Policy #: Title: Patient Financial Assistance Policy. Category: Effective Date: 9/1/2004. Revised Date: 4/1/2014. Reviewed Date: 1/12/2018

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1 Policy #: Title: Patient Financial Assistance Policy Category: Effective Date: 9/1/2004 Revised Date: 4/1/2014 Approved By: MidMichigan Health s Corporate Finance Committee Signed by: Diane Postler-Slattery, President & CEO Reviewed Date: 1/12/2018 Owner: Trudy Shira Next Review Date: 1/12/2019 LOCATION: Support Services-Patient Accounts PURPOSE: Patient financial assistance for medical bills APPLICABILITY: MidMichigan Medical Center-Alpena, MidMichigan Medical Center-Clare, MidMichigan Medical Center- Gladwin, MidMichigan Medical Center-Gratiot, MidMichigan Medical Center-Midland, MidMichigan Physicians Group POLICY: MidMichigan Health is committed to providing financial assistance to any person who has healthcare needs regardless of their ability to pay or any outstanding balance from prior visits. MidMichigan Health provides fair pricing of the medical services it provides and the financial assistance program is here to assist patients that are uninsured, have limited benefits or have exhausted all other benefits. All patients are treated with compassion, dignity and respect. Patients and/or guarantors are expected to accept responsibility for any financial obligations to MidMichigan Health for medical services provided. Responsibility is demonstrated through actions such as providing complete and accurate information, timely payment and compliance with agreed upon payment plans and enrolling in medical coverage. The medical coverage may be employer provided, a private program or a government supported program such as Medicare, Medicaid or any other third party payor.

2 Services billed by MidMichigan Medical Center-Alpena, Medical Center-Clare, MidMichigan Medical Center-Gladwin, MidMichigan Medical Center-Gratiot, and MidMichigan Medical Center-Midland (herein referred to as Medical Centers, and MidMichigan Physicians Group (hereinafter referred to as the Physicians Group ) are eligible for MidMichigan Health s financial assistance program under this policy. This program is designed to address those situations where a qualifying patient has a medical need for services and is not eligible for health insurance coverage or is insured but has limited financial resources. This policy does not cover convenience items, elective procedures and surgeries, drugs from an independent pharmacy, home health, long term care, durable medical equipment, or services provided by independent providers other than those listed in Appendix A. The list of facilities, sites and providers participating in MidMichigan Health s financial assistance program can also be obtained free of charge from the MidMichigan Health website or by calling the providers offices. Eligibility: Services eligible for financial assistance include those considered medically needed or medically necessary. Such services include health care services that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are generally accepted standards of medical practice. Such services include emergency care. Qualifying for Financial Assistance Qualification for this program will be determined on a case by case basis. Patients will qualify for the program by meeting the following criteria: Patient legally resides in the United States and lives within MidMichigan Health s service area; Patient is seeking treatment for a medical need diagnosed by a MidMichigan Health provider at a MidMichigan facility; and Patient meets one of the following criteria: o Annual aggregate household income is at or below 150% of the Federal Poverty Guidelines; or o Annual aggregate household income is between 151% and 250% of the Federal Poverty Guidelines; or o Segmentation score of four or five based on credit score and household income at or below 150% of the Federal Poverty Guidelines; or o Segmentation score of four or five based on credit score and household income between 151% and 250% of the Federal Poverty Guidelines. Patients meeting the above qualification for financial assistance will be eligible for one of the following discounts:

3 o Patients with annual household incomes at or below 150% of the Federal Poverty Guidelines will be eligible for a 100% discount on all medically necessary services; or o Patients with annual household incomes between 151% and 250% of the Federal Poverty Guidelines will not be charged more than the Amounts Generally Billed Medicare (AGB). For 2018, the discount to arrive at AGB will be as follows: MidMichigan Medical Center- Alpena, Clare, Gladwin, Gratiot & Midland 72% MidMichigan Physicians Group 45%; or o Patients with a segmentation score of four or five based on credit score and have household incomes at or below 150% of the Federal Poverty Guidelines will be eligible for a 100% discount on all medically necessary services; or o Patients with a segmentation score of four or five based on credit score and household incomes between 151% and 250% of the Federal Poverty Guidelines will not be charged more than the Amounts Generally Billed Medicare (AGB). In addition, MidMichigan Health may determine qualification for the program based on a presumptive basis. This basis may include such factors as homelessness; eligibility for state or local assistance programs (such as food stamps, subsidized school lunch programs, subsidized prescription programs or low-income subsidized housing). MidMichigan Health will contract with an outside agency to obtain credit scores for segmentation. o Patients meeting the presumptive qualification for the program will be eligible for a 100% discount on all medically necessary services. Applying for Financial Assistance Application for assistance is made by contacting the MidMichigan Health financial counseling staff and by providing certain financial and supporting information detailed on the application form. External sources such as credit scores may also be used to assist in verifying eligibility and in helping patients qualify for financial assistance under the program. Patients and/or responsible parties may apply post discharge for financial assistance at any time up to 240 days after MidMichigan Health provides the initial billing to the patient and/or guarantor. The responsible parties must cooperate with the financial counselors to explore alternative means of assistance, if necessary, including Medicare and Medicaid. MidMichigan Health will process the application and make a determination of qualification within 30 calendar days after the completed application is received. The appropriate individual will be notified in writing of the determination of eligibility and the basis for such determination. Once confirmed, eligibility will remain in effect for six months from the date of the application. Exceptions may be made on a case by case basis as a result of special circumstances. However, any such circumstance will not constitute a change in policy nor does it guarantee that this same decision will be made in the future. Presumptive Eligibility

4 MidMichigan Health will contract with an outside agency to obtain credit reports that will aid in determining financial assistance. Credit report information will include segmentation score and credit score. No financial assistance application is required to qualify for presumptive eligibility. The appropriate individual will be notified in writing of the determination of eligibility and the basis for such determination. Presumptive eligibility is determined on an encounter/visit level. Not Qualifying for Financial Assistance other discount Patients who over a 12-month period have accumulated a large medical debt at MidMichigan Health as a result of a catastrophic medical event that resulted in out-ofpocket expenses that exceeded 30% of their gross annual household income will receive 100% assistance; or Uninsured patients who do not meet the criteria for financial assistance will receive a 40% discount on gross charges. Patient Billing and Collection Actions that may be taken by MidMichigan Health for nonpayment are described in a separate patient billing and collections policy. The Medical Centers and the Physicians Group will not pursue collection actions against any responsible party without first using reasonable efforts to determine if such individual is eligible for financial assistance. A free copy of the billings and collections policy may be requested free of charge by contacting MidMichigan Health s financial counseling staff or online at MidMichigan Health s website: Definitions Amounts Generally Billed means the average amount that MidMichigan Health anticipates being paid based on claims allowed by Medicare to insured patients for emergency or other medically necessary care. See below for the Calculation of this amount. Household Income includes before tax earnings, unemployment compensation, workers compensation, Social Security, Supplemental Security Income, public assistance, veterans payments, survivor benefits, pension or retirement income, interest, dividends, rents or royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. This DOES NOT include non-cash benefits such as food stamps any housing subsidies or capital gains or losses. If a person lives with a family, the income of all household members must be included (including those of domestic partners) unless the family members are paying rent and are not considered dependents of the homeowners. Non-relatives are not to be included. Dependency status will be determined on a case by case basis, depending on the facts and circumstances. Medical Need, Medically Necessary or Medical Necessity means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are generally accepted standards of medical practice, including emergency care and urgent care

5 services. Preventive or screening services are only covered if ordered by a MidMichigan Health provider. o Emergency Care includes immediate care which is necessary to prevent serious jeopardy to a patient's health; serious impairment to bodily functions; and/or serious dysfunction of any organs or body parts. o Urgent Care Services include services necessary in order to avoid the onset of illness, injury, disability, death, serious impairment, or dysfunction if not treated within 12 hours. MidMichigan Health Provider for this purpose includes all employed providers as well as private providers credentialed at a MidMichigan Health facility and included in Appendix A when they are rendering care to a MidMichigan Health patient at a MidMichigan Health facility or in their office. Responsible Party means the person held accountable for the patient s bill. Segmentation Score involves a credit check that will score encounters based on likelihood to pay debts. Calculation of the Amount Generally Billed Percentage Individuals eligible for financial assistance under this program will not be charged more than the Amount Generally Billed to individuals who have insurance for emergency and other medically necessary care. This value will be calculated annually for each facility using the "look-back" method. The lowest Amount Generally Billed amount calculated for any one of the medical centers will be used by all medical centers. The Amount Generally Billed for medically necessary care is determined by multiplying gross charges for that care by the Amount Generally Billed percentage. The Amount Generally Billed percentage for each medical center and the Physicians Group is calculated by dividing the amount received from all claims paid by Medicare fee-for-service for the prior twelve-month period by the gross charges for those claims. Communication of the Financial Assistance Program The Medical Centers and the Physicians Group s financial assistance policy, summary of the financial assistance policy, and the financial assistance application are available free of charge to all patients and responsible parties in English. The plain language summary of the financial assistance policy will be provided to each inpatient during their stay. Financial counselors are available at each Medical Center s Cashier Office to assist in the application process for the Medical Centers as well as the Physicians Group. Go to our website: Send a request by mail to MidMichigan Health Business Office, 4000 Wellness Drive, Midland, MI 48670; or Contact us (844) to request a copy

6 Appendix A: Providers (will be revised to include those that do not participate) The following MidMichigan Health Providers are included in MidMichigan Health s financial assistance program: 1. Providers billed by MidMichigan Physicians Group 2. Contracted emergency room physicians: Midland Emergency Room Corporation, PC, Emergency Room Physicians of Clare and Gladwin, PLC, Greater Midland Emergency Physicians, PC and Sound Physicians Emergency Medicine of Michigan, PLLC. SUBSIDIARY ADDENDUM: (optional) DEFINITIONS: (optional) REFERENCES: (optional) PROFILE: Patient Financial Assistance Policy; Collection and Bad Debt Policy KEY WORDS: Financial Assistance, Charity Care, Billing