Policy On Financial Assistance for Sutter Hospitals (Charity Care

Policy On Financial Assistance for Sutter Hospitals (Charity

Care)

EFFECTIVE DATE

The effective date of this Policy on Financial Assistance for Sutter Hospitals (Charity Care) is

January 1, 2024.

PURPOSE

The purpose of this policy is to establish guidelines for Financial Assistance (Charity Care)

available at Sutter hospital facilities and to outline the process for determining eligibility for

Financial Assistance.

POLICY

It is policy to provide patients, regardless of ability to pay, with understandable written

information regarding Financial Assistance and to provide income-based Financial Assistance

(Charity Care) to qualified patients. Unless otherwise specified, this policy does not apply to

physicians or other medical providers, including emergency room physicians, anesthesiologists,

radiologists, hospitalists, pathologists, etc., whose services are not included in a hospital's bill.

This policy does not create an obligation for the hospital to pay for such physicians' or other

medical providers' services. In California, an emergency physician, as defined in Health and

Safety Code section 127450, who provides emergency services in a hospital is required to

provide discounts to uninsured patients or patients with high medical costs who are at or below

400 percent of the federal poverty level. Sutter provides, without discrimination, an examination,

medical screening and care for emergency medical conditions (within the meaning of section

1867 of the Social Security Act (42 U.S.C. 1395dd)) to individuals regardless of their eligibility

under the Policy on Financial Assistance for Sutter Hospitals (Charity Care), within the

capabilities and capacity of the facility. Sutter will not engage in any actions that discourage

individuals from seeking treatment for emergency medical conditions.

SCOPE

This policy applies to Sutter Health and any legal entity for which Sutter Health is the sole

member or directly or indirectly controls greater than 50% of the voting power or equity interest

and does not have a third-party manager (herein referred to as Sutter).

DEFINITIONS

Charity Care means full financial assistance (i.e., 100% discount) to qualifying patients that

relieves the patient and his or her guarantor of their entire financial obligation to pay for eligible

services. Charity Care does not reduce the amount, if any, that a third-party may be required to

pay for eligible services provided to the patient.

Complex/Specialized Services means services that a Sutter hospital determines are complex and

specialized (e.g., transplants, experimental and investigational services) as well as certain

elective services that are typically excluded from coverage under health plan coverage

agreements (e.g., cosmetic procedures).

Federal Poverty Level (FPL) means the measure of income level published annually by the

United States Department of Health and Human Services (HHS) and is used by hospitals for

determining eligibility for Financial Assistance.

Financial Assistance means to provide full charity care adjustments and/or high medical cost

charity care adjustments (as outlined in section A (Eligibility)).

Hospital Services means all services that a hospital is licensed to provide, including emergency

and other medically necessary care (excluding Complex/Specialized Services).

Insured Patient means a patient who has a third-party source of payment for a portion of their

medical expenses.

NHSC Clinic means a Rural Health Clinic that has been approved by the Health Resources and

Services Administration as a National Health Service Corps site.

Patient Responsibility means the amount that an Insured Patient is responsible to pay out-of-

pocket after the patient's third-party coverage has determined the amount of the patient's benefits.

Primary Language of Hospital's Service Area means a language used by the lesser of 1,000

people or 5% of the community served by the hospital based upon the most recent community

health needs assessment performed by hospital.

Uninsured Patient means a patient who has no third-party source of payment for any portion of

their medical expenses, including without limitation, commercial or other insurance, government

sponsored healthcare benefit programs, or third-party liability, and includes a patient whose

benefits under all potential sources of payment have been exhausted prior to an admission.

PROCEDURE

A. ELIGIBILITY

1. Eligibility Criteria (non-NHSC Clinic): During the application process set forth

in sections B and C below, hospitals shall apply the following eligibility criteria

for Financial Assistance:

Financial

Assistance

Category

Patient Eligibility

Criteria

Available Discount

FULL CHARITY

CARE

All Patients with a family

income (as defined

below) of no more than

400% of the most recent

FPL.

A full write-off (full

100% discount) of

patient responsibility

charges for NHSC

Clinic Services (SLCC

and SLMP) and

Hospital Services

provided by the ED of

Sutter Lakeside

Hospital.

B. CALCULATING FAMILY INCOME

1. To determine a patient's eligibility for Financial Assistance, the hospital shall first

calculate the patient's family income, as follows:

a. Patient Family: The patient family shall be determined as follows:

i. Adult Patients: For patients over eighteen (18) years of

age, the patient family includes their spouse, domestic

partner, and dependent children less than twenty-one (21)

years of age, whether living at home or not.

ii. Minor Patients: For patients under eighteen (18) years of

age, the patient family includes their parents, caretaker

relatives, and other children less than twenty-one (21) years

of age of the parent(s) or caretaker relatives.

b. Proof of Family Income: Patient shall only be required to provide recent

pay stubs or tax returns as proof of income when submitting an

application. Family income is earnings of all members of the patient

family as shown by the recent pay stubs or income tax returns, less

payments made for alimony and child support. Recent tax returns are tax

returns that document a patient's income for the year in which the patient

was first billed or 12 months prior to when the patient was first billed.

Recent paystubs are paystubs within a 6-month period before or after the

patient is first billed by the hospital, or in the case of preservice, when the

application is submitted. Income included in this calculation is every form

of income, e.g., salaries and wages, retirement income, near cash

government transfers like food stamps, and investment gains. Annual

income may be determined by annualizing year-to-date family income.

Sutter may validate income by using external presumptive eligibility

service providers, provided that such service must determine eligibility

using only information permitted by this policy.

c. Calculating Family Income for Expired Patients: Expired patients, with

no surviving spouse, may be deemed to have no income for purposes of

calculation of family income. Documentation of income is not required for

expired patients; however, documentation of estate assets may be required.

The surviving spouse of an expired patient may apply for Financial

Assistance

d. Calculating Family Income as a Percentage of FPL: After determining

family income, hospital shall calculate the family income level in

comparison to the FPL, expressed as a percentage of the FPL. For

example, if the FPL for a family of three (3) is $20,000, and a patient's

family income is $60,000, the hospital shall calculate the patient's family

income to be 300% of the FPL. Hospitals shall use this calculation during

the application process to determine whether a patient meets the income

criteria for Financial Assistance. Use U.S. Federal Poverty Guidelines as

the guide for eligibility, see Attachment E.

e. Special Circumstance – Benefits Exhausted During Inpatient Stay:

When an Insured Patient's third-party coverage pays only a portion of the

expected reimbursement for the patient's stay because the patient

exhausted their benefits during the stay, the hospital should collect from

the patient the balance of the expected reimbursement that would have

been due from the third-party coverage if the benefits were not exhausted.

A hospital shall not pursue from the patient any amount in excess of the

amount that would have been due from the third-party coverage if the

benefits were not exhausted, plus the patient's share of cost or co-

insurance. A patient who exceeded their benefit cap during a stay is

eligible to apply for Financial Assistance. If the patient is eligible for

Financial Assistance, the hospital shall write off all charges for services

that the hospital provided after the patient exceeded the benefit cap.

f. Medi-Cal/Medicaid Denied Patient Days and Non-covered Services:

Medi-Cal/Medicaid patients are eligible for charity care write-offs related

to denied charges and non-covered services. These Treatment

Authorization Request (TAR) denials and any lack of payment for non-

covered services provided to Medi-Cal/Medicaid patients are to be

classified as charity, excluding share of cost identified in Section B.1.g.ii

below.

g. Financial Assistance Exclusions/Disqualification: The following are

circumstances in which Financial Assistance is not available under this

policy:

i. Uninsured Patient seeks Complex/Specialized Services:

Generally, Uninsured Patients who seek

Complex/Specialized Services (e.g. transplants,

experimental or investigational procedures), and seek to

receive Financial Assistance for such services, must receive

administrative approval from the individual responsible for

finance at the hospital (or designee) prior to the provision

of such services. Hospitals shall develop a process for

patients to seek prior administrative approval for services

that require such approval. Elective services that are

normally exclusions from coverage under health plan

coverage agreements (e.g., cosmetic procedures) are not

eligible for Financial Assistance.

ii. Medi-Cal/Medicaid Patients with Share of Cost: Medi-

Cal/Medicaid patients who are responsible to pay share of

cost are not eligible to apply for Financial Assistance to

reduce the amount of share of cost owed. Hospitals shall

seek to collect these amounts from the patients.

iii. Patient declines covered services: An Insured Patient who

elects to seek services that are not covered under the

patient's benefit agreement (such as an HMO patient who

seeks out-of-network services from Sutter, or a patient

refuses to transfer from a Sutter hospital to an in-network

facility) is not eligible for Financial Assistance.

iv. Insured Patient does not cooperate with third-party

payer: An Insured Patient who is insured by a third-party

payer that refuses to pay for services because the patient

failed to provide information to the third-party payer

necessary to determine the third-party payer's liability is

not eligible for Financial Assistance.

v. Payer pays patient directly: If a patient receives payment

for services directly from an indemnity, Medicare

Supplement, or other payer, the patient is not eligible for

Financial Assistance for the services.

vi. Information falsification: Hospitals may refuse to award

Financial Assistance to patients who falsify information

regarding family income, household size or other

information in their eligibility application.

vii. Third party recoveries: If the patient receives a financial

settlement or judgment from a third-party tortfeasor that

caused the patient's injury, the patient must use the

settlement or judgment amount to satisfy any patient

account balances and is not eligible for Financial

Assistance.

viii. Professional (physician) Services: Services of

physicians such as anesthesiologists, radiologists,

hospitalists, pathologists, etc. are not covered under this

policy. Any exceptions are set forth in Attachment A.

Many physicians have charity care policies that allow

patients to apply for free or discounted care. Patients should

obtain information about a physician's charity care policy

directly from their physician.

C. APPLICATION PROCESS

1. Each hospital shall make all reasonable efforts to obtain from the patient or their

representative information about whether private or public health insurance may

fully or partially cover the charges for care rendered by the hospital to a patient. A

patient, upon initial presentation, annually, and any time the patient indicates

financial need will be evaluated for ability to pay and when indicated for

Financial Assistance. To qualify as an Uninsured Patient, the patient or the

patient's guarantor must verify that they are not aware of any right to insurance or

government program benefits that would cover or discount the bill. All patients

should be encouraged to investigate their potential eligibility for government

program assistance if they have not already done so.

2. Patients may request assistance with completing the application for financial

assistance in person at the Sutter hospitals listed (see Attachment A), over the

phone at 855-398-1633, through the mail, or via the Sutter website

(www.sutterhealth.org).

3. Patients who wish to apply for Financial Assistance shall use the Sutter

standardized application form, the application for Financial Assistance (see

Attachment B (for non-NHCS Clinics) and Attachment C (for NHCS

Clinics).

4. Patients should mail applications for Financial Assistance to Sutter Health, P. O.

Box 619010, Roseville, CA 95661-9998 Attn: Charity Care Application.

5. Patients should complete the application for Financial Assistance as soon as

possible after receiving Hospital Services. Failure to complete and return the

application within two hundred and forty (240) days of the date the hospital first

sent a post-discharge bill to the patient may result in the denial of Financial

Assistance.

D. FINANCIAL ASSISTANCE DETERMINATION

1. The hospital will consider each applicant's application for Financial Assistance

regardless of ability to pay and grant Financial Assistance when the patient meets

the eligibility criteria set forth in section A.1. or section A.2., depending upon

location of services. Non-NHSC sites may use Attachment D to determine

eligibility; otherwise, eligibility will be based upon family size and income alone.

2. Patients also may apply for governmental program assistance, which may be

prudent if the particular patient requires ongoing services.

a. The hospital should assist patients in determining if they are eligible for

any governmental or other assistance, or if a patient is eligible to enroll

with plans in the California Health Benefit Exchange (i.e., Covered

California) or for Hawaii residents, the federal health insurance

marketplace (see healthcare.gov).

b. If a patient applies, or has a pending application, for another health

coverage program while they apply for Financial Assistance, the

application for coverage under another health coverage program shall not

preclude the patient's eligibility for Financial Assistance.

3. Once a full charity care or high medical cost charity care determination has been

made, a notification form (see Attachment F) will be sent to each applicant

advising them of the hospital's decision.

4. Patients are presumed to be eligible for Financial Assistance for a period of one

(1) year after the hospital issues the notification form to the patient. After one

(1) year, patients must re-apply for Financial Assistance.

5. If the Financial Assistance determination creates a credit balance in favor of a

patient, the refund of the credit balance shall include interest on the amount of the

overpayment from the date of the patient's payment at the statutory rate (10% per

annum) pursuant to Health and Safety Code section 127440, provided that

hospitals are not required to refund a credit balance that is, together with interest,

less than five dollars ($5).

E. DISPUTES

A patient may seek review of any decision by the hospital to deny Financial Assistance

by notifying the individual responsible for finance at the hospital or designee, of the basis

of the dispute and the desired relief within thirty (30) days of the patient receiving notice

of the circumstances giving rise to the dispute. Patients may submit the dispute orally or

in writing. The individual responsible for finance at the hospital or designee shall review

the patient's dispute as soon as possible and inform the patient of any decision in writing.

F. AVAILABILITY OF FINANCIAL ASSISTANCE INFORMATION

1. Languages: This policy shall be available in the Primary Language(s) of

Hospital's Service Area. In addition, all notices/communications provided in this

section shall be available in Primary Language(s) of Hospital's Service Area and

in a manner consistent with all applicable federal and state laws and regulations.

2. Information Provided to Patients During the Provision of Hospital Services:

a. Preadmission or Registration, and Discharge: During preadmission or

registration (or as soon thereafter as practicable) hospitals shall provide all

patients with a copy of Attachment G (non-NHCS Clinics) or

Attachment H (NHCS Clinics), which includes a plain language

summary of the Financial Assistance policy and also contains information

regarding their right to request an estimate of their financial responsibility

for services. If the hospital does not provide a copy of Attachment G or H

to the patient during preadmission or registration, it shall be provided upon

the patient’s discharge. If Attachment G or H is not provided upon

discharge, it shall be mailed to the patient’s last known address within 72

hours of their discharge. Hospitals shall maintain a contemporaneous

record that Attachment G or H was provided to the patient, and such

record shall be retained in accordance with the hospital's record retention

requirements outlined in state and federal law. Hospitals shall identify the

department that patients can visit to receive information about, and

assistance with applying for, Financial Assistance.

b. Financial Assistance Counselors: Patients who may be Uninsured

Patients shall be assigned financial counselors, who shall visit with the

patients in person at the hospital. Financial counselors shall give such

patients a Financial Assistance application, as well as contact information

for hospital personnel who can provide additional information about this

Financial Assistance policy and assist with the application process.

c. Emergency Services: In the case of emergency services, hospitals shall

provide all patients a plain language summary of the Financial Assistance

policy as soon as practicable after stabilization of the patient's emergency

medical condition or upon discharge.

d. Government Program Applications Provided at Discharge: At the time

of discharge, hospitals shall provide all Uninsured Patients with

applications for Medi-Cal/Medicaid and California Children's Services or

any other potentially applicable government program.

3. Information Provided to Patients at Other Times:

a. Billing Statements: Hospitals shall bill patients in accordance with the

Policy on Billing and Collections for Sutter Health Hospitals. Billing

statements to patients shall include Attachment I (non-NHCS Clinics) or

Attachment J (NHCS Clinics), which contains a plain language summary

of the Financial Assistance policy, a phone number for patients to call

with questions about Financial Assistance, and the website address where

patients can obtain additional information about Financial Assistance

including the Financial Assistance Policy, a plain language summary of

the policy, and the application for Financial Assistance. A summary of

patient’s legal rights is included in Attachment I and J, and shall be

included on the patient's final billing statement.

b. Contact Information: Patients may call 1-855-398-1633 or contact the

hospital department listed on Attachment K to obtain additional

information about Financial Assistance and assistance with the application

process.

c. Upon Request: Hospitals shall provide patients with paper copies of the

Financial Assistance Policy, the application for Financial Assistance, and

the plain language summary of the Financial Assistance Policy upon

request and without charge.

4. Publicity of Financial Assistance Information

a. Public Posting: Hospitals shall post copies of the Financial Assistance

Policy, the application for Financial Assistance, the plain language

summary of the Financial Assistance Policy, and the Help Paying You

Bill notice (see Attachment L) in a prominent location in the emergency

room, admissions area, and any other location in the hospital where there

is a high volume of patient traffic, including, but not limited to, the

waiting rooms, billing offices, and hospital outpatient service settings

(including observation units). These public notices shall include

information about the right to request an estimate of financial

responsibility for services.

b. Website: The Financial Assistance Policy, application for Financial

Assistance and plain language summary shall be available in a prominent

place on the Sutter website (www.sutterhealth.org) and on each individual

hospital's website. Persons seeking information about Financial Assistance

shall not be required to create an account or provide any personal

information before receiving information about Financial Assistance. The

Sutter website shall include the information require by 22 California Code

of Regulations section 96051.11.

c. Mail: Patients may request a copy of the Financial Assistance Policy,

application for Financial Assistance and plain language summary be sent

by mail, at no cost to the Patient.

d. Advertisements/Press Releases: As necessary and on at least an annual

basis, Sutter will place an advertisement regarding the availability of

Financial Assistance at hospitals in the principal newspaper(s) in the

communities served by Sutter, or when doing so is not practical, Sutter

will issue a press release containing this information, or use other means

that Sutter concludes will widely publicize the availability of the policy to

affected patients in our communities.

e. Community Awareness: Sutter will work with aligned organizations,

physicians, community clinics and other health care providers to notify

members of the community (especially those who are most likely to

require Financial Assistance) about the availability of Financial

Assistance.

G.  MISCELLANEOUS 
1.  Recordkeeping: Records relating to Financial Assistance must be readily 
accessible. Hospitals must maintain information regarding the number of 
Uninsured Patients who have received services from the hospital, the number of 
Financial Assistance applications completed, the number approved, the estimated 
dollar value of the benefits provided, the number of applications denied, and the 
reasons for denial. In addition, notes relating to a patient's approval or denial for 
Financial Assistance should be entered into the patient's account. 
2.  Payment Plans: Patients may be eligible for a payment plan. Payment plans shall 
be offered and negotiated per the Policy on Billing and Collections for Sutter 
Health Hospitals. 
3.  Billing and Collections: Hospitals may employ reasonable collection efforts to 
obtain payment from patients. Information obtained during the application process 
for Financial Assistance may not be used in the collection process, either by the 
hospital or by any collection agency engaged by the hospital. General collection 
activities may include issuing patient statements, phone calls, and referral of 
statements have been sent to the patient or guarantor. Affiliates and revenue cycle 
departments must develop procedures to confirm that patient questions and 
complaints about bills are researched and corrected where appropriate, with 
timely follow up with the patient. Hospital or collection agencies will not engage 
in any extraordinary collection actions (as defined by the Policy on Billing and 
Collections for Sutter Health Hospitals). Copies of the Policy on Billing and 
Collections for Sutter Health Hospitals policy may be obtained free of charge on 
the Sutter website at www.sutterhealth.org, by calling 855-398-1633, or within 
the hospital patient registration, patient financial services offices and the 
emergency department. 
4.  Submission to HCAI: Sutter hospitals will submit Financial Assistance policies 
to the California Department of Health Care Access and Information (HCAI) and 
information can be located on the HCAI website. 
5.  Amounts Generally Billed: In accordance with Internal Revenue Code Section1. 
501(r)-5, Sutter adopts the prospective Medicare method for amounts generally 
billed; however, patients who are eligible for Financial Assistance are not 
financially responsible for more than the amounts generally billed because 
eligible patients do not pay any amount. 

REFERENCES

Internal Revenue Code section 501(r)

26 Code of Federal Regulations 1.501(r)-1 through 1.501(r)-7

California Health and Safety Code section 124700 through 127446

22 California Code of Regulations sections 96051 through 96051.37

Policy on Billing and Collections for Sutter Health Hospitals

ATTACHMENTS

Attachment A – Providers Covered and Not Covered by Policy

Attachment B – Application for Financial Assistance (non-NHCS Clinics)

Attachment C -- Application for Financial Assistance (NHCS Clinics)

Attachment D – Financial Assistance Calculation Worksheet

Attachment E: U.S. Federal Poverty Guidelines

Attachment F – Notification Form Sutter Health Eligibility Determination for Charity Care

Attachment G – Important Billing Information for Patients (non-NHCS Clinics)

Attachment H -- Important Billing Information for Patients (NHCS Clinics)

Attachment I – Notice of Rights (non-NHCS Clinics)

Attachment J– Notice of Rights (NHCS Clinics)

Attachment K – Sutter Health Affiliate Hospitals, Physical Address and Website Address for

Financial Assistance

Attachment L – Help Paying Your Bill

Attachment A

Providers Covered and Not Covered by Policy

Unless otherwise specified, the Sutter Health Financial Assistance Policy for Hospitals

does not apply to physicians or certain other medical providers who care for you while

you are in the hospital. This includes emergency room doctors, anesthesiologists,

radiologists, hospitalists, pathologists, and other providers. These doctors will bill you

separately from the hospital bill. This policy does not create an obligation for the

hospital to pay for the services of these physicians or other medical providers.

Some medical professionals who care for you in the hospital are covered by the

Financial Assistance Policy for Hospitals. Those categories of providers are listed

below.

• Nurses who do not have advance practice licenses

• Registered nurses, including registered nurse first assistants

• Licensed vocational nurses

• Certified nursing assistants, medical assistants and other non-licensed

assistants (dental, et cetera.)

• Physical therapists, occupational therapists (including hand therapists), speech-

language therapists and therapy assistants

• Pharmacists

• Technologists or technicians – all types

• Laboratory scientists

• Respiratory therapists

• Registered dietitians

• Diabetes educators (who are typically licensed as registered dieticians or

registered nurses)

Attachment B

APPLICATION FOR FINANCIAL ASSISTANCE (Non-NHCS Clinics)

PATIENT NAME ____________________________ SPOUSE ___________________________

ADDRESS ____________________________ PHONE___________________________

ACCOUNT# ____________________________ SNN _____________ ___________

(PATIENT) (SPOUSE)

FAMILY STATUS: List any spouse, domestic partner, or children under the age of 21. If patient is a minor,

list all parents, caretaker relatives, and siblings under 21

Name Age Relationship

_____________________________ ___________ ________________

EMPLOYMENT AND OCCUPATION

Employer: ___________________________________ Position: ______________________________________

Contact Person & Telephone: ____________________________________________________________________

If Self-Employed, Name of Business: _____________________________________________________________

Spouse Employer: _____________________________ Position: ________________________________

Contact Person & Telephone: ____________________________________________________________________

If Self-Employed, Name of Business: _____________________________________________________________

CURRENT MONTHLY INCOME Patient Other Family

Gross Pay (before deductions)

Add: Income from Operating Business (if Self-Employed) ___________ __________

Add: Other Income:

Interest and Dividends ___________ __________

From Real Estate or Personal Property ___________ __________

Social Security ___________ __________

Other (specify): ___________ __________

Alimony or Support Payments Received ___________ __________

Subtract: Alimony, Support Payments Paid ___________ __________

Equals: Current Monthly Income ___________ __________

Total Current Monthly Income (add Patient + Spouse) ___________ __________

Income from above ___________ __________

FAMILY SIZE

Total Family Members ___________

(Add patient, parents (for minor patients), spouse and children from above)

Yes No

Do you have health insurance?  

Do you have other Insurance that may apply (such as an auto policy)?  

Were your injuries caused by a third party (such as during a car accident or slip and fall)?  

By signing this form, I agree to allow Sutter Health to check employment for the purpose of determining

my eligibility for a financial discount, I understand that I may be required to provide proof of the

information I am providing in the form of recent pay stubs or tax returns. Sutter Health will consider other

forms of proof of income if submitted.

_________________________________________ ___________________

(Signature of Patient or Guarantor) (Date)

_________________________________________ ___________________

(Signature of Spouse) (Date)

Attachment C

APPLICATION FOR FINANCIAL ASSISTANCE (NHSC Clinic)

PATIENT NAME ____________________________ SPOUSE ___________________________

ADDRESS ____________________________ PHONE___________________________

ACCOUNT# ____________________________ Social Security Number________________

(PATIENT) (SPOUSE)

FAMILY STATUS: List any spouse, domestic partner, or children under the age of 21. If patient is a minor,

list all parents, caretaker relatives, and siblings under 21

Name Age Relationship

_____________________________ ___________ ________________

EMPLOYMENT AND OCCUPATION

Employer: ___________________________________ Position: _______________________________

Contact Person & Telephone: _____________________________________________________

If Self-Employed, Name of Business:_____________________________________________________

Spouse Employer: _____________________________ Position: _______________________________

Contact Person & Telephone: _____________________________________________________

If Self-Employed, Name of Business: _____________________________________________________

CURRENT MONTHLY INCOME Patient Other Family

Gross Pay (before deductions)

Add: Income from Operating Business (if Self-Employed) ___________ __________

Add: Other Income:

Interest and Dividends ___________ __________

From Real Estate or Personal Property ___________ __________

Social Security ___________ __________

Other (specify): ___________ __________

Alimony or Support Payments Received ___________ __________

Subtract: Alimony, Support Payments Paid ___________ __________

Equals: Current Monthly Income ___________ __________

Total Current Monthly Income (add Patient + Spouse) ___________ __________

Income from above ___________ __________

FAMILY SIZE

Total Family Members ___________

(Add patient, parents (for minor patients), spouse and children from above)

By signing this form, I agree to allow Sutter Health to check employment for the purpose of determining

my eligibility for a financial discount, I understand that I may be required to provide proof of the information

I am providing in the form of recent pay stubs or tax returns. Sutter Health will consider other forms of

proof of income if submitted.

_________________________________________ ________________

(Signature of Patient or Guarantor) (Date)

_________________________________________ ________________

(Signature of Spouse) (Date)

Attachment D

FINANCIAL ASSSISTANCE CALCULATION WORKSHEET

Patient Name: ________________________________ Patient Account #: ______________________

Sutter Health Affiliate: _______________________________________________________________________

Special Considerations/Circumstances: ____________________________________________________________

____________________________________________________________________________________________________

Yes No

Does Patient have Health Insurance?  

Is Patient Eligible for Medicare?  

Is Patient Eligible for Medi-Cal/Medicaid?  

Is Patient Eligible for Other Government Programs (i.e. Crime Victims,

etc.)?  

If the patient applies, or has a pending application, for another health coverage program at the same time

that he or she applies for a charity care or discount payment program, neither application shall preclude

eligibility for the other program.

Does Patient have other insurance (i.e., auto medpay)?  

Was Patient inured by a third party?  

Is Patient Self-Pay?  

Charity/Financial Assistance Calculation:

Total Combined Current Monthly Income

(From Statement of Financial Condition) $

Family Size (From Statement of Financial Condition)

Qualification for Charity Care/Financial Assistance (circle one): Full/High Medical Cost/Catastrophic

(Identify using eligibility guide) No Eligibility

Catastrophic Charity Write-off Calculation (complete section only if patient qualifies for catastrophic charity w/o):

A. Patient Liability (total charges unless another discount $

has been applied)

B. Annual Income $

C. Patient Liability as Percent of Annual Income. $

D. Is Line A divided by Line B greater than .30 (30%)? Yes  No 

E. If no, patient is not eligible for this type of write-off $ 0

F. If yes, multiply Line B by 30 % to identify the patient liability amount $

G. If yes, subtract line F from Line A to identify the write-off amount. $

Total Amount of Recommended Charity Write-offs(s): $

Worksheet Completed by: Phone:

Approved by: Date:

Attachment E:

U.S. Federal Poverty Guidelines (Excludes Hawaii and Alaska)

Annualized: Based on Family Size

Family

of 1

Family

of 2

Family

of 3

Family of

Each

additional

person

Poverty

Level

Patient

Discount

$15,060

$20,440

$25,820

$31,200

$36,580

$41,960

$47,340

$52,720

$5,380

100%

$18,825

$25,550

$32,275

$39,000

$45,725

$52,450

$59,175

$65,900

$5,380

125%

100%

$22,590

$30,660

$38,730

$46,800

$54,870

$62,940

$71,010

$79,080

$5,380

150%

100%

$26,355

$35,770

$45,185

$54,600

$64,015

$73,430

$82,845

$92,260

$5,380

175%

100%

$30,120

$40,880

$51,640

$62,400

$73,160

$83,920

$94,680

$105,440

$5,380

200%

100%

$60,240

$81,760

$103,280

$124,800

$146,320

$167,840

$189,360

$210,880

$5,380

< or = 400%

100%

From U.S. Federal Poverty Guidelines, 2024

Attachment F

NOTIFICATION FORM

SUTTER HEALTH

ELIGIBILITY DETERMINATION FOR FINANCIAL ASSISTANCE

Sutter Health has conducted an eligibility determination for financial assistance for:

________________________ ______________________ _____________________

PATIENTS NAME ACCOUNT NUMBER DATE(S) OF SERVICE

The request for financial assistance was made by the patient or on behalf of the patient

on___________.

This determination was completed on _____________________.

Based on the information supplied by the patient or on behalf of the patient, the following

determination has been made:

Your request for financial assistance has been approved for services rendered

on_________________________.

After applying the financial assistance reduction, the amount owed is

$___________________________. You may elect to make payment arrangements for this

amount. A Financial Agreement must be signed before the Patient Financial Services

office can accept payment arrangements that allow patients to pay their hospital bills

over time. These arrangements are interest-free for low income uninsured patients and

certain income-eligible patients with high medical costs. The payment plan is

negotiated between the Hospital and the patient. Please contact Patient Financial

Services at 855-398-1633 to discuss payment arrangements.

Your request for financial assistance is pending approval. However, the following

information is required before any adjustment can be applied to your account:

_______________________________________________________________________

Your request for financial assistance has been denied because:

REASON: _______________________________________________________________________

_______________________________________________________________________

Granting of financial assistance is conditioned on the completeness and accuracy of the

information provided to the hospital. In the event the hospital discovers you were injured

by another person, you have additional income, you have additional insurance or provided

incomplete or inaccurate information regarding your ability to pay for the services

provided, the hospital may revoke its determination to grant Financial Assistance and

hold the you and/or third parties responsible for the hospital’s charges.

If an application has been submitted for another health coverage program at the same

time that you submit an application for Financial Assistance, neither application shall

preclude eligibility for the other program.

Hospital Bill Complaint Program: The Hospital Bill Complaint Program is a state

program, which reviews hospital decisions about whether you qualify for help paying your

hospital bill. If you believe you were wrongly denied financial assistance, you may file a

complaint with the Hospital Bill Complaint Program. Go to

HospitalBillComplaintProgram.hcai.ca.gov for more information and to file a complaint.

Help Paying Your Bill. There are free consumer advocacy organizations that will help you

understand the billing and payment process You may call the Health Consumer Alliance

at 888-804-3536 or go to https://healthconsumer.org for more information.

If you have any questions on this determination, or would like to appeal the decision,

please contact:

_____________________________________________

Patient Financial Services

855-398-1633

Attachment G

[For non-NHCS Clinic]

Important Billing Information for Patients

Financial Assistance Plain Language Summary

Thank you for choosing Sutter Health. This handout is designed to help our

patients understand the Financial Assistance that is available to eligible patients,

the application process for Financial Assistance, and your payment options. Your

hospital bill will not include any bill for services you may receive during your

hospital stay from physicians, anesthesiologists, clinical professionals,

ambulance companies, and other providers that may bill you separately for their

services. If you wish to seek assistance with paying your bills from these other

providers, you will need to contact the providers directly.

Emergency Services: If you received emergency services at the hospital you will

receive a separate bill for the emergency room physician. Any questions pertaining

to the emergency room physician’s services should be directed to the physician.

An emergency room physician, as defined in Section 127450 of the Health and

Safety Code, who provides emergency medical services in a hospital that provides

emergency care is required by law to provide discounts to uninsured patients or

insured patients with high medical costs who are at or below 400% of the federal

poverty level.

Payment Options: Sutter Health has many options to assist you with payment of

your hospital bill.

Payment Plans: Patient account balances are due upon receipt. Patients may elect

to make payment arrangements for their hospital bill. A Financial Agreement must

be signed before the Patient Financial Services office can accept payment

arrangements that allow patients to pay their hospital bills over time. These

arrangements are interest-free for low income uninsured patients and certain

income-eligible patients with high medical costs. The payment plan is negotiated

between the Hospital and the patient.

Medi-Cal/Medicaid & Government Program Eligibility: You may be eligible for a

government-sponsored health benefit program. Sutter Health has staff available

to assist you with applying for government programs like Medi-Cal/Medicaid.

Please contact Patient Financial Assistance at (855) 398-1633 if you would like

additional information about government programs, or need assistance with

applying for such programs. This facility also contracts with organizations that

may assist you further with applying for government assistance, if needed.

Covered California: You may be eligible for health care coverage under Covered

California, which is California’s health benefit exchange under the Affordable Care

Act. Contact the hospital financial assistance department at (855) 398-1633 for

more detail and assistance to see if you quality for health care coverage through

Covered California.

Summary of Financial Assistance (Charity Care): Sutter Health is committed to

providing financial assistance to qualified low-income patients and patients who

have insurance that requires the patient to pay significant portion of their care.

The following is a summary of the eligibility requirements for Financial Assistance

and the application process for patient who wish to seek Financial Assistance.

The following are categories of patients who are eligible for Financial Assistance:

• Patients who have no third-party source of payment, such as an insurance

company or government program, for any portion of their medical expenses

and have a family income at or below 400% of the federal poverty level.

• Patients who are covered by insurance but have (i) family income at or below

400% of the federal poverty level; and (ii) medical expenses for themselves or

their family (incurred at the hospital affiliate or paid to other providers in the

past 12 months) that exceed 10% of the patient’s family income.

• Patients who are covered by insurance but exhaust their benefits either before

or during their stay at the hospital and have a family income at or below 400%

of the federal poverty level.

You may apply for Financial Assistance using the application form that is available

from Patient Financial Services, which is located within the Patient

Access/Registration Departments at the Hospital or by calling Patient Financial

Services at 855-398-1633, or on the Sutter Health or Hospital website

(www.sutterhealth.org). You may also submit an application by speaking with a

representative from Patient Financial Services, who will assist you with

completing the application. During the application process you will be asked to

provide information regarding the number of people in your family, your monthly

income, and other information that will assist the hospital with determining your

eligibility for Financial Assistance. You may be asked to provide a pay stub or tax

records to assist Sutter with verifying your income.

After you submit the application, the hospital will review the information and notify

you in writing regarding your eligibility. If you have any questions during the

application process, you may contact the Patient Financial Services office at (855)

398-1633.

If you disagree with the hospital’s decision, you may submit a dispute to the

Patient Financial Services office.

Copies of this Hospital’s Financial Assistance Policy, the Plain Language

Summary and Application, as well as government program applications are

available in multiple languages in person at our Patient Registration and Patient

Financial Services offices as well as at www.sutterhealth.org and available by

mail. We can also send you a copy of the Financial Assistance Policy free of

charge if you contact our Patient Financial Services office at 855-398-1633.

In accordance with Internal Revenue Code Section 1.501(r)-5, Sutter Health adopts

the prospective Medicare method for amounts generally billed; however, patients

who are eligible for financial assistance are not financially responsible for more

than the amounts generally billed because eligible patients do not pay any amount.

Pending applications: If an application has been submitted for another health

coverage program at the same time that you submit an application for charity care,

neither application shall preclude eligibility for the other program.

Notice of Availability of Financial Estimates: You may request a written estimate

of your financial responsibility for hospital services. Requests for estimates must

be made during business hours. The estimate will provide you with an estimate

of the amount the hospital will require the patient to pay for health care services,

procedures, and supplies that are reasonably expected to be provided by the

hospital. Estimates are based on the average length of stay and services provided

for the patient’s diagnosis. They are not promises to provide services at fixed

costs. A patient’s financial responsibility may be more or less than the estimate

based on the services the patient actually receives.

The hospital can provide estimates of the amount of hospital services only. There

may be additional charges for services that will be provided by physicians during

a patient’s stay in the hospital, such as bills from personal physicians, and any

anesthesiologists, pathologists, radiologists, ambulance companies or other

medical professionals who are not employees of the hospital. Patients will receive

a separate bill for these services.

If you have any questions about written estimates, please contact Patient Access

at 855-398-1637. If you have any questions, or if you would like to pay by

telephone, please contact the Patient Financial Services at 855-398-1633.

Hospital Bill Complaint Program: The Hospital Bill Complaint Program is a state

program, which reviews hospital decisions about whether you qualify for help

paying your hospital bill. If you believe you were wrongly denied financial

assistance, you may file a complaint with the Hospital Bill Complaint Program. Go

to HospitalBillComplaintProgram.hcai.ca.gov for more information and to file a

complaint.

Help Paying Your Bill. There are free consumer advocacy organizations that will

help you understand the billing and payment process You may call the Health

Consumer Alliance at 888-804-3536 or go to https://healthconsumer.orgfor more

information. Please contact Patient Financial Services for further information.

Price Transparency. Healthcare cost transparency is important to help

consumers make informed decisions about their care. We post a list of standard

charges for more than 300 services provided in Sutter hospitals. Please visit the

following website for more information:

https://myhealthonline.sutterhealth.org/mho/GuestEstimates

ATTENTION: If you need help in your language, please call 855-398-1633 or visit

the Patient Financial Services office at the hospital. Our telephone hours are 8:00

A.M. to 5:00 P.M., Monday through Friday. Aids and services for people with

disabilities, like documents in braille, large print, audio, and other accessible

electronic formats are also available. These services are free.

Attachment H

[For NHCS Clinic]