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Charity Assistance Program Forms and Documents

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Charity Assistance Program Policy

At SwedishAmerican Hospital we provide treatment, prevention and education of exceptional quality, value and service to our patients. We will provide medically necessary services, within our capacity, to our patients regardless of their ability to pay. If you feel you will need help to pay for your hospital services, please contact our Business Office in confidence at (815) 391-7380 to request information about our charity assistance program.


To establish a financial assistance program that applies to all emergency care and other medically necessary care provided by SwedishAmerican Hospital (the “Hospital”) consistent with the requirements set forth in 26 CFR 1.501(r) and the requirements set forth in the Illinois Hospital Uninsured Patient Discount Act (210 ILCS 89/1 et seq), the Illinois Fair Patient Billing Act and the OAG financial assistance rule (77 Ill. Admin Code 4500).   


This policy applies to all patients of inpatient and outpatient departments of SwedishAmerican Hospital, including the Regional Cancer Center, and to all employees of SwedishAmerican Health System (SAHS) who communicate with patients regarding charity care or financial assistance.


It is the responsibility of SwedishAmerican Health System’s patient accounting services to administer this policy.


The Hospital offers financial assistance ranging from partial discounts to full write-offs for emergency care and other medically necessary care provided to Self-pay Patients and Uninsured Patients who meet the eligibility criteria set forth in this policy.  Exceptions to these criteria may be made at the sole discretion of the Hospital.  Discounts provided under this policy are in addition to other discounts offered by the Hospital. Patients unable to pay for services should consult Hospital financial counselors for assistance with identifying available resources to meet financial obligations.  The Hospital will provide emergency medical care (within the meaning of Section 1867 of the Social Security Act) without discrimination to all individuals regardless of their eligibility under this policy.

  1. Responsibilities of the Hospital and the Patient Regarding Financial Assistance – Both the Hospital and the patient are accountable for their role in the financial assistance process:
    1. Hospital Responsibilities –
      1. The Hospital is responsible for: (i) making a reasonable effort to publicize its financial assistance program to residents of the community served by the Hospital and notifying Hospital visitors about the financial assistance program; (ii) evaluating patient eligibility for financial assistance based on this policy; and (iii) notifying the patient of payment options.
      2. When determining patient eligibility for financial assistance, the Hospital will strive to be fair, consistent and timely.
      3. The Hospital may use internal staff or third-party agents to assist patients in securing Medicaid or other coverage if eligible. 
    2. Patient Responsibilities - The patient is responsible for:
      1. Cooperating with the Hospital to provide the information and documentation necessary to apply for other existing financial resources that may be available to pay for health care, such as Medicare, Medicaid, third-party liability, etc.
      2. Promptly providing the Hospital with financial and other information needed to determine eligibility for financial assistance under this policy, including completing the application form required by Section IV.D and cooperating fully with the information gathering and assessment process. Accurate information and documentation necessary to establish eligibility under this policy must be provided by the later of the last day of the Application Period or 30 days after a request for such information.
      3. Cooperating with the Hospital in establishing a reasonable payment plan and making good-faith efforts to honor the payment plan for the discounted Hospital bills if applicable.
      4. Promptly notifying the Hospital of any change in financial status so that the impact of this change may be evaluated under this financial assistance policy, the discounted Hospital bills or provisions of payment plans.
      5. Informing the Hospital, in subsequent inpatient admissions or outpatient encounters, that the patient has previously received health care services from the Hospital and was determined to be eligible for discounted care if applicable.
  2. Definitions.  As used in this policy, the following terms shall have the meaning provided below:
    1. “Medically Necessary Services” or “Medically Necessary Care” means any inpatient or outpatient hospital service, including pharmaceuticals or supplies, provided by Hospital to a patient covered under Title XVIII of the federal Social Security Act (“Medicare”) for beneficiaries with the same clinical presentation as the uninsured patient. Medically Necessary Services do not include: 1) non-medical services such as social and vocational services; and 2) elective cosmetic surgery, but does include plastic surgery designed to correct disfigurement caused by injury, illness, or congenital defect or deformity.
    2. “Emergency Care” means non-elective Hospital services without which 1) the patient’s health will be placed in serious jeopardy; or 2) the patient might experience serious impairment to bodily functions or serious dysfunction to a bodily organ.
    3. “Self-pay Patient” means a patient to whom any of the following may apply:
      1. Patient is uninsured;
      2. Third-party coverage is available, but with limited benefits (i.e., patient has an outstanding balance after insurance) and excluding any usual and customary reductions made by insurance;
      3. Third-party coverage is denied due to pre-existing conditions;
      4. Patient is already eligible for assistance (e.g., Medicaid), but the particular services are not covered;
      5. Medicare or Medicaid benefits have been exhausted, and the patient has no further ability to pay; or
      6. Welfare assistance is denied due to resources and/or income, but the patient is found to be in circumstances where an illness will make it impossible to meet their financial obligations.
    4. An “Uninsured Patient” is a Patient who is not covered under a policy of health insurance and is not a beneficiary under a public or private health insurance, health benefits, or other health coverage program, including high deductible health insurance plans, workers’ compensation, accident liability insurance, or other third-party liability insurance.
    5. For Uninsured Patients who qualify for financial assistance under this policy, “Qualifying Services” refers to Medically Necessary Services received at the Hospital. For all other Self-pay Patients who qualify for financial assistance under this policy, “Qualifying Services” refers to Emergency Care only.
  3. Eligibility Criteria:
    1. Patient is a resident of Illinois;
    2. Patient is a Self-pay Patient who qualifies for assistance based on financial need as determined by Section IV.G.
    3. Patient receives Qualifying Services;
    4. Patient completes a Financial Assistance Application form as required by Section IV.D and/or meets the Presumptive Eligibility criteria set forth in Section IV.E
  4. Financial Assistance Application Form – With the exception of patients who are presumptively eligible for financial assistance as described in Section IV.E, patients requesting financial assistance will be required to complete the Hospital’s Financial Assistance Application form and submit it to the Hospital Business Office for processing in order to establish eligibility.

    In support of his or her application, each patient must submit:

    1. Proof of Illinois residence such as a valid state-issued identification card, a lease agreement, a recent utility bill, mail addressed to the patient from an Illinois government agency, a voter or vehicle registration card or a letter from a homeless shelter;
    2. Proof of income including employer pay stubs, employer attestation, a copy of the most recent W-2 form and/or a copy of the most recent IRS tax return summary;

    An uninsured patient will not be required to submit a social security number in order to qualify for financial assistance under this policy. However, a social security number may be requested in order to assist the patient in determining his or her eligibility for public programs, such as Medicare or Medicaid. In addition, Medicare beneficiaries are subject to an additional asset test in accordance with Federal Law.

  5. Presumptive Eligibility – Self-pay Patients who fall into one or more of the following categories will be considered eligible for financial assistance even in the absence of a completed Financial Assistance Application form upon confirmation of the applicable circumstance:
    1. Patient is homeless.
    2. Patient is deceased and has no known estate able to pay patient’s debt to the Hospital.
    3. Patient is currently eligible for Medicaid but was not at the date of the health care service.
    4. Patient is enrolled in one of the following assistance programs with eligibility criteria at or below 200% of the federal poverty income guidelines:
        a. Women, Infant and Children Nutrition Program (WIC);

        b. Supplemental Nutrition Assistance Program (SNAP);

        c. Illinois Free Lunch and Breakfast Program;

        d. Low Income Home Energy Assistance Program (LIHEAP);

        e. Temporary Assistance for Needy Families (TANF);

        f. An organized community-based program providing access to medical care that assesses and documents limited low income financial status as a criterion for eligibility; or

        g. A grant assistance program for medical services.

        Furthermore, a Self-Pay Patient meeting one or more of the Presumptive Eligibility Criteria who submits a Financial Assistance Application shall not be required to report gross income or report information regarding monthly expenses.
  6. Process for Review of Applications and Determinations:
      1. Financial Assistance Application forms may be submitted at any time during the 240 day period which begins on the date the first billing statement is sent to the patient (the “Application Period”).

      2. Requests for financial assistance may be submitted by a variety of sources, including the patient, a family member, a community organization, a church, a collection agency, caregiver, Hospital administration and others. Requests received from a third party will be sent to the Hospital’s Business Office, which will obtain the patient’s consent before working with the third party on the patient’s behalf. The Business Office will work with the third party to provide available resources to assist the patient in the application process.

      3. The Hospital Business Office will review the completed Financial Assistance Application form and supporting documentation, make a determination of eligibility for financial assistance and approve or deny the Application.

      4. Following the eligibility determination, the patient will be notified in writing of the Hospital’s determination, and, if applicable, the assistance for which he or she is eligible. The determination notification will include the basis for the outcome. A patient may contact the Hospital Business Office to confirm his or her account status.

      5. Eligible patients will be provided with a billing statement indicating the amount the patient owes and instructing the patient as to how he or she can obtain additional information regarding the calculation of the AGB and the patient’s financial assistance determination. Following review, the approved financial assistance amount, determined in accordance with Section IV.G, will be applied to the patient account by the Hospital Business Office.

      6. If the event an incomplete Application is submitted, the Hospital provides written notice to the patient describing the additional information and documentation required to complete the Application, informs the patient of the completion deadline and any extraordinary collection activities that may be taken against him or her if the Application is not completed and encloses a plain summary of the financial assistance policy. The completion deadline shall be the later of the last day of the Application Period or thirty (30) days after written notice is provided under this Section.

      7. Eligibility for financial assistance will be re-assessed periodically, but not more frequently than with each subsequent encounter.

  7. Guidelines for Determining the Amount of Financial Assistance:
      1. A patient who is eligible to receive financial assistance under this policy (“FAP Eligible Individual”) shall be charged less than the “gross charges” for all services, in accordance with Internal Revenue Code Section 501(r)(5)(B). For emergency or other medically necessary care provided to patients who are eligible to receive financial assistance under this policy, Hospital shall not charge amounts in excess of amounts generally billed (AGB) to individuals who have insurance covering such care as required by Internal Revenue Code Section 501(r)(5)(A). The AGB are determined using the look back method described in 26 CFR § 1.501(r)-5(b). The Hospital determines the AGB for any emergency or other medically necessary care it provides to an FAP Eligible Individual by multiplying the Hospital’s gross charges for the care provided to the individual by the applicable AGB percentage. The Hospital calculates the AGB percentage at least annually by dividing the sum of all Claims for emergency and other medically necessary care that have been paid in full to the Hospital during a prior 12-month period by the sum of the associated gross charges for those Claims. As used herein, “Claims” includes all claims paid both Medicare fee-for-service and all private health insurers as primary payers, together with any associated portions of these claims paid by Medicare beneficiaries or insured individuals in the form of copayments, co-insurance, or deductibles. The Hospital begins applying the AGB percentage by the 45th day after the end of the 12-month period the Hospital used in calculating the AGB percentage.

      2. Financial Assistance Application forms will be reviewed according to the guidelines set forth in this policy and the Financial Assistance Application form. To be eligible to receive a reduction equal to 100% of the charges for Qualifying Services, eligible Self-pay Patients must have a Family Income (as defined below) at or below 200% of the current Federal Poverty Guidelines. In addition, a 100% discount will be applied to uninsured patients receiving medically necessary services who are presumptively eligible under Section IV.E.

      3. Uninsured patients with a Family Income (as defined below) exceeding 200%, but less than or equal to 600%, of the Federal Poverty Guidelines, will be eligible for a significant discount determined in accordance with the Illinois Hospital Uninsured Patient Discount Act.

      4. “Family Income” means the sum of a family’s earnings and cash benefits from all sources before taxes, less payments made for child support. When determining the patient’s Family Income, the household size and income includes all immediate family members and other dependents in the household. This includes an adult (and spouse, if applicable), natural or adopted minor children of adult or spouse, students over 18 years of age dependent on the family for over 50% support, and any other persons dependent on the Family Income for over 50% support. (A current tax return of the responsible adult is required.)

      For verification purpose, the Hospital may require the patient or responsible adult to submit a personal financial statement, copies of W-2/1040 forms, bank statements, or any other form of documentation that supports reported income as stated in Section IV.D. The Hospital may also obtain a credit report for the purpose of identifying additional expense, obligations, and income to assist in developing a full understanding of the patient’s financial circumstances.

      5. The maximum amount that may be collected in a 12-month period from an uninsured patient with Family Income of less than or equal to 600% of the Federal Poverty Guidelines for medically necessary services is 25% of that patient’s Family Income. The Hospital will determine, on a case-by-case basis, whether to extend the same or similar 12-month maximum collectible amount to any other qualifying Self-pay Patient with Family Income of less than or equal to 600% of the Federal Poverty Guidelines for qualifying services. The Hospital reserves the right to exclude patients having assets with a value in excess of 600% of the Federal Poverty Guidelines from the application of this 12-month maximum collectible amount. For purposes of determining the applicability of the 12-month maximum collectible amount, the following assets shall not be counted:

        a. The uninsured patient’s primary residence.

        b. Personal property exempt from judgment under Section 12-1001 of the Code of Civil Procedure.

        c. Any amounts held in a pension or retirement plan, provided, however, that distributions and payments from pension or retirement plan may be included as income.

      To be eligible to have this maximum amount applied to subsequent charges, a patient shall inform the Hospital, in subsequent Hospital inpatient admissions or outpatient encounters, that the patient has previously received medically necessary services from the Hospital and was determined to be entitled to discounted care under this policy. 6. Assets are not considered in determining a Self-pay Patient’s eligibility for financial assistance under this policy, except for purposes of:

        a. Determining the applicability of the 12-month maximum collectible amount described above; and

        b. In the case of a Medicare beneficiary, applying the mandatory asset test for Medicare beneficiaries described above.

  8. Review of Unusual/Extenuating Circumstances – The Hospital Business Office is authorized to approve timeframe and documentation exceptions to this policy on a case-by-case basis due to unusual or extenuating circumstances.

  9. Payment Plans/Collection Activity:

      1. The provisions of this Section apply to Hospital’s collection of any self-pay balance owed.

      2. Before pursuing collection against a Self-pay Patient, Hospital will give the Self-pay Patient the opportunity to:

        a. Review the accuracy of the bill;

        b. Apply for financial assistance under this policy; and

        c. Avail himself or herself of a reasonable payment plan in accordance with this policy.

      3. SwedishAmerican Hospital does not report information about patient debt to consumer credit reporting agencies or credit bureaus; however, a third party collection agency to which debt is referred may report this information.

      4. All collection activities on a patient account, including those accounts referred to a third party for collection, will be suspended for those patients who have submitted an application for financial assistance prior to the expiration of the 240 day Application Period while the application is being reviewed and considered. In the event the Hospital refers or sells the patient account to a third party prior to the end of the Application Period, the Hospital will obtain a legally binding written agreement that the third party will:

        a. Refrain from engaging in extraordinary collection activities during the one hundred twenty (120) period after the first billing statement until the Hospital has made used reasonable efforts to determine the patient’s eligibility for financial assistance under this policy;

        b. Suspend extraordinary collection activities if a patient submits a Financial Assistance Application during the Application Period;

        c. Take reasonable measure to reverse any extraordinary collection activities against the patient if the patient’s Application is approved

        d. Require any other party to which it refers or sells the patient account to enter into a legally binding written agreement which includes the terms of this Section.

      5. Patients receiving partial financial assistance who are unable to pay the full amount of any self-pay balance in one payment will be offered a reasonable payment plan. Payment plans for patients receiving partial discounts will be developed on a case-by-case basis with the patient. No interest will accrue to the account balance on any such account while payments are being made, unless the patient has voluntarily chosen to participate in a long-term payment arrangement that bears interest applied by a third-party financial agent.

      6. The Hospital will not pursue legal action for non-payment of Hospital bills against uninsured patients or patients receiving financial assistance under this policy who clearly demonstrate they have neither sufficient income nor assets to meet their financial obligations, provided the patient has provided the Hospital with all relevant information to determine financial eligibility under this policy and reasonable payment plan options, and has notified the Hospital of any material change that may affect such determinations. However, the Hospital may, after a period of one hundred twenty (120) days from the date of the first billing statement, send an unresponsive or otherwise inactive patient account to a third-party collections agency, provided the Hospital has sent the patient at least thirty (30) days’ written notification of the collections activities that may be undertaken if the patient does not submit a Financial Assistance Application or pay the amount due within the one hundred twenty (120) day period. Additionally, if a patient is in violation of the patient’s payment plan, the patient fails to make a monthly payment on any self-pay balance and the patient fails to respond to written inquiry from the Hospital, the Hospital may refer the patient to a third party collection agency or an attorney for collections or other legal action.

      7. The terms of the Hospital’s collections activity are further described in its ‘Patient Collection’ policy. A copy of the Patient Collection policy may be obtained free of charge from registration and admission areas and from the Hospital Business Office.

  10. All third-party agents to submit or collect bills on behalf of Hospital are required by written agreement to comply with this policy.


    A. A record, paper or electronic, will be maintained reflecting Hospital’s determinations regarding financial assistance, along with a copy of the Financial Assistance Application form.

    B. A financial assistance report will be provided annually with the Community Benefit Report in accordance with Illinois law. The report will include:

      1. The Financial Assistance Application Form;

      2. A copy of the Presumptive Eligibility Policy;

      3. Financial assistance statistics including the number of applications submitted, the number of applications approved, and the number of applications denied;

      4. The cost of care provided (not charges) using the most recently available operating cost and the associated cost-to-charge ratio; and

      5. A description of the electronic and information technology used in administering this policy.

    C. The provision of financial assistance may now, or in the future, be subject to change in accordance with federal, state, or local law.


    Hospital makes reasonable efforts to notify and inform patients of its financial assistance program and to identify eligible patients. This policy, a plain language policy summary, the Financial Assistance Application form, signage and financial counselor contact information are available in English and Spanish.

    A. Signage informing visitors that the Hospital provides financial assistance in accordance with its policy is posted prominently at all points of admission and registration in the Hospital (including the Emergency Department). The Hospital’s financial assistance policy, a plain summary of the policy and copies of the Financial Assistance Application form are available in admission and registration areas. The Hospital’s financial assistance policy, Financial Assistance Application form and financial counselor contact information are also posted on the Hospital’s website at http://www.swedishamerican.org/patients_visitors/charity_care_policy/. The Hospital makes efforts to publicize its policy, including details about how to obtain more information about the policy, in print and television media, wherever practicable.

    B. The Hospital’s pre-registration and registration procedures are designed to promote the identification of patients who may be eligible for financial assistance. The Hospital’s financial counselors attempt to contact all registered, self-pay inpatients during their Hospital stay to assess financial needs. If indicated, interpreters will be used, to allow for meaningful communication with individuals who have limited English proficiency. All uninsured outpatients receive a copy of this financial assistance policy with the first billing statement.

    C. At the time of discharge, all Self-pay inpatients are provided with a plain language summary of this policy and a copy of the Financial Assistance Application form.

    D. All patient billing communications during the period from the date care is first received until One Hundred Twenty (120) days after the date of the first billing statement inform patients of the availability of financial assistance. Each bill, invoice, or other summary of charges to a Self-pay Patient includes with it, or on it, a prominent statement that Self-pay Patients who meets certain income requirements may qualify for financial assistance and provides information on how to apply for consideration under the Hospital’s financial assistance policy. In addition, during this period, Self-pay Patients are informed of the policy during all oral communications regarding the amount due for care.

    E. In addition, a written copy of this policy is provided free of charge upon request. For further information, please call the SwedishAmerican Health System Business Office at 815-391-7380.


    Issued and approved by the President and Chief Executive Officer.
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