ADVENTIST HEALTH VALLEJO
525 OREGON STREET
VALLEJO, CA 94590
http://www.sthelenahospital.com
Contact:
Joni McAllister
(707) 571-2819
License:
Acute Psychiatric Hospital
Total Beds: 61
Emergency Room: Yes
OSHPD ID:
106481015
Fair Pricing Policy Information
Policy Effective Date:1/1/2007
Download:
Federal Poverty Level for Free Care:
200%
Discount Payment Effective Date:1/1/2007
Discount Payments:
Discount Payment 1
FPL Range: 201%-300%
Payment Basis:
Other: 50% of the Amount Generally Billed (AGB)
Discount Payment 2
FPL Range: 301%-400%
Payment Basis:
Other: 75% of the Amount Generally Billed (AGB)
Discount Payment 3
FPL Range: 0%-0%
Payment Basis:
Other Discount Payment Information:
Expenses. Patients not eligible based on income may be eligible for Financial Assistance through an exception-based review if their Allowable Medical Expenses have depleted the family’s income and resources so that they are unable to pay for eligible services. The following two qualifications must both apply: a. Expenses: The patient’s Allowable Medical Expenses must be greater than 50% of the Household Income. b. Resources: The patient’s excess medical expenses (the amount by which Allowable Medical Expenses exceed 50% of the Household Income) must be greater than available Qualifying Assets
Application Form Information
Application Form Eff Date:1/1/2007
Download:
Income Type Used:
Salary Received
Interest Received
Pension Received
Language Information
Available Languages:
English
Spanish
Vietnamese
Hmong
Tagalog
Korean
Chinese
Armenian
Russian
Other: Japanese, French
Additional Information
Emergency and Medically Necessary Care – Uninsured – Income of 0% to 200% of the federal poverty level (FPL) equals zero patient liability. Income of 201% of the FPL to 300% of the FPL equals patient liability of 50% of the Amount Generally Billed (AGB). Income of 301% of the FPL to 400% of the FPL equals patient liability of 75% of the Amount Generally Billed (AGB). Income of greater than 400% of the Federal Poverty Level is not covered under the policy. Emergency and Medically Necessary Care – Commercial Insurance or non-Contracted Managed Care plans & High Medical Costs – Income of 0% to 400% of the federal poverty level (FPL) equals the amount that would be allowed by the Amount Generally Billed for the same service LESS the amount paid by the patient’s insurer. If the insurer paid an amount equal to or greater than the Amount Generally Billed, patient liability is zero. Non-Emergency and Non-Medically Necessary Care – Income of 0% to 200% of the FPL equals patient liability of 50% of the Amount Generally Billed (AGB). Income of 201% of the FPL to 400% of the FPL equals patient liability of 100% of the Amount Generally Billed (AGB). Non-Emergency and Non-Medically Necessary Care – Commercial Insurance or non-Contracted Managed Care plans & High Medical Costs – Income of 0% to 350% of the federal poverty level (FPL) equals the amount that would be allowed by the Amount Generally Billed for the same service LESS the amount paid by the patient’s insurer. If the insurer paid an amount equal to or greater than the Amount Generally Billed, patient liability is zero.
Source” : https://syfphr.oshpd.ca.gov/SearchDetail.aspx?oshpdid=106481015