Indiana Regional Medical Center's Financial Assistance Program helps eligible persons receive medically necessary healthcare services at no cost or reduced cost, depending on their family income. Please see the following income range table to determine your eligibility and share of covered charges.
|
Income range less than or equal to |
||||
|---|---|---|---|---|
|
Family Size |
Category A |
Category B |
Category C |
Category D |
|
1 |
$14,580 | $29,160 | $43,740 | $58,320 |
|
2 |
$19,720 | $39,440 | $59,160 | $78,880 |
|
3 |
$24,860 | $49,720 | $74,580 | $99,440 |
|
4 |
$30,000 | $60,000 | $90,000 | $120,000 |
|
5 |
$35,140 | $70,280 | $105,420 | $140,560 |
|
6 |
$40,280 | $80,560 | $120,840 | $161,120 |
|
7 |
$45,420 | $90,840 | $136,260 | $181,680 |
|
8 |
$50,560 | $101,120 | $151,680 | $202,240 |
|
For each additional family member, add: |
$5,140 |
$10,280 |
$15,420 |
$20,560 |
If your income is less than or equal to the amount in Category A, and you do not have assets exceeding $10,000 individual or $15,000 couple, you are eligible for no-cost healthcare services. These figures are defined by the Department of Health & Human Services guidelines for the current year.
The patient's share of charges is as follows:
- Category A: 0%.
- Category B: 25%.
- Category C: 50%.
- Category D: 75%.
For more information, call 724.471.1472.
For your convenience, an Indiana Regional Medical Center representative will make a written determination of your eligibility for the Financial Assistance Program within two working days of your request.
A medical assistance denial letter, stating excess income, is required for all self-pay patients and those with insurance deductibles greater than $1,000.
Application process
If you are interested in applying for the Financial Assistance Program, download the Financial Assistance Program application (PDF). Please complete the form in its entirety.
Verification of the following information is needed to complete your application for Financial Assistance. Failing to provide all the requested/required documents will cause a delay in application processing. Proof of Medical Assistance application may be required if applicable.
Mail or bring to the Financial Counseling Office along with the following:
Proof of Income:
- Household income is defined as all income for individuals in the household who have a tax/taxable relationship to the patient. (File joint return or is a dependent on another individual’s return) This follows the same definition guidelines as PA Medicaid.
- Income Tax Return (if applying in first three months of calendar year)
- Pay Stubs and/or Unemployment Compensation Income statements for the past three months (for applications April through December)
- Unemployment Compensation
- Social Security verification
- Pension
- Workers Compensation
- Sick Benefits
- Self-Employment
- Rental Income
- Child Support
- Interest or Dividends
- Any other income into the household
- MA162 with income information
- Payments from personal insurance policies that provide additional income or payment to defray medical related incident costs.
- Current Photo ID (Driver’s license, State issued ID, Work Visa)
Proof of Assets: **(Balance over $10,000/person or $15,000/couple not qualified for Financial Assistance. Please proceed with application to apply for extended payment plan)**
- Checking Account – most recent statement
- Savings Account – most recent statement
- Certificate of Deposit (CD)
- US Savings Bond
- Stocks or Bonds
HRA, HSA, FSA, or any medical savings or reimbursement account
Disclaimer Points:
- You must apply within 240 days from date of self-pay balance or application will be denied.
- Any material misrepresentations will result in the reversal of approved applications, and denial of open applications. Any related reductions will be reversed and the applicant will be barred from participation for a period of 3 years.
- Services considered to be personal and/or cosmetic will not qualify for Financial Assistance.
- Medical savings, reimbursement and all other similar accounts must be depleted prior to providing any type of financial assistance
- A PA Medical Assistance denial may be required before Financial Assistance eligibility can be determined.
The completed application can be mailed or returned in person to:
Indiana Regional Medical Center
Attn: Financial Assistance Program
P.O. Box 788
Indiana, PA 15701
Visit a financial counselor at the Financial Services Office in Indiana Regional Medical Center's main building lobby level on the 2nd Floor. Please ask at the volunteer desk for directions.
Application hours are Monday through Friday, from 8 a.m. to 3:30 p.m. Please call to schedule an appointment.