Financial Aid Law (FAL)
[HOSPITAL NAME]
Financial Assistance Summary
[Hospital Name] recognizes that there are times when patients in need of care will have difficulty paying for the services provided. [Name of Hospital's financial assistance program] provides discounts to qualifying individuals based on your income. In addition, we can help you apply for free or low-cost insurance if you qualify. Just contact our Financial Counselor at [Phone number] or go to Room [Room Number] for free, confidential assistance.
Who qualifies for a discount?
Financial Assistance is available for patients with limited incomes and no health insurance. [If your hospital has voluntarily extended financial assistance to under-insured patients, please indicate your policy here.]
Everyone in New York State who needs emergency services can receive care and get a discount if they meet the income limits.
Everyone who lives in [list counties in PSA or statewide] can get a discount on non-emergency, medically necessary services at [Hospital Name] if they meet the income limits. You cannot be denied medically necessary care because you need financial assistance.
You may apply for a discount regardless of immigration status.
What are the income limits?
The amount of the discount varies based on your income and the size of your family. If you have no health insurance, these are the income limits: [If your hospital has voluntarily expanded the income limits, please indicate here.]
| Family size | Annual Family Income | Monthly Family Income | Weekly Family Income |
|---|---|---|---|
| 1 | Up to $30,630 | Up to $2,553 | Up to $589 |
| 2 | Up to $41,070 | Up to $3,423 | Up to $790 |
| 3 | Up to $51,510 | Up to $4,293 | Up to $991 |
| 4 | Up to $61,950 | Up to $5,163 | Up to $1,191 |
| 5 | Up to $72,390 | Up to $6,033 | Up to $1,392 |
| 6 | Up to $82,830 | Up to $6,903 | Up to $1,593 |
| * Based on the 2007 Federal Poverty Guidelines | |||
What if I do not meet the income limits?
If you cannot pay your bill, [Hospital Name] offers a payment plan to those patients that meet the income limits. The amount you pay depends on the amount of your income. [If you extend your payment plans to others that exceed income limits, please indicate your policy here.]
Can someone explain the discount? Can someone help me apply?
Yes, free, confidential help is available. Call [person or department] at [DIRECT PHONE].
If you do not speak English, someone will help you in your own language.
The Financial Counselor can tell you if you qualify for free or low-cost insurance, such as Medicaid, Child Health Plus and Family Health Plus.
If the Financial Counselor finds that you don't qualify for low-cost insurance, they will help you apply for a discount.
The Counselor will help you fill out all the forms and tell you what documents you need to bring.
What do I need to apply for a discount?
[Indicate materials needed to apply such as a form of picture ID, a bill indicating his/her address, paystub or W- 2, etc.]
If you can not provide any of these, you may still be able to apply for financial assistance.
What services are covered?
All medically necessary services provided by [Hospital Name] are covered by the discount. This includes outpatient services, emergency care, and inpatient admissions.
Charges from private doctors who provide services in the hospital may not be covered. You should talk to private doctors to see if they offer a discount or payment plan.
How much do I have to pay?
The amount for an outpatient service or the emergency room starts from $0 for children and pregnant women, depending on your income. The amount for outpatient service or the emergency room starts from $15 for adults, depending on your income.
Our Financial Counselor will give you the details about your specific discount(s) once your application is processed.
[If your hospital requires a deposit prior to providing services, please clearly indicate how it is fairly applied to eligible patients. Hospitals are encouraged not to set lump sum deposits at a level that would discourage patients from obtaining care.]
How do I get the discount?
You have to fill out the application form. As soon as we have proof of your income, we can process your application for a discount according to your income level.
You can apply for a discount before you have an appointment, when you come to the hospital to get care, or when the bill comes in the mail.
Send the completed form to [Hospital Name and address] or bring it to Room [room number]. You have up to 90 days after receiving services to submit the application.
How will I know if I was approved for the discount?
[Hospital Name] will send you a letter within 30 days after completion and submission of documentation, telling you if you have been approved and the level of discount received.
What if I receive a bill while I'm waiting to hear if I can get a discount?
You cannot be required to pay a hospital bill while your application for a discount is being considered. If your application is turned down, the hospital must tell you why in writing and must provide you with a way to appeal this decision to a higher level within the hospital.
What if I have a problem I cannot resolve with the hospital?
You may call the New York State Department of Health complaint hotline at 1-800-804-5447.
