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Financial Assistance Policy (Complete)

Policy Statement

It is the policy of Crozer Health, collectively referred to as Crozer Health Entity (ies)  Crozer-Chester Medical Center, Taylor Hospital, Springfield Hospital, and Delaware County Memorial Hospital  to provide medically  necessary health care to all patients, without regard to the patient’s ability to pay at each facility ( whether operated directly or through a joint venture) that is required by a state to be licensed, registered or recognized as a hospital ( “ Hospital Facility”)

Crozer Health will provide, without discrimination, care for emergency medical conditions to individuals regardless of their financial assistance eligibility or ability to pay. It is the policy of Crozer Health to comply with the standards of the Federal Emergency Medical Treatment and Active Labor Transport Act of 1985 (EMTALA) and the EMTALA regulations in providing a medical screening examination and such further treatment as may be necessary to stabilize an emergency medical condition for any individual coming to the emergency department seeking treatment, regardless of the individual’s medical or psychiatric condition, race, religion, age, gender, color, national origin, immigration status, sexual preference, handicap, or ability to pay.

As health care providers and tax-exempt organization, Crozer Health Entities are called to meet the needs of the patients and other who seek care regardless of their financial abilities to pay for services provided.

The purpose of this Policy is to outline the circumstances under which Crozer Health Entities will provide free or discounted care to patients who are unable to pay for the service and to address how Crozer Health Entities calculate amount charged to patient.

A listing of all providers, other than the Crozer Health hospital facility itself, providing emergency or other medically necessary care in the Crozer Health hospital facility specifying which providers are covered by this FAP and which are not can be found at www.crozerhealth.org.  The provider listings will be reviewed quarterly and updated if necessary.


Amounts Generally Billed (AGB) - Gross charges for any emergency or other medically necessary care times the AGB Percentage.

Application Period-  The Application Period provides an individual 240 days from the date the individual is provided with the first post-discharge billing statements to complete the Financial Assistance  Application (FAP Application)

Extraordinary Collection Actions - Actions taken in order to obtain payment from patients, including but not limited to taking legal or judicial action, selling a patient’s debt to another party or reporting adverse information against the individual to consumer credit reporting agencies or credit bureaus.

Financial Assistance  - Financial assistance provided to Crozer Health Entities patients by writing off all or a portion of their “ out of pocket” balances, based on criteria contained in this policy. Financial assistance represents health care services that are provided for medically necessary services but are not anticipated to result in full payment. Eligible patients are those patients who are uninsured, underinsured and or ineligible for governmental or other insurance coverage and who have family incomes not in excess of 400 percent of the Federal Poverty Level (“FPL”).  No FAP-eligible individual will be charged more than AGB for medically necessary health care services provided by Crozer Health Entities.

Financial Counselor – The financial counselor, manager, vendor employee or other Crozer Health employee or representative who interacts with the patient regarding satisfying a Crozer Health Entities account balance.

Family – Using the Census Bureau definition, a group of two or more people who reside together and who are related by birth, marriage, or adoption. According to the Internal Revenue Service (IRS) rules, if the patient or the financially responsible individual, claims an individual as a dependent on their income tax return, they may be considered a dependent for purposes of the provision of financial assistance.

Family Income  - For the purposes of determining Financial Assistance eligibility, family income is defined as the pre-tax household income of all family members and include but is not limited to wages, self-employed earnings, unemployment compensation, worker’s compensation, Social Security, Supplemental Security Income, public assistance, veteran’s payment, survivor’s benefits, pension or retirement income, interest dividends, rents, royalties, and income from estates or trust. For these purposes family income excludes educational assistance, child support, alimony, capital gains/losses, and non-cash benefits (food stamps, etc.) See Exhibit 1 Financial Assistance Fee Schedule for Family Size and Income Amounts.

Federal Poverty Level (FPL): The Federal Poverty Levels are issued each year in the Federal Register by the Department of Health and Human Services and are used for determining financial eligibility.

Medically Indigent Patients - Those patients whose health insurance coverage, if any, does not provide full coverage for all of their medical expenses, despite their income, have a low level of liquid assets such that payment of their medical bills would be seriously detrimental to their basic financial well-being and survival.

Medical Necessity - Any diagnostic test, study, service, or procedure reasonably determined to prevent, diagnose, correct, cure, alleviate or avert the worsening of conditions that endanger life, cause suffering or pain, resulting in illness or infirmity, threatening to cause or aggravate a handicap, or cause physical deformity or malfunction if there is no other equally effective, more conservative or less costly course of treatment available.

Notification Period - Crozer Health must notify the individual about the Financial Assistance Policy (FAP) before initiating any extraordinary collection actions (“ECAs”) to obtain payment and refrain from initiating any ECA for at least 120 days from the date the patient is provided the first post-discharge billing statement for care.

Plain Language Summary (“PLS”) - The PLS is a written statement that notifies an individual that the hospital facility offers financial assistance and provides information regarding this FAP in language that is clear, concise, and easy to understand.

Presumptive Financial Assistance Eligibility - There are instances when a patient may appear eligible for financial assistance, based on information obtained from onsite Medical Assistance vendors and/or third party vendors/agencies to estimate income amounts. Crozer Health Entities will utilize these sources in order to determine FAP-eligibility and discount amounts. Once determined, due to the inherent nature of presumptive circumstances, the only discount that can be granted is a 100 percent write-off of the account balance. Presumptive eligibility may be determined on the basis of individual life circumstances that may include :

  1. Homeless - A homeless person is an individual who has no home or place of residence and depends on charity or public assistance;
  2. Eligibility for PA or other state Medicaid Assistance Programs (spend down or patient pay amounts);
  3. Patient is deceased with no known estate; and
  4. Inmates - Patients who are incarcerated may be considered eligible in the event the State or County has made a determination that the State or County is not responsible for charges incurred prior to arraignment.

Uninsured Patient - An individual who does not have any third party health care coverage through either a Federal or State Health Care Program, including without limitation to Medicare, Medicaid, Medicaid Managed Care, Health Choices, CHIP, Adult Basic and Tricare third-party insurer, Workers’ Compensation, Auto, COBRA, program through Insurance Exchange or any other coverage that would pay for all or part of their medical care bill.

Underinsured Patient - An individual who has medical insurance coverage at the time treatment is provided, but such coverage is limited, has high “out-of-pocket” balances and/or policy maximums that would result in his or her medical bills not being fully paid.

Eligibility Criteria

After an assessment of medical necessity and financial ability is determined (Exhibit 1) Crozer Health Entities may provide free or discounted care to patients who qualify for financial assistance under this policy. Crozer Health Entities will follow standard procedures in determining eligibility for financial assistance as follows:

Medical Necessity


Any patient seeking urgent or emergent care (within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd) at a Crozer Health hospital shall be treated without discrimination and without regard to a patient’s ability to pay for care. Crozer Health shall operate in accordance with all federal and state requirements for the provision of urgent or emergent health care services, including screening, treatment, and transfer requirements under the federal Emergency Medical Treatment and Active Labor Act (EMTALA). Crozer Health shall consult and be guided by their emergency services policy, EMTALA regulations, and applicable Medicare/Medicaid Conditions of Participation in determining what constitutes an urgent or emergent condition and the processes to be followed with respect to each.

  • Other Medically Necessary Services

In addition to services covered under EMTALA, Crozer Health will grant free or discounted care to FAP-eligible individuals for all other medically necessary services.

Financial Criteria

Basic Review

Financial Assistance for medically necessary services is available on a sliding scale of up to 100 percent of charges, and up to a full waiver of co-payments / co-insurance after third-party insurance payments. A discount up to 100 percent will be granted to those uninsured or underinsured patients whose family income is equal to or less than 200 percent of the Federal Poverty Level - Income Guidelines (FPL). See Exhibit 1.

Medical Indigence

Patients may also be granted a discount based upon medical indigence. A determination as to a patient’s medical indigence takes into consideration significant medical bills not covered by insurance, in addition to the patient’s income level and liquid assets. For example, a patient suffering a serious or extended medical illness may have a reasonable level of income, but limited liquid assets such that the payment of their medical bills would be seriously detrimental to their basic financial well-being and survival. Such patients may be extended discounted or free care, based upon the facts, circumstances and the documentation supplied in the financial assistance application.

Crozer Health Financial Counselors / Patient Financial Services (“PFS”) Management personnel – have the ability to gather data , work with the patient and obtain all required information and present to the Patient Access Director for consideration as to whether to extend a discount related to patient accounts that do not clearly qualify under the basic financial criteria (i.e., those patients seeking financial assistance on the basis of medical indigence). Extension of financial assistance based on medical indigence will be approved by the Vice President of Revenue Cycle based upon the review of documents either provided by the patient and/or available through Crozer Health third-party vendors/agencies in addition to those evidencing income. Those documents may include one or more of the following, but are not limited to:             

  • Evidence of high-dollar patient/guarantor co-pays, co-insurance, deductibles;
  • Letter from physician confirming medical necessity of services provided;
  • Information concerning available insurance coverage; and
  • Copies of unpaid patient/guarantor hospital and/or physician bill.


Hospital Financial Assistance Assessment Methodology

Crozer Health Entities will establish and determine a consistent methodology when assessing uninsured and/or underinsured patients for financial assistance eligibility. The methodology shall consider patient/guarantor, income, family size and available resources.

  • See attached Exhibit 2: Crozer Health Application For Financial Assistance form (“Application”).

Identifying patients eligible for full or partial financial assistance

  • Patients who qualify for 100 percent free care or partial free care will be identified as soon as possible, either, before, during, or after care is provided.
  • If a Financial Assistance determination cannot be made prior to services being rendered, such determination will be made as soon as possible.  Patients or the financially responsible individual will have 240 days from the first post-discharge billing statement to apply for financial assistance.

Eligibility for Financial Assistance

General Criteria

  1. The patient may be requested to apply for Medical Assistance or any other third party coverage (i.e., Individual and/or group coverage, Medicare, workers’ compensation, automobile, third-party liability and other programs, COBRA, CHIP, Insurance Exchange) for which they may be eligible at the request of the Crozer Health Financial Counselor, and they must provide a denial for such coverage, if requested. If the Crozer Health Financial Counselor determines that the patient would not qualify for other coverage, Financial Assistance may be extended to the patient.
  2. Patients with Healthcare Reimbursement Accounts (“HRA”) or Healthcare Saving Accounts (“HAS”) are considered to have insurance if the HRA or HSA can be used to pay for patient “out of pocket” responsibility amounts, i.e., deductibles, co-pays or co-insurance amounts.
  3. Crozer Health may use information obtained from contracted business partners to assist in making a final determination on the application, and presumptive eligibility may be granted based on information obtained from Medical Assistance Vendor or other hospital business partner.
  4. Medicaid applicants meeting established Financial Assistance income/family size guidelines whose eligibility status has not been established for the period during which the medical services were rendered should be granted Financial Assistance for those services.
  5. Patients requesting financial assistance must reside within the counties listed below, with the exception of patients being treated in the Emergency Department, labor and delivery, Burn or Trauma Units:
    1. Pennsylvania: Delaware County, Philadelphia County, Chester County, Montgomery County
    2. New Jersey: Camden County, Glouster County
    3. Delaware: New Castle County
  6. Persons known to be homeless (indicate they are homeless at registration or provide a known shelter address as their residence) may be granted 100 percent Financial Assistance based solely on their homeless status (without application).
  7. Deceased patients with no estate may be granted Financial Assistance based solely on their status (without application).
  8. Persons who have filed for bankruptcy and whose bankruptcies have been approved by the court may be granted Financial Assistance solely on their status (without application).

Income Criteria

Income qualification is based on the most recent version of the FPL Income Guidelines.  Eligibility and the level of patient responsibility are outlined on the table in Exhibit 1.

  • Eligibility for full Financial Assistance shall be granted for patients who fall between 0 - 200 percent of the Federal Poverty Income Guidelines as published annually in the Federal Register.
  • Eligibility for partial Financial Assistance shall be granted for patients who fall between 201 percent - 400 percent of the Federal Poverty Income Guidelines as published annually in the Federal Register

Widely Publicizing

The FAP, Application and PLS are all available in English and in the primary language of populations with limited proficiency in English that constitute the lesser of 1,000 individuals or 5 percent of the community served by each Crozer Health hospital facility’s primary service area. Translation services will be made available as needed.  Every effort will be made to ensure that the FAP documents are clearly communicated to patients whose primary languages are not included among the available translations

Crozer Health makes reasonable efforts to inform patients of the potential availability of financial assistance. When a patient inquires about financial assistance, staff will advise the patient that financial assistance may be available but only under the criteria set forth in this policy and that for further information, the patient or physician should contact the Patient Financial Resource Center.

The FAP, Applications and PLS will be conspicuously displayed in the following manner:

  • A) The FAP, Applications and PLS are widely available on Crozer Health's website: www.crozerhealth.org;
  • B) Paper copies of the FAP, Applications, and PLS are available upon request without charge by mail and in public locations of each hospital facility (this includes at a minimum the emergency room and admissions areas) located at the following address:

Crozer-Chester Medical Center
One Medical Center Boulevard
Upland, PA 19013-3995

Taylor Hospital
175 East Chester Pike
Ridley Park, PA 19078

Springfield Hospital
190 West Sproul Road
Springfield, PA 19064

Delaware County Memorial Hospital
501 North Lansdowne Avenue
Drexel Hill, PA 19026

  • C) Inform and notify members of the community served by each Crozer Health hospital facility about the FAP in a manner which will reach members of the community who are most likely to require financial assistance; and
  • D) Notify and inform members who receive care from Crozer Health hospital facilities about the FAP by:
    • Offering a paper copy of the PLS to inpatients as part of the intake or discharge process.
    • Including conspicuous written notice which informs patients about the availability of financial assistance on all billing statements
    • Displaying conspicuous signs that notify and inform patients about the availability of financial assistance in public locations in each Crozer Health hospital facility.

Determination of Eligibility and Applying for Financial Assistance

Upon pre-registration/registration or after services are rendered, and after all EMTALA requirements are met, hospital patients without Medicare/Medicaid or any other third party insurance coverage will be referred to a Financial Counselor or PFS Manager who will review Crozer Health Financial Assistance Policy/Procedure and complete the Crozer Health Application For Financial Assistance based on income and family size provided by patient and/or outside source i.e., contracted business associate.

All available financial resources shall be evaluated before determining financial assistance eligibility.

A basic Financial Assistance application (Exhibit 2) will be completed for each applicant, except for patients addressed as homeless, deceased, bankrupt, or deemed presumptively eligible as noted above.  The patient will provide supporting documentation as requested by the Crozer Health Financial Counselor. 

The application may be completed in person, by phone; Patient Financial Resource Center- 610-447-2336 via website: www.crozerhealth.org  or Financialcounselor@crozer.org, and/or, mail.

All completed applications should be mailed to the following address:

Crozer Health
Attn: Financial Resource Center
One Medical Center Blvd.
Upland, PA 19013

All information obtained from patients and guarantors shall be treated as confidential to the extent required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Eligibility for full or partial Financial Assistance will be granted for a period of six (6) months from the date of the first post discharge billing statement, the Application Period.  At the discretion of Crozer Health, the patient may be asked to reconfirm information on the original application upon each visit in order to maintain eligibility. Crozer Health will retroactively apply Financial Assistance adjustments to accounts for all self-pay balances for the applicant accounts that are still active in the accounts receivable at the time of the approval. 

Approval/rejection of an application will be made within 10 working days of receiving a completed application with all requested information and will be notified via mail.

If Crozer Health receives an incomplete Application, written notice will be provided to the patient, or the financially responsible individual, outlining the additional information and/or documentation needed in order to determine FAP-eligibility.  Patients, or the financially responsible individual, will be given the greater of 30 days or amount of days remaining in the Application Period (240 days from the date of the first post-discharge billing statement) to submit a completed Application including any additional information requested by Crozer Health. Additionally, patients will be provided a PLS.


There are some circumstances when patients may be excluded from Financial Assistance consideration.  They include:

  1. Individuals who did not follow their insurance policy rules (e.g., using a non-participating provider, failing to obtain a referral;
  2. Patients/guarantors refusing to provide information necessary to process the Financial Assistance application (unless mentally incapacitated);
  3. Elective non- medically necessary studies or elective non-medically necessary surgical procedures covered under Crozzer Health Self-Pay Package Agreements; and
  4. Professional fees (physician) other than Crozer Health Medical Group (CHMG) physicians are generally not eligible for Crozer Health Financial Assistance. A listing of all providers, other than the Crozer Health hospital facility itself, providing emergency or other medically necessary care in the Crozer Health hospital facility specifying which providers are covered by this FAP and which are not can be found at www.crozerhealth.org.   The provider listings will be reviewed quarterly and updated if necessary.

In the event that Crozer Health determines that a patient is ineligible for full or partial Financial Assistance, the patient/guarantor may appeal the decision in writing to:

Crozer Health
Attn; Financial Resource Center / Director Financial Assistance
One Medical Center Blvd.
Upland PA 19013

The written appeal must be received within thirty (30) days following receipt of the statement for which financial assistance was requested. Failure to appeal the determination in a timely fashion will result in the decision becoming final. The determination of the Director, Financial Assistance shall not be subject to further appeal

Method used to determine Amounts Generally Billed (AGB) for Emergency or Medically Necessary Care

Crozer Health utilized the -Prospective Method, Medicare fee for service rates to calculate an Amount Generally Billed (AGB) -. The AGB is calculated annually based on Medicare rates. The AGB limits the amount charged to what Medicare would allow for the care including copays and deductibles.

Any patient eligible for financial assistance will always be charged the lesser of the AGB or any discounted rate available under this FAP.

In accordance with Internal Revenue Code §501(r)(5), in the case of emergency or other medically necessary care, patients eligible for financial assistance under this FAP will not be charged more than an individual who has insurance covering such care.

It is the policy of Crozer Health to pursue collection of patient balances from patients who have the ability to pay for these services. Collection procedures will be applied consistently and fairly for all patients. All collection procedures will comply with applicable laws and Crozer Health mission. 

Financial Assistance Fee Schedule ( Exhibit 1)

2017 Percentage of Federal Poverty Level - Income Guidelines

Family Size        Poverty



201% - 300%

301% - 400%

> 400%


Family Income Levels

  1                        $12,060




Patients do not qualify

  2                        $16,240




for Financial Assistance

  3                        $20,420




but are eligible for

  4                        $24,600




Self-pay discounts.

  5                        $28,780





  6                        $32,960




See Self-Pay Discount

  7                        $37,140





  8                        $41,320





Patient Responsibility  0%


50%( Medicare Rate)

75%( Medicare Rate)

100% (Medicare Rate)

Balance After Insurance,  Deductibles, Co-insurance, Co-payments       0%






50%(Medicare Rate)



75%(Medicare Rate)



100% ( Medicare Rate)



Patient Name: ________________


___  Crozer Chester Medical Center

Account #: ___________________

(if known)

___  Taylor Hospital

Patient Date of Birth: ___________


___  Springfield Hospital

_____Delaware County Memorial Hospital





Insured Name

Social Security

Date of Birth




Street Address


State and Zip





Home Phone

Cell Phone




Monthly Family Income

Family Assets

Family Members (immediate family living in the household)




Date of Birth





Savings Account/CDs








Soc Sec




Checking Account












Stocks, Bonds








Public Assistance




Other Assets








Total Monthly Income


Total Assets


Total Number of Family Members (including applicant)

I certify that the above information is true and accurate to the best of my knowledge.  Furthermore, I will make application for any

insurance coverage (Medicaid, Medicare, Insurance, etc.), which may be available for payment of my hospital charges, and I will take

any action reasonably necessary to obtain such assistance and will assign or pay to the hospital the amount recovered for hospital

charges.  I understand that it is my obligation to provide the hospital with proof of determination for Medicaid, if requested. If hospital

requests additional documentation and I do not provide it, I understand my application for financial assistance may be denied and I

will be financially responsible for any bills incurred.


I understand that this application is made so that the hospital can judge my eligibility for financial assistance under Crozer Health’s Financial

Assistance Policy, (see page 2 of Exhibit 2 for required documents needed to complete the financial assistance application)  If any information I have given proves to be untrue, I understand that the hospital may reevaluate my financial status

and take whatever action becomes appropriate.

            _______________________________________               ________________________________________________________

                        Date of Request                                                     Applicant’s Signature




All completed applications should be mailed to the following address:

Crozer Health

Attn: Financial Resource Center

One Medical Center Blvd. Upland, PA 19013



Eligibility Determination


Date of Eligibility Determination

___Application Approved – Level 1 (S62)

___Application Approved – Level 2 (S64)

___Application Approved – Level 3 (S66)

___Application Auto Approved – Level 1 (S61)

___Application Denied – Over Income

___Application Denied – Patient Uncooperative

___Application Denied – Other (Residency, assets, etc.)


Financial Assistance Termination Date


Signature of Person Making Determination                       Date




Financial Assistance Program Application Checklist

  1. If you have income:
    • Attach a copy of your most recent Federal Income Tax Return (1040, 1040A, 1040EZ If you filed taxes you must supply a copy of the return)
  2. If you did not file a federal tax return, you must:
    • State in writing why you did no file a Federal Income Tax Return on a separate sheet of paper
    • Send us a copy of the most recent Federal Income Tax Return of anyone who claimed you as a dependent
  3. Attach additional proof of household income, if applicable
    • 1099 forms or award letters: Social Security, Pension/Retirement, Disability, etc….
    • Unemployment Notice of Final Determination or Workers Compensation
    • Pay stubs for the last three months
    • If you are self-employed, you must include a schedule C and/or statement of income and expenses
  4. If you have no income:
    • A notarized letter of no income will be required (A Crozer Health Notary can notarize a letter stating the patient or financially responsible individual has no income)
  5. Letter of Denial for Medical Assistance:
    • Based on initial financial screening, you may need to apply for Medical Assistance and provide a copy of your Letter of Denial before Crozer Health can approve your application
  6. Completed and signed Financial Assistance Program application:
    • Make sure to complete and include all information that applies to you
    • Provide a photo ID ie. driver’s license, passport, state ID
    • Provide additional documents Requested _________________________
    • ____________________________________________________________