Discount Programs for Insured Patients

PURPOSE

Southwest Community Health System (“Southwest”) understands the financial burden unplanned medical expenses can place on a household. Southwest offers options to help ease the financial burden. These options are offered to allow patients alternatives, if funds are not available to pay the patient balance owed in full. These options include:

1. A Monthly Installment Program
2. Flat Rate Discounts for Maternity services and Baby Imprints.
3. Financial Assistance for insured individuals with family income up to 250% of the Federal Poverty Guideline.

SCOPE

This policy applies to all hospital related services delivered within the Southwest network, including physicians employed by SGMG. This policy does not apply to those physicians not employed directly by SGMG or any professional fees from physicians or other healthcare professionals whose services are not billed by Southwest facilities. Southwest does not have the authority to alter any charge from physicians or other health professional.

POLICY STATEMENT

It is Southwest Community Health System’s intention to provide interest free alternatives to enable patients to pay for their portion of medical expenses. In the event a patient is determined to not have the appropriate means to pay using one of the options mentioned in this policy financial assistance programs will be explored, provided the patient is willing and able to share additional income information. This information will be used to determine the patient’s ability to pay and all assistance program eligibility.

PROCEDURES

I. Payment Arrangements

Monthly payments may be arranged for outstanding balances. The table below provides the minimum monthly payment amount and maximum number of months that payment can be made. This table is not apply to employees of Southwest General Health Center who elect payroll deduction as a payment option.

Patient Balance Range	Minimum Monthly Pmt	Maximum Months
Under $250	$25	3
$251- $500	$25	6
$501- $1500	$25	12
Over $1501	$25	24

Southwest General Health Center employees may pay for services via biweekly payroll deduction payments for a minimum of $25 per pay, per encounter with an outstanding balance, not to exceed 24 months per encounter, owed to Southwest General Health Center. This does not apply to balances owed to, Southwest pharmacy charges or any physician charges.

If arrangements will exceed these guidelines the patient must apply for a bank loan or seek other external financing options.

Customer Service or Financial Counselor will set up payment plan and track monthly status of each account.

Failure to make 2 consecutive established monthly payments may result in immediate placement to a collections agency.

Failure to make an arrangement may result in placement with a bad debt / collections agency.

Extended payment arrangements may be considered with the approval of the Southwest Chief Financial Officer and/or Patient Financial Services Director.

II. Flat Rate Discounts

Flat Rate Discounts are for hospital services only. These flat rates do not include any professional fees from physicians or other healthcare professionals whose services are not billed by Southwest facilities.

If a patient receives a flat rate discount no other discounts will be provided. Individuals requesting the flat rate discount will be required to complete a financial assistance application in order for the Health Center to determine whether a greater discount should be provided. Failure to comply with this request will delay approval of the flat rate discount.

Maternity
Vaginal Delivery (2 day stay for mom & 1 baby)		$6,315.00
Cesarean Section Delivery (3 day stay for mom & 1 baby)		$9,475.00
Additional rate per day:
Mom		$875.00
Baby		$875.00
Baby Imprints The following rate schedule applies to the purchase of baby imprints that are not medically necessary:
Requisition 802	3D US Pkg 15 min Single	Length 23	$76.00
Requisition 803	3D US Pkg 15 min Twins	Length 22	$106.00
Requisition 804	3D US Pkg 20 min Single	Length 23	$101.00
Requisition 805	3D US Pkg 20 min Twins	Length 22	$131.00
Requisition 806	3D US Pkg 30 min Single	Length 23	$131.00
Requisition 807	3D US Pkg 30 min Twins	Length 22	$161.00
Requisition 808	3D US Pkg each add. baby	Length 25	$31.00

BreakThru (Self-Referral Detox)

BreakThru Program (3 Day Stay)	$4500.00
Additional Rate Per Day	$ 600.00

Hyperbaric Oxygen Therapy

Hyperbaric (Daily Charge-2 Hr. Treatment)

$600.00

Dental Procedures:

Self Pay patients that do not otherwise have insurance coverage (or their coverage does not extend to these procedures) or do not qualify for Medicaid or hospital financial assistance.

Procedures defined as extractions, including wisdom teeth; pulpotomies; flouride treatment; prophy; crowns; sealants; fillings; spacer maintainers; and bond and brackets.

Alveoloplasty procedures will be charged a separate, per quadrant rate.

Please note: Any other procedure not listed above will be considered a medical procedure and will be billed with a procedure level charge.

	1st Hour	1.5 Hours	2 Hours
Dental Procedure*	$880.00	$1025.00	$1,175.00
Alveoloplasty with Dental Procedure: Add-on charge $375.00, per quadrant
*Includes recovery services; does not include anesthesia professional bill.

III. Financial Assistance for insured individuals with family income up to 250% of the Federal Poverty Guideline.

Southwest General Health Center offers financial assistance to those individuals who do not qualify for assistance under the Financial Assistance Policy, which provides charity discounts to those individuals who are uninsured or who qualify under the State of Ohio Mandated Free Care Rule 5160-2-07.17 “Hospital Care Assurance Program”.

This assistance applies to all emergency and medically necessary hospital services delivered within the Southwest network, including, physicians employed by Sout00hwest General Medical Group.

Individuals requesting the flat rate discount for maternity services will be required to complete a financial assistance application in order to for the Health Center to determine whether a greater discount should be provided. Failure to comply with this request will delay approval of the flat rate discount.

Financial assistance is available to individuals who carry limited insurance coverage (including high deductibles of $10,000 or more or limited coverage plans with service exclusions Specific discounts can be determined by using the Discount Schedule displayed below:

2024

Family Income as Compared to the FPL	101% - 250%
Maximum Discount Applied	100%
Family Size
1	$37,650
2	$51,100
3	$64,550
4	$78,000
5	$91,450
Additional Family Members	$13,450
Insured Eligible	YES

IV. Patients Eligible for Out-of-State Medicaid for which Southwest cannot, or could not obtain authorization for claim, and not identified at point of service would be eligible for a Discount.

WHO TO CONTACT

Southwest provides the following resources that can assist you with the financial assistance application, understanding our policies, and any billing questions you may have:

• Customer service 844-902-3811 weekdays 8am – 7pm
• Financial clearance at 440-816-4701 Weekdays 8am – 4:30pm
• Southwest General Medical Group “SGMG” Customer Service 440-816-6440
• By conspicuously including plain English information and applications on the Southwest website at https://swgeneral.patientcompass.com/hc/guarantor/contactus.do

DEFINITION OF TERMS

Family includes the patient, patient’s spouse (regardless of whether they live in the home) and all of the patient’s children, natural or adopted, under the age of 18 who live at home. If the patient is under the age of 18, the family shall include the patient, the patient’s natural or adoptive parent(s) (regardless of whether they live in the home), and the parent(s)’ children, natural or adopted under the age of 18 who live in the home.

FPG is the Federal Poverty Income Guidelines that are established annually by the U.S. Department of Health and Human Services and in effect at the date the services were provided.

HCAP Hospital Care Assurance Program is a state mandated program (State of Ohio Mandated Free Care Rule 5160-2-07.17) providing free care to patients at or below the federal poverty guidelines.

Medically necessary care is defined by using the same definition for medical necessity as the Ohio Medicaid definition found in the Ohio Administrative Code at 5160-01. This policy does not cover any outpatient prescriptions, cosmetic procedures, tubal or vasectomy reversals and or services provided under a package rate agreement.