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Financial Assistance Policy (Full Version)

 

We offer financial help to our patients who cannot pay all or part of their medical bills. You may apply for help through our Community Care program. This program covers charges for many of our services at our clinic and hospital.

Financial Assistance Policy (Full Version)

 

Effective: January, 2020
Department: Business Office

The Financial Assistance Policy is available in the following languages, other than English: Spanish, Somali, Hmong, German, Dutch, French, Korean, Lao, Hindi, Albanian, Tagalog, Polish, Vietnamese, Russian and Chinese (Simplified). The financial policy is only translatable, for the additional languages, on our website. For a printed document in one of the above languages, please contact OMC at 715-294-2111.

Getting help paying your hospital bills

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 (see chart below).

Before applying for the Community Care program, you may be asked to first apply for help with the county or state. please visit Access website or call 1-888-283-0012. If you are not a Wisconsin resident, visit your state’s health care reform website.

What is Community Care?

You may qualify for discounted care based on your household income and assets.

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, considered experimental or care not approved by an OMC doctor

  • Care not offered at OMC

  • Services given at OMC by independent providers

  • Services not billed OMC

How do I apply?

To apply, call 715-294-5637. We will mail an application to you along with a list of the required documents (you will need to show proof of your income and property). You can also stop by the hospital/clinic information desk or call a financial counselor for assistance with the application process. You can also access the applications online.

To determine if the care you are seeking is covered by OMC’s Community Care, please ask us.

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.

Amount Generally Billed (AGB)

Following a determination of financial aid eligibility, a financial aid-eligible individual will not be charged more than the amount generally billed (AGB) to individuals who have insurance for emergency or medically necessary care.

 

2022 Poverty Guidelines - Updated 1/12/22
100%
150%
200%
220%
240%
260%
280%
300%
301%
Title
$13,590
$20,385
$27,180
$29,898
$32,616
$35,334
$38,052
$40,770
$40,906
1
$18,310
$27,465
$36,620
$40,282
$43,944
$47,606
$51,268
$54,930
$55,113
2
$23,030
$34,545
$46,060
$50,666
$55,272
$59,878
$64,484
$69,090
$69,320
3
$27,750
$41,625
$55,500
$61,050
$66,600
$72,150
$77,700
$83,250
$83,528
4
$32,470
$48,705
$64,940
$71,434
$77,928
$84,422
$90,916
$97,410
$97,735
5
$37,190
$55,785
$74,380
$81,818
$89,256
$96,694
$104,132
$111,570
$111,942
6
$41,910
$62,865
$83,820
$92,202
$100,584
$108,966
$117,348
$125,730
$126,149
7
$46,630
$69,945
$93,260
$102,586
$111,912
$121,238
$130,564
$139,890
$140,356
8
100%
100%
100%
95%
90%
85%
80%
75%
70%
Community Care Percent

*Families/Households with more than 8 persons, add $393.34 for each additional person.

How to Apply

 

Thank you for your interest in Osceola Medical Center’s Community Care Program. To apply, review the instructions below and complete our Community Care application.

Step 1: Complete and the Community Care application.

  • 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 (HAS).

  • 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.

 

Note: You will keep receiving bills until we have your complete application. This includes the records listed above.

Provider Lists

 

Osceola Medical Center has a list of all provider groups that provide emergency and medically necessary services to patients at OMC. The list identifies which providers are covered by OMC’s Financial Assistance Policy:
Warren Abell, Jr., DO; Jennifer Belisle, MD; Felix Blanco, MD; Natalia Cropper, FNP; Erika Helgerson, DO; Brad Johnson, MD; David Lang, MD; Bridget McGill, DO; Rene Milner, MD; Kevin Nepsund, MD; Tony Huy Nguyen, MD; William Ryan, PA-C; Valerie Saladin, PA-C; Rochelle Samarasekera, DO; Nicole Smith, MD; Nicole Svihel, PA-C; Amanda Tembreull, MD; Eric Valder, DO. ; Anastasios Pappas, MD; Andrew Clary, DO; Anthony Sterk, PA-C; Chukwunonso Chime, MD; Coby Somsen, FNP; Dan Anderson, MD; Desiree Scholl, DPM FACFAS; Glenn Ciegler, MD PHD; Geoffrey Service, MD; John Moore, MD; Josiah Nelson, MD; Raymond Watts, MD; Shawn O’Keefe, PA-C; Talha Khan, MD. Aaron Ous, CRNA; Bradley Byker, CRNA; Diane Voelker-Huhn, CRNA; Grant Brekken, CRNA; Jason Hoechst, CRNA; Jeffrey Simkins; Jennifer Tretsven, CRNA; Jillian Pechacek, CRNA; John Santer, CRNA; Kris Budke, CRNA; Lisa McBrayer, CRNA; Mark Waterman, CRNA; Todd Peterson, CRNA

Financial Assistance Plain Language Summary

 

The Financial Assistance Plain Language Summary is available in the following languages:

  • Downloadable from OMC website – English Only

  • Website Translation - Spanish, Somali, Hmong, German, Dutch, French, Korean, Lao, Hindi, Albanian, Tagalog, Polish, Vietnamese, Russian and Chinese (Simplified).

  • Request by phone or email – Spanish, Somali, Hmong, German, Dutch, French, Korean, Lao, Hindi, Albanian, Tagalog, Polish, Vietnamese, Russian and Chinese (Simplified).

Billing and Collections Policy

  • The billing and collections policy is available in the following languages, other than English: Spanish, Somali, Hmong, German, Dutch, French, Korean, Lao, Hindi, Albanian, Tagalog, Polish, Vietnamese, Russian and Chinese (Simplified).

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