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Community Care Fund

The Community care program covers charges at Osceola Medical Center’s clinic and hospital. You may qualify if your income is at or below 301% of the Federal Policy Guidelines.

Before applying for the Community Care program, you may be asked to first apply for help with the county or state. If you currently have no coverage and are a Wisconsin resident, please visit Access website or call 1-888-283-0012. If you are not a Wisconsin resident, visit you state’s health care reform website.

Services covered

The Osceola Medical Center Community Care program covers charges for most OMC hospital-based and clinic-based services. It does not cover charges for:

  • Care that is not needed care not approved by a OMC doctor or trial treatments)

  • Care not offered at OMC

  • Services given at OMC by independent providers

  • Services not billed OMC

 

If you do not know whether the care you are seeking is covered by OMC’s Community Care, please ask us. If you have questions, call 715-294-5637 or (toll free) 1-888-565-4662.

Income Guidelines

If you qualify for the program, 70 percent up to 100 percent of your bill may be paid depending on your gross annual income, family size and asset guidelines. You must comply with all the terms of the program when you apply, and we also ask you to follow the rules set by your insurance plan.

100%
150%
200%
220%
240%
260%
280%
300%
301%
Title
Persons in Family
100%
100%
100%
95%
90%
85%
80%
75%
70%
Community Care Percentage
Community Care Percent
$46,630
$69,945
$93,260
$102,586
$111,912
$121,238
$130,564
$139,890
$140,356
8
8
$41,910
$62,865
$83,820
$92,202
$100,584
$108,966
$117,348
$125,730
$126,149
7
7
$37,190
$55,785
$74,380
$81,818
$89,256
$96,694
$104,132
$111,570
$111,942
6
6
$32,470
$48,705
$64,940
$71,434
$77,928
$84,422
$90,916
$97,410
$97,735
5
5
$27,750
$41,625
$55,500
$61,050
$66,600
$72,150
$77,700
$83,250
$83,528
4
4
$23,030
$34,545
$46,060
$50,666
$55,272
$59,878
$64,484
$69,090
$69,320
3
3
$18,310
$27,465
$36,620
$40,282
$43,944
$47,606
$51,268
$54,930
$55,113
2
2
$13,590
$20,385
$27,180
$29,898
$32,616
$35,334
$38,052
$40,770
$40,906
1
1

How to Apply

To apply, review the instructions below and complete our Community Care Application (in PDF). The application is also available in Spanish, Somali, Hmong, German, Dutch, French, Korean, Lao, Hindi, Albanian, Tagalog, Polish, Vietnamese, Russian and Chinese (Simplified).

Step 1

Complete and sign this form.

  • List the names and birth dates for each family member applying for the program. If you do not list them on the form, they will not be included.

  • If your spouse is also applying for this program, both of you must sign the form.

  • Your family includes a spouse, dependent children and any person for whom you have legal guardianship.

 

Step 2

Attach these items to the form. We will keep your records confidential (private). Please include records for all adults in your household.

  • A copy of your most recent 1040 Federal Income Tax form. Do not include W2 forms.

  • Records of income are to include copies of the two most recent payroll stubs. (Example: pay stubs that show your year-to-date earnings).

  • Copies of bank statements for all checking and savings accounts for the last 30 days. Include the last statement for any CDs (Certificates of Deposit).

  • Records of all retirement savings: employee pension plans, 401K plans, 403b plans, annuities, IRAs.

  • Record of current balances in all health savings accounts (HSA).

  • Optional: a letter explaining any recent events that might affect your ability to pay your medical bills.

Step 3

Return the form with the above records to the following address:
Osceola Medical Center Attn: Community Care 2600 65th Avenue, PO Box 218, Osceola, WI 54020

Step 4

If you have applied for insurance coverage via Forward Health or MNSure for the Affordable Care Act, send the application results. You will keep receiving bills until we have your complete application. This includes the records listed above.

For more information, call one of our financial counselors or patient advocate at 715-294-2111 or 888-565-4662.

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