Financial Assistance and Patient Payment Responsibility Page 1 of 7

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1 Financial Assistance and Patient Payment Responsibility Page 1 of 7 Policy LD.2001.ORG FINANCIAL ASSISTANCE AND PATIENT PAYMENT RESPONSIBILITY Effective May 1, 2015 to April 30, 2016 Purpose: As a tax-exempt, non-profit organization, Boulder Community Health (BCH) serves the health care needs of the community. In fulfilling its obligation, the hospital will participate in Medicaid, Colorado Indigent Care Program (CICP), sponsor its own financial assistance program called "We Care" and support other community health improvement activities. We Care and CICP are available to residents of the hospital's service area (Addendum A). There are no geographical restrictions on services to Medicaid beneficiaries; however, there are enrollment caps to medicaid beneficiaries as indicated in this policy. This policy will be made readily available to prospective and current patients and to the community at large. Scope: Any Boulder Community Health (BCH) inpatient or outpatient account, excluding BCH owned and operated physician clinics. Policy Statements: For purposes of clarifying payment responsibilities, patient's responsibilities fall into one of four categories: o Colorado Medicaid or CICP beneficiaries BCH, may elect for certain services, to LIMIT the number of enrollees under Colorado Medicaid. This is including but not limited to, Physician Clinics and Outpatient Rehabilitation. Deductible and co-pays are required in accordance with laws and regulations governing the programs. When allowed, deductibles and copays are due at the time of service. o We Care For those patients residing in the service area specified by zip codes listed in Addendum A, discounts will be granted on a sliding scale included in Addendum A. o Insured Patients with Medicare and Commercial insurance may apply for CICP within the program time-limits. For insured patients, We Care discounts will be evaluated in o rare circumstances that are extraordinary on a case-by-case basis. Without health insurance, not qualifying for the above listed coverage programs. Prompt-pay discounts are available according to the guidelines within this policy. Payment plans may also be requested and will be granted according to policy. All patients without health insurance will be expected to pay for hospital services the day they receive services. Patients with health insurance coverage will be requested to pay deductible balances, estimated coinsurance, and/or any co-pays due the day they receive services. EXCEPTIONS: o Emergency or obstetric services, as defined by EMTALA

2 Financial Assistance and Patient Payment Responsibility Page 2 of 7 o Prenatal and Mammography services for People s Clinic Plan patients o Infectious Disease ongoing and follow-up treatment referred to by Beacon Clinic o Approved payment plan contract in effect o Medical emergent services as determined by a physician o Participants in clinical trials or grant programs Boulder Community Health will provide care, without discrimination, for emergency medical conditions regardless of patients ability to pay. Financial arrangements with Emergency Room patients will not be discussed until the patient has been assessed and treated per the hospital EMTALA policy. Procedural Guideline Statements: 1. We Care Discounts: a. Patients without health insurance who cannot pay prior to services nor within 30 days, or who cannot pay the total charges under an approved payment plan may be eligible for We Care discounting. Patients with health insurance, may be eligible, as long as they follow the guidelines of those health plans in order to access We Care discounting. Patients may apply or reapply for financial assistance before, during or after care or after collection agency assignment if their situation changes by contacting a Boulder Community Health, financial counselor at (303) to make an appointment. Their office is on 1155 Alpine Avenue, Suite 285 b. We Care Discounting Requirements: i. Patients residing in the service area specified by zip codes listed in Addendum A (unless covered under an exception listed above). ii. Proof of CICP program eligibility, or proof of People's Clinic Plan eligibility, or submission of income and asset documentation to appropriate hospital personnel for determination of eligibility for any hospital discounting program (including CICP, if appropriate). c. Appropriate hospital personnel will determine eligibility based on Federal Poverty Guidelines (updated annually} using the sliding scale included in Addendum B. d. Any patient eligible for We Care discounting will be required to pay their co-pay or percentage due upon determination of their eligibility or they must sign an approved payment plan contract. We Care discounts will be applied to any and all outstanding hospital bills of a patient determined to be currently eligible for any We Care or public assistance program that BCH participates in, including Medicaid or CICP programs. Discounted charges will not exceed the lowest average commercial payor reimbursement rate. e. Presumptive We Care Eligibility i. Patients without health insurance or other verified funding sources, who meet any of the following criteria, will be granted eligibility by BCH personnel for the We Care program: 1. Verified resident address of the Boulder Homeless Shelter, without signed CICP or Financial Assistance Application on file. 2. Presence form on file. 3. Verified homeless" or "transient" status, without signed CICP or Financial Assistance Application on file.

3 Financial Assistance and Patient Payment Responsibility Page 3 of 7 4. For medically urgent or emergent services that are verified with current eligibility in a Medicaid or other public assistance program in a state other than Colorado, of which BCH is not an enrolled provider. 5. Account is identified in official bankruptcy notice. 6. Accounts where patient is deceased and there are no estate assets 7. Undocumented patients as applicable under Section 1011, Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens 1. Prompt Pay Discounts a. Patients without health insurance, or who choose not to elect insurance billing, who do not qualify for We Care discounting and who pay in full prior to receiving services will be eligible for a 60% prompt pay discount. For medically urgent or emergency admissions where it is not practical to collect payment in advance of receiving services, the 60% prompt payment discount will be accepted for 72 hours following discharge. A 50% prompt pay discount will be given if account is paid within 30 days after services or discharge date for medically urgent, emergency, prenatal, and obstetric services. b. Excluded Services i. Cosmetic procedures with packaged pricing. ii. Audiology supplies, including hearing aids, hearing aid accessories, and battery packs. iii. Lab kit draw fees, venipuncture fees and outpatient TB skin tests are excluded if not performed in conjunction with other BCH Laboratory services. iv. Procedures which are already discounted to prevailing market rates (UCR), including but not limited to self-pay fee schedules for Imaging and Lab services, self-referred screening studies (Cardiac Calcium Scores, Colonoscopy, etc.), and any other procedure(s) deemed at BCH discretion to be determined as discounted. v. Physician services provided by BCH. vi. All pediatric, Neuro Ortho Rehab Center (NORC), and adult physical rehabilitation services and all behavioral health services except those where the patient is directly admitted through the emergency room or is a direct EMTALA transfer. vii. High-cost implantable devices and chemotherapy drugs; hospital will make every attempt to have high-cost devices and chemotherapy drugs provided at no cost by the vendors for patients eligible for We Care discounting. In the event the high cost implantable or pharmaceutical cannot be donated, BCH will discount these items down to the purchase price (BCH cost) and the patient will be financially responsible for this component of their care. viii. Services not covered or deemed medically necessary by the CICP and/or Colorado Medicaid programs. ix. Physician services provided by BCH. c. If actual charges exceed the estimated amount paid at the time of service, a 60% prompt pay discount will be applied to the total charge amount. d. When actual charges exceed the amount originally estimated by the hospital an effort will be made on a case-by-case basis to adjust the charges if requested by the patient.

4 Financial Assistance and Patient Payment Responsibility Page 4 of 7 2. Multiple Discounts a. A We Care discount and a prompt pay discount cannot be combined together nor combined with any other discount offered by the hospital, such as, but not limited to, the employee discount or the Medical Staff discount. Definitions: 1. Medicaid or CICP beneficiaries: Deductible and co-pays are required in accordance with laws and regulations governing the programs. When allowed, deductibles and co-pays are due at the time of service. 2. We Care: For those patients residing in the service area specified by zip codes listed in Addendum A, discounts will be granted on a sliding scale included in Addendum B. 3. Insured: Patients with Medicare and Commercial insurance may apply for CICP within the program time-limits. For insured patients, We Care discounts will be evaluated in rare circumstances that are extraordinary on a case-by-case basis. a. Without health insurance, not qualifying for the above listed coverage programs. Prompt-pay discounts are available according to the guidelines within this policy. Payment plans may also be requested and will be granted according to policy. Resources: References: Key Words: Financial Assistance, Patient Assistance, Financial Content Reviewers: Nancy Coppom, Director Patient Financial Services Jon Wiik, Chief Revenue Officer William Munson, Vice President and CFO Final Approval: Robert J. Vissers, Executive Vice President and CEO Effective Date: 12/10 Last Review Date: 12/13

5 Financial Assistance and Patient Payment Responsibility Page 5 of 7 Boulder Addendum A Eligibility Zip Codes Eldorado Springs Allenspark Jamestown Nederland Pinecliff Rollinsville Ward Conditionally Eligible Boulder County Zip Codes: a. Lafayette*80226 b. Louisville/Superior* c. Broomfield** 80023, d. Longmont** 80501,80502, 80503,80504 * Patients with these zip codes are eligible for We Care discounting if they have Boulder Community Health services not provided by their local hospitals. **Patients referred by an BCH owned and operated physician practice located within the zip codes are eligible for We Care discounting for services provided by BCH within the zip codes.

6 Financial Assistance and Patient Payment Responsibility Page 6 of 7 Addendum B Federal Poverty Guidelines 2017 Rate N A B C D E Family Size 1 $4,824 $7,477 $9,769 $12,060 $14,110 $16,040 2 $6,496 $10,069 $13,154 $16,240 $19,001 $21,599 3 $8,168 $12,660 $16,540 $20,420 $23,891 $27,159 4 $9,840 $15,252 $19,926 $24,600 $28,782 $32,718 5 $11,512 $17,844 $23,312 $28,780 $33,673 $38,277 6 $13,184 $20,435 $26,698 $32,960 $38,563 $43,837 Poverty Level 40% 62% 81% 100% 117% 133% Rate F G H I J K Family Size 1 $19,175 $22,311 $24,120 $30,150 $36,180 $42,210 2 $25,822 $30,044 $32,480 $40,600 $48,720 $56,840 3 $32,468 $37,777 $40,840 $51,050 $61,260 $71,470 4 $39,114 $45,510 $49,200 $61,500 $73,800 $86,100 5 $45,760 $53,243 $57,560 $71,950 $86,340 $100,730 6 $52,406 $60,976 $65,920 $82,400 $98,880 $115,360 Poverty Level 159% 185% 200% 250% 300% 350%

7 CICP/ Wecare Rate/FPL Financial Assistance and Patient Payment Responsibility Page 7 of 7 Inpatient Facility Addendum C Copay Table Effect 11/10/2017 Ambulatory Surgery MRI, CT, NM, SleepLab, Cath Lab Emergency Room Specialty Outpatient (ie: Echo, EKG) Imaging / Ultrasound Z/0-40% $0 $0 $0 $0 $0 $0 $0 N/0-40% $15 $15 $15 $15 $15 $5 $5 A/41-62% $65 $65 $65 $25 $25 $10 $10 B/63-81% $105 $105 $105 $25 $25 $10 $10 C/82-100% $155 $155 $155 $30 $30 $15 $15 D/ % $220 $220 $220 $30 $30 $15 $15 E/ % $300 $300 $300 $35 $35 $20 $20 F/ % $390 $390 $390 $35 $35 $20 $20 G/ % $535 $535 $535 $45 $45 $30 $30 H/ % $600 $600 $600 $45 $45 $30 $30 I/ % $630 $630 $630 $50 $50 $35 $35 Laboratory J/ % 15% 15% 15% 15% 15% 15% 15% K/ % 20% 20% 20% 20% 20% 20% 20% * Multiple services will be charged separate copays, with the exception of lab tests. 2 x-rays, 2 copays. X-ray & lab, 2 copays. * Peoples Clinic plan is equal to our WeCare. * CICP cards will state CICP on them. (Colorado Indigent Care Program) * CR visits will be charged either the ER copay or the MRI/CT/NUC MED copay (if one of these services is provided during ER visit) but not both. * For J and K Wecare rates, patient is responsible for a percent of their total charges not the balance after insurance.