Financial Assistance Application- PDF
Financial Assistance Plain Language Summary – PDF

SPRINGFIELD HOSPITAL FINANCIAL ASSISTANCE POLICY

Purpose:
To specify the criteria for identifying individuals that are eligible to receive services rendered by Springfield Hospital either free of charge (i.e.: 100% discount) or at partially discounted rates.

Policy:
Patients qualifying under the Financial Assistance Policy (FAP) will be exempt from liability for the determined discount.

The FAP applies Federal Poverty Guidelines, updated annually, adjusted for household size, to identify patients with a documented inability to pay for either the entirety or for a portion of the services rendered. Individuals who receive a partial discount are liable for balances not discounted and will be subject to collection efforts by Springfield Hospital for the balance due after the discount. See Springfield Hospital Medical Discount Schedule Attachment A.

The FAP does not apply to services that are not deemed medically necessary. Patients are encouraged to inquire prior to the rendering of services as to whether or not a service qualifies for the FAP.  Medically necessary health care services means health care services, including diagnostic testing, preventive services, and aftercare, that are appropriate to the patient’s diagnosis or condition in terms of type, amount, frequency, level, setting, and duration. Medically necessary care must:

a. be informed by generally accepted medical or scientific evidence and be consistent with generally accepted practice parameters as recognized by health care professions in the same specialties as typically provide the procedure or treatment, or diagnose or manage the medical condition;

b. be informed by the unique needs of each individual patient and each presenting situation; and

c. meet one or more of the following criteria: help restore or maintain the patient’s health; prevent deterioration of or palliate the patient’s condition; or prevent the reasonably likely onset of a health problem or detect an incipient problem.

Policy Provisions:

General Requirements:

a. Financial assistance will be granted only after the submission of a complete, signed application for financial assistance by the patient, relative, legal guardian, power of attorney, or Springfield Hospital Patient Financial Counselor with written authorization from the patient/guarantor/legal guardian.

b. In order to be eligible for financial assistance for services provided by Springfield Hospital, the patient/guarantor must be a resident of the State of Vermont, or Sullivan or Cheshire Counties in New Hampshire. A Vermont resident is an individual, regardless of citizenship and including undocumented immigrants, who resides in Vermont, is employed by a Vermont employer to deliver services for the employer in this State in the normal course of the employee’s employment, or attends school in Vermont, or a combination of these. The term includes an individual who is living in Vermont at the time that services are received but who lacks stable permanent housing.

c. Springfield Hospital does not engage in extraordinary collection activities before Springfield Hospital has made reasonable efforts to determine whether the individual is eligible for financial assistance under the financial assistance policy.

i. Springfield Hospital will not charge eligible patients more for emergency or other medically necessary services than the amount generally billed (AGB) to patients who have Medicare and private health insurance. The amount generally billed (AGB) is calculated based on the look-back method, as set forth in 26 C.F.R. § 1.501(r)-5(b)(3), including all its claims for emergency or other medically necessary care that have been allowed by Medicare fee-for-service and all private health insurers during a prior 12-month period.  The calculation of AGB will be updated at least annually and made available upon request.

 ii. Patient balance will be placed in the self-pay category upon discharge if the patient is uninsured or after all insurance has been processed and a statement is generated.

iii. Statements will contain contact information regarding inquiries for financial assistance and budget payments.

iv. Patient accounts may be sent to a collection agency for unpaid balances greater than 120 days from the date of the first bill and the patient has not applied for financial assistance.

v. Any credit bureau reporting done by the collection agency after the 120-day billing period will be reversed should a complete application be received within 240 days of the first bill and the applicant is determined to be eligible for financial assistance.

d. Applicants may qualify for full or partial financial assistance under the following circumstances.

i. Federal Poverty Guidelines: The household’s income is equal to or less than the federal poverty guidelines outlined in Springfield Hospital’s Medical Discount Schedule in Attachment A and liquid assets are at or below 400 percent of the federal poverty level. Liquid assets available to settle medical debt shall not include the household’s primary residence and retirement assets such as 401(k) accounts or pension plans.

ii. Medicare Beneficiaries: Deductibles and coinsurances due from Medicare beneficiaries can be eligible for a discount under the FAP assuming the patient submits an application and qualifies.

iii. Medicaid Beneficiaries Presumptive Eligibility: Coinsurances due from Medicaid beneficiaries qualify for FAP. A Medicaid beneficiary may not be required to complete a FAP application in order for coinsurances to qualify.

iv. Catastrophic Medical Indigency: A patient with medical bills exceeding 20 percent of the household income and household income at or below 600 percent of the federal poverty level, may qualify for catastrophic financial assistance to reduce the amount owed to no more than 20 percent of the household income.

v. Extenuating Circumstances: Accounts that fall outside of the established Springfield Hospital guidelines but involve extenuating circumstances can be approved by the Director, Revenue Management, Patient Financial Services in consultation with the Chief Financial Officer.

e. A patient who applies for financial assistance will receive a written notice of the determination of Springfield Hospital within 30 days of submission of a complete, signed application and all required supporting documentation. Supporting documentation required includes:

i. A complete copy of the most recent federal or state income tax return, including all supporting schedules. If the applicant does not file an income tax return (i.e. not required to file based on income level, undocumented immigrant), alternative supporting documentation for income determination is required, such as two recent consecutive pay stubs, statement of unemployment benefits or workers compensation benefits, statement of any public assistance, Social Security benefit statement, support for pension or other retirement distribution(s), and/or profit and loss statement for self-employed applicants or undocumented immigrants.

ii. The applicant has the option to provide additional supporting documentation for income, as described above, to be considered with the application should income be significantly different than that of the most recent filed income tax return.

iii. Two recent, consecutive monthly statements for all bank accounts or investment accounts held by any member of the household. Retirement account statements are not required (i.e. 401(k), 403(b), IRA, pension accounts).

iv. If the applicant is requesting consideration of extenuating circumstances, a written letter describing the circumstances is required.

f. If Springfield Hospital determines the patient to be eligible for financial assistance, this determination may be in effect for 1 year from the date of the initial determination. If approved for financial assistance, any and all changes regarding income, insurance status, family size, etc. must be reported to Springfield Hospital. Patients who are eligible for partial assistance may submit a request, verbally or in writing, to the financial counselor for a monthly payment plan for remaining balances. Monthly payments plans will not exceed five percent of the patient’s gross monthly household income.

g. Springfield Hospital shall not discriminate on the basis of race, color, national origin, ethnicity, ancestry, citizenship, immigration status, primary language, religion, creed, sex, sexual orientation, gender identity, marital status, disability, medical condition, genetic information, or age in its application of policies concerning the acquisition and verification of financial information, and eligibility for financial assistance.

h. The patient and/or guarantor must cooperate fully with Springfield Hospital to complete the application and explore all possible alternative insurance coverage, if applicable. The patient and/or guarantor are encouraged to maintain coverage through New Hampshire Medicaid, Vermont Medicaid, or one of the marketplace plans available through the Vermont Health Connect.  Refusal to apply for private health insurance will not be grounds for denying financial assistance.

 2. Criteria for Notification and Assistance of the Availability of Financial Assistance

a. Notification:

i. Patients will be made aware of the availability of the Financial Assistance Policy through the posting of signs in all registration areas throughout Springfield Hospital and in the Patient Financial Services offices located at 192 Park Street, Springfield, VT 05156.

ii. Springfield Hospital shall make available copies of the Financial Assistance Policy application at any and all registration areas where patients access Springfield Hospital services. The policy and application form will also be easily accessible on Springfield Hospital’s website.

iii. On an Inpatient admission that occurs outside the hours of operation of the patient access department, the financial counselor will be responsible for delivering the application to the patient the following business day or as soon as possible prior to discharge.

iv. Springfield Hospital will inform the public of its Financial Assistance Policy through the Springfield Hospital website (www. springfieldhospital.org) and/or use of public announcements, paid advertising, etc.

v. Springfield Hospital will provide oral and written translations of the financial assistance policy and application upon request.

b. Assistance:

i. Springfield Hospital will assist all patients with the completion of an application for Financial Assistance and whenever possible with applications for other programs such as Medicaid, Medicare Part D, Vermont Health Connect, etc. A patient may obtain confidential and compassionate assistance at the Springfield Hospital Patient Business Services offices located at 192 Park Street, Springfield, VT 05156 or by calling (802) 885-7081, extension 7785.  The hospital may work in collaboration with other non-profit organizations and government agencies to ensure that patients receive support needed to apply for financial assistance and other public assistance programs. 

ii. Applicants should call to make an appointment and be prepared to submit all requested documentation and the application completed to the best of their ability in advance.

3. Documentation and Audit:

a. Each financial assistance application shall be accompanied by patient documentation of all efforts made by Springfield Hospital to determine eligibility.

b. Financial Assistance application documentation shall be kept on file for a period of 5 years. After 5 years all paperwork may be permanently destroyed.

4. Decision of Eligibility for Financial Assistance:

a. Patient Financial Services will make the initial determination of eligibility for financial assistance using the above policy. This information will be recorded in writing in the appropriate section of the application forms. Patient Financial Counselors will submit any applications for extreme hardship that falls outside the guidelines but involve extenuating circumstances to the Director, Revenue Management, Patient Financial Services for approval in consultation with the Chief Financial Officer. An attestation may need to be provided by the applicant.

b. If the application is denied the applicant may submit an appeal within 60 days following receipt of written determination letter. The applicant is to be notified of its approval or denial of the appeal within 60 days following receipt of the appeal.

5. Providers Participating in Springfield Hospital Financial Assistance Policy

a. Springfield Hospital physicians and other providers participate in the Springfield Hospital Financial Assistance Policy. Please see our physician directory at http://www.springfieldhospital.org where each provider’s biography page indicates whether the provider is a participant in the Springfield Hospital Financial Assistance Policy. The Provider’s financial assistance participation will be reviewed and updated quarterly.

6. Review and Approval

a. This policy will be reviewed and approved by the Board of Trustees at least once every three years.

 (revised 3/28/2024)