Adventist Health



-49530-63251800Exhibit AFinancial Assistance Plain Language SummaryThe following is a summary of Financial Assistance available for services provided at Rideout Memorial Hospital, the application process and your payment options. Please visit our website: , contact Patient Access Financial Counselors at (530)749-4402, 726 4th Street, Marysville, California, 95901 or Patient Financial Services at (530)740-1910, 614 J Street, Marysville, California, 95901 for assistance with your hospital bill, a free copy of the Financial Assistance Policy or Application in person or by mail and any questions you may have regarding Financial Assistance. Your hospital bill will not include any bill for services you may receive during your hospital stay from physicians, ambulance companies, anesthesiologists, clinical professionals, and other providers that may bill you separately for their services. Please contact those providers directly for assistance with their bills.Summary of Financial Assistance (Charity Care): Rideout Memorial Hospital is committed to providing financial assistance to qualified low income patients. The following is a summary of the eligibility requirements for Financial Assistance and the application process for patients requesting Financial Assistance.The following categories of patients are eligible for Financial Assistance with the required supporting documentation:Patients who have exhausted all third-party sources of payment (insurance, auto, work comp, government payers, etc.) that would cover a portion of approved services and their family income is at or below 400% of the federal poverty level.Patients who have medical expenses for the family at the Hospital or paid to other providers in the past 12 months exceeding 10% of the patient’s family monthly income.Pending Applications: If an application has been submitted for Financial Assistance and another health coverage program at the same time, neither application shall preclude eligibility for the other program.Medi-Cal, Covered California and Government Programs: You may be eligible for a government-sponsored health benefit program or coverage under Covered California which California’s health benefit exchange under the Affordable Care Act. Payment Options: Patient account balances are due at the time of service. Rideout Memorial Hospital has many options to assist you with payment of your hospital bill including short term interest free payment arrangements. Emergency Services: 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 and are at or below 350% of the federal poverty level. You will receive a separate bill for the emergency room physician if you received emergency services at the hospital. Please contact the physician with any questions related to their services.Financial Estimates: Financial estimates are available upon written request during business hours. The hospital can provide estimates of the amount of the hospital services only. The estimates are based on the average length of stay and services provided for the patient’s diagnoses or procedures. They are not promises to provide services at fixed cost. A patient’s financial responsibility may be more or less than the estimate based on the services the patient actually receives. If insured, your insurance determines the amount of your patient responsibility. Please contact your insurance company with any questions related to their determination. Patients will receive a separate bill for services provided by physicians, pathologists, radiologists, ambulance companies or other medical professionals who are not employees of the hospital.Generally Billed Amount: Rideout Memorial Hospital adopts the prospective Medicare method for amounts generally billed In accordance with Internal Revenue Code Section 1.501r-5: 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. ................
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