Charity Care and Partial Charity Care Discount Policy

Mission

AHMC Healthcare Inc. (“AHMC”) and its affiliated hospitals are committed to excellence in providing quality health care services to our communities with a team of compassionate and dedicated professionals, within a culturally rich and ethically appropriate environment.

In order to better serve the community and further our mission, the AHMC hospitals will accept a wide variety of payment methods and will offer resources to assist patients and responsible parties in resolving any outstanding balance. The hospitals will treat all patients equitably, with dignity, respect and compassion, and, wherever possible, help patients who cannot pay for all or part of their care.

AHMC recognizes that there are unfortunate occasions when a patient is not able to pay for their medical care, and in such situations we at AHMC will adhere to applicable Federal, state, and local law. In this connection, the hospitals have established guidelines pursuant to which patients may apply and, as appropriate, qualify for, charity care or partial charity care (including a discount payment plan).

The scope of this policy and the financial assistance programs herein constitutes the official Financial Assistance Policy for each hospital owned, leased, or operated by AHMC Healthcare, Inc. See list below:

AHMC Anaheim Regional Medical Center
AHMC Doctors Hospital of Riverside
AHMC Garfield Medical Center
AHMC Greater El Monte Community Hospital
AHMC Monterey Park Hospital
AHMC San Gabriel Valley Medical Center
AHMC Seton Medical Center
AHMC Seton Medical Center – Coastside
AHMC Whittier Hospital Medical Center

Purpose

The purpose of this policy is to define the eligibility criteria for charity care and partial charity care assistance and provide administrative guidelines for the identification, evaluation, classification, and documentation of patients’ accounts as charity care or
partial charity care. The AHMC hospitals will ensure that these policies are effectively communicated to those in need, that we assist patients in applying and qualifying for
known programs of financial assistance, and that all policies are accurately and consistently applied. Furthermore, the AHMC hospitals will define the standard and
scope of services to be used by our outside agencies that are collecting on our behalf, and we will obtain this agreement in writing to ensure that our policies are adhered to throughout the entire collection process.

Definitions

Amount Generally Billed (AGB) means the average amount allowed for reimbursement by Medicare, Medi-Cal, and/or other third-party payers, including boththe amount the insurer will pay and the amount (if any) the patient is personally responsible for paying in the form of co-payments, co-insurance, and deductibles. This is usually expressed as a percent of gross charges. Pursuant to state law, in California, AGB applies to all hospitals regardless of ownership status and is based on the amount of payment the hospital would expectto receive for providing services from Medicare or Medi-Cal, whichever is greater.

Application Period means the period during which the facility must accept and process an application for financial assistance submitted by an individual in order to
determine whether the individual is eligible for financial assistance under this policy.

Charity Care means 100% free medical care for services provided by the AHMC hospitals. Patients who are uninsured for the relevant, medically necessary services, who are ineligible for governmental or other insurance coverage, and who have family incomes not in excess of 200% of the Federal poverty level will be eligible to receive
Charity Care.

Debt Collection means any act or practice in connection with the collection of medical debt from a patient, including but not limited to the following:

Any attempt to contact a patient regarding a debt more than 90 days past-due, including, but not limited to the following communication methods: mail, email, text, phone calls, and in-person.

The sale or assignment of a patient’s debt to a third party for collections purposes.

Reporting adverse information about the patient to a consumer reporting agency.

Any civil actions undertaken to collect a medical debt, including but not limited to placing a lien on a patient’s property, attaching, or seizing a patient’s bank account or any other personal property, obtaining an order for examination pursuant to California Code of Civil Procedure Section 708.120, or garnishing a patient’s wages.

Delaying or denying care because a patient has an unpaid medical debt.

Engaging in any other Extraordinary Collection Action not mentioned above.

Discounted Care Discounted Care is a program that offers partial financial assistance to qualifying patients based on financial need, reducing the amount they and their
guarantor owe for eligible medical services. This assistance doesn't affect payments from health insurance or other third-party payers for these services. The amount paid by patients who are eligible for Discounted Care cannot exceed the AGB.

Extraordinary Collection Action (ECA) Per the IRS Extraordinary Collection Actions are actions taken by a hospital facility against an individual related to obtaining
payment of a bill for care covered under the hospital facility’s Financial Assistance Policy (FAP). These actions include, but are not limited to:

Selling an individual’s debt to another party,
Reporting adverse information about an individual to consumer credit reporting agencies or credit bureaus (collectively, “credit agencies”),
Deferring or denying, or requiring a payment before providing, medically necessary care because of an individual’s non-payment of one or more bills for previously provided care covered under the hospital facility’s FAP.
Any actions that require a legal or judicial process

Essential Living Expenses (ELE) means expenses that may include, but are not limited to, the following: rent or house payments and maintenance; food and household supplies; utilities and telephone; clothing; medical and dental payments; insurance; school or childcare costs; child or spousal support; transportation and auto-related expenses (including insurance, gas, and repairs); installment payments; laundry and cleaning; and other extraordinary expenses.

Federal health care program means any health care program operated or financed at least in part by the Federal government.

Federal poverty level means the poverty guidelines are updated periodically in the Federal Register by the United States Department of Health and Human Services under authority of subsection (2) of Section 9902 of the United States Code. Federal Poverty Level for the current year can be obtained from the following website: https://aspe.hhs.gov/poverty

Hospital Bill Complaint Program means the state program which reviews hospital decisions about whether patients qualify for help in paying the Patient’s Responsibility for healthcare services rendered. If a patient believes financial assistance was wrongly denied, then the patient may file a complaint with the Hospital Bill Complaint Program. Go to: https://HospitalBillComplaintProgram.hcai.ca.gov for more information and/or to file a complaint.

Household Income (at the time of first billing) means all income of all family members who live in the same household, defined as the home address the patient uses on income tax returns, or on other government documents. This may include the following: gross wages, salaries, unemployment compensation, workers' compensation, Social Security, Supplemental Security Income, interest, dividends, income from rental properties, estates and trusts, alimony, child support, assistance from outside the household, and other miscellaneous sources.

Limited English Proficiency (LEP) Group pertains to a group of people who either do not speak English, or who are unable to effectively communicate in English because it is not their native language. The size of the group is the lesser of either 1,000 individuals, or five percent (5%) of the community served by the facility, or the non English speaking populations likely to be, affected or encountered, by the facility. The facility may use any reasonable method to determine the number, or percentage, of LEP patients that may be affected, encountered, or are served by the facility.

Medically Necessary refers to inpatient or outpatient health care services provided to evaluate, diagnose, or treat an injury, illness, disease, or its symptoms, where without treatment the patient’s health would be at risk. For individuals 21 years of age or older, a service is medically necessary when it is reasonable and necessary to protect life, prevent significant illness or significant disability, or alleviate severe pain (Welf. & Inst. Code § 14059.5). For individuals under 21 years of age, medically necessary services include those needed to treat, correct, or ameliorate conditions identified by screening services, consistent with the EPSDT standard at 42 U.S.C. §1396d(r)(5). All medically necessary services are eligible for the Discount Payment Program. Hospitals may, but are not required to, provide discount payment for non emergency services provided to patients with high medical costs for out-of-network care not covered by a third-party payer if the patient declines transfer to an in network facility. For purposes of patient complaint investigations, services performed within the hospital are presumed to be medically necessary unless the hospital provides the Department an attestation that the hospital services at issue in the complaint were not medically necessary; an attestation is valid if it is signed by the provider who referred the patient for the hospital services at issue in the complaint or by the supervising health care provider for the hospital services at issue; the hospital must obtain the required attestation before denying a patient’s eligibility for the Discount Payment Program on the basis that the services at issue were not medically necessary.

Medi-Cal Presumptive Eligibility provides qualified individuals immediate access to temporary, no-cost Medi-Cal while applying for permanent Medi-Cal coverage or other health coverage.

Out-Of-Pocket (OOP) expenses or costs means any amounts owed for medical care that are not reimbursed by insurance or a health coverage program, such as Medicare copays or Medi-Cal cost sharing, and are the responsibility of the patient.

Partial Charity Care means care at a discount rate for services provided by the AHMC hospitals. Patients who are uninsured or patients with high medical costs for the
relevant medically necessary services and whose household incomes exceed 200%, but does not exceed 400% of the Federal Poverty Level may be eligible for partial charity care discounts. Eligibility shall be determined based solely on household income and family size in accordance with Federal Poverty Level guidelines. Partial Charity Care in the form of a discount off inpatient and/or outpatient charges. The discounted payment policy shall also include an extended payment plan to allow payment of the discounted price over time (which payment plan shall be interest free).

The hospital shall limit the amount a patient is expected to pay for services, for patients at or below 400 percent of the federal poverty level, (as defined in subdivision (b) of Section 127400) and eligible under the hospital’s discount payment policy to no more than the amount of payment the hospital would expect to receive, in good faith, from Medicare or Medi-Cal, whichever is greater.

Patient’s family means the following:

1. For persons 18 years of age and older, spouse, domestic partner, as defined in Section 297 of the Family Code, and dependent children under 21 years of age, or any age if disabled, consistent with Section 1614(a) of Part A of Title
XVI of the Social Security Act, whether living at home or not.

2. For persons under 18 years of age or for a dependent child 18 to 20 years of age, inclusive, parent, caretaker relatives, and parent’s or caretaker relatives’ other dependent children under 21 years of age, or any age if disabled, consistent with Section 1614(a) of Part A of Title XVI of the Social Security Act.

Patients with high medical costs means a person whose family income does not exceed 400 % of the federal poverty level, as defined in subdivision (b). For these purposes, “high medical costs” means any of the following:

1. Annual out-of-pocket costs incurred by the individual at the hospital that exceed the lesser of 10 percent of the patient’s current family income or family income in the prior 12 months. Out-of-pocket costs means any expenses for medical care that are not reimbursed by insurance or a health coverage program, such as Medicare copays or Medi-Cal cost sharing.

2. Annual out-of-pocket expenses that exceed 10 percent of the patient’s family income, if the patient provides documentation of the patient’s medical expenses paid by the patient or the patient’s family in the prior 12 months. Out of-pocket expenses means any expenses for medical care that are not reimbursed by insurance or a health coverage program, such as Medicare copays or Medi-Cal cost sharing.

3. A lower level determined by the hospital in accordance with the hospital’s charity care policy.

Reasonable Payment Plan means an extended interest free payment plan that is negotiated between the Hospitalm and the patient/guarantor for any OOP amounts owed. The payment plan will take into account the patient's income, essential living expenses, assets, the amount owed, and any prior payments. Monthly payments will not be greater than ten (10) percent of a patient’s Family Income for a month, excluding deductions for essential living expenses. Essential living expenses include any of the following: rent or house payment and maintenance, food and household supplies, utilities and telephone, clothing, medical and dental payments, insurance, school or child care, child or spousal support, transportation and auto expenses, including insurance, gas, and repairs, installment payments, laundry and cleaning, and other extraordinary expenses.

Self-Pay Discount means a discount provided to patients who do not qualify for a Charity Care Full Discount, a Charity Care Partial Discount, or a High Medical Cost Discount and who do not have a third-party insurance carrier or whose insurance does not cover the service provided or who have exhausted their benefits.

Self-pay patient means an individual who does not have any third-party health care coverage from either: (a) a third party insurer, (b) a Federal health care program, (including without limitation Medicare, Medi-Cal, California Children’s Services program, Healthy Families Program and TRICARE), (c) workers’ compensation, (d) medical saving accounts, or (e) other coverage, for all or any part of the bill, including claims against third parties covered by insurance to which the AHMC hospitals are subrogated, but only if payment is actually made under such insurance.

Underinsured Patient means a patient who has some amount of insurance or health coverage but still has out-of-pocket expenses that exceed their ability to pay.

Uninsured Patient means a patient with no level of health coverage or insurance to help pay their medical bills.

Policy

The AHMC hospitals are committed to treating uninsured patients and patients with high medical costs who have financial needs with the same dignity and consideration that is extended to all of its patients. The AHMC hospitals consider each patient’s ability to pay for his or her medical care and, as appropriate, extend Charity Care or Partial Charity Care to eligible patients. This policy is intended to implement and fully comply with applicable Federal, state, and local laws (including without limitation California Health and Safety Code Section 127400 et seq.) and any regulations promulgated thereunder (collectively, “Applicable Law”), and shall be construed in such manner as to do so. In the event of any inconsistency between the provisions of this policy and mandatory provisions of Applicable Law, the provisions of Applicable Law shall apply. Where provisions of this policy are different from those mandated by Applicable Law, but are nonetheless permitted by Applicable Law, the provisions of this policy shall control.

Responsibilities of AHMC Hospital to Communicate with Patients

Each AHMC hospital will have a means of communicating the availability of Charity Care and Partial Charity Care to all patients.

Patients will be provided with a statement that if the patient does not have health insurance coverage the patient may be eligible for Medicare, Medi-Cal, Healthy Families Program, coverage offered through the California Health Benefit Exchange (Covered California), California Children’s Services program, other governmental programs, or charity care, and that these applications will be provided to admitted patients prior to discharge or to patients receiving emergency or outpatient care at the time of service. The hospital shall also provide patients with a referral to a local consumer assistance center housed at legal services offices.

If a patient lacks or has inadequate insurance, and meets certain low-and moderate income requirements, the patient will be informed that the patient may qualify for Charity Care or Partial Charity Care. Patients will also be provided with the name and telephone number of a hospital employee or office from whom or which the patient may obtain information about the hospital’s Charity Care and Partial Charity Care policies, and how to apply for that assistance.

Applications

Patients may apply (or reapply) for financial assistance at any time in the collection process including, but not limited to, after collection agency placement. If a patient applies, or has a pending application, for another health care coverage at the same time the patient applies under the hospital’s charity care policies, neither application shall preclude eligibility for the other program.

For purposes of determining eligibility for Charity Care, documentation of assets may include information on all monetary assets, but shall not include statements on retirement or deferred compensation plans qualified under the Internal Revenue Code, or nonqualified deferred compensation plans. The hospitals can require a waiver or release form from the patient or patient’s family authorizing the hospitals to obtain account information from financial or commercial institutions, or other entities that hold or maintain the monetary assets, to verify their value. For purposes of determining eligibility for Partial Charity Care (discounted payment), documentation of income shall be limited to recent pay stubs or income tax returns. Information received from patients in connection with the application for Charity Care or Partial Charity Care (discounted payment) may not be used for collection activities; however, this does not prohibit the use of information obtained by the hospital or its collection agencies independently of the application process for Charity Care or Partial Charity Care (discounted payment).

AHMC staff in the Central Business Office, patient registration, and emergency departments will understand the charity care policy and will be able to direct questions regarding the policy to the proper hospital representative. The hospital staff that regularly interact with patients will also be familiar with the charity care policy, and if necessary, will be able to direct questions regarding the policy to knowledgeable hospital representatives or departments.

The hospital Financial Counselor or MEP will attempt to identify potential charity care patients at admission or while the patients are in-house.

Financial Counselor/MEP Procedure

The FC/MEP Patient Advocate must screen patients for potential linkage to government/county programs. During the screening for eligibility process, the Advocate should secure the application. The application is used to determine eligibility for Charity Care and Partial Charity Care.

Patient Qualification & Eligibility

The criteria for eligibility is based upon a patient’s individual or family income as compared to AHMC scheduled discount based on the current year’s Department of Health and Human Services Federal poverty guidelines. This guideline is reviewed annually, subject to changes in the consumer price index, and is published each year. A financially qualified patient who has family income at or below 200% of the Federal poverty level will be eligible for a 100% (free) discount, with a sliding scale discount for financially qualified patients with an individual or family income from 201% to 500% of the Federal poverty level.

In determining eligibility under the charity care policy, AHMC hospitals shall consider a patient’s income and family size, consistent with the application of the federal poverty level guidelines. AHMC hospitals shall not consider a patient’s monetary assets for the purpose of determining eligibility.

Definition of Income

For the purpose of determining income, all sources of income will be included in the calculation of financial need, including employment income and any unearned income. Self-employment income shall be the individual’s net earnings as reported on the individual’s most recent federal income tax return. For purposes of determining eligibility for discounted payment, documentation of income shall be limited to recent pay stubs or income tax returns.

Some examples of income.
Income includes money wages and salaries before any deductions; gross receipts from non-farm self-employment (including business, professional enterprise, and partnership, before deductions), gross receipts from farm self-employment (receipts from a farm which one operates as an owner, renter, or sharecropper, before deductions for farm operating expenses, excluding non-cash expenses); regular payments from Social Security, railroad retirement, unemployment compensation, strike benefits from union funds, worker’s compensation, automobile insurance, veteran’s payments, public assistance, (including Temporary Assistance for Needy Families, supplemental security income, emergency assistance money payments, and non-federally funded general assistance, or general relief money payments, and training stipends; alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household; private pensions, government, employee pensions (including military retirement pay), and regular insurance or annuity payment; college or university scholarships, grants, fellowships, and
assistantships; and dividend, interest, net rental income, net royalties, and net gambling or lottery winnings.

Some examples of what would not be included as income.
Capital gains, any assets drawn down as withdrawal from a bank, the sale of primary residence, tax refunds, gifts, loans, lump-sum inheritance, and one-time insurance payments. Also excluded are non-cash benefits, such as the employer-paid or union paid portion of medical insurance or other employee fringe benefits, food or housing received in lieu of wages, the value of food and fuel produced and consumed on farms, the imputed value of rent from owner-occupied, non-farm or farm housing, and such Federal non-cash benefits programs as Medicare, Medi-Cal, Supplemental Nutrition Assistance Program (food stamps), school lunches, and housing assistance.

VERIFICATION OF INCOME

For purposes of determining eligibility, patients are responsible to make every reasonable effort to provide information that is reasonable and necessary for the hospital to make a determination. Information required for eligibility determination may include, but is not limited to, the following:

AHMC requests patients to attest to the patient’s family income set forth in the patient’s application. In determining a patient’s total income, AHMC may consider other financial assets and liabilities of the patient, as well as patients’ family income, when assessing the ability to pay. If a determination is made that the patient has the ability to pay the patient’s bill, such determination does not preclude a reassessment of the patient’s ability to pay upon presentation of additional documentation (e.g., regarding essential living expenses). 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. An income statement is recommended for all self-employed persons. In the absence of income, a letter of support and/or declaration of no income can be accepted from the patient and/or responsible party with the letter detailing how the patient’s current living needs are being met. Other examples of income documentation:

W-2 FORM OR PAY STUBS
SELF EMPLOYED SCHEDULE C FORMS
MEDICAL ASSISTANCE ELIGIBILITY/DENIAL NOTICE, IF APPLICABLE
SOCIAL SECURITY CHECK STUBS
BANK STATEMENTS, CHECKING AND SAVINGS
WORKERS’ COMPENSATION CHECK STUBS
UNEMPLOYMENT CHECK STUBS
PROOF OF DEPENDENCY MAY BE REQUIRED IN ORDER TO CLAIM A DEPENDENT CHILD
OTHER REASONABLE INFORMATION THAT THE AHMC HOSPITALS MAY DEEM RELEVANT IN ASSISTING THEM IN MAKING THE MOST APPROPRIATE CHARITY CARE DETERMINATION

Failure to provide reasonable and necessary requested information will be grounds for denial of charity care. Income may be verified using information for either the previous 12 months or that is annualized based on partial year information. In addition to historical information, future earnings capacity, along with the ability to meet a patient’s obligations within a reasonable time, may be considered in connection with a patient’s application. Providing false information or excluding requested information may result in denial of application and eligibility. This financial information is considered confidential and is protected to ensure that such information will only be used to assist in enrollment or evaluating eligibility for financial assistance. Furthermore, this information may not be used for collection activities; however, this does not prohibit the use of information obtained by AHMC, the AHMC hospitals or their collection agencies independently of the application process for charity care.

GENERAL APPLICATION GUIDELINES

An application, whenever possible, should be submitted and approved before services are provided; however, no application will be required, or financial consideration taken into account, for emergency medical treatment or services that are provided without advance notification from a physician or other referral source. Applications should be completed as soon as possible keeping in mind the patient’s medical needs as the primary focus. Applications to cover emergency treatment will be made after the services are provided.

It is crucial that charity care applicants cooperate with AHMC’s and the AHMC hospitals’ need for accurate and detailed information within a reasonable time frame. If information is not legible, or is incomplete, applications may be denied or returned to applicants for revision or supplemental information, subject to management’s discretion.

Upon approval for charity care, the patient’s application and supporting documentation may be used for re-evaluation for future services, along with other updated pertinent supplemental information, for up to six months. Exceptions may be granted during this six-month period based on management’s discretion, taking into consideration any change in circumstances from the time of the initial approval.

RESTRICTIONS ON COLLECTION ACTIVITIES BY AHMC AND THE AHMC HOSPITALS

AHMC and the AHMC hospitals shall not use wage garnishments or liens on any real property as a means of collecting unpaid hospital bills in dealing with patients eligible under the hospital’s charity care or discount payment.

AHMC and the AHMC hospitals will not pursue collection action against a qualified charity care patient who has clearly demonstrated that he or she does not have sufficient income or assets to meet any part of his or her financial obligation.

AHMC and the AHMC hospitals will not use a forced court appearance to require a qualified charity care patient or responsible party to appear in court.

AHMC will not garnish wages for the financially qualified charity care patient.

Once charity care status is determined, it will be applied retroactively to all qualifying accounts.

For an uninsured patient or for a patient who may be a patient with high medical costs, AHMC and the AHMC hospitals shall not report adverse information to a consumer credit reporting agency and shall not commence civil action against the patient for nonpayment before 180 days after initial billing.

If an uninsured patient has requested charity assistance and/or applied for other coverage and is cooperating with the hospitals, the hospitals will not pursue collection action until a decision has been made that there is no longer a reasonable basis to believe the patient may qualify for coverage.

ADDITIONAL RESPONSIBILITIES FOR PATIENTS WHO HAVE RECEIVED PARTIAL DISCOUNTED CHARITY CARE

When a patient has been approved under the charity care policy for partial discount, the AHMC hospitals will work with the patient or the responsible party to establish a reasonable payment option, taking into consideration the patient’s family income and essential living expenses. If the hospital and the patient cannot agree on the payment plan, the hospital shall offer a reasonable payment plan, meaning monthly payments that are not more than 10% of the patient’s monthly family income, excluding deductions for essential living expenses. For purposes of creating a reasonable payment plan, “essential living expenses” means expenses for any of the following: rent or house payment and maintenance, food and household supplies, utilities and
telephone, clothing, medical and dental payments, insurance, school or child care, child or spousal support, transportation and auto expenses, including insurance, gas, and repairs, installment payments, laundry and cleaning, and other extraordinary expenses.

If a patient complies with a payment plan that has been agreed upon by the AHMC hospital, the AHMC CBO will not pursue collection action.

An extended payment plan may be declared no longer operative after the patient’s failure to make all consecutive payments during a 90-day period. Before declaring an extended payment plan no longer operative, the hospital shall: (1) make a reasonable attempt to contact the patient by phone and to give notice in writing that the extended payment plan may become inoperative, and of the opportunity to renegotiate the extended payment plan; and (2) if requested by the patient, attempt to renegotiate the terms of the defaulted extended payment plan. The hospital, or its collection agency, shall not report adverse information to a consumer credit reporting agency or commence a civil action against the patient or responsible party for nonpayment prior to the time the extended payment plan is declared to be no longer operative. The telephone call and notice provided for above may be made to the last known telephone number and address of the patient.

COLLECTION POLICY

Accounts will not be sent to a collection agency if the patient is attempting in good faith to settle the account by negotiating a payment plan or is making regular partial payments. Any extended payment plans negotiated with a qualified patient under the discounted fee arrangement must be provided without interest so long as the patient does not default on their payment arrangement.

Any extended payment plans negotiated with a qualified patient under the discounted fee arrangement shall be provided without interest, penalties, or fees. The patient’s financial responsibility shall not exceed the discounted amount previously determined.

If a patient is appealing a denial of insurance coverage or payment and is making a reasonable effort to keep the AHMC hospital informed of the patient's appeal status, the account shall not be reported to a consumer credit reporting agency until a final determination is made on the appeal. In any event, for an uninsured patient or for a patient who may be a patient with high medical costs, AHMC and the AHMC hospitals shall not report adverse information to a consumer credit reporting agency and shall not commence civil action against the patient for nonpayment before 180 days after the date of the initial billing.

Accounts may be sent only to collection agencies that have been provided with, and have agreed in writing to abide by, the hospital’s standards and scope of practices for the collection of debt.

APPLICATION PROCESS

A completed AHMC Charity Care application (see attached Exhibit) will be processed by the hospital’s admitting department, MEP worker, Financial Counselor or CBO staff in accordance with the Revenue Cycle/Patient Financial Services policy. When the AHMC Charity Care application is received, the front line staff will review and determine whether the application is complete and whether the documentation supports eligibility for Charity Care or Partial Charity Care.

The MEP/FC worker is responsible to verify that all figures used to calculate eligibility are correct, and if needed, they have authority to seek additional verification before submitting the application for approval. The CFO will evaluate the recommendations, verify calculations and documentation and either approve, deny, or forward the application to the appropriate person (DPS) for further consideration as may be necessary.

Patients who are provided Partial Charity Care in the form of a discount must sign a written agreement to pay the amount of the hospital bill remaining after deducting the discount. The patient will receive a bill showing charges, the amount of the discount and the amount due. Professional services provided by physicians and other services provided by outside vendors are not covered by this policy. Patients seeking a discount for such services should contact the physician or outside vendor directly.

Patients should also be informed that emergency physicians who provide emergency medical services in the hospital are required by law to provide discounts to uninsured patients or patients with high medical costs who are at or below 400% of the Federal poverty level. This statement shall not be construed to impose any additional responsibilities upon the hospitals.

Patients who do not provide the requested information necessary for the hospital to completely and accurately assess their financial situation in a timely manner and/or who do not cooperate with efforts to secure governmental health care coverage will not be eligible for Charity Care or Partial Charity Care.

This policy is available in English, Spanish, and Chinese. The written notices of Charity Care and Partial Charity Care will be posted in the Emergency Room, Central Business Office, Outpatient Services, and Admitting Department where patients are presented for services.

To obtain more information on how to apply for Charity Care or Partial Charity Care, patients should contact a hospital MEP worker for assistance.

Widely Publicizing Financial Assistance

We will share information about financial assistance in our community as required by California law and federal rules. This will include, but not be limited to: (CA H&SC 127400)

1. Website posting. We will post the full, current policy on our website, along with translations for patients with limited English proficiency, the plain language summary, and the financial assistance application. These materials will be easy to find and free to access, as required by federal and California law.

2. Notice to patients. All patients who receive services will get a written notice about this Financial Assistance Policy. The notice explains who may qualify, how to apply, other payment programs, and how to get help. It includes contact information for our financial assistance office:

Anaheim Regional Medical Center
714-774-1450
Email: pfs.ana@ahmchealth.com

Doctors Hospital of Riverside
951-688-2211
Email: pfs.dhr@ahmchealth.com

Garfield Medical Center
626-573-2222
Email: pfs.gmc@ahmchealth.com

Greater El Monte Community Hospital
626-579-7777
Email: pfs.gem@ahmchealth.com

Monterey Park Hospital
626-570-9000
Email: pfs.mp@ahmchealth.com

San Gabriel Valley Medical Center
626-289-5454
Email: pfs.sgv@ahmchealth.com

Seton Medical Center
650-992-4000
Email: pfs.set@ahmchealth.com

Seton Medical Center - Coastside
650-563-7100
Email: pfs.sec@ahmchealth.com

Whittier Hospital Medical Center
562-945-3561
Email: pfs.wht@ahmchealth.com

For emergency department visits, we will give you a paper copy at the time of service or before discharge, as required by California law. Patients who receive emergency or outpatient care and are not admitted will also receive the notice. The notice and any other letters we send will be in the language you speak, as required by state and federal law. Free copies are available on request, and we can mail them to you at no charge. (CA H&SC 127410)

3. Notices in key locations. We post clear notices in the emergency department, admissions or registration areas, and the billing office that explain our Financial Assistance Policy, who may qualify, and how to get help, an application, or a copy of the policy. Free paper copies of the plain language summary, the application, and the full policy are available on request, and we can mail them to you at no cost. Materials are available in English and in other languages for patients with limited English proficiency. During intake or discharge, we will offer you a paper copy of the plain language summary.(Treas. Reg.§1.501(r)4(b)(5)(i)(D))

4. Help Paying Your Bill webpage. We will keep a webpage titled “Help Paying Your Bill.” It will include, at a minimum but not be limited to:

a. Who may qualify for free care or a discount.
b. How to apply.
c. Links to this policy, the plain language summary, and the application.
d. How to reach the office for more information, including phone, email, location, and hours.
e. Information about the State of California’s Hospital Bill Complaint Program.

5. Finding the page. A link called “Help Paying Your Bill” will be easy to find on our website and will appear:

Hospital website’s footer.
On any webpage where the patient may find information about paying a bill.
In the hospital website’s header or within one click on the hospital’s drop down menu from the hospital website’s header.

6. Notices in public areas. We will place clear signs in public areas of the hospital, at least in the emergency department and in admissions or registration areas. The signs will tell patients that financial assistance is available and where to get:

More information about this policy and how to apply.
Free copies of this policy and translations for patients with limited English proficiency.
The financial assistance application and translations for patients with limited English proficiency.
The plain language summary of this policy and translations for patients with limited English proficiency.

7. Billing statements. Every bill will include a clear notice that financial assistance is available. The notice will list the phone number for our financial assistance office and the direct web address https://ahmchealth.patientsimple.com/guest/#/articles/index?sid=FinancialAssistance_Help-With-Your-Medical-Bills where you can get this policy, the application, and the plain language summary.

8. Community notice. We will share information about financial assistance with the community we serve in ways that are likely to reach people who need it most. The notice will explain that help is available and how to get:

More information about this policy.
Help with the application process.
Free copies of this policy, the application, and the plain language summary.
We may share this information through community groups, events, clinics, social service agencies, and social media, etc.

9. Translations. We will provide free translations of this policy, the application, and the plain language summary in the main languages in our community. We will translate into any language spoken by at least five percent of the community we serve or one thousand people, whichever is smaller, and for groups we are likely to serve. We will also provide qualified interpreters at no cost for any conversations about financial assistance.

External Providers. Some care at our hospitals is provided by doctors and other health care professionals who are not employed by or affiliated with the given facility. They bill for their own services, and their bills are not covered by this financial assistance policy. If you are approved for help under our policy, you may share your approval letter with their billing office in case they offer their own financial assistance. This policy covers care provided at our hospital's facilities and including all locations that fall under hospital’s licenses.

1. If you are determined to be eligible for free care under this policy, you will not be billed by these external vendors. Patients for whom an eligibility determination is pending may receive bills from these healthcare providers.

2. We contract with and allow some outside doctors to treat patients at our hospital. These doctors must follow this policy. They agree to honor our financial assistance decisions for their professional charges for care given at our hospital. This is a condition of getting and keeping permission to treat patients here.

a. To support fair access to care and our mission to serve patients regardless of ability to pay, all credentialed medical staff agree to honor our Financial Assistance Program (FAP) decisions for care provided at our hospital. This is a condition of getting and keeping privileges. Aligning their bills with our decisions helps reduce harms from medical debt, including missed follow up care, trouble paying for prescriptions, housing instability, and food insecurity.

3. Emergency physicians. Under California law, emergency physicians who provide care in our hospital must follow this policy and offer free care or discounted care to eligible patients. This includes uninsured patients and patients with high medical costs whose household income is at or below 400 percent of the federal poverty level, as set out in California Codes. (CA H&SC 127450(a) and (b))

REVENUE CLASSIFICATION

It will be the responsibility of the Business Office to maintain the integrity of account classification on the hospital’s patient accounting system. Prior to month-end close, MEP is responsible for providing a detailed report listing critical changes in account class between self-pay and charity care for any AR account assigned in-system (CPSI).

The Business Office is required to use those reports to update the changes in the patient accounting system prior to the month-end.

Critical changes in account class are defined as:

1. Any account originally assigned to MEP as self-pay that is re-classed as a result of meeting the criteria for Charity Care or Partial Charity Care (a patient with high medical costs) patients.

2. Any account originally assigned to the CBO as Charity Care or Partial Charity Care that is re-classed to self-pay as a result of denying charity care.

MAXIMUM OUT-OF-POCKET

As outlined in the hospital’s charity care guidelines, a maximum out-of-pocket payment will be applied to all patients whose income falls within the hospital’s guidelines.

Patient or family out-of-pocket medical expenses will not exceed 10% of the patient’s family income (excluding deductions for essential living expenses) within a 12-month period, if the patient’s family income is less than 400% of the Federal poverty level.

DENIED CHARITY CARE RECOMMENDATIONS

In the event the CFO denies a patient’s application for charity care, documentation is to be placed in the hospital’s collection system explaining the reasons for the rejection of the application. The CFO is also to indicate on the Confidential Financial Application the reason for denial and the date of the denial. The packet is then to be forwarded to DFS for review. After an initial review and discussion with the CFO, for those patient accounts where disagreement still prevails, and the accounts that meet AHMC guidelines for Charity Care as set forth here, a denial summary will be sent to the respective AHMC Corporate Vice President of Finance for resolution. For those patient accounts that the CFO of the facility has denied that have met the AHMC charity care guidelines as set forth here, a denial summary will be sent to the respective VP, Corporate Office.

AHMC Health Care Inc.
500 E Main Street
Alhambra, CA 91801
Attention: Director of CBO

In the event that a patient disputes an eligibility determination, the patient may seek review from the CFO or other designated hospital representative.

HELP PAYING YOUR BILL

There are free consumer advocacy organizations that will help you understand the billing and payment process and can help you apply for assistance or help appeal or reapply if your application is denied. You may call the Health Consumer Alliance at 888-804-3536 or go to healthconsumer.org/ for more information.

HOSPITAL BILL COMPLAINT PROGRAM

The Hospital Bill Complaint Program is a State of California program. 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.

If you do not qualify for financial assistance and do not set up a payment plan, we may start our collection process as allowed by law.

THIRD PARTY PAYER LANGUAGE

Charity care will be granted on an “all, partial, or nothing” basis. There is a category of patients who qualify for Medi-Cal, but who do not receive payment for their entire stay. Under the charity care policy, these patients are eligible for charity care write offs. These write-offs do not include Share of Cost (SOC) amounts that the patient must pay before the patient is eligible for Medi-Cal. In addition, the hospital specifically includes as charity care the charges related to denied stays, denied days of care, and non-covered services. These Treatment Authorization Request (TAR) denials and any lack of payment for non-covered services provided to Medi-Cal patients are to be classified as charity care. These patients are receiving the service, and they do not have the ability to pay for it. In addition, Medicare patients who have Medi-Cal coverage for their co-insurance/deductibles, for which Medi-Cal does not make payment, and for which Medicare does not ultimately provide bad debt reimbursement, will also be included as charity care. These patients are receiving a service for which a portion of the resulting bill is not being reimbursed.

EMERGENCY PHYSICIANS

Emergency physicians who provide emergency medical services in a hospital that provides emergency care are also required by law to provide discounts to uninsured patients or patients with high medical costs who are at or below 400% of the Federal poverty level. This statement shall not be construed to impose any additional responsibilities upon the AHMC hospitals.

CUSTODIAN OF RECORDS

FC will serve as the custodian of records for all charity care documentation for all accounts identified by CBO, MEP, and DPS.

APPROVAL PROCESS:

Charity Care assistance must be approved by the hospital’s CEO/CFO
2025 Federal Poverty Guidelines
UP to 500% FPL = Discount to Medicare DRG RATE
Up to 200% FPL = 100% Charity Write Off

As of January, 2026 FPL amounts were as follows. These amounts are subject to change.

SELF-PAY PATIENT DISCOUNTS ELIGIBILITY REQUIREMENTS:

1. A patient who does NOT qualify for charity care under the charity care program and who does not have insurance or who has inadequate insurance coverage and are considered “Self-Pay” will be eligible for a prompt payment discount.

2. A patient who qualifies for a prompt payment discount must make a full deposit of estimated charges at the time of or prior to receiving services in order to qualify for the prompt payment discount.

3. If a patient makes other payment arrangements, the patient will be billed for the remainder of the patient’s balance due and the balance must be paid in full within 30 days of receipt of the bill. If payment is not received with 30 days, the prompt payment discount will be rescinded and the full billed charges will be due and payable upon receipt of the bill.

4. Cosmetic procedures are excluded from the prompt payment discount program.

5. Discount payments require full payment at the time of service or within 30 days after discharge or the date of service unless other arrangements have been made.

SELF–PAY DISCOUNT:

1. 40% OFF charges for payment received under the self-pay discount’s requirement -- see above.

2. AHMC considers APC calculation at 130%

Exhibit – Confidential Financial Application

AHMC Confidential Medical and Financial Assistance Application

SECTION A

MEDICAL ASSISTANCE SCREENING - Please check the answer "Y" for yes to "N" for no.

SECTION B

In order to determine qualifications for any discounts or assistance programs the following information is necessary.

SECTION C

HOMELESS AFFIDAVIT

I, hereby certify that I am homeless, have no permanent address, no job, savings, or assets, and no income other than potential donations from others.

______________ Patient/Guarantor Initials

ATTESTATION OF TRUTH

I hereby acknowledge that all of the information provided herein is true and correct. I understand that providing false information will result in the denial of this Application.

Additionally, depending upon applicable law, providing false information to defraud a hospital for obtaining goods or services may be considered an unlawful act. I also consent to the hospital obtaining such credit reports and/or taking such other measures as may be necessary to verify information provided herein. I fully understand that the AHMC Charity Care program(s) is a “Payor of Last Resort” program and hereby confirm all prior assignments of benefits and rights, which may include liability actions, personal injury claims, settlements, and any and all insurance benefits which may become payable, for illness or injury, provided to AHMC or its subsidiaries which have provided care.

PATIENT/GUARANTOR SIGNATURE_________________________________

DATE_______________________

SECTION D

FINANCIAL ASSISTANCE SCREENING

Total Number of Dependent Family Members in Household __
(Include patient, patient’s spouse or domestic partner, and any children the patient has under the age of 21 living in the home. If the patient is a minor, include mother/father and/or legal guardian, and all other children under the age of 21 living in the home.)

Estimated Gross Annual Household Income $________

Calculate Income to FPG Ratio: $________

Gross Annual Income ÷ FPG Based on Family Size: _____%

Type of Service Check One: ER ☐ OP ☐ IP ☐ MULTI ☐

Total Co-pay Amount Due: $________