Click here to download and print an application for Financial Assistance
St. Mary’s Good Samaritan, Inc.
FINANCIAL ASSISTANCE ELIGIBILITY CRITERIA
St. Mary’s Good Samaritan, Inc., as part of its charitable mission and healing ministry, provides a reasonable amount of its services without charge or at a reduced charge to eligible persons who cannot afford to pay for health care. Financial assistance with your health care is limited to those services provided by St. Mary’s Good Samaritan, Inc. Services not eligible for financial assistance include, but are not limited to, medically unnecessary services and services generally not covered by 3rd party payors.
The amount of financial assistance for which you are eligible is based upon the following porverty guidelines issued by the Department of Health and Human Services. They may be found in the Federal Register with effective date February 1, 2013. St. Mary’s Good Samaritan, Inc., will provide care without charge to anyone whose family income is less than 2 times the poverty guideline, if the required financial documentation is presented in a timely manner:
|
Size of Family |
Poverty Guideline |
Without Charge Guideline |
|
1 |
$11,490 |
$22,980 |
|
2 |
$15,510 |
$31,020 |
|
3 |
$19,530 |
$39,060 |
|
4 |
$23,550 |
$47,100 |
|
5 |
$27,570 |
$55,140 |
|
6 |
$31,590 |
$63,180 |
|
7 |
$35,610 |
$71,220 |
|
8 |
$39,630 |
$79,260 |
|
For each additional family member, add |
$ 4,020 |
$ 8,040 |
If your income exceeds these financial guidelines and you believe you are unable to pay your account or have unusual or extenuating circumstances, please submit a completed application with necessary documentation and your eligibility will be reviewed.
If you think you may be eligible for financial assistance with your hospital bill, please inform Patient Accounts at St. Mary’s Good Samaritan, Inc. A written conditional or final determination of your eligibility for uncompensated services will be made as soon as possible.
If you are potentially eligible for Medicaid, we must have a copy of your approval or denial from Illinois Department of Public Aid. Our Financial Counselor can tell you if your circumstances require a Medicaid determination of eligibility.