To outline the circumstances under which Little River Memorial Hospital (“LRMH”) will provide free or discounted care to patients who are unable to pay for services and to address how LRMH will calculate amounts charged to patients. Patients who receive emergent or medically necessary care at LRMH and do not have third party insurance coverage for their entire hospital bill, and who have difficulty paying their hospital bill because of financial hardship, are covered under the terms of this policy.


AGB – Amount Generally Billed. LRMH will not bill an individual eligible for assistance under this policy more than the AGB to individuals who have insurance covering such care. LRMH will utilize the Prospective Method to calculate its AGB. 

Household Income – The income for all working members of the household as attested either in a federal income tax return or an earnings statement from the patient’s employer. Household income includes, but is not limited to, assets such as bank account balances, trusts and investments but excludes primary residence.

Application Period– From date of service until 240 days following date of when LRMH provides patient/guarantor with the first post-discharge billing statement for the care.

Assets – These include, but are not limited to, checking accounts, savings accounts, trust funds and other investments. Additionally, countable assets include the liquidated value of land (including farmland), equity in recreational vehicles, boats, second home, etc. 

Emergency Care or Emergency Treatment – An acute medical condition that, if not given immediate medical attention, could reasonably be expected to result in (a) Placing the health of the individual in serious jeopardy; (b) Serious impairment of bodily functions; or (c) Serious dysfunction of any bodily organ or part.

EMTALA – The Emergency Medical Treatment and Active Labor Act (42 U.S.C. §1395d).

Family – The patient, patient’s spouse (regardless of whether they live in the same home) and all of the patient’s children, natural or adoptive, under the age of eighteen who live at home. If the patient is under the age of eighteen, the “family” includes the patient, the patient’s natural or adoptive parent(s) (regardless of whether they live in the home) and the parent(s) children, natural or adoptive under the age of eighteen who live in the home. In the case of unmarried adults living together all adults’ income will be considered as income in financial assistance determination.

FPG – Federal Poverty Guidelines – that are published from time to time by the U.S. Department of Health and Human Services and in effect at the date of service for award of financial assistance under this Policy.

FAP – LRMH’s Financial Assistance Policy.

Financially/Medically Indigent– Uninsured or underinsured patient who is accepted for care with no obligation, or with a discounted obligation, to pay for the services rendered based on a demonstrated inability by income and family size, to meet their LRMH financial obligations. 

Medically Necessary Care– Medically Necessary Care are those services that are reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap or cause physical deformity or malfunction and if there is no other equally effective (although more conservative or less costly) course of treatment available or suitable for the beneficiary requesting the service.

Notification Period– From date of service until 120 days following date of first statement to patient/guarantor when LRMH patient account representatives will notify patient/guarantor in all written and oral communications of LRMH FAP.

Policy – The Financial Assistance Policy as in effect and which may be amended from time to time.

Under-Insured Patient– Patients who are insured or qualify for governmental or private programs that provide coverage for the services rendered but do not have the resources to pay the private portion of the bill.

Uninsured Patient– Individuals who do not have governmental or private health insurance or whose insurance benefits have been exhausted.


LRMH affirms and maintains its commitment to meet the health and medical needs of our communities in a manner consistent with the Mission Vision, and Core Values of LRMH. 

LRMH is dedicated to the efficient and responsible use of hospital resources to provide a comprehensive range of quality health services. This program is designed to aid LRMH in distinguishing true bad debt expenses from charity care, and to increase the public’s awareness of LRMH by enabling recognition for the financial assistance provided. In accordance with this mission, LRMH will provide emergent and medically necessary health care to all patients without regard to the patient’s financial ability to pay for such care. Helping to meet the needs of the low-income uninsured and underinsured is an important element of our commitment to the community. For all who seek financial assistance, confidentiality will be maintained out of respect for our patients and their integrity.

LRMH will exhaust all other payments options and avenues to obtain financial assistance and third party payments including, but not limited to local, state, and federal assistance programs before considering an applicant for financial assistance. Financial assistance will only apply to the remaining balance after all third party payments are applied. Applicants who are identified as potentially eligible for Medicaid benefits must first make application to Medicaid and, if applicable, through the Healthcare Exchange program.

Financial assistance is not subject to race, age, gender, social or immigrant status, sexual orientation, religious affiliation, or creed. This Policy will be applied equally to all patients regardless of payer source. LRMH shall operate in accordance with all federal and state requirements for the provision of health care services, including screening and transfer requirements under EMTALA. Further, this policy prohibits LRMH from engaging in actions that discourage individuals from seeking emergency medical care, such as demanding payment before receiving treatment for an emergency medical condition or by permitting debt collection activities that interfere with the provision of emergency medical care. 

If you believe that LRMH has failed to provide services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with either:

Little River Memorial Hospital

James Dowell

451 W Locke St

Ashdown, AR  71822

Phone: 870-898-5011 Ext 128

Fax: 870-898-6106

Email: [email protected]

U.S. Department of Health and Human Services

U.S. Department of Health and Human Services 200

Independence Ave., SW

Room 509F, HHH Building

Washington, D.C. 20201

Phone: 1-800-368-1019 or TDD 1-800-537-7697


LRMH will perform an assessment of medical necessity and financial ability, and based on the assessment results, may provide free or discounted care, in accordance with the levels set out below, to patients who qualify for financial assistance under this Policy. Each request for financial assistance will be evaluated on its own merits utilizing patient account procedures based on this Policy. Evaluation of the need for a particular patient will likely include such factors as: (a) income, assets, and liabilities (b) the medical condition of the patient, (c) the potential for long term medical care, (d) availability of other forms of reimbursement whether insurance, social programs, or other financial resources, and (e) suitability of LRMH for the patient’s particular needs and whether a more appropriate facility is available at which some form of payment would be available. In order to determine the patient’s financial ability to pay, patient/guarantor household size, household income, and the Federal Income Poverty Guidelines published annually by the Department of Health and Human Services will be key elements used to determine eligibility. Granting Financial Assistance is based on household adjusted grow income prior to living expenses. Unusual or catastrophic expenses will also be considered.

All patients will be offered, as part of the registration and/or discharge process, a copy of the plain language summary of this policy. See Appendix C. Additionally, all patients identified as potential financial assistance recipients or anyone requesting financial assistance will be offered the opportunity to apply for financial assistance. If this evaluation is not conducted until after the patient leave the facility, or in case of outpatients or emergency patients, the Business Office will mail a financial assistance application to the patient for completion. In addition, LRMH will provide a plain language summary of the financial assistance policy to the patient upon request, following the first billing statement. 


A. General Eligibility Considerations

In furtherance of its purpose, the Board of Directors of LRMH has resolved and is committed to providing financial assistance to patients who are eligible for such assistance in accordance with this Policy and the related federal guidelines. Patients may be eligible for such assistance if all of the following circumstances are met:

1. The patient needs emergency or other medically necessary care, as identified by a licensed physician or other healthcare provider.

2. LRMH has been chosen to provide the patient’s care, by the patient or the patient’s authorized representative.

3. The individual is financially unable to pay for the needed care. 

B. Procedure for Determining Financial Assistance 

1. Patients requesting financial assistance will be provided with an application form. Approval will be based on verification of the information provided. 

2. Financial assistance and resulting discounts will be applied uniformly to all applicants and are based solely on the ability to pay and LRMH’s resources. Patients shall not be discriminated against on the basis of age, sex, race, ethnicity, religion or national origin. Individuals may also be referred to alternative resources and services in the community, such as governmental health care coverage.

3. Completed financial assistance applications and supporting documentation should be returned to Patient Financial Services for review.

4. Patients who do not provide the requested information necessary to completely and accurately assess their financial situation in a timely manner and/or who do not cooperate with efforts to secure governmental healthcare coverage may not be eligible for financial assistance.

5. This policy will be applied equally to all patients regardless of payer. Applications that do not meet established criteria may be approved based upon extraordinary circumstances with the documented approval of the Chief Financial Officer.

6. Applications for financial assistance should be reviewed within thirty (30) days of receipt of a completed application, when possible. Patients will be notified of the LRMH’s eligibility determination in a timely manner.

7. If a patient has applied for and received financial assistance within the past twelve (12) months, and the patient’s financial circumstances have not changed, the patients will be deemed eligible for financial assistance without having to submit a new application. Applications for financial assistance will be maintained for a period of one (1) year.

8. In the event a patient approved for financial assistance fails to comply with payment terms for a period of more than 120 days, the account may be turned over to a collection agency or reported to a credit agency in accordance with normal collection procedures. Any collection agencies used by the Hospital will agree to refrain from abusive collection practices such as bench warrants and foreclosures. 

9. The Federal Poverty Guidelines provide the initial framework for determining an individual’s eligibility for financial assistance based on earned income. Other factors that will be considered when determining eligibility include, but are not limited to, investments, financial accounts, real estate, other assets, family size, net worth, unemployment status, earning capacity and other financial obligations. When other resources are identified, these cases should be referred to the business office supervisor and/or manager for special consideration. 

10. If the patient’s annual household income is less than or equal to 100% of the federal poverty guidelines, the patient may be eligible for a 100% discount. 

11. If the patient’s income is between 120% and 300% of the federal poverty guidelines, the patient may be eligible for a partial discount as noted in the sliding scale above.

12. If the patient’s income is greater than 300% of the federal poverty guidelines, the patient is not eligible for financial assistance. Exceptions may be made in the event of a catastrophic medical bill. 

13. Patients with low or moderate incomes who incur catastrophic health expenses beyond their insurance coverage or own ability to pay may be provided catastrophic protection by limiting payment liability. Determinations to provide catastrophic protection will be made by the Chief Financial Officer for hospital and clinic charges.

14. Self-pay patients who are not eligible for financial assistance, may still be eligible to receive a discount under the Hospital’s prompt payment discount policy.

15. Patients eligible for Medicaid who have an outstanding balance due to a co-pay or Medicaid denial will be assessed for financial assistance in accordance with this policy.

16. Adjustments will be applied as appropriate following receipt of a completed application for financial assistance and review of the individual’s credit report. Individuals authorized to approve charity adjustments  are as follows:

Hospital Charges

Account Balance Approving Designee

Less than $5000 Business Office Manager

Between $5000 and $10,000 Chief Financial Officer

Greater than $10,000 Chief Executive Officer

17. Supporting documentation required to process the financial assistance application may include, but is not limited to: recent pay stubs or other income documentation; verification of employment/unemployment; verification of rent, mortgage payments or other financial obligations; recent bank statements and/or copies of prior or current year’s tax returns.

18. Following application review, the Approving Designee will notify the patient/guarantor in writing of whether financial assistance has been fully approved, partially approved or denied.


The financial forms are used to help determine the extent of a patient’s financial means. Hospital staff will assist the patient with completion of the screening during their stay, but it is the patient’s responsibility to comply with the information gathering process. 

The Financial Evaluation forms (1) allow the hospital to determine if the patient has declared income and/or assets giving them the ability to pay for the health care services they will continue to receive; (2) provide documentation of a financial status determination; and, provide an audit trail in documenting the hospital’s commitment to its financial assistance program.

In order to determine a patient’s inability to pay their hospital bill in full or partial, Patient Financial Services staff will make a good faith effort to obtain the following information:

· Individual or family income and expense

· Employment status. For determination of ability to meet payment plans.

· Individual or family net worth including assets, both liquid and non-liquid, less liabilities and claims against assets.

· Unusual expenses or liabilities.

· Family size. For purposes of determining patient’s status under federal poverty income guidelines.

· Eligibility for Medicaid at present or potential for eligibility in the future. 

Information used by the FAP will be based upon a signed declaration of the patient or patient’s family, verification through documentation provided by the patient or the patient’s family. Additional information may be required for special circumstances or as determined by hospital management. It is understood that in some cases information will not be obtainable and LRMH staff will indicate such when necessary on the financial evaluation form(s). 

Given the LRMH service area demographics and the organization’s mission to meet the health care needs of its community, the primary qualifying levels are based upon 200% of the FPL. In subsequent years, this percentage may be evaluated and modified as necessary. 

The presence of an applicable recent bankruptcy of a patient or third party providing coverage for the patient will result in a consideration of eligibility for financial assistance.

If the hospital is unable to obtain adequate information regarding ability to pay for any patient treated in the ED, the patient may be granted 100% financial assistance after appropriate billing and/or other attempts to collect information.

In certain situations, services denied or non-covered by Medicaid or other programs which provide care to low-income patients, may be considered under the FAP. 


With regard to location of care, emergency and other medically necessary care that is provided in the hospital facility, including hospital itself or in any provider-based clinic or department of the hospital, will be considered for purposes of financial assistance. Specifically, the locations include those delineated on Appendix A. 


If the patient receives care that is covered under this Policy, a determination will need to be made as to whether the provider who actually provided the care is a covered provider. Every provider associated with the hospital itself, a department of the hospital, or a provider-based clinic will be a “covered provider” when that provider is providing covered care, including all the clinics and departments set out on Appendix A. The charges related to care not provided by a provider from the hospital facility or clinic, are not eligible for financial assistance. See Appendix B. 


1. Availability of Separate Billing and Collections Policies. 

LRMH maintains separate policies containing its billing and collections policies as they apply to all patients, not solely to patients seeking financial assistance. Patients may obtain copies of those policies, including list of covered location and providers, free of charge, by writing or calling the following address/telephone number: Little River Memorial Hospital; Attention: Patient Financial Services ; 451 W Locke St, Ashdown AR 71822 or calling 870-898-5011 Ext. 3160. The Policy is also available on the LRMH website at the following link:

2. General Billing and Collection Matters 

LRMH sends patients account statements on a monthly (35-day) cycle. Generally, if the account is not paid, LRMH will send three statements, with the final statement serving as final notice that the account may be referred to a third-party collection agency if payment is not received within 30 days after the date of the final notice. LRMH requires any collection agency it uses to agree to refrain from abusive collection practices. 

LRMH will not engage in “extraordinary collection actions” until reasonable efforts have been made to determine whether an individual is eligible for assistance under this Policy. Extraordinary collection actions include selling debt to third parties (except as legally allowed), reporting to consumer credit reporting agencies and credit bureaus, denying future medical care because of nonpayment, filing lawsuits, foreclosing on real estate, attaching or seizing bank accounts or personal property, placing liens on residences, arrests, body attachments, and similar activities, unless all collection activities have been exhausted and the account has been turned over to a collection agency. 

If a patient account has been referred to a collection agency, that patient may still apply for financial assistance for a period of 120 days. While the application is being completed and while the determination of eligibility for financial assistance is pending, collection efforts will be suspended. 

3. Notices to be Provided Before Extraordinary Collection Actions are Taken 

LRMH may initiate an extraordinary collection action under certain circumstances. First, LRMH may initiate extraordinary collection actions when it provides the patient with at least 30 days’ written notice that the action is being initiated and provides a deadline for the patient to bring his or her account current. With that notice, LRMH will provide a plain language summary of this Policy. LRMH will also make reasonable efforts to provide the patient with notice that it is initiating an extraordinary collection action. 

LRMH recognizes that some patients will receive multiple episodes of care or care on multiple occasions. In that event, LRMH will only initiate an extraordinary collection action on the aggregate of the patient’s outstanding bills after 120 days have passed since LRMH provided the first post-discharge billing statement for the patient’s most recent episode of care. 

4. Limitation on Charges 

If a patient has been determined eligible for financial assistance under this Policy and receives care from a provider listed on Appendix A, the patient’s charges will be limited. For emergency and other medically necessary care, the patient cannot be charged more than the amounts generally billed for such care. For all other care, the patient must be charged less than gross charges. “Charges,” for purposes of this Section, mean the amount the patient is personally responsible for paying, after all deductions, discounts, insurance reimbursements, or other reductions have been applied. This applies to care provided by any of the locations listed on Appendix A. 


Covered Care Locations

Inpatient hospital, including swing beds

Little River Memorial Hospital Emergency Department (hospital services)

Memorial Medical Clinic

OP Services

Home Health



Radiology Group


Pathology Group

Reference Lab

ED Group


Air Ambulance