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(701) 628-2424

615 6th St SE, Stanley, ND 58784

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Financial Assistance - Plain Language Summary

 

Plain Language Summary of Hospital Financial Assistance Policy (FAP)

Mountrail County Medical Center is committed to providing financial assistance to persons who have health care needs and are uninsured, underinsured, ineligible for a government healthcare benefit program or otherwise unable to pay for their care based on their individual financial situation and are within Mountrail County Medical Center’s established guidelines for eligibility and availability of resources.

  1. Financial Assistance Guidelines

Financial Assistance is only available for emergency medical care and medically necessary care provided by a Mountrail County Medical Center facility (see the financial assistance policy for the definition of medically necessary). Office visits, elective procedures, supplies, and non-medically necessary services are not covered under the program. Services not billed by Mountrail County Medical Center are not eligible for the program.

Financial assistance is available for an episode of care that has occurred within the last 240 days

Eligibility is determined after reviewing an applicant’s financial circumstances, as discussed below.

All alternative payer resources, including governmental payers (i.e. Medicaid, IHS, etc.), must be exhausted prior to applying for financial assistance

  1. Required Documentation for Mountrail County Medical CenterFinancial Assistance:

To be considered complete, a submitted application must include the following:

Completed and Signed Financial Assistance application

Approval/Denial letter from Medicaid if applicable.

Copies of most recent Federal Tax Return (Form 1040 or equivalent), including all schedules

Two months of complete bank statements, both checking and savings accounts

Verification of current income, if applicable: examples include the two most recent pay stubs, pension and retirement benefits, Social Security benefits, unemployment compensation, Workers Compensation, Veteran’s benefits, etc.

If an individual has no source of income, a letter of hardship and/or a letter of support will be accepted.Other documentation may be requested by Mountrail County Medical Center to verify information on the Financial Assistance application.

  1. Program Qualifications

Financial assistance will be given to an individual if their household annual gross income (AGI) meets the following criteria.Annual Gross Income includes the annual income of the individual and all immediate family members who reside with them.

An individual is not eligible for financial assistance if their household’s combined Adjusted Gross Income (AGI) greater than 200% of Federal Poverty Guidelines (FPG).

An individual with AGI below these thresholds qualifies for 100% financial assistance.

An individual who qualifies for financial assistance will not be required to pay more for emergency medical care and other medically necessary care than the amounts generally billed to individuals who have insurance covering such care.

  1. Accessing/Applying for the Financial Assistance Policy(FAP)

Copies of the Financial Assistance Policy and application are available online at

http://stanleyhealth.org/resources

Copies of these documents are also available Mountrail County Medical Center’s Emergency Room and all admissions areas.

All documents are provided free of charge.

To obtain copies of these documents, in person or by mail, ask questions, receive assistance with completing a financial assistance application, or submit a completed Financial Assistance Application contact Mountrail County Medical Center’s Business Office through the following methods:

A. Phone: 701-628-1405

B. Fax: 701-628-3990

C. In Person: Mountrail County Medical Center, 615 6th ST SE Stanly, ND 58784

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