Subject: Financial Assistance Discount Policy Page: 1 Of: 19

Transcription

1 Revenue Cycle Management Policy and Procedure Policy Number: 1 LD. RC.0026 Subject: Financial Assistance Discount Policy Page: 1 Of: 19 Effective: October 1, 1991 Revised: October 1, 2016 Approved by: Board of Directors on October 27, 2015 Revised Approval by: Sr. VP of Finance and CFO This Financial Assistance Discount Policy of Mission Health is applicable to health care services provided by the Mission Health facilities listed in Appendix C. I. POLICY Within the constraints of prudently available resources, it is the policy of Mission Health to provide relief for medical expenses incurred by individuals and families who do not have the financial resources to pay in whole for their health care services. Mission Health will balance obligations to provide uncompensated care for patients who are unable to pay with its fiduciary responsibility to preserve assets for serving future patients. Mission Health will make reasonable efforts to screen patients who are uninsured in an effort to identify a source of financial sponsorship. Cases may be reviewed during hospitalization, post discharge upon patient s request, or if Mission Health staff identifies an additional need. This policy defines financial assistance discount parameters for individual patients. Mission Health s financial assistance discount capacity for a given fiscal period defines the parameters within which management will seek to administer this policy. Financial assistance discounts are determined using criteria such as the application time period, income, and the availability of payment sources, considered in relation to the nature and extent of medical services required. With these criteria, patients may be eligible to receive a discount off their total responsibility of account balances based on their annualized total income in relation to the most recently published Health and Human Services (HHS) Federal Poverty Guidelines (FPG). Percentage of HHS FPG Inpatient, Observation, OP Surgery, OP Cath Uninsured Patients: Financial Assistance Discount Amount ER & Other Outpatient Physician Services Less than or equal to 100% 100%, $50 Visit Fee 100%, $25 Visit Fee 100%, $10 Visit Fee 101% to 200% 100%, $500 Visit Fee 100%, $75 Visit Fee 100%, $20 Visit Fee 201% - 300% 70% 70% 70% Percentage of HHS FPG Inpatient, Observation, OP Surgery, OP Cath Insured Patients: Financial Assistance Discount Amount ER & Other Outpatient Physician Services Less than or equal to 100% 100% 100% 100% 101% to 200% 100% 100% 100% 201% - 300% 70% 70% 70%

2 Financial Assistance Discount Policy -- #D Page: 2 Of: 19 II. PURPOSE AND GUIDING PRINCIPLES 1. We serve the emergency health care needs of all patients regardless of the patient s ability to pay. 2. For non-emergency health care needs, even for patients who might qualify for discounts under this policy, patients must work collaboratively with a Mission Health Representative to establish appropriate payment arrangements. Financial counseling is provided to patients who seek health care services including efforts to help such patients identify available programs or financial assistance for which they might qualify. 3. It is the intent of this policy that all patients qualifying under the policy will receive a discount equivalent to the discount received by Medicare and privately insured patients. This minimum discount level is calculated at least annually by dividing the sum of all Medicare and commercial insurance payments for emergency and other medically necessary care from claims that have been paid in full, by the sum of the associated gross charges for those claims. 4. Upon request, patients are provided detailed charge information in a meaningful format for the charges they incurred for services. 5. Mission Health informs the public about the Financial Assistance Discount policy, the policy application form, and the plain language summary of the policy by messaging on patient billing statements, the Mission Health website, conspicuous postings throughout each facility, patient friendly materials in public areas of the facilities, financial counseling with patients and families, and upon request without charge. The plain language summary of the policy is offered to patients as part of the admission process and displayed on the back of the billing statements. 6. Patients can get additional information, including a list of hospitals and physician practices covered under the Mission Health Financial Assistance Discount policy, as well as apply for financial assistance by the following: On-line at the Mission Health web site: In person at the Mission Health Business office, 50 Schenck Parkway, Asheville, NC By phone at (828) or Mission Health staff will work in collaboration with the patient and appropriate community health and human services agencies, and other organizations that assist people in need of health care services to determine available funding sources. 8. All policies and procedures applying to financial assistance and financial clearance are applied consistently and include reasonable efforts to ensure that financial assistance is offered before any collection agency assignment. 9. Mission Health staff members who work closely with patients are educated and trained about billing, financial assistance, and collection policies. 10. All patients are afforded an opportunity to establish reasonable payment plans.

3 Financial Assistance Discount Policy -- #D Page: 3 Of: Mission Health reserves the right to amend a final decision or reverse a financial assistance discount previously recorded if it is needed to secure third party insurance coverage, if it is determined that additional third party payer resources were or would have been available, if the patient did not cooperate fully as required by this policy, if some information provided may be false, or if the determination was made in error. Patients will be notified and afforded an opportunity to provide clarification. 12. Mission Health reserves the right to require proof of income if there is reason to believe the information provided is not complete and accurate. 13. Mission Health will comply with all rules and regulations related to financial assistance policies. In particular, Mission Health will comply with 26 USC 501(r) as it relates to requirements regarding financial assistance policies, emergency medical care policies, limitation on charges and billing and collection requirements. 14. Mission Health limits amounts charged for emergency or other medically necessary care provided to individuals eligible for assistance under the Financial Assistance Discount Policy (FADP) to not more than the amounts generally billed to individuals who have insurance covering such care and prohibits the use of gross charges. III. DEFINITIONS A. Amounts Generally Billed (AGB) Mission will use the look-back method in determining AGB for any emergency or other medically necessary care it provides to a FADP-eligible individual. The AGB percentage will be calculated annually by dividing the sum of all claims for emergency and medically necessary care that have been paid in full during a prior 12-month period by the sum of the associated gross charges for those claims. Claims paid will include claims paid by both Medicare fee-for-service and all private health insurers as primary payers, together with any associated portions of these claims paid by Medicare beneficiaries or insured individuals in the form of Visit Fees, co-insurance or deductibles. The AGB percentages for each hospital facility are listed below: Facility AGB Mission Hospital 39.90% Angel Medical Center 37.97% Blue Ridge Regional Hospital 38.77% Highlands-Cashiers Hospital 58.10% McDowell Hospital 35.29% Transylvania Regional Hospital 41.94% CarePartners 65.91% Asheville Specialty Hospital 40.30% B. Federal Poverty Guidelines The standards used by the United States Department of Health and Human Services (HHS) for determining whether a person or family is financially eligible for assistance or services under a particular federal program. The Federal Poverty Guidelines (FPG) is updated annually by HHS, and is published each year in the Federal Register. The FPG in effect at the time of the Financial Assistance Application review and determination will be used. Current information about the FPG can be found on the HHS web site at:

4 Financial Assistance Discount Policy -- #D Page: 4 Of: 19 C. Financial Assistance Application Period The application time period patients may apply for financial assistance discounts is 240 days from the first billing statement. Accounts beyond this 240 day application period are not eligible for a financial assistance discount unless there are special circumstances that warrant an exception and are approved by management. D. Financial Assistance Discount Policy (FADP) - Eligible Account An eligible account is an account of a patient from a Mission Health facility listed in Appendix A where there is an outstanding balance due from the guarantor, where the annualized total income (based on Mission Health s procedure for calculating income) is at or below 300% of the Federal Poverty Guidelines for the patient s family/household, and where medical necessary services were provided. Any other discounts negotiated with patients, third party payers, employers, attorneys, or others are not governed under this policy. Accounts for services listed in Appendix A are not eligible for financial assistance. E. Eligible Weight Management Services Weight management services that are eligible for a discount include office visits with a licensed or registered provider (MD, PA/FNP, Psychologist, Behaviorist, and Dietician) at Mission s Weight Management Center. Bariatric surgery services are eligible for those patients who reside in Mission Health s 18 county service area in Western North Carolina (Appendix B) and have been approved by Mission s Weight Management Center. Bariatric surgery Financial Assistance discount criteria is as follows: HHS FPG 0% to 200% - Eligible for a 100% discount with a $500 Visit Fee paid in advance. HHS FPG 201% to 300% - Eligible for a 70% discount. F. Family/Household The family/household is inclusive of those living in a home comprising a single family. Dependents of the financially responsible party are also included regardless of their residence. Examples of individuals which can be included as members of a family/household include (but are not limited to): Patient Spouse Partner sharing the home Mother/Legal guardian of dependent child(ren) 17 years old and under Father/Legal guardian of dependent child(ren) 17 years old and under Dependent children 17 years old and under Other adults living in the home G. Financial Assistance When Mission Health qualifies a patient for financial assistance based on approved qualification criteria, it conditionally and gratuitously suspends its legal right to demand full compensation for outstanding charges due from the patient. Full compensation shall mean the amount of money that Mission Health is entitled to receive for a particular health care service or product if no discounts are applied. An application is initiated by completion of the Financial Statement. Any financial assistance discount for which a patient may be deemed eligible is strictly provisional until it becomes final as provided in this policy. Until a provisional discount becomes final, the patient s legal obligation to render full compensation continues. In addition, a discount determination that has become final may be reopened and modified by Mission in the circumstances specified herein. This policy is not a contract, and no financial assistance discount determination, whether provisional or final, neither constitutes a contractual agreement nor creates

5 Financial Assistance Discount Policy -- #D Page: 5 Of: 19 any legal or equitable right or property interest for the patient. No financial assistance discount administered pursuant to this policy involves a transfer of any funds, federal or otherwise. H. Uninsured Patient A person who has no health insurance, or no health insurance coverage. I. Insured Patient A person who has a health insurance policy. IV. PROCEDURE FOR DISCOUNT DETERMINATION A. Emergency Services 1. Mission Health fully complies with all obligations imposed by the Emergency Medical Treatment and Active Labor Act ( EMTALA ) and the 501(r)(4)(B)), Emergency Medical Care Policy, and related regulations. This includes but is not limited to providing a medical screening exam to any patient who comes to Mission Health emergency departments and requests an examination or treatment for an emergency medical condition, including active labor without regard to a patient s ability to pay and without requiring any pre-treatment financial screening. This practice also relates to the provision of either stabilizing treatment or transferring patients with emergency medical conditions. Additionally, Mission Health will not engage in actions that discourage patients from seeking emergency medical care nor will any activities be undertaken that interfere with the provision of emergency medical care. Prohibited actions include demanding emergency department patients to pay before receiving treatment or permitting debt collection activities to occur in the emergency department and in other locations where emergency medical care is provided. B. Discount Determination Procedures 1. Mission Health may automate some financial assistance determinations. Patients may appeal an automated decision for manual review. There are certain situations that qualify an account for a 100% presumptive or indigent discount and do not require an application or supporting financial documentation. Account notes and medical records may support eligibility determination for Medicaid eligible patients with residual balances, patients living in government assisted housing, homeless patients, incarcerated patients, patients in substance abuse treatment programs, deceased patients without an estate, or patients in situations that make it impractical to apply for financial assistance. In addition, 100% presumptive discounts may be automatically applied to accounts where the patient s financial assistance expiration date is within 12 months of the date of service. 2. Any patient who has or anticipates incurring financial obligations to Mission Health for FADP eligible services, may at any time (preadmission, during the course of a treatment, or at any time after treatment) request a determination for qualification for financial assistance. This policy applies to both patients with and without insurance benefits. 3. A patient s insurance status (Uninsured or Insured) will be based on whether the patient has insurance coverage on the date of service and will be evaluated at the account level. 4. All insured patients with a denied claim on a FAP-Eligible Account, which leaves them responsible for the charges, are eligible to apply for a financial assistance discount. 5. For financial assistance eligibility, the assessment of the annualized total income of those legally liable for health care services will be required. This may include those who have

6 Financial Assistance Discount Policy -- #D Page: 6 Of: 19 signed a Potential Health Plan Denial (PHPD), those who have signed an Advance Beneficiary Notice (ABN), the patient, the financially responsible party, or a spouse if living in the household or legally responsible for the health care debt. 6. Upon evaluation of the patient s annualized total income and satisfaction of any other eligibility criteria contemplated herein, financial assistance discounts will be provisionally applied according to the chart in policy section I, contained herein. A Self-Employed patient s annualized income will be calculated based on the total income reflected on their most recent tax return. Patients with a total income greater than 300% of the most recently published HHS Federal Poverty Guidelines may be eligible for a discount under the catastrophic provision of this policy. 7. Verification of income may be done in a variety of ways. Some of the most common include, but are not limited to, pay stubs, tax records including W2 s and tax returns, and bank statements. If a patient does not have income or does not have any documentation of their income, they will be asked to complete and sign a Statement of Daily Living Expenses as documentation of their situation and how they are able to meet daily living needs. 8. Other situations qualify for a 100% indigent care discount and do not require an application or supporting financial documentation. In these situations, qualified hospital staff will reasonably determine indigent status using due diligence, documenting their findings based on available information in the account notes, medical records and external sources. 9. To complete the discount determination process for any discount described in this policy, an applicant must cooperate fully with Mission Health staff and other potential payers to exhaust the possibility of qualifying for governmental or other third party payment for medical services requested or received. Exhaustion of such possibilities includes fulfilling a deductible waiting period, which means postponing the finalization of any provisional financial assistance discount for which a patient might be eligible until such time as it is reasonably determined by Mission that the medical bill at issue cannot be used to reduce or satisfy the patient s deductible or spend-down for purposes of governmental or thirdparty insurance. 10. An essential element of the financial assistance process involves provision by the patient of complete information and verification as needed about all relevant income information for the patient and anyone else financially obligated for payment of the medical services requested or provided. This information includes but is not limited to completion of the Patient Financial Statement and provision of any related verifications requested. Additionally, if the balances are $2,000 or less, the patient is not required to sign the Patient Financial Statement or provide income verifications. 11. Patients who are eligible for provisional discounts will be notified in writing at the time of approval as to the level of the provisional discount, any applicable Visit Fees, and the approval period. 12. All provisional discounts as reductions in the patient s financial obligation to Mission Health will become final and will be credited to the patient s account only following a final determination by Mission that the patient has complied with this policy including the requirements of cooperation, exhaustion, and deductible waiting periods. A record of all discounts that become final and are written off pursuant to this policy will be maintained.

7 Financial Assistance Discount Policy -- #D Page: 7 Of: Financial assistance discounts for unisured accounts will be applied to the gross charges for the account. Financial assistance discounts for insured accounts will be applied to the patient s responsibility after the insurance benefits have been applied to the account. 14. Once the provisional discounts have been applied, any remaining balance including Visit Fees will be the patient s responsibility and collected through the normal patient billing and collection procedures and if unpaid, may be placed with a third party collection agency. The actions which may be taken in the event of nonpayment for outstanding balances is described in a separate billing and collections policy, a copy of which may be obtained at no cost by contacting the Mission Health Business Office, 50 Schenck Parkway, Asheville, NC 28803, (828) or At the time of approval, provisional discounts will be applied to all existing account balances meeting the eligibility criteria described in the policy. Financial Assistance Visit Fees will not be applied to existing balances being discounted at the time of approval, but will be due at the time of service for all future services during the patient s approval period. Visit Fees not paid at the time of service will remain the patient s responsibility and will be collected through the normal patient billing and collection procedures and, if unpaid, may be placed with a third party collection agency. 16. Patients approved for a provisional discount pursuant to Mission Health Financial Assistance Discount Policy will need to be re-evaluated for financial assistance when they require future services after 6 months from last discount approval date. If the patient is receiving a Social Security monthly check, the financial assistance approval will be valid for one year versus a 6 month period. All balances will be subject to the approved discount percentage with the exception of accounts beyond the 240 day application period and those accounts where the patient is deceased with an outstanding estate. A guarantor may reapply within the application period for financial assistance when total income or household family unit change in a manner that warrants re-evaluation. C. Catastrophic Discounts Separate from the Financial Assistance discounts described in this policy, patient balances may also be eligible for a Catastrophic Discount. In order to qualify, a completed Patient Financial Statement must be signed by the guarantor, and all income must be verified. Upon meeting these requirements, the patient s balance due will be provisionally discounted such that after other discounts in this policy become final and have been applied, the remaining balance will not exceed 15% of the annualized total income, as documented on the signed financial statement. D. Control Mechanisms 1. Any person with authorized approval to sign off on provisional or final financial assistance discounts will be prohibited from taking applications and/or making recommendations for financial assistance write offs on their family members and friends. These applications must be referred to another staff member for determination and completion. If any relationships/situations are questionable, they should be forwarded to another authorized person for completion. Violations will warrant disciplinary action. 2. Once a financial statement is completed and signed and a determination is made regarding qualification for a provisional financial assistance discount, proof of income will be required

8 Financial Assistance Discount Policy -- #D Page: 8 Of: 19 when the total amount of the balances at the time of determination are greater than $2,000. Additionally, if the total amount of the balances at the time of determination are $2,000 or less, the patient is not required to sign the financial statement or provide income verifications. In cases where the determination is made on balances less than $2,000, additional verifications will not be required during the approval period even if new balances exceed $2, A Revenue Cycle management team member will conduct quarterly departmental audits of five random financial assistance applications. Results will be shared with a designated Director of the Revenue Cycle followed by remedial education as appropriate. 4. Approval levels for Mission Health are: $1 - $10,000 Designated Revenue Cycle Staff Members $10,001 - $50,000 Designated Revenue Cycle Supervisor or Manager $50,001 - $100,000 Designated Revenue Cycle Director or Executive Director Over $100,000 Revenue Cycle Vice President 5. Mission Health Financial Assistance Discount Policy will be reviewed at least annually by the Vice President of Revenue Cycle Management and recommendations for revisions, updates and/or confirmation of no changes to the policy will be made and forwarded to the Sr. Vice President of Finance and CFO for review and approval/signature. Effective: 12/1/07 Reviewed: 10/91, 1/05, 10/06, 9/07, 8/09, 11/10, 4/11, 6/11, 11/11, 9/10/12, 10/31/12, 2/18/13, 8/15/13, 12/16/13, 7/01/14, 11/10/14, 10/01/16

9 Financial Assistance Discount Policy -- #D Page: 9 Of: 19 Appendix A Accounts for elective and not medically necessary services are not eligible for financial assistance discounts. Some examples of these services include, but are not limited to: Cosmetic procedures and surgery Food Products Supplements Other services that are not eligible for financial assistance discounts include: Prosthetics and Orthotics Adult Day Care Private Duty Nursing Hospice Transitional Care Driving Evaluations Outpatient rehab services beyond the Medicaid treatment guidelines for patients with Medicaid and uninsured patients. Weight Management Center Program Fees

10 Financial Assistance Discount Policy -- #D Page: 10 Of: 19 Appendix B Bariatric surgery services are eligible for Financial Assistance discounts if the patient meets the criteria described in the policy and resides in Mission Health s 18 county service area in Western North Carolina listed below: Avery Buncombe Burke Cherokee Clay Graham Haywood Henderson Jackson Madison Macon McDowell Mitchell Polk Rutherford Swain Transylvania Yancey

11 Financial Assistance Discount Policy -- #D Page: 11 Of: 19 Appendix C The Mission Health Financial Assistance Discount Policy is applicable to health care services provided by the following Mission Health facilities: Hospitals: Mission Hospital McDowell Hospital Transylvania Regional Hospital Blue Ridge Regional Hospital Angel Medical Center Highlands Cashiers Hospital CarePartners Asheville Specialty Hospital Physician Practices: Advanced Cardiac Care Clinic Advanced Cardiac Care Clinic - South Angel Home Health and Hospice Angel Medical Center - Anesthesia Services Angel Medical Center - Emergency Services Angel Medical Center - Hospitalists Angel Orthopaedic Associates Angel Pediatrics Angel Primary Care Angel Surgical Associates Angel Surgical Associates - Highlands Angel Urgent Care Center Asheville Cardiology Associates Asheville Cardiology Associates - Brevard Asheville Cardiology Associates - Franklin Asheville Cardiology Associates - Hendersonville Asheville Cardiology Associates - Highlands Asheville Cardiology Associates - Rutherfordton Asheville Cardiology Associates - Sylva Asheville Family Medicine Asheville Hospitalist Group Asheville Orthopedics Associates - Marion Asheville Orthopedics Associates & Mission Asheville Orthopedics Associates & Mission - Biltmore Park Asheville Pulmonary & Critical Care Associates Blue Ridge Medical Center - General Surgery Blue Ridge Medical Center - Yancey Campus Blue Ridge Regional Hospital - Hospitalist Dept Brevard Cancer and Infusion Center

12 Financial Assistance Discount Policy -- #D Page: 12 Of: 19 Brevard Family Practice Brevard Internal Medicine and Pulmonology Brevard Orthopaedics P.A. Cancer Care of Western North Carolina CarePartners Hospice & Palliative Care CarePartners Outpatient Medical Clinic CarePartners PACE CarePartners Rehabilitation Hospital Carolina Spine and Neurosurgery Center Carolina Spine and Neurosurgery Center - Arden Carolina Vascular Carolina Vascular and Mission Cashiers Medical Center Community Medicine Old Fort Family Medicine - Glenwood Family Medicine - Nebo Fullerton Genetics Center Highlands-Cashiers Hospital - Anesthesia Dept Highlands-Cashiers Hospital - Eckerd Living Center Highlands-Cashiers Hospital - Emergency Department Hope Women's Cancer Centers Jane Woodruff Clinic Low Vision Center McDowell Hospitalist Group McDowell Internal Medicine McDowell OB/GYN McDowell Internal Medicine McDowell Pediatric Associates McDowell Surgical Services McDowell Urgent Care McDowell Urology McDowell Women's Care Medical Associates of Transylvania Regional Hospital Mission Cancer Care Mission Children's - Bryson City Mission Children's - Sylva Mission Children's Dental Program Mission Children's Specialists Mission Children's Specialists - 5 Vanderbilt satellite Mission Children's Specialists - Child Safety Mission Children's Specialists - Endocrinology Mission Children's Specialists - Hospitalists Mission Children's Specialists - Intensivists Mission Children's Specialists - Neonatology Mission Children's Specialists - Neurology Mission Children's Specialists - Orthopaedics Mission Children's Specialists - Pediatric Palliative Care Mission Children's Specialists - Pulmonology Mission Children's Specialists - Surgery Mission Community Anesthesiology Specialists Mission Community Obstetrics and Gynecology Mission Community Orthopedics and Sports Medicine Mission Community Primary Care - Grassy Creek

13 Financial Assistance Discount Policy -- #D Page: 13 Of: 19 Mission Community Primary Care - Haywood Mission Community Primary Care - Highlands Mission Community Primary Care - Spruce Pine Mission Community Primary Care-Cashiers (RHC) Mission Community Primary Care-Highlands (RHC) Mission Diabetes Project (Hospitalists) Mission Family Practice Mission Infectious Disease Associates Mission Internal Medicine Mission My Care Plus - Biltmore Park Mission My Care Plus - Candler Mission My Care Plus - Leicester Mission Neurology - Inpatient Mission Neurology - Outpatient Mission Neurosurgery Mission Orthopedic Trauma Services Mission Pain Management - Angel Medical Center Mission Pain Management - McDowell Mission Pain Management - Spruce Pine Mission Pain Management - Transylvania Mission Palliative Care Mission Pediatric Hematology/Oncology Mission Primary Care - Burke Mission Trauma Services Mission Urology - Burke Mission Weight Management Center Mission Women's Care Bryson City Mission Women's Care Franklin Mission Women's Care Sylva Mission WorkWell Mission WorkWell - Marion Mission WorkWell - Spruce Pine MMA Psychiatric Services Mountain Radiation Oncology and Mission Olson Huff Center Pisgah Surgical Associates Pisgah Urology Regional Surgical Specialists Tallulah Health Center Toxaway Health Center Transylvania Home Care and Hospice Transylvania Regional Hospital - CRNA Association Transylvania Regional Hospital - ER Dept Transylvania Regional Hospital - Hospitalist Dept Transylvania Women's Care Victoria Urological Associates Vista Family Health Western Carolina Women's Specialty Center William M. Huffstutter, MD, PA Wound Healing and Hyperbaric Center

14 Financial Assistance Discount Policy -- #D Page: 14 Of: 19 The Mission Health Financial Assistance Discount Policy does not apply to services provided by the following: 21st Century Oncology ABC Pediatrics of Asheville ABC Podiatry Center ABCCM Medical Ministry Advanced Dermatology & Skin Surgery Adventist Health System Albert B. Anderson, MD, PA All Kids Pediatrics AllCare Clinical Associates, PA Allergy Partners of Western North Carolina Alta Ridge Foot Specialists American College of Obstetricians & Gynecologists Andrew Lewis Rogers MD Appalachian Eye Associates Appalachian Foot & Ankle Associates Arden Family Health Center Art of Internal Medicine and Pediatrics Asheville Aesthetic Plastic Surgery Asheville Arthritis and Osteoporosis Center Asheville Children's Medical Center Asheville Dermatology Center Asheville Endocrinology Consultants Asheville Eye Associates Asheville Family and Sports Medicine Asheville Family Health Center Asheville Gastroenterology Associates Asheville Gynecology and Wellness Asheville Head, Neck & Ear Surgeons Asheville Heart Asheville Hematology and Oncology Asheville Hematology and Oncology - Marion Asheville Internal Medicine Asheville Medicine and Pediatrics Asheville Neurology Specialists, PA Asheville Obstetrics & Gynecology Asheville Pediatric Associates Asheville Pediatric Dentistry Asheville Podiatry Associates Asheville Psychiatry at the Grove Clinic Asheville Radiology Associates Asheville Urological Associates Asheville Women's Medical Center Autumn Care Bakersville Community Medical Clinic Biltmore Dermatology Associates Biltmore Family Medicine Biltmore Medical Associates

15 Financial Assistance Discount Policy -- #D Page: 15 Of: 19 Biltmore OB/GYN Associates Biltmore Plastic Surgery Black Mountain Neuro-Medical Treatment Center Blue Mountain Surgery Blue Ridge Bone & Joint Clinic Blue Ridge Bone & Joint Clinic - South Blue Ridge Bone and Joint Clinic Blue Ridge Cardiology Blue Ridge Community Health Services Blue Ridge Ear, Nose, and Throat, Inc. Blue Ridge Family Practice & Sports Medicine Blue Ridge Pediatric Dentistry Blue Ridge Podiatry Associates Blue Ridge Premier Medicine Blue Sky Pediatrics Asheville Brevard Health Center Brian T. MacDowell, MD Brosnan Eye Associates Burrell Family and OB Care Cannon Family Health Cardiology Associates of the Carolinas Carolina Hand and Sports Medicine Carolina Internal Medicine Associates Carolina Mountain Dermatology Carolina Mountain Emergency Medicine Carolina Mountain Gastroenterology Carolina Mountain Psychiatry Carolina Ophthalmology Celo Health Center Center for Family Guidance, LPC Center for Plastic Surgery Charles A. Shaller MD PLLC Charles D. Lefler, MD PA Charles George VA Medical Center - Compensation and Pension Charles George VA Medical Center - Medical Service Charles George VA Medical Center - Primary Care Charles J. DePaolo, MD, PA Chinese Acupuncture Clinic Clayton Pediatric Dentistry Community Family Practice Comp Health Locum Tenens Comprehensive Pain Consultants of the Carolinas Crescent Anesthesia Associates D&Y Locum Tenens Dale Nash, MD Private Practice Daniel M. Raiford, DDS, PA David C. Matthews MD PA Delta Locums Dennis R. Campbell, DDS, PA Dermatology of North Asheville Dula Springs Wellness Center, PA East Asheville Family Health Care

16 Financial Assistance Discount Policy -- #D Page: 16 Of: 19 EmCare Physician Services Extension Care Physicians F J Ragaz, MD Family Care of Fairview Family To Family Forest Dermatology Foundation in Spine Health Four Seasons Hospice & Palliative Care Frances Warde Family Health Franklin Family Practice French Broad Pediatric Associates, PLLC Fusion Healthcare Staff Gainesville Eye Associates Grace OB/GYN, PA Great Beginnings Gregory J. Dray, MD, PA Hart Family Practice Hayes Locums Haywood Pathology Associates Hendersonville Pediatric Dentistry Hendersonville Pediatrics, PA - Brevard Hendersonville Pediatrics, PA - Hendersonville Hensley & Associates Highlands Dermatology HMP of Buncombe County, PLLC Hominy Valley Family Health Center Hospice and Palliative Care Center of Mitchell County Hospice of McDowell County Hot Springs Health Program HP Partners IPC Healthcare J. Paul Martin, MD J. Scott Baker, MD - Family and Community Care James B. Payton, MD, PA James C. Elliott, DDS, PA JFK Alcohol & Drug Treatment Center Joshua D. Paynich, DDS, PA Kani L. Nicolls, DDS, PA Kevin J. Foley, M.D., PA KidzCare Pediatrics Laborde Eye Group Laurel OB/GYN Lifepath Palliative Care Locum Tenens LocumTenens.com Locumtenens.com LLC Looking Glass Eye Center Macon Cancer Center Macon County Public Health MAHEC Dental Health Center MAHEC Family Health at Newbridge MAHEC Family Health Center at Cane Creek

17 Financial Assistance Discount Policy -- #D Page: 17 Of: 19 MAHEC Family Health Center Biltmore MAHEC OB/GYN Specialists Marianne C. Soufas, MD Mars Hill Medical Center Matthew K. Howard MD LLC McCreary Cancer Center McGee Dermatology Clinic medage Medical Doctor Associates Medical Heights OB-GYN, PA Melissa Thingvoll MD PLLC MemoryCare Moore Foot & Ankle Specialists, PA Morganton Eye Physicians, PA Mountain Area Family Health Center Mountain Area Pathology, PA Mountain Area Pediatric Associates Mountain Care Urology PLLC Mountain Diabetes & Endocrine Center Mountain Docs Family Medicine Mountain Ear, Nose and Throat Mountain Ear, Nose and Throat - Franklin Mountain GI Associates Mountain Integrative Medicine Mountain Kidney & Hypertension Associates, PA Mountain Medical and Surgical Group Mountain Medical Arts, PLLC Mountain Medical Associates Mountain Podiatry, PA Mountain Regional Arthritis Center Nantahala Counseling Center New Dawn Midwifery, Inc New Horizons Women's Cancer Center North Buncombe Family Medicine October Road, Inc. Office of Dr. Smoker and Dr. Folkner Our Family Doctor Pardee Urological Associates Park Ridge Health Family Medicine Park Ridge Pediatrics Parkway Medical Group Phoenix Physicians Piedmont Reproductive Endocrinology Group Pineiro Family Practice Pisgah Family Health Plastic Surgery Center Plastic Surgery of Asheville Richard T. Parmley, MD Rockcliff Place Maxillofacial & Oral Surgeons Sean Skierczynski, OD Sentient Medical Systems Sisters of Mercy Urgent Care Centers

18 Financial Assistance Discount Policy -- #D Page: 18 Of: 19 Smoky Mountain Foot Clinic Southeastern Sports Medicine and Podiatry Staff Care Steven Dean Stacy, DDS Steven L. Cahan, MD, PA Stewart J. Harley, MD Stress Assessment Center Susan B. Wise, OD PA Taylor F. Townsend, DDS, PLLC The Pisgah Institute TIVA Healthcare Trillium Family Medicine, PLLC Twardon Family Care Vein Clinic of North Carolina Vickery Family Medicine VISTA Staffing Solutions Wayah Internal Medicine Weatherby Locum Tenens Western Carolina Digestive Consultants Western Carolina Retinal Associates Western North Carolina Community Health Services Wiley S. Cozart III, DDS William J. Claiborne, DDS, PA WNC Dermatological Associates WNC Ear, Nose, Throat, Head & Neck Surgeons WNC Hypertension & Wellness Center WNC Ray of Hope Woodridge Psychological Associates Woolfson Eye Institute