MEMORIAL HOSPITAL

"The household income must be at or below the guidelines listed below: Size of Family FPL Guidelines 100% Assistance *No Patient Share Tier One *Patient Share is 25% Tier Two *Patient Share is 50% 1 $15,060 $22,590 $22,591 $30,120 $30,121 $45,180 2 $20,440 $30,660 $30,661 $40,880 $40,881 $61,320 3 $25,820 $38,730 $38,731 $51,640 $51,641 $77,460 4 $31,200 $46,800 $46,801 $62,400 $62,401 $93,600 5 $36,580 $54,870 $54,871 $73,160 $73,161 $109,740 6 $41,960 $62,940 $62,941 $83,920 $83,921 $125,880 7 $47,340 $71,010 $71,011 $94,680 $94,681 $142,020 8 $52,720 $79,080 $79,081 $105,440 $105,441 $158,160 *For family units with more than 8 members, add $5,380 for each additional member >8."

documented · checked 2026-10-14 · [PDF] Policy, Financial Assistance Policy 0624

"Eligibility for charity will be considered for those individuals who are uninsured and underinsured for services without third party payments"

documented · checked 2026-10-14 · [PDF] Policy, Financial Assistance Policy 0624

"A patient in this situation is presumed to be eligible and therefore does not need to complete a financial assistance application if they can provide proof that they meet one of the following criteria: a. Patient states that he/she is homeless. The due diligence efforts must be documented. b. Patient is deceased with no known estate. c. Patient is mentally incapacitated with no one to act on their behalf. d. Patient is currently eligible for Medicaid, but was not eligible on a prior date of service or for non-covered services. Instead of making the patient duplicate the required paperwork Memorial Hospital will rely on the financial assistance determination process from Medicaid. e. Patients eligible for energy assistance or food stamps. f. Accounts deemed uncollectible by a contracted collection agency."

documented · checked 2026-10-14 · [PDF] Policy, Financial Assistance Policy 0624

"Applicants requesting financial assistance under this policy may be asked to provide the following information: a completed application, income verification and income taxes from the previous year."

documented · checked 2026-10-14 · [PDF] Policy, Financial Assistance Policy 0624

"Applications for financial assistance can be picked up and should be returned to Patient Accounts, 1454 N CO RD 2050 E, PO Box 160, Carthage, IL 62321. All inquiries about this policy should be referred to Patient Accounts – 217-357-6591. Applications are available at all facility locations and on Memorial Hospital’s web site at www.mhtlc.org."

documented · checked 2026-10-14 · [PDF] Policy, Financial Assistance Policy 0624

"Applications for financial assistance will be available on accounts for 240 days from first bill past discharge."

documented · checked 2026-10-14 · [PDF] Policy, Financial Assistance Policy 0624

"Determination will be made within thirty (30) days of receipt of all requested information."

documented · checked 2026-10-14 · [PDF] Policy, Financial Assistance Policy 0624

"All inquiries about this policy should be referred to Patient Accounts – 217-357-6591."

documented · checked 2026-10-14 · [PDF] Policy, Financial Assistance Policy 0624

"Covered Providers: Memorial Hospital, Memorial Medical Clinics, Memorial Medical Clinics Employed Providers, NES Health, Hancock County Senior Services Association."

documented · checked 2026-10-14 · [PDF] Policy, Financial Assistance Policy 0624