Financial Assistance Policy Application


Rural Health Resources of Jackson Co Inc (RHRJC), d.b.a. Holton Community Hospital, a not-for-profit corporation, is committed to providing financial assistance to persons who have health care needs and are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay for emergency or other medically-necessary care based on their household financial situation. As a participant in the Medicare/Medicaid program, RHRJC will provide, without discrimination, care of emergency medical conditions to individuals regardless of their ability to pay at the time of service.


Individuals expressing an inability to pay for emergency and other medically necessary care at Rural Health Resources of Jackson County (RHRJC) will be asked to complete a financial assistance application form and supply supporting documentation so they can be evaluated for Financial Assistance discounts. Financial Assistance is extended with the expectation that patients will cooperate with RHRJC procedures for applying for such financial assistance.


This policy applies to all RHRJC facilities including but not limited to:

1) Holton Community Hospital

2) Family Practice Associates - Holton

3) Family Practice Associates - Hoyt

4) Family Practice Associates - Wetmore

5) Holton Community Hospital - Home Health

6) Holton Community Hospital - Hospice

RHRJC has several Non-affiliated providers who provide professional services at the above locations. These providers bill for their own services and may not adopt or follow this procedure. These providers are listed in Appendix A.

Eligibility Criteria

Individuals will be evaluated for financial assistance eligibility under this policy. RHRJC will not deny requested health care services and shall not discriminate in the provisions of services to an individual because the individual is unable to pay for the services.

RHRJC will accept and process financial assistance application forms for up to 240th day after RHRJC provided the individual with the first patient billing statement.

Financial Assistance Discounts

RHRJC determines the level of financial assistance discounts based on the Federal Poverty Levels that is issued annually by the Department of Health and Human Services. For annual incomes between 0%-100%, the financial assistance discount is 100% of charges for any emergency or other medically necessary care. For annual incomes between 101%-200%, the financial assistance discount is based on the requirement of section 501 (r)(5) that limits the amount charged for any emergency or other medically necessary care to not more than the Amounts Generally Billed (AGB) to individuals with insurance covering that care. Applicable rates are listed on the Financial Assistance Application.

Basis for Calculating Financial Assistant Discounts and Amount Charged to Patients

RHRJC uses the "look-back" method to calculate the AGB. This method is based on 12 months of paid claims for Medicare fee-for-service and private health insurers. The amount paid includes both the insurance payment and the patient's out-of-pocket responsibility for emergency and other medically necessary care. RHRJC will calculate its AGB percentages no less than annually by dividing the sum of claim payments to RHRJC by the sum of the associated gross charges for these claims. RHRJC will apply its AGB percentage by the 45th day after the end of the 12-month period RHRJC used in calculating the AGB percentage.

RHRJC will multiply the AGB percentage times the individual's gross charges to arrive at the financial assistance discount. The financial discount will be subtracted from gross charges to determine the AGB that will be billed to the individual.

How To Apply For Financial Assistance

Individuals can apply for financial assistance by:

1) Obtaining a paper Financial Assistance Application form with instructions on how to complete and required documentation to submit, free of charge, by visiting the hospital or clinic patient registration areas, or by calling the Business Office to have an application mailed.

2) Downloading/printing a Financial Assistance Application form from the RHRJC website. (

3) Requesting a Financial Assistance Application form from a collection agency if the account has been turned to collections due to non-payment.

Business Office staff will be available to assist individuals with questions on how to complete financial assistance applications.

Actions That May Be Taken In The Event of Nonpayment

RHRJC will not engage in extraordinary collections actions (ECA) against an individual before making reasonable efforts to determine whether the individual has insurance coverage or is eligible for financial assistance.

For the purposes of this policy, ECA includes lawsuits, liens on residents, arrests, subjecting individual to writ of body attachments, garnishment of wages, foreclosure of real property, seizure of bank account or other personal properly, sale of debt to another party, and reporting to credit agencies.

For the purposes of this policy, reasonable efforts to determine financial assistance eligibility includes providing individual with a plain language summary (brochure) of the financial assistance program, a notice on all patient billing statements and other written communications regarding billings, oral communications regarding amount due, and other means available to RHRJC to identify individuals who may be eligible for insurance coverage or financial assistance.

If there is no payment, or a financial assistance application has not been submitted by the 120th day after RHRJC provided the individual with the first patient billing statement RHRJC may engage in ECA. The Business Office Manager will have responsibility for determining if RHRJC made reasonable efforts to identify individuals who are eligible for financial assistance, before proceeding with ECA.

Measures to Publicize Financial Assistance Program (FAP) in the Community

RHRJC will widely publicize the financial assistance program by posting information on the RHRJC website, notifying and distributing information to patients at all RHRJC registration areas when they present for service, making information available in registration waiting rooms, including information on patient billing statements, mentioning FAP when discussing an individual's bill over the phone, and by publicizing FAP to community health centers and social service agencies.

Financial Assistance Policy Application