Foundation Health, LLC offers a Basic and an Enhanced Financial Assistance Program to Uninsured Patients. An Uninsured Patient is someone who does not have any health coverage at all, whether through insurance or any government program, and who does not have any right to be reimbursed by anyone else for their healthcare expenses. An Underinsured patient is a patient who has at least one form of health insurance but lacks the financial protection needed to cover out-of-pocket medical expenses.

The same financial assistance application can be used for both Hospital and Tanana Valley Clinic services.

If you are an Uninsured or Underinsured Patient with Hospital services, you will qualify for the Basic Program if you have an annual household income of less than $125,000 and lack any other assets to pay the Hospital’s full charges.

If you are an Uninsured Patient with Tanana Valley Clinic (TVC) services, you will qualify for the Basic Program if you have an annual household income of less than $125,000 and lack any other assets to pay Tanana Valley Clinics full charges. TVC DOES NOT offer any discount for underinsured patients under the basic financial assistance program. If you qualify for the Basic Program, you will be charged “Amounts Generally Billed,” which is based upon the average of the amounts that would have been paid to the Hospital or TVC by private health insurers and Medicare (and co-pays and deductibles) for the medically necessary services that you receive, if you had been insured.

If you are an Uninsured Patient with Hospital Services, you will qualify for the Enhanced Program 

(1) if you have an annual household income equal to or less than 350% of the Federal Poverty Level and lack other assets to pay the Hospital’s full charges and, 

(2) if requested to do so by the Hospital, you apply for Medicaid/AHCCCS, fully cooperate in the application and determination process, and are denied Medicaid/AHCCCS coverage. If you qualify for the Enhanced Program, emergency services will be provided to you free of charge. You will be charged for other medically necessary services at the Amounts Generally Billed (see above).

If you are an Uninsured Patient with TVC Physician charges for Hospital based services (an inpatient stay, an outpatient surgery or an outpatient procedure), you will qualify for the Enhanced Program 

(1) if you have an annual household income equal to or less than 350% of the Federal Poverty Level and lack other assets to pay the Hospital’s full charges and, 

(2) if requested to do so by the Hospital, you apply for Medicaid/AHCCCS, fully cooperate in the application and determination process, and are denied Medicaid/AHCCCS coverage. If you qualify for the Enhanced Program, emergency services will be provided to you free of charge. You will be charged for other medically necessary services at the Amounts Generally Billed (see above). The Enhanced Program discount given varies on a sliding scale based on household incomes when compared to multiples of the Federal Poverty Line. For households with less overall income and insufficient assets, the discount will be greater as compared to households with more overall income and insufficient assets.

If you are applying for the Basic Financial Assistance Program, complete the first and last pages of the financial assistance application. If you are applying for the Enhanced Financial Assistance program, fill out the entire application.

If you qualify for either the Basic or the Enhanced Programs, you will in no case be charged more than Amounts Generally Billed for emergency services or other medically necessary services. In addition, you will never be required to make advance payment or other payment arrangements in order to receive emergency services. However, you will be required in most situations to make a substantial advance deposit or other payment arrangements based upon an estimate of the Amounts Generally Billed in order to receive non-emergency services.

A free copy of the Hospital and TVC financial assistance policy, the billing policy, and the application forms are available on the FHP website. Free copies are available at the Hospital in the admitting area located near the main entrance of the Hospital (located at 1650 Cowles St. Fairbanks, AK 99701 and follow the signs to “Admitting” or “Registration”). Free copies are also available in the emergency room. Additionally, free copies of this information are also available via mail by contacting Hospital Patient Financial Services at (907) 458-5510 or Credit and Finance for Tanana Valley Clinic at (907) 459-3580. You can apply for financial assistance under the Basic or Enhanced Programs by any of the following methods:

(a) advising Hospital staff in the Admitting area that you are uninsured or underinsured, completing the application form, and returning it to the Hospital staff in the Admitting area, 

(b) downloading the financial assistance application form 

(c) requesting the form by mail from Hospital Patient Financial Services at (907) 458-5510 and mailing the completed application to Hospital Patient Financial Services at the address indicated on the application form, 

(d) requesting the form by mail from Credit and Finance Services at (907) 459-3580 and mailing the completed application to Clinic Credit and Finance Services at the address indicated on the application form, or 

(e) in accordance with the instructions that accompany any billing statement that you received following the receipt of services.

The Hospital Patient Financial Services staff and the Credit and Finance staff for TVC are available to answer questions and provide information about the Basic and Enhanced Programs, assist with the application process, and provide information regarding any nonprofit organizations and government agencies that can assist with these applications. The Hospital Patient Financial Services staff is located in the Hospital’s Admitting area and can be reached by phone at (907) 458-5510. The Credit and Finance staff are located at 1001 Nobel St. Suite 400, Fairbanks, AK 99701 and can be reached by phone at (907) 459-3580.

Other language translations of this Summary, the Hospital’s and TVC’s financial assistance and billing policies, and the applications forms are available on the Hospital website, and in the Hospital’s Admitting area. They may also be requested by contacting the Hospital Patient Financial Services staff at (907) 458-5510 or by contacting the Credit and Finance staff for TVC at (907) 459-3580.