Financial Aid Program FSPA-03 Page 1 of 2

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Tamsin Stephens
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1 WENTWORTH-DOUGLASS HOSPITAL WENTWORTH-DOUGLASS PHYSICIAN CORP. Financial Aid Program FSPA-03 Page 1 of 2 Effective Date: 3-89 Last Reviewed: 08/06; 03/07; 04/08; 04/09; 09/10; 02/11; 06/12; 04/13 Function: Dept. Specific: Fiscal (Patient Accounts) Last Revised: 08/06; 03/07; 04/08; 04/09; 09/10; 02/11; 06/12; 04/13 Next scheduled review date: 04/16 Supersedes: Authorization: Director, Revenue Cycle Operations Vice President of Finance I. PURPOSE To offer assistance to patients and families who have incurred medical expenses and are unable to pay. II. III. POLICY To ensure that medical care is accessible to all patients, regardless of their ability to pay, Wentworth-Douglass Hospital/Wentworth-Douglass Physician Corp. (WDPC) has established a Financial Aid Program. Financial Aid will be available for any service provided and billed by Wentworth-Douglass Hospital/WDPC and will be granted according to financial need, based on income and assets. Public notice shall be given annually via posting on the Wentworth-Douglass Hospital website after Federal Poverty Guidelines promulgated by The Department of Health and Human Services are published in the Federal Register. Elective procedures will not be covered under financial assistance. These include but are not limited to: breast augmentation, acupuncture, vasectomy, vasectomy reversal, tubal ligation, reverse tubal ligation, abdominoplasty and other cosmetic or elective procedures as determined by the Chief Financial Officer (CFO) or his/her designee. RESPONSIBILITY: It is the responsibility of the patient, family or guarantor to complete the Financial Aid Packet. Included in this packet is a Financial Assistance application that is dispersed at the time of registration or upon patient request. It is the responsibility of the Wentworth-Douglass Hospital financial assistance staff to process the completed application.

2 Financial Aid Program FSPA-03 Page 2 of 2 IV. PROCEDURE (See attachment) V. DISTRIBUTION This policy shall be distributed to Patient Registration, Emergency Room, Financial Assistance Office and Wentworth-Douglass Physician Corporation Offices and Fiscal Services and on the web sites. VI. FILING INSTRUCTIONS This policy shall be filed in Fiscal Services (Patient Accounts) section of the Wentworth-Douglass Hospital Dept.-Specific Policy Manual and online. It supersedes any and all previous policies related to this subject.

3 Financial Aid Program FSPA-03 ATTACHMENT 1 Page 1 of 3 PROCEDURE When a patient, family or guarantor requests Financial Assistance information, they will be given a Financial Assistance packet. (For balances $ or less, a short form is available to the patient in the Financial Assistance Office). Long form packets will be available at the time of registration or in the Financial Assistance Office and all Wentworth-Douglass Physician Corporation offices. Financial Assistance cannot be pre-approved for Hospital and Physician Services, excluding the Wentworth-Douglass Community Dental Center. Patients must have a balance for Financial Assistance processing. A. The patient, family, or guarantor will complete a financial assistance packet for all active Hospital and Physician Corporation accounts. If patients request assistance with the financial assistance process, the financial assistance staff will be available to assist. For an application to be deemed complete, all questions and required information must be complete and verifiable. Any incomplete application will be denied and returned to the patient. All account balances are the responsibility of the patient until an application has been approved. B. Any patient or applicant s dependant (s), deemed to be eligible for any Medicaid or MaineCare program will need to complete and sign the appropriate application. Refusal to follow the complete Medicaid application process in its entirety may deem the applicant ineligible for financial assistance. If State assistance is denied due to asset level, WDH may award Financial Assistance for a brief period but require that assets are decreased to meet State Assistance guidelines before any further Financial Assistance be considered. Any hospital or Physician accounts that are pending any type of liability or litigation will not be considered until post settlement by the responsible party. (For example: auto, workers comp, or liability). Accounts that are found to be liability related after Financial Aid award can be reversed and will be considered Patient Responsibility. C. Documentation supporting income and asset figures will include but not limited to the following: 1. Complete copy of your most recent Federal Income Tax Return and all supporting schedules also include W-2 s. 2. Copies of the three (3) most recent, consecutive paycheck stubs of a statement from your employer on company letterhead. 3. Self-employed individuals must provide current year to date profit & loss statements. In addition to Personal Federal Income Tax Return, we require business Federal Return if applicable. 4. Copies of three (3) most recent bank statements (e.g. savings, checking, money market, IRA, 401K, etc.) If required, WDH can reserve the right to request proof of closed bank accounts. If patient has no bank accounts, we require patient to complete a No Bank Account affidavit form. 5. Copies of unemployment or disability compensation benefit statements (include start date). 6. Copy of pension benefits. 7. Copies of Social Security income (yearly benefit statements, copy of check or direct deposit).

4 Financial Aid Program FSPA-03 Attachment 1 Page 2 of 3 8. Copy of Food Stamp allocation. 9. Copy of rental assistance form City. 10. Copy of any approvals or denials from the Medicaid program. 11. Copy of Worker s compensation (indicate date of injury). 12. Rental Property 13. Copies of child support paid and/or received. 14. Available lines of credit 15. For applicants who state they are not working and receiving no income, the Hospital will need a signed statement attesting to this. The statement will need to specify dates when no income has been received and how the applicant is currently paying monthly expenses. Large assets and additional sources of income will be reviewed including but not limited to: 1. Capital gains 2. Inheritances 3. Non-cash benefits 4. Interest/Dividends 5. Mutual funds 6. Individual stock and bond fund portfolios 7. Trust fund distributions 8. Gambling winnings K, 403B, IRA s (Amounts will be reviewed if contributing) 10. Bank accounts (checking, savings) greater than $5,000 per person or $10,000 per family. 11. Additional Properties/Land other than primary residence or Business Property, if self-employed. Credit checks from a local credit-reporting agency may be requested prior to the approval of free care. Applications will remain active for 6-12 months. If the patient becomes disabled and could be eligible for state assistance, financial assistance will be discontinued until the Medicaid process is complete and determined. Any individual that does not adhere to the state process entirely, financial assistance will be discontinued indefinitely. A six-month review for anyone who qualifies on the basis of income from unemployment, worker s compensation or temporary disability, will be necessary. D. Wentworth-Douglass Hospital s & Wentworth-Douglass Physician Corporation s Poverty Guidelines will be 200% of those published by the Department of Health and Human Services. See Attachment 2 for a detail of guidelines. E. The Director of Revenue Cycle Operations in conjunction with the Vice President of Finance/CFO and the Patient Account Manager may modify eligibility guidelines at any time to enhance free care funds for the community. F. The program will be overseen by the Revenue Managers. The Financial Assistance staff will review the application and make a determination. Once the

5 Financial Aid Program FSPA-03 Attachment 1 Page 3 of 3 determination is made the patient will be notified, in writing, within 45 days of the amount of financial assistance granted and the particular account or accounts will be handled appropriately. G. If an application is denied, the patient will be notified, in writing, of the reasons for the decision and the opportunity to appeal. H. Appeals Process: In the event a patient is determined not eligible after a review of all hardship and financial criteria, the patient will be advised that they may appeal the decision to the hospital s Vice President of Finance/CFO. The patient may request an appeal in writing by sending their request to the hospital s CFO. Said review will take place within thirty (30) business days and the patient will be advised of the final decision, in writing, immediately thereafter. I. The letter of appeal must be submitted within 30 days from denial date.

6 Financial Aid Program FSPA-03 ATTACHMENT 2 Page 1 of 1 Wentworth-Douglass Hospital & Wentworth-Douglass Physician Corporation Financial Assistance Guidelines Effective Household Size FEDERAL PROVERTY GUIDELINES WDH Gross Annual Income Guidelines 1 $11,490 $22, $15,510 $31, $19,530 $39, $23,550 $47, $27,570 $55, $31,590 $63, $35,610 $71, $39,630 $79, For families/households with more than 8 persons, add $4,020 for each additional person. *Figures obtained from Federal Register*

Financial Assistance Program Application

Financial Assistance Program Application Guidelines: 1. The hospital uses a sliding scale for Financial Assistance Program sponsorship based on annual income for all family members, residing in the same