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Financial Assistance

FINANCIAL ASSISTANCE POLICY

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Section 1. PURPOSE

Baxter Health Fulton County Hospital (BHFCH) is a not-for-profit healthcare delivery system that recognizes its obligation to provide financial assistance to patients in need. BHFCH is committed to using its resources to aid the communities and patients it serves to preserve human dignity and worth as well as general quality of life. At the same time, however, BHFCH strives to provide the highest quality care possible, which requires it to use its financial resources wisely to ensure a strong financial position that will allow for the replacement of buildings and equipment, adequate reserves for emergencies, and the potential for future technological developments and medical services.  This Policy applies specifically to emergency or other medically necessary care provided by BHFCH or its substantially related entities. Due to the COVID-19 public health emergency, BHFCH has updated this Policy for 2024 to include a broader range of income levels that qualify for financial assistance. BHFCH will review the Policy in one year to assess the qualifying income levels.

Section 2. NON-DISCRIMINATION STATEMENT AND TRANSLATION SERVICES

Baxter Health Fulton County Hospital complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Baxter Health Fulton County Hospital does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Baxter Health Fulton County Hospital provides (1) free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats, and (2) free language services to people whose primary language is not English, such as qualified interpreters and written information in other languages. If you need these services, call 1-866-720-2122.

If you believe that Baxter Health Fulton County Hospital has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with either:

 

Baxter Health Fulton County Hospital

Civil Rights Coordinator

679 N Main St

Salem, AR 72576

(870) 895-2691

Fax:  870-895-3287

Email: chaley@fultoncountyhospital.org

 

U.S. Department of Health and Human Services

U.S. Department of Health and Human Services

200 Independence Ave., SW

Room 509F, HHH Building

Washington, D.C. 20201

Phone: 1-800-368-1019, 1-800-537-7697 (TDD)

Web: https://ocrportal.hhs.gov/ocr/portal/ lobby.jsf

 

If you need help filing a grievance, the Civil Rights Coordinator is available to help you. For U.S. Department of Health and Human Services complaints, complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.


TRANSLATION SERVICES

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-720-2122.


CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-1-866-720-2122.

LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1-866-720-2122.

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-866-720-2122。

PAUNAWA:   Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-866-720-2122.

ACHTUNG:         Wenn     Sie     Deutsch    sprechen,     stehen     Ihnen    kostenlos    sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-866-720-2122.


ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-866-720-2122


LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-866-720-2122.

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-866-720-2122. 번으로 전화해 주십시오.

ATENÇÃO:     Se fala português, encontram-se disponíveis serviços linguísticos, grátis.  Ligue para 1-866-720-2122.

注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-866-720-2122まで、お電話にてご連絡ください。


1-866-720-2122ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

Section 3. Definitions

The following terms are used in this policy as defined below: Amounts Generally Billed (AGB) - the sum of all "allowed" claims for all medical care, as paid by Medicare fee-for-service and all private insurers, during the prior 12-month period and divided by the sum of the associated gross charges for all medical care claims.

  1. Household Income - the income for all working members of the household as attested either in a federal income tax return or an earnings statement from the patient's employer.
  2. Presumptive eligibility - program under which a person is presumed to be eligible for financial assistance based on evidence of need.
  3. Qualified Financial Assistance Recipient (QFAR) - A person who meets the eligibility requirements of Section 3.3 of this policy, completes the application process for financial assistance, and is determined by BHFCH to be qualified for financial assistance under this policy.
  4. Substantially Related Entity - an entity that is treated as a partnership for federal tax purposes in which a hospital organization owns a capital or profits interest (or a disregarded entity of which the hospital organization is the sole owner or member) and that provides, in a hospital facility operated by the hospital organization, emergency or other medically necessary care that is not an unrelated trade or business with respect to the hospital organization.

Section 4. ELIGIBILITY FOR FINANCIAL ASSISTANCE

Section 4.1. General Eligibility Considerations

In furtherance of this purpose, the Board of Directors of Baxter Health Fulton County Hospital has resolved and is committed to providing financial assistance to patients who are eligible for such assistance according to this Policy and its underlying federal regulations. Patients may be eligible for such assistance if all of the following circumstances exist:

  1. The patient needs emergency or other medically necessary care, as identified by a licensed physician or other healthcare provider.
  2. BHFCH has been chosen to provide the patient's care, by the patient or an appropriate decision-maker for medical issues.
  3. The individual is financially unable to pay for the needed care.

Despite these criteria, BHFCH conforms in all cases to applicable requirements of the Emergency Medical Treatment and Active Labor Act ("EMTALA") and provides emergency medical care and medically necessary care without regard to the patient's ability to pay.


Section 4.2.     Services Generally Eligible for Financial Assistance

Patients seeking financial assistance must satisfy three conditions:

  1. The patient is determined to be eligible for financial assistance according to the Eligibility Criteria in Section 4.3 below,
  2. The patient successfully completes the application process described in Section 3 below, and
  3. BHFCH determines that the patient is a Qualified Financial Assistance Recipient.

A patient satisfying these three conditions is known as a Qualified Financial Assistance Recipient. A Qualified Financial Assistance Recipient ("QFAR") may receive financial assistance in the form of a reduction in cost of care between 50-100%.

QFARs will not be charged for emergency or other medical care at rates higher than the amounts generally billed to third parties or patients with health insurance, nor will BHFCH bill a QFAR's covered services as "gross charges," meaningful amounts. BHFCH uses the "look- back" method to determine AGB by taking the full amount of all medical care allowed during the prior 12-month period and dividing by the sum of the associated gross charges for all medical claims. Amounts generally billed and discount percentages are reviewed annually, and appropriate adjustments are effective upon the approval of an updated version of this Financial Assistance Policy.

AGB% = Sum of Claims Allowed Amount $ / Sum of Gross Charges $ for those claims

AGB for 2024 = 33 %

Section 4.3.      Criteria for Financial Assistance Eligibility

Patients may be eligible for financial assistance under this Policy based on their family income. Patients are eligible for financial assistance if they meet these criteria, without regard to who is the actual payer of that patient's bill. BHFCH has established levels of eligible financial assistance based on applicants' family income and the national poverty guidelines, as well as other criteria. If the patient-applicant satisfies those criteria and the patient's family income is within a certain range, that patient will be eligible to receive that type of financial assistance.

Each request for financial assistance will be evaluated on its own merit using the income and other criteria in this Section.

In order to establish family income, the patient must provide acceptable income verification. Acceptable sources of income verification include:

  1. The most recent federal income tax return applicable to the patient, if the patient applies for financial assistance before March 31 (the first quarter) of the same year,
  2. The most recent federal income tax return applicable to the patient, plus an employer's verification of earnings for the current year, if the application is filed after March 31 (the first quarter) of the year, or
  3. For self-employed individuals, the most recent federal income tax return and copies of all current quarterly returns.

If the applicant does not have documentation proving household income, he or she may call the financial assistance office and discuss other evidence that may be provided to demonstrate eligibility

BHFCH will also need, if applicable, the patient's last two months of bank statements and their two most recent pay stubs. Patients will also need to apply for Medicaid in order to qualify for financial assistance. If BHFCH needs more information from an applicant, other eligibility criteria may also include (1) assets and liabilities, (2) most current property tax assessment, (3) the patient's medical condition, (4) the potential need for long-term medical care, (5) the availability of other forms of reimbursement, including insurance, social programs, or other financial resources, and (6) the suitability of the facility for the patient's particular needs and the availability of a more appropriate facility that would offer payment for care. BHFCH will also take into account any out-of-pocket medical expenses you have paid over the past 12 months, as demonstrated by statements or documentation from your physician, pharmacy, or other provider. If a patient cannot provide any of the required information, they should contact Patient Financial Services to discuss what other information they may provide to apply.

If a patient (1) states that he or she is homeless at the time care is needed or (2) is physically or mentally incapacitated and has no one to act on his or her behalf, and if BHFCH does not find any evidence to the contrary through its own diligence, that patient will be considered a Qualified Financial Assistance Recipient and will not be required to complete the application for such financial assistance.  Patients with those circumstances will be eligible for care without cost to the patient.

Under extraordinary circumstances, BHFCH's Financial Assistance Committee may consider an applicant for financial assistance even if that individual does not otherwise qualify for financial assistance under this policy. Such discounts will be capped for self- pay individuals as determined by the Financial Assistance Committee.

Section 4.4.  Presumptive Eligibility for Financial Assistance

In some situations, BHFCH may consider a patient presumptively eligible for financial assistance. A patient may be presumptively eligible if BHFCH has received information from an appropriate third party, such as a means tested public program, that leads BHFCH to believe the patient is eligible, or if the patient has qualified for financial assistance under this Policy in the past.

If a patient is presumptively eligible, BHFCH will notify that patient in writing of his or her presumptive eligibility, including the reason why BHFCH considers the patient presumptively eligible and how the patient can apply for financial assistance under a more generous financial assistance program (such as this Policy). BHFCH will also provide the patient with a reasonable time to apply for financial assistance, and if the patient completes the application within that time period, BHFCH will determine whether the patient is a QFAR.

Additionally, if an individual has applied for and received financial assistance within the previous 12 months and the patient's financial situation has not changed, the individual will be deemed eligible for financial assistance without having to submit a new application. All applications are maintained for a period of one year.

Section 4.5. Rate Reduction Schedule for Qualified Financial Assistance Recipients

 A patient's cost for care will be based on his or her income in comparison to the national poverty guidelines (discussed below in this Section) and other eligibility criteria. If a patient is a QFAR, the patient's cost of care will first be reduced to an amount equivalent to the amounts generally billed for that care, as described in Section 4.2. After that preliminary reduction, the patient will then be entitled to another 50-100% reduction in cost for emergency or other medically necessary care, depending on the patient's eligibility.

National poverty guidelines are established each year and, for that reason, a patient's rate of financial assistance will change as well. The currently applicable rate reduction schedule for BHFCH patients is available on BHFCH's website, in the Emergency Room, and at all points of registration in the hospital, and by mail or telephone at the following address/number (all free of charge):

Baxter Health Fulton County Hospital

Attention: Patient Financial Services

679 N Main St

Salem, AR 72576

(870) 895-2691

https://www.fultoncountyhospital.org

For example, based on the national poverty guidelines for 2024, a Qualified Financial Assistance Recipient would be eligible for rate reductions on covered medical care at BHFCH as shown on the chart below.

 

2024 Schedule of Rate Reduction and Income Limitations

Income Limits for Each Level of Financial Assistance

Based Patient Income as a % of National Poverty Guidelines

0-138% of NPG

(100% Reduction)

Family Size: Individual: Patient Income $0 - 20,783
Family Size: Family of 2: Patient Income $0 - 28,207
Family Size: Family of 3: Patient Income $0 - 35,632
Family Size: Family of 4: Patient Income $0 - 43,056
Family Size: Family of 5: Patient Income $0 - 50,480
Family Size: Family of 6: Patient Income $0 - 57,905
Family Size: Family of 7: Patient Income $0 - 65,329
Family Size: Family of 8: Patient Income $0 - 72,754

 

139-200% of NPG
(75% Reduction)

Family Size: Individual: Patient Income $20,784-30,120
Family Size: Family of 2: Patient Income $28,208-40,880
Family Size: Family of 3: Patient Income $35,633-51,640
Family Size: Family of 4: Patient Income $43,057-62,400
Family Size: Family of 5: Patient Income $50,481-73,160
Family Size: Family of 6: Patient Income $57,906-83,920
Family Size: Family of 7: Patient Income $65,330-94,680
Family Size: Family of 8: Patient Income $72,755-105,440

200-300% of NPG

(50% Reduction)

Family Size: Individual: Patient Income $30,121-45,180
Family Size: Family of 2: Patient Income $40,881-61,320
Family Size: Family of 3: Patient Income $51,641-77,460
Family Size: Family of 4: Patient Income $62,401-93,600
Family Size: Family of 5: Patient Income $73,161-109,740
Family Size: Family of 6: Patient Income $83,921-125,880
Family Size: Family of 7: Patient Income $94,681-142,020
Family Size: Family of 8: Patient Income $105,441-158,160

 

The schedule for rate reductions for the current calendar year may be found in Addendum A to this Policy.

Section 4.6 Safe Harbor for Eligible Patients who are Later Qualified for Financial Assistance

In the unusual situation when (1) a patient is charged more than the amount generally billed for medical services, (2) that patient has not yet completed an application for financial assistance, and (3) the patient later completes the application and is determined to be a QFAR, BHFCH will reimburse the patient for any amounts paid in excess of that patient's maximum out-of-pocket charge for the service (unless that amount is less than $5.00). However, BHFCH will never make the patient's payment of charges in excess of amounts generally billed a precondition to receipt of emergency or other medically necessary care.

Section 4.7.     Covered Care and Providers

This Policy applies to emergency provided in a BHFCH "hospital facility," including any department or provider-based clinic of the hospital itself, whether located inside the hospital's physical structure on N Main St. or elsewhere, if that care is provided by the hospital facility or any entity substantially related to the hospital facility for tax purposes. That is, the applicability of this Policy will depend on two factors, including (1) where the care was provided and (2) which provider provided the care. Elective or non-emergent care is not eligible for financial assistance.

Section 4.7.a. Covered Care Locations

With regard to the location of care, emergency and other medically necessary care that is provided in a "hospital facility," including hospital itself or in any provider- based clinic or department of the hospital, will be considered for financial assistance. Specifically, that includes the Inpatient hospital floors, the Swingbed unit, Outpatient departments, Emergency Department, Wound Care, Therapy, Radiology, Laboratory and Endoscopy departments and Family Clinic. 

Section 4.7.b. Covered Providers

If the patient receives care that is covered under this Policy, a determination will need to be made as to whether the provider who actually provided the care is a covered provider. Every provider associated with the hospital itself, a department of the hospital, or a provider-based clinic will be a "covered provider" when that provider is providing covered care, including all the clinics and departments included in Section 4.7.a.  Likewise, if covered care is provided at the hospital facility by a provider from one of the clinics related to BHFCH for tax purposes, including all of those clinics listed in Section 4.7.a., such as the Family Clinic, that provider is covered under this Policy.  However, that provider is only covered for care that occurs in the hospital facility or a provider-based clinic or department.

If the patient receives care that is covered under this Policy but that care is not provided by a provider from the hospital facility or any substantially related clinic or other medical facility, that patient's care is not eligible for financial assistance.

A list of providers with privileges and credentialing at the hospital, and a notation of whether those providers' care is covered or not, is found in Addendum B to this Policy.


Section 5. APPLYING FOR FINANCIAL ASSISTANCE

Section 5.1. Availability of Application for Financial Assistance and Other Information

If any person believes that a patient may qualify for financial assistance under this Policy, BHFCH encourages the person to request assistance. Copies of this Policy, a plain language summary of the policy, and the application form may be found in any of these locations, including (1) on the BHFCH website, https://www.fultoncountyhospital.org,  (2) in the BHFCH Emergency Room, and (3) at every point of registration into the hospital. Any member of the public or any state or federal governmental entity may also obtain copies of this Policy, the plain language summary of the policy, and the application form by mail or telephone at the following address/number (all free of charge):

 

Baxter Health Fulton County Hospital

Attention: Patient Financial Services
679 N Main St

Salem, AR 72576

(870) 895-2691

Applicants may also write or call Baxter Health Fulton County Hospital at this address/telephone number to ask questions about or receive other assistance with the application process and the Financial Assistance Policy. Notices regarding the Financial Assistance Policy are also included on all billing statements and may be found posted in public areas around the hospital, including the Emergency Room and Admissions. Similarly, copies of the plain language summary of this Policy will be included with patients' admission or discharge paperwork, depending on the circumstances.

Section 5.2. Availability of Application for Financial Assistance and Other Information in Languages Other Than English (Limited English Proficiency)

BHFCH also makes copies of its Financial Assistance Policy, the plain language summary, and the application form available in certain languages other than English for those with limited English proficiency. Those documents are provided free of charge and are made available for all languages, as required by federal law, that BHFCH has determined may be spoken by a significant population of the communities BHFCH serves. To determine whether these documents are available in a particular language, and to obtain copies of those documents, an individual may write or call the following address/telephone number:

Baxter Health Fulton County Hospital

Attention: Patient Financial Services

679 N Main St

Salem, AR 72576

(870) 895-2691

Section 5.3.     Financial Assistance for Patients with Medicaid Coverage

If a patient has applied for financial assistance under this Policy and has also filed an application for assistance under Medicaid, BHFCH may postpone its determination until the Medicaid application has been completed and a decision has been made.

Section 5.4.     Application and Eligibility Determination Process

 The process for completing an application for financial assistance under this Policy will generally follow these steps:

  1. The patient or the patient's representative requests financial assistance. Anyone may request financial assistance on any patient's behalf but only the patient or his or her representative may complete the application.
  2. The patient or the patient's representative completes the application form and returns it to BHFCH's Patient Financial Services Department ("PFS"). In the event of a patient's death, the patient's family will be given an opportunity to complete an application for financial assistance under this Policy.
  3. PFS reviews the application for completeness within 30 days of receipt. If the application is incomplete, PFS contacts the patient or his or her representative to obtain the missing information. If the necessary information is not provided to PFS within 30 days of notice that the application is incomplete, the application will be denied.
  4. PFS reviews income verification documentation. If income documentation is missing or the documentation provided does not meet the documentation requirements in this Policy (Section 4.3), PFS contacts the patient or representative to obtain the proper documentation. If the needed documentation is not provided within 30 days, the application will be denied.
  5. PFS reviews the services provided to verify that they are services covered under the Financial Assistance Policy. If the service is covered by a third-party payor, such as insurance or government assistance, the patient or representative is contacted and those payment avenues are pursued. If the question of extraordinary circumstances arises, the account will be referred to the appropriate management personnel for determination of eligibility. Following that determination, the account will be either returned to PFS for processing or denied. If denied, PFS will discuss payment options with the patient or representative.
  6. If the services in question are covered and there is no alternative payment option, PFS will review family income according to current national poverty guidelines (Section 4.5) and determine whether the patient is eligible discounted care. If so, BCFCH will notify the patient or representative of eligibility, explain the details of the discount procedure, apply the appropriate discount, establish a payment plan (if necessary), and update the patient's account record accordingly. Determinations are generally made within 30 days.
  7. If the patient does not qualify for financial assistance, the patient or representative will be notified.
  8. If an individual has applied for and received financial assistance within the previous 12 months and the patient's financial situation has not changed, the individual will be deemed eligible for financial assistance without having to submit a new application. All applications are maintained for a period of one year.

Section 6. BILLING AND COLLECTION FOR QUALIFIED FINANCIAL ASSISTANCE RECIPIENTS

Section 6.1. Availability of Separate Billing and Collections Policies

BHFCH maintains separate policies containing its billing and collections policies as they apply to all patients, not solely to patients seeking financial assistance. Patients may obtain copies of those policies, free of charge, by writing or calling the following address/telephone number:

Baxter Health Fulton County Hospital
Attention: Patient Financial Services

679 N Main St

Salem, AR 72576

(870) 895-2691

Section 6.2. General Billing and Collection Matters

BHFCH sends patients account statements on a monthly (30-day) cycle. Generally, if the account is not paid, BHFCH will send three statements, with the final statement serving as final notice that the account may be referred to a third-party collection agency if payment is not received within 30 days after the date of the final notice. BHFCH requires any collection agency it uses to agree to refrain from abusive collection practices.

BHFCH will not engage in "extraordinary collection actions" until reasonable efforts have been made to determine whether an individual is eligible for assistance under this Policy. Extraordinary collection actions include selling debt to third parties (except as legally allowed), reporting to consumer credit reporting agencies and credit bureaus, denying future medical care because of nonpayment, filing lawsuits, foreclosing on real estate, attaching or seizing bank accounts or personal property, placing liens on residences, arrests, body attachments, and similar activities.

If a patient account has been referred to a collection agency, that patient may still apply for financial assistance for a period of 120 days. While the application is being completed and while the determination of eligibility for financial assistance is pending, collection efforts will be suspended.

Section 6.3.     Notices to be Provided Before Extraordinary Collection Actions are Taken

BHFCH may initiate an extraordinary collection action against a QFAR under certain circumstances. First, BHFCH may initiate extraordinary collection actions when it provides the patient with at least 30 days' written notice that the action is being initiated and provides a deadline for the patient to bring his or her account current. With that notice, BHFCH will provide a plain language summary of this Policy. BHFCH will also make reasonable efforts to provide the patient with oral notice that it is initiating an extraordinary collection action.

BHFCH recognizes that some patients will receive multiple episodes of care or care on multiple occasions.  In that event, BHFCH will only initiate an extraordinary collection action on the aggregate of the patient's outstanding bills after 120 days have passed since BHFCH provided the first post-discharge billing statement for the patient's most recent episode of care.

Section 6.4.     Limitation on Charges

If a patient has been determined to be a Qualified Financial Assistance Recipient under this Policy and receives care from a provider with the hospital or a substantially related clinic, that provider will limit the charges to the patient. For emergency and other medically necessary care, the patient cannot be charged more than the amounts generally billed for such care (Section 4.2). For all other care, the patient must be charged less than gross charges. "Charges," for purposes of this Section, mean the amount the patient is personally responsible for paying, after all deductions, discounts, insurance reimbursements, or other reductions have been applied. This applies to care provided outside the hospital, a department of the hospital, or a provider-based clinic, and includes all clinics or other medical facilities substantially related to BHFCH for tax purposes.

Section 7. MAJOR MEDICAL EXPENSES

 Out of pocket patient obligations resulting from medical services provided by Baxter Health Fulton County Hospital will not exceed the following thresholds:

  1. If family income is more than 300% but not in excess of 400% of the federal poverty level, the maximum out of pocket is 35% of family income.
  2. If family income is more than 400% but not in excess of 600% of the federal poverty level, the maximum out of pocket is 45% of family income.
  3. If family income is more than 600% of the federal poverty level, the maximum out of pocket is 55% of family income.

 

Family Income Limits Eligible for Stated Maximum Out of Pocket

35%
Family Size: 1: Family Income Limits: $45,181-60,240
Family Size: 2: Family Income Limits: $61,321-81,760
Family Size: 3: Family Income Limits: $77,461-103,280
Family Size: 4: Family Income Limits: $93,601-124,800
Family Size: 5: Family Income Limits: $109,741-146,320
Family Size: 6: Family Income Limits: $125,881-167,840
Family Size: 7: Family Income Limits: $142,021-189,360
Family Size: 8: Family Income Limits: $158,161-210,880

45%
Family Size: 1: Family Income Limits: $60,241-90,360
Family Size: 2: Family Income Limits: $81,761-122,640
Family Size: 3: Family Income Limits: $103,281-154,920
Family Size: 4: Family Income Limits: $124,801-187,200
Family Size: 5: Family Income Limits: $146,321-219,480
Family Size: 6: Family Income Limits: $167,841-251,760
Family Size: 7: Family Income Limits: $189,361-284,040
Family Size: 8: Family Income Limits: $210,881-316,320

55%
Family Size: 1: Family Income Limits: >$90,361
Family Size: 2: Family Income Limits: >$122,640
Family Size: 3: Family Income Limits: >$154,921
Family Size: 4: Family Income Limits: >$187,201
Family Size: 5: Family Income Limits: >$219,481
Family Size: 6: Family Income Limits: >$251,761
Family Size: 7: Family Income Limits: >$284,041
Family Size: 8: Family Income Limits: >$316,321

ADDENDUM A
PROVIDER LIST

The following is the list of providers who may deliver emergency or other medically necessary care in BHFCH's hospital facility with a notation about whether that provider's care would be "covered care" under this Policy.  Care provided in the hospital facility, a hospital department, or a provider-based clinic (Section 4.7) by a covered provider is eligible for the rate reductions discussed in this Policy. Care provided b a non-covered provider, no matter where that care is given, is not eligible for the rate reductions discussed in this Policy.

Provider Name: Adam Gray
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Anthony Anston
Provider Type: DO
Is the Provider's Care Covered: Yes 

Provider Name: Arnold Griffin II
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Brian K. Linn
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Christopher Cochran
Provider Type: MD
Is the Provider's Care Covered: No

Provider Name: Dana Kinney
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Jeffery Don Coon
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Jimmy Bozeman
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Larry D. Ezell
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Lauren Bloch
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Phillip Sadler
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Jennifer M. Sadler
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Michael Elkins
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Warren Edward Scott Jr.
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Jennifer Sadler
Provider Type: MD
Is the Provider's Care Covered: Yes

Provider Name: Renee Audrey Crowl
Provider Type: APRN
Is the Provider's Care Covered: Yes

Provider Name: William Smart
Provider Type: CRNA
Is the Provider's Care Covered: No

Provider Name: Cindy Hall
Provider Type: CRNA
Is the Provider's Care Covered: No