection agency.

If a patient is approved for Financial Assistance under this policy, KDHCD and any collection agencies acting on its behalf shall assess the patient’s financial status over the previous 8 months to determine eligibility for charity care. KDHCD will reimburse financially qualified patients for the amount actually paid, if any, in excess of the amount due for debt related to care received from KDHCD. Any payments made during the previous 8 months when the patient would have been financially eligible for full charity care shall be considered payments "in excess of the amount due," and shall be reimbursed. If the patient is eligible for partial charity care, any outstanding balance the patient owes will be reduced according to the sliding scale terms of partial charity care. Any payments the patient made while eligible for partial charity care will be reassessed using the same sliding scale amount; any amount the patient paid in excess of the partial charity care amount due in that month shall be reimbursed. Payments made for debt related to care received from KDHCD at a time when the patient was not eligible for Financial Assistance shall not be reimbursed.

KDHCD and any collection agencies acting on its behalf shall take all reasonably available measures to reverse any extraordinary collection actions taken against the individual for debt that was 1) incurred for care received from KDHCD during the previous 8 months; and 2) incurred at any time at which the patient was eligible for Financial Assistance under this policy. These reasonably available measures include but are not limited to vacating any judgment, lifting any levy or lien on the patient’s property, and removing any adverse information reported to any consumer reporting agency from the individual’s credit report.
For further information regarding KDHCD’s internal and external collections policies and practices, including information about actions that may be taken to obtain payment before and after referral to external collections, when and under whose authority patient debt is advanced for collection, policies and practices for the collection of debt, timelines for reporting debt to consumer credit reporting agencies, and the rights and responsibilities of patients, KDHCD and external collection agencies retained by KDHCD, see the KDHCD Credit and Collection Policy.

Recordkeeping

KDHCD keeps records for 10 years relating to potential charity care patients that are readily obtainable.

Application of Policy

This policy only applies to charges or services provided by KDHCD and included in a bill from KDHCD for such services. Charity care and discounted payment options may or may not be available through non-employed physician groups. At the patient’s request, KDHCD will advise patients to apply for charity care to the physician’s billing company upon the patient’s receipt of a bill for services from that billing company.

Public Notice and Posting

KDHCD widely publicizes this policy in a manner that is reasonably calculated to reach, notify and inform those patients in our communities who are most likely to require financial assistance.

KDHCD accommodates all significant populations that have limited English proficiency (LEP)36 by translating this policy, the application form, and the plain language summary of this policy into the primary language(s) spoken by each LEP language group that constitutes the lesser of 1,000 individuals or five percent of the community served by KDHCD, or the population likely to be affected or encountered by KDHCD. KDHCD will make further efforts to publicize this policy in languages other than English as appropriate and consistent with requirements under the law.

Public notice of the availability of assistance through this policy shall be made through the following means:

Availability of Policy and Application

• KDHCD makes this policy, applications for assistance, and the plain language summary of this policy, as well as other important information about the availability of financial assistance, widely available on the KDHCD website.

• KDHCD makes paper copies of this policy, the application for assistance under this policy, and the plain language summary of the policy available upon request and without charge, both by mail and in public locations in the hospital facility, including, at a minimum, in the emergency department, admissions areas, and billing department.

Posted Notices

• KDHCD posts notices in a visible manner in locations where there is a high volume of inpatient or outpatient admitting/registration, such as the emergency department, billing office, admitting office, and hospital outpatient service settings.

• Posted notices are in English and Spanish and in a manner consistent with all applicable federal and state laws and regulations.

• Posted notices contain the following information:

  • A plain language statement indicating that KDHCD has a financial assistance policy for low-income uninsured or underinsured patients who may not be able to pay their bill and that this policy provides for full or partial charity care write-off or a discount payment plan.

  • A KDHCD contact phone number that the patient can call to obtain more information about the policy and about how to apply for assistance.

  • A statement explaining that for patients who speak a language other than English or Spanish or who have other accessibility needs, KDHCD will provide language assistance services and accessibility accommodations free of charge.

  • KDHCD sets up conspicuous public displays(or other measures reasonably calculated to attract patients' attention) that notify and inform patients about the policy in public locations in KDHCD facilities, including, at a minimum, the emergency department, admissions areas, billing office, and other outpatient settings.

Written Notices

• KDHCD provides all written notices in the language spoken by the patient, as required by applicable state and federal law.

• Upon admission or discharge, KDHCD provides to every patient a written, plain language summary of the KDHCD Financial Assistance Policy that contains information about the availability of KDHCD’s charity care policy, eligibility criteria, and the contact information for a KDHCD employee or office where the patient may apply or obtain further information about the policy.

• KDHCD includes a conspicuous written notice on all billing statements that notifies and informs patients about the availability of financial assistance under this policy and includes the telephone number of the office or department which can provide information about the policy and application process, and the direct Web site address (or URL) where copies of this policy, the application form, and the plain language summary of this policy may be obtained.

• With each billing statement sent to uninsured patients, KDHCD provides a clear and conspicuous notice that contains all of the following:

  • A statement of charges for services rendered by KDHCD.

  • A request that the patient inform KDHCD if the patient has health insurance coverage, Medicare, Medi-Cal, or other coverage.

  • A statement that, if the patient does not have health insurance coverage, the patient may be eligible for Medicare, Healthy Families Program, Medi-Cal, coverage offered through the California Health Benefit Exchange, California Children’s Services program, other state- or county-funded health coverage, or charity care.

  • A statement indicating how patients may obtain applications for the programs identified in paragraph (c) above.

  • A referral to a local consumer assistance center housed at legal services offices.

  • Information regarding applications for assistance under this policy, including the following:

    • A statement that indicates that if the patient lacks, or has inadequate, insurance, and meets certain low- and moderate-income requirements, the patient may qualify for discounted payment or charity care.

    • The name and telephone number of a hospital employee or office from whom or which the patient may obtain information about the hospital’s discount payment and charity care policies, and how to apply for that assistance.