Charity Assistance Program
We’re Here to Help
At SwedishAmerican Hospital we provide treatment, prevention and education of exceptional quality, value and service to our patients. We’ll provide medically necessary services, within our capacity, to our patients regardless of their ability to pay.
If you need help paying for your hospital services and would like to request information in confidence, about our charity assistance program, please call our Business Office at:
If you wish to be considered for charity assistance, please download and complete the application and financial disclosure on this page.
Then, send it with supporting documentation outlined in our charity policy below to:
1401 East State Street
Rockford, IL 61104-9863
Charity Assistance Program Policy
To establish a financial assistance program that applies to all Emergency Care and other Medically Necessary Care provided by SwedishAmerican Hospital and SwedishAmerican Medical Center/Belvidere (together, the "Hospital") and that is 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 Illinois OAG financial assistance rule (77 Ill. Admin Code 4500).
This policy applies to all patients of inpatient and outpatient departments of the Hospital, including the Regional Cancer Center and all other provider-based outpatient departments, 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 will provide emergency medical care (within the meaning of Section 1867 of the Social Security Act) in accordance with its EMTALA Policy without discrimination to all individuals regardless of their eligibility for financial assistance under this policy. The Hospital offers financial assistance in the form of partial or full discounts 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 the eligibility 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 financial counselors in the Hospital’s Business Office for assistance with identifying available resources to meet financial obligations. Physicians providing care at the Hospital may bill separately for their services and may not be required to comply with this policy. For a list of physicians providing care at the Hospital, including which physicians or groups offer financial assistance under this policy and which do not, see Schedule A.
A. Responsibilities of the Hospital and the Patient Regarding Financial Assistance – Both the Hospital and the patient are accountable for their role in determining eligibility for the Hospital’s financial assistance program and in making payment arrangements for the discounted amount owed, if any.
Hospital Responsibilities –
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; (iii) notifying the patient of payment options; and (iv) notifying patients of Extraordinary Collection Actions the Hospital intends to pursue against the patient as required by Section IV.I.4 of this policy.
When determining patient eligibility for financial assistance, Hospital staff will strive to be fair, consistent and timely.
The Hospital may use internal staff or third-party agents to assist patients in securing Medicaid or other coverage if eligible.
Patient Role - The patient is responsible for:
a. 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 and third-party liability insurance.
Promptly providing the Hospital with financial and other information needed to determine eligibility for financial assistance under this policy. This includes completing the Financial Assistance Application required by Section IV.D of this policy and cooperating fully with the information gathering and assessment process.
Patient must provide accurate information and documentation necessary to establish eligibility under this policy by the last day of the Application Period, as defined in Section IV.F, or thirty (30) days after a request for the information, whichever is later.
Cooperating with the Hospital in establishing a reasonable payment plan and making good-faith efforts to honor payment plans for discounted Hospital bills if applicable.
Promptly notifying the Hospital of any change in financial status so that the Hospital can evaluate the impact of this change on eligibility for financial assistance, outstanding Hospital bills and agreed payment plans.
Informing the Hospital, upon subsequent inpatient admissions and 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.
Contacting the Hospital Business Office for information about assistance with the Financial Assistance Application if needed.
B. 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 appropriate pharmaceuticals and supplies, provided by the 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 do 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:
Patient is uninsured;
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;
Third-party coverage is denied due to pre-existing conditions;
Patient is already receiving financial assistance (e.g., Medicaid), but the particular services are not covered;
Medicare or Medicaid benefits have been exhausted, and the patient has no further ability to pay; or
Welfare assistance has been denied due to the patient’s resources and/or income, but the patient is found to be in circumstances where an illness will make it impossible to meet 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 plan, 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 Emergency Care and 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.
6. For purposes of this policy "Post-Discharge" means after the care has been received and after the patient has left the Hospital facility.
Financial Assistance Eligibility Criteria:
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; and
Patient completes a Financial Assistance Application as required by Section IV.D and/or meets the Presumptive Eligibility criteria set forth in Section IV.E.
Financial Assistance Application – With the exception of patients who meet the Presumptive Eligibility Criteria in Section IV.E, patients seeking financial assistance must complete the Hospital’s Financial Assistance Application and submit it to the Hospital Business Office in order to determine eligibility under this policy.
In support of his or her Financial Assistance Application, each patient must submit:
Proof of Illinois residence. Acceptable forms of proof are 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; and
2. Proof of income. A copy of the responsible adult’s most recent IRS tax return is required. In addition, additional proof of income may be required. Acceptable forms of additional proof are employer pay stubs, employer attestation and a copy of the most recent W-2 form.
If the identified forms of proof are unavailable, the patient may contact the Hospital Business Office to discuss whether an alternative form of proof may be submitted. An Uninsured Patient will not be required to submit a social security number in order to qualify for financial assistance under this policy. However, the Hospital may request a patient’s social security number in order to assist the patient in determining his or her eligibility for public programs, such as Medicare or Medicaid.
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 upon confirmation of the applicable circumstance:
Patient is homeless.
Patient is deceased and has no known estate able to pay patient’s debt to the Hospital.
Patient is currently eligible for Medicaid but was not at the date of the health care service.
Patient is enrolled in one of the following assistance programs with eligibility criteria at or below two hundred percent (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.
A. Submission and Processing of Financial Assistance Applications:
1. Generally, a Financial Assistance Application may be submitted at any time during the two hundred forty (240) day period which begins on the date the first Post-Discharge billing statement is sent to a Self-pay Patient (the "Application Period").
2. A request 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, a caregiver, Hospital administration and others. Requests received from third parties will be directed 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 identify and/or provide available resources to assist the patient in the application process.
3. The Hospital Business Office will review the completed Financial Assistance Application and supporting documentation, make a determination of eligibility for financial assistance and approve or deny the Application within a reasonable time, typically fourteen (14) business days (with the exception of FAP eligible individuals with pending applications for Medicaid or other coverage).
4. Following an eligibility determination in accordance with Section IV.G, any approved financial assistance discount will be applied to the patient account by the Hospital Business Office.
5. 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 notification will include the basis for the determination. A patient may contact the Hospital Business Office to confirm his or her account status. Eligible patients will be provided with a revised billing statement indicating the discounted amount owed and instructing the patient as to how to obtain additional information regarding the calculation of the AGB and the patient’s financial assistance determination.
Despite the likely absence of a complete Financial Assistance Application, a patient who is presumptively eligible also will be notified in writing of the Hospital’s eligibility determination and of the discount applied to the balance owed by the patient.
6. In the event an incomplete Financial Assistance Application is submitted, the Hospital will provide written notice to the patient describing the additional information or documentation required to complete the Application. The notice will provide contact details for the Hospital Business Office and inform the patient of the completion deadline. The completion deadline shall be the later of the last day of the Application Period or thirty (30) days after the written notice required by this Subsection is provided.
7. Unless the patient notifies the Hospital Business Office of a change in financial circumstance, eligibility for financial assistance will be re-assessed periodically, but not more frequently than with each subsequent episode of care to which this policy applies.
Guidelines for Determining the Amount of Financial Assistance:
1. In accordance with Internal Revenue Code Section 501(r)(5)(B), a patient who is eligible to receive financial assistance under this policy (a "FAP Eligible Individual") shall be charged less than "gross charges" for all Emergency Care and Medically Necessary Care. Further, as required by Internal Revenue Code Section 501(r)(5)(A), for Emergency Care or other Medically Necessary Care provided to FAP Eligible Individuals, the Hospital shall not charge amounts in excess of amounts generally billed ("AGB") to individuals who have insurance covering such care. Using the look back method described in 26 CFR § 1.501(r)-5(b), the Hospital determines the AGB for any Emergency Care or other Medically Necessary Care by multiplying the Hospital’s gross charges for the care provided to the FAP Eligible Individual by the applicable AGB percentage. At least annually, the Hospital calculates a single AGB percentage applicable to all facilities by dividing the sum of all Claims, other than elective cosmetic surgery, paid to the Hospital during a prior twelve (12)-month period by the sum of the associated gross charges for those Claims. As used in this policy, "Claims" means all claims allowed by Medicare fee-for-service and all private health insurers as primary or secondary payers, including Medicare Care Advantage plans, together with any associated portions of these claims paid by Medicare beneficiaries or insured individuals in the form of copayments, co-insurance and deductibles. The Hospital shall implement the AGB percentage within one hundred twenty (120) days of the end of the twelve (12)-month period used to calculate the AGB percentage. To obtain the current AGB percentage, please contact the Director of Patient Financial Services in the Hospital Business Office at 815-391-7380.
2. Financial Assistance Applications will be reviewed according to the guidelines set forth in this policy and the Financial Assistance Application. To be eligible to receive a reduction equal to one hundred percent (100%) of the charges for Qualifying Services, FAP Eligible Individuals must have Family Income (as defined below) at or below two hundred percent (200%) of the current Federal Poverty Guidelines.
3. Self-pay Patients who meet the Presumptive Eligibility Criteria under Section IV.E will receive a reduction equal to one hundred percent (100%) of charges for Qualifying Services.
4. Uninsured Patients with a Family Income (as defined below) exceeding two hundred percent (200%), but less than or equal to six hundred percent (600%), of the Federal Poverty Guidelines, will be eligible for a significant discount determined in accordance with the Illinois Hospital Uninsured Patient Discount Act.
5. "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 eighteen (18) years of age dependent on the family for over fifty percent (50%) support, and any other persons dependent on the Family Income for over fifty percent (50%) support.
For verification purpose, the Hospital will require a current tax return of the responsible adult and may require the patient or responsible adult to submit a current tax return, 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 expenses, obligations, and income to assist in developing a full understanding of the patient’s financial circumstances.
6. The maximum amount the Hospital will collect for Qualifying Services in a twelve (12)-month period from an Uninsured Patient with Family Income of less than or equal to six hundred percent (600%) of the Federal Poverty Guidelines is twenty-five percent (25%) of that patient’s Family Income. The Hospital will determine, on a case-by-case basis, whether to extend the same or similar twelve (12)-month maximum collectible amount to any other FAP Eligible Self-pay Patient with Family Income of less than or equal to six hundred percent (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 six hundred percent (600%) of the Federal Poverty Guidelines from the application of this twelve (12)-month maximum collectible amount. For purposes of determining the applicability of the twelve (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 Illinois 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 Qualifying Services from the Hospital and was determined to be entitled to discounted care under this policy. Assets are not considered in determining a Self-pay Patient’s eligibility for financial assistance under this policy, except for purposes of determining the applicability of the twelve (12)-month maximum collectible amount described above.
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.
D. Payment Plans/Collection Activity:
1. The provisions of this Section apply to the Hospital’s collection of any self-pay balance owed by a Self-pay Patient for Emergency Care or Medically Necessary Care.
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 in accordance with this policy; and
- c. Select a reasonable payment plan offered by the Hospital in accordance with this policy.
3. All collection activity on a Self-pay Patient account for the care at issue, including collection of debts referred to a third party, will be suspended for those patients who subsequently submit or complete a Financial Assistance Application prior to the expiration of the two hundred forty (240) day Application Period or thirty (30) days after a request for additional information is provided to patient, whichever is later. In the event the Self-pay Patient is determined to be an FAP Eligible Individual, the Hospital will return all overpayments in excess of the discounted amount the patient is determined to owe. In addition, the Hospital or debt collection agency will reverse all Extraordinary Collection Actions (as defined below) taken against the FAP Eligible Individual and start the collection process anew. Extraordinary Collection Actions may be resumed for patients found to be ineligible for financial assistance in accordance with this policy.
4. Extraordinary Collection Actions - The Hospital may, after a period of one hundred twenty (120) days from the date of the first Post-Discharge billing statement, pursue the following Extraordinary Collection Actions against a Self-pay Patient who fails to submit a Financial Assistance Application, fails to respond to inquiries from the Hospital regarding an incomplete Financial Assistance Application or fails to comply with patient’s payment plan:
a. Referral or sale of the debt to a third party collection agency or lawyer which fails to comply with Section IV.I.6 of this policy;
b. Referral of the debt to a lawyer for legal action; and
Although the Hospital does not report information about patient debt to consumer credit reporting agencies or credit bureaus, a third party collection agency to which a debt is referred or sold is not prohibited from reporting this information and may do so. 5. Notification of Extraordinary Collection Actions
a. Prior to commencing Extraordinary Collection Actions against an FAP Eligible Patient, a Self-pay Patient who has not submitted a Financial Assistance Application or a Self-pay Patient who has submitted an incomplete Financial Assistance Application and has failed to provide requested documentation or other information in support of the application within a reasonable time, the Hospital must provide the patient at least thirty (30) days written notification of the Extraordinary Collection Actions the Hospital intends to undertake if the patient does not submit a Financial Assistance Application or pay the amount due within one hundred twenty (120) days of the first Post-Discharge billing statement. The notice must include a copy of the Plain Language Summary of this policy.
b. During all oral communications regarding billing beginning at least thirty (30) days prior to commencing Extraordinary Collection Actions, the Hospital Business Office will notify a FAP Eligible Patient or Self-pay Patient whose eligibility is undetermined of Extraordinary Collection Actions the Hospital intends to undertake.
c. The Hospital is not required to provide a thirty (30) day notice prior to commencing Extraordinary Collection Actions against an individual who:
i. Submits a Financial Assistance Application and is found to be ineligible for financial assistance;
ii. Fails to make payments for medical care other than Emergency Care and Medically Necessary Care; or
iii. Fails to submit a complete Financial Assistance Application by the end of the Application Period or thirty (30) days after a request for additional information or documentation in support of a Financial Assistance Application, whichever is later.
6. In the event the Hospital refers or sells a Self-pay Patient’s debt to a third party prior to the end of the Application Period, the Hospital will obtain a legally binding written agreement which shall include the following provisions:
a. The third party will refrain from engaging in Extraordinary Collection Actions during the one hundred twenty (120) day period which begins on the date the first Post-Discharge billing statement is provided to the patient, unless a complete Financial Application has been submitted and the Hospital has determined that the patient is ineligible for financial assistance under this policy;
b. The third party will suspend extraordinary collection activities if a patient submits a Financial Assistance Application during the Application Period;
c. The third party will refrain from charging interest on the debt in excess of the rate in effect under section 6621(a)(2) at the time the debt is sold (or such other interest rate set by notice or other guidance published in the Internal Revenue Bulletin);
d. The debt is recallable by the Hospital if the Hospital determines the patient is FAP-eligible.
e. If not returned or recalled, the purchaser must ensure that the patient does not pay and has no obligation to pay the Hospital and purchaser together more than he or she is required to pay as an FAP-eligible patient.
f. The third party will reverse any extraordinary collection activities against the patient if the patient’s Application is approved.
g. The third party will require any other party to which it refers or sells the debt to enter into a legally binding written agreement which includes the terms of this Section.
The sale or referral of a debt which complies with this subsection is not an Extraordinary Collection Action. 7. FAP Eligible Individuals receiving partial financial assistance who are unable to pay the full amount of any discounted balance in one payment will be offered a reasonable payment plan. Payment plans for patients receiving partial discounts will be developed with the individual patient on a case-by-case basis. 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.
8. If an Uninsured Patient or an FAP Eligible Individual receiving financial assistance under this policy clearly demonstrates that they have neither sufficient income nor assets to meet their financial obligations, the Hospital will not pursue legal action for non-payment of Hospital bills against the patient provided the patient has submitted all relevant information required to determine financial eligibility and reasonable payment options and has notified the Hospital of any material change that may affect such determinations.
9. The terms of the Hospital’s collections activities 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.
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.
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;
2. A copy of the Financial Assistance and 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.
VI. PUBLICATION OF THE FINANCIAL ASSISTANCE POLICY:
Hospital makes reasonable efforts to notify and inform patients of its financial assistance program and to identify eligible patients. This Financial Assistance and Presumptive Eligibility Policy, a Plain Language Summary of this policy, the Patient Collections Policy, the Financial Assistance Application, 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 financial assistance 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 Language Summary of the policy and copies of the Financial Assistance Application are available in all admission and registration areas. The Hospital’s financial assistance policy, Financial Assistance Application 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 under this policy. The Hospital’s financial counselors attempt to contact all registered, Self-pay Patients during an inpatient Hospital stay to assess financial need. If indicated, interpreters will be used, to allow for meaningful communication with individuals who have limited English proficiency.
C. Prior to discharge, Self-pay Patients receiving inpatient care are offered a plain language summary of the Hospital’s financial assistance policy and a copy of the Financial Assistance Application. All Self-pay Patients in all outpatient departments are offered a plain language summary of the financial assistance policy at an appropriate time between intake, and discharge.
D. With the first Post-Discharge billing statement provided to each Self-pay Patient, the Hospital will include a prominent notification that Self-pay Patients who meet certain income requirements may qualify for financial assistance. The notification will include the telephone number of the Hospital Business Office which can provide the patient with information about the Financial Assistance Application process and the direct web site address (or URL) to access copies of this financial assistance policy, the plain language summary of this policy and the Financial Assistance Application.
E. A written copy of this policy is provided free of charge upon request. Further information regarding the Financial Assistance Application and assistance with the application can be obtained from the SwedishAmerican Health System Business Office. The Business Office can be contacted at 815-391-7380.
Issued and approved by the President and Chief Executive Officer.