Affordable Care Plan
Affordable Care Plan
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2013 Financial Assistance Policy Summary

To provide relief for medical expenses incurred by patients who reside within our primary service area who do not have the financial resources to pay for their Roper St. Francis Healthcare services. 

Roper St Francis Healthcare (“RSFH”) will offer financial assistance and Medical Indigency Adjustments to patients who meet the established Financial Assistance guidelines. Family size and the Federal Poverty Guidelines published annually by the Department of Health and Human Services will be the primary factors used to determine Financial Assistance eligibility. 

The patient and/or guarantor’s gross income, assets and expenses, and the dollar amount of the hospital bill may be taken into consideration. Patients with an annual income of 400% or less of the Federal Poverty Guidelines may be eligible for Charity Adjustments. Medical Indigency Adjustments may be available for patients whose RSFH medical expenses outweigh the ability to pay, constituting a financial hardship. This is based on medical expenses that exceed 20% of the guarantor’s annual gross income per calendar year. 

The hospital shall send to anyone who requests information on the hospital’s Financial Assistance Program a letter outlining required information and a financial assistance application form. Requests for financial assistance may be proposed by sources other than the patient, such as the patient’s physician, family members, social service organizations, community or religious groups, or hospital personnel. Applications for Financial Assistance must be complete and accurate to qualify for financial assistance. 

RSFH shall render services to all members of the community who are in need of medical care regardless of the ability of the patient, insured or uninsured, to pay for services. The determination of full or partial financial Assistance will be based on the patient’s ability to pay and will not be abridged on the basis of age, sex, race, creed, religion, disability, sexual orientation or national origin. Non U.S. residents must provide necessary documentation proving legal visitation rights, for example, a tourist, work or student visa.

Financial Assistance Services:
Financial Assistance applications will be accepted for consideration for all services. (Each Family member over the age of 18 must complete and sign their own application.) Cosmetic services, sterilization reversals, Bariatric Services and erectile dysfunction are not eligible. Birth defects are not considered cosmetic. Accounts indicating possible third party involvement (i.e., worker’s compensation, auto accident coverage) will be reviewed in detail and may require proof of no third party liability.

Determination of Eligibility:
Verifiable proof of total household income and/or assets may be required to approve financial assistance.   Examples of verifiable proof include, but are not limited to:

  • Current year Federal Income Tax Return
  • W-2 forms
  • Social Security Benefits
  • Alimony
  • Trusts
  • Annuities
  • Pensions
  • Retirement Benefits
  • Disability Income
  • Unemployment Benefits
  • Student Loan Disbursements
  • Unreported income
  • Payroll check stubs
  • Tax records
  • Current SNAP Approval Letter
  • 3 consecutive months of Bank Statements from the Date application was received


All other avenues of payment must be exhausted prior to granting Hospital Financial Assistance (i.e., government and commercial insurance payments, third party payments, Medicaid, Third Party Liability, Workers Comp, etc.).

Patients that abuse the RSFPP Financial Assistance Program, either by requesting unnecessary procedures, inappropriate actions toward staff, or by utilizing an unnecessary treatment location, may be denied Financial Assistance. These instances will be reviewed by RSFPP Management to determine if the services are to be excluded.

Total Household Income is defined as all available income to the dependent patient, which is indicated on the Federal Income Tax Return, and/or all other income sources listed above.  If a current Federal Income Tax Return and/or the above income sources are unavailable, the income information and/or the monthly expenses listed on the application may be considered for charity calculations.

Guarantors who have filed for bankruptcy under chapter 7 and 13 (discharged and voluntary) are considered destitute and will be approved for 100% Charity adjustment. Upon determination that a patient has filed for bankruptcy, we will obtain the Bankruptcy Letter to determine the timeframe and entities for relief of debt.  If we are listed as a debtor, the balance will be adjusted.

The need for Financial Assistance may be a sensitive and deeply personal issue for the recipients.Confidentiality of information and preservation of individual dignity shall be maintained for all who seek charitable services. Orientation of staff and the selection of personnel who will implement this policy and procedure should be guided by these standards. No information obtained in the patient’s Financial Assistance Application will be released without expressed permission for such release.  Applications will be scanned in the imaging system and only accessible to select personnel. Hard copy documentation will be shredded.