Financial Assistance / Charity Care Policy

Brookhaven Memorial Hospital Medical Center provides free or discounted emergent and non-emergent necessary care for uninsured and underinsured patients residing in Suffolk and Nassau County, as well as emergent care to patients residing in all other areas of New York State.

Specific Exclusions

Charity Care will not be available as part of its mission for non-medically necessary services, including but not limited to cosmetic surgery. Physician's fees are NOT covered by Charity Care policy.

Family Income

Includes earnings, unemployment, worker's compensation, Social Security, pension/retirement income, interest, alimony, supplemental or other income and royalties.

Eligibility

Eligibility is based upon family size and income level.

Patients qualify for 100% of Charity Care if their family income is at or below 200% of the Federal Poverty Level (FPL).

If family income is betweenQualifies for % of Charity Care
201%-250% 90%
251%-300% 80%
301%-350% 45%
351%-400% 25%
401%-425% 10%

Patient eligibility for free care is determined by measuring family income against the Income Poverty Guidelines established by the U.S. Department of Health and Human Services. The current requirements are as follows:

Size of Family UnitTwo Times the Poverty Guidelines
1 $23,760
2 $32,040
3 $40,320
4 $48,600
5 $56,880
6 $65,160
7 $73,460
8 $81,780

For family units with more than 8 members add $4,160.00. for each additional member
Reimbursement rates are based upon Medicare Prospective payment rates
**If Financial Assistance Policy is approved = Approval valid for 6 continuous months, for future services
*If hospital reasonably believes applicant may be eligible for Medicaid or other government sponsored insurance coverage - applicant shall be required to cooperate by applying for such coverage as a condition of receiving financial assistance.

Patient eligibility for partial charity care will be based on a sliding fee scale when family income exceeds the above stated amounts. Family unit and income are defined using guidelines issued by the Department of Health and Human Services.

If you think you may be eligible for free care or care at reduced rates and wish to request it, please complete the Hospital's charity care application attached and return it to the Patient Financial Services Department at the address below. Documentation to support the income for all related family members residing at the same address must also be submitted. The Patient Financial Services Department will make a written determination of eligibility after reviewing the application and the information submitted to support the family income reported. If however, based on income and family size, we believe that you may qualify for Medicaid benefits, you may first need to apply for Medicaid or other government sponsored program for the uninsured before a determination will be made under this charity care policy.

If you are returning the application in person, please bring it along with proof of family income to the Hospital Cashier's office. Office located near the Emergency Department at the hospital. Hours of operation are Monday through Friday 8:am through 4:00pm.

Please call the Patient Financial Services Department at (631) 654-7130 or 654-7140 if you have any questions regarding this process.

Application

Patient can seek to apply for financial assistance within 90 days from the date of service. The completed application must be submitted within 240 days from the date of the first billing notice.

Acceptable Documentation for Charity Care

The completed signed application listing all family members, must be filled out and returned to the Patient Financial Services department along with the following:

  1. Proof of income for the last three (3) consecutive months.
    Examples of Acceptable Documents include: pay stubs, W-2's, Social Security checks, unemployment checks.
    (If Self Employed - a copy of Income Tax filed for the prior year, current P&L, income for the last 3 months may be requested)
  2. Verification of the number of Dependents and Marital status.
    Examples of Acceptable Documents include:
    a) Copy of Marriage License
    b) Copies of Birth Certificate for each dependent
    c) A copy of Page 1 of the prior years filed tax return to indicate the # of dependents claimed.
  3. If you have no income information, and you are being supported by another person, You must provide a letter signed by the person providing the support indicating the amount of support provided to you.
  4. If you are paid by your employer in Cash - a written, signed statement prepared by your employer on your employer's letterhead indicating the amount paid to you must be provided to the Medical Center.

Download Application Forms

Charity Care Application
PolĂ­tica de Asistencia Financiera

Application Decisions

All decisions will be rendered in writing to the applicant within 30 days of hospital's receipt of a completed application.

Payment Determinations

If financial assistance is approved - a clear explanation of balance due and how the decision was derived will be supplied. Monthly payment plans can be arranged; not to exceed 10% of the applicant's monthly gross income.

If the applicant defaults on a financial agreement with the hospital, the account(s) in question will be considered delinquent and may be referred to a collection agency.

Appeals Process

Applicant has the right to appeal hospitals decision on eligibility of Charity Care within 30 days of notification of non-eligibility. Appeal can only be submitted based upon the following:

  • A change in the applicant's financial status has occurred
  • Incorrect information was provided
  • Or due to extenuating circumstances

*Director of Patient Accounts will decide appeals in cases where change in applicants financial status or incorrect information was provided. The VP &/or Director of Patient Accounts will decide appeals on cases involving extenuating circumstances.

Appeal should be in writing and addressed to:
Director of Patient Accounts
Brookhaven Memorial Hospital Medical Center
101 Hospital Rd
Patchogue, NY 11772

Patient Financial Services will make reasonable efforts to issue an appeal decision within 45 days of receipt of applicant appeal. Patient Financial Services, at its discretion, may request that an applicant appeal be filed for government sponsored benefits as part of the Charity Care appeal process.

Collection Agencies

Must follow the same principals as outlined in the hospital collection policy, as well as follow hospitals Financial Assistance policy.

Communication

Financial Assistance signs are posted in both English and Spanish in Patient Financial Services, the Emergency Room, OutPatient registration areas. Applications and Financial Assistance policy are part of the admission/discharge packets for uninsured patients, supplied in direct response to inquiries made to Patient Financial Service department, is referenced on bills sent to all self pay patients/guarantors.

** A copy of the hospitals collection policy can be obtained here

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