Download - ST. AGNES HOSPITAL KEV CAI THIAB KEV UA HAUJLWM SAU … · 2017. 12. 20. · tswv cuab kom ua raws li yam ua tau, los sis tsis yog xa cov nqi rau lwm lub tuam tsev kev sau nqi kom

ST. AGNES HOSPITAL KEV CAI THIAB KEV UA HAUJLWM AGNESIAN HEALTHCARE

SAU TXOG:

CHAV XA NUJ NQI THIAB KEV SAU NQI

Hais kom them nuj nqi:

Chav Ua Ntaub Ntawv Nplooj 1 ntawm 8

Txoj Cai: 1

Pib Thaum Hnub Tim:

Rau Hli Ntuj, 2014 Pom Zoo Los Ntawm:

s/Bonnie Schmitz

THAWJ COJ

SAIB RAU HNUB TIM NO:

9/86, 7/89, 6/95, 6/04, 4/08 DCO, 5/10 DCO, 5/2011 DCO, 10/2012 DCO, 9/2013 DCO/ 6/2016 LMS

Tsim Thaum Hnub Tim No: 3/83 TXOJ CAI: Pebtxojkevpabyeejmuajfeemntauraucovtibneegnyobpuagncigpeb.Covtibneeguahaujlwmraupeblosyogcovnyobzepeb.Covtswvcuablosyogpebcovphoojywg.Pebnyobraulubzosuassibkoomteszoo,sibhlubliibtseneeg,thiajliuaraulubchawuahaujlwmtiaspebsihlubliibtseneeg.Vimtiaspebmuajkevmobsiablinopebcovphoojywgthiabcovnyobzepebyuavnojqabhaushuvzoodua.AgnesiantxojKevCaiRauKevThemNqiYusTusKheejthiabKevCaiSauNqiyeejyoguarawslipeblubhomphiajthiabkevntseeg.Yeejtauuarawslitagnhrocovkevcaihauvnomtswvtsoomfwv, lubxeev,thiablubzos,rawlitiamsistsisyoglintawvxwb,tshooj1.501(r)rauInternalRevenueServiceCoderau1986,tauhloov,thiabcovkevcairauhauv,thiabFederalPatientProtectionthiabAffordableCareAct(ACA).YuavkomAgnesiantswjtau lawvcovnujnqi thiabpabtau lawvcovtswvcuabuasxavtaukevpabthemnqi,covtswvcuabtauthemlawvcovnqikhomobraws li lawvthemtausthiab lossisraws li lawvcov insurancehaiskomthem.TxojKevCaiRauKevThemNqiYusTusKheejthiabKevCaiSauNqithiabKevCaiPabThemNqi(FAP)yuavyogcovcaipebsivntauthaumuaKevCaiRauKevThemNqiYusTusKheejthiabKevCaiSauNqi.TxojcainoqhiatxogtiasAgnesiantxojkevyuavlosualicasthaumcovtswvcuabtauthemlawvcovnqithiabqhiaraucovtswvcaubtxogAgnesiantxojcaiFAP. Rawslitxojcai,yuavtsismuajlwmkevsaunqirautustswvcuab,lossistuslavnqithem,uantejyeejsaibtaglawmtiastustswvcuablossistuslavnqintawdpuasyuavtsimnyograuAgnesianKevCaiPabThemNqi.CovtswvcuabuastautxaiskevpabrauchavxwmkublossiskevpabkhomobtseemceebyuavmuajlubcaijthovraukevpabthemnqikhomobrawslicovkevcaiACAthiablwmcovkevcaitswj.Agnesianyuavtsisxaivntsejmuagrawslihnubyug,pojniamlossistxivneej,haivneeg,kevntseeg,ximtawvnqaij,yogtusneegtsistaus,nyiamuapojniamlossistxivneej,tuajtxawvtebchaws,lossisyoglostsisyogpejxeemthaumlostxiavtximtxogkevpabthemnqi. Txojkevcainomuajfeemraucovnujnqikhomobraucovtsevkhomobntawmno:St.AgnesHospital,RiponMedicalCenter,WaupunMemorialHospital,FondduLacRegionalClinicsthiabConsultantsLaboratory,tomqabno,sivtagnhrolubnpehuuaAgnesian. KEV KHIAV HAUJLWM: A. TXHAISLICASCovlustxhaishauvqabntawmnoyograutxhuakevcaino.

SAU TXOG: TXOJ CAI TXOG KEV XA NQI THIAB KEV SAU NQI Nplooj 2 ntawm 8 Lubcaijuantawvthov:Uantej240hnubntawmthawjzaugtsevkhomobxatsabdaimntawvteevnqituaj.NujNqiPhem:Thaumibtugtswvcuabcovnqiuastsisthemli120hnubtomqabAgnesiantwbnrogthamtaglawmtiasyeejmuajfeemtauthemthiabtauxathawjdaimnqirautustswvcuab,lossistuslavnqi,lossistsisthemrawslitaucoglusraukevthemnqi.KevPabLuvCovNqi:Kevpabluvnqinoyogluvcovnqikhomobtsawgzog-luvrawsnyiajtxiag-raucovtsimnyog,tus lavnqi, covtaunyiaj rau ibyigtshaj165%feempuatiamsis tseemtsawgtshaj lossis ibyamli300%feempuantawmtsoomfwvtxojcai tiasyogcovneegtxomnyemthiabmuajcuabyeejcuabtamtsawgtshaj$2,000rauibtsevneeg.KevHaisPlaubKomThemNqi(ECA):ThaumhaiskomtugneeglavnqitsisthemcovnqiyuamAgnesiancojmushaisplaubrawskevcailijchoj,lossisqhiaraulubchawqhianeegtsisthemnqirauteevcia(creditreportingagencieslossiscreditbureaus)txogtuslavnqi.ECAtsisyogxanqirautustswvcuablossistuslavnqi,tsisyoghuxovtoojrautustswvcuabkomuarawsliyamuatau,lossistsisyogxacovnqiraulwmlubtuamtsevkevsaunqikomuarawslitxojcai29CFR1.501(r)-6(b)(2)thiabcojmushaisrautsevhaisplaub. KevPabThemNqi:Kevpabmuajraucovtswvcuablossiscovlavnqiuastsimnyog,covuasyuavraugkevnyuajraunyiajtxiag,komtxotaumentsislossistagnrhocovnqikhomobthaummuajxwmkubceevlossiscovmoblojthaumtuajhauvAgnesian. PabDawb:Pomzootxotagnhro100%covnqikhomoblosntawmAgnesianraucovtswvcuabtsimnyog,lossiscovlavnqi,yogcovnyiajtxiagraulawvtsevneegyoglossistsawg165%ntawmtsoomfwvtxojcaitiasyogcovneegtxomnyemthiabmuajcuabyeejcuabtamtsawgduabli$2,000rautseneeg TusLavNqi:Tusneegmuajtxojhaujlwmlosthemtustswvcuabcovnqikhomob.NqiTauThemTagNhro:Covnqiuaslaijrawslicovnqikhomobuantejluvcovnyiaj.CovNtsiabLusSauYoojYim:Tsabntawvsaucovntsiab lus rau txojKevCaiPabThemNqikommeej, siv cov lustseebkomthaumtwgnyeemlosthiajlitotaubkomsaithiabtotaubtagnhro.KevThemNqi:TxojkevthemnqirawscaijuaspomzoolosntawmAgnesianthiabtustswvcuab,lossistuslavnqi,raucovnqitauthem.Txojkevthemnqiyograwslintawmtustswvcuabtaunyiajntaulicas,covnyiajtauthemntaulicas,thiabnwsthemlicasyavtagloslawm. KevThemNqiYusTusKheejlossisHaujlwmRauKevThemNqiYusTugKheej:Covnqiuastustswvcuab,lossistuslavnqi,yuavtauthemncajnraimrauAgnesian. Tej zaum cov nqi no yog cov seem tom qab insurance them taglawm,covnqirautustswvcuabtsismuajinsurance,lossisthaumkhocovnqikhomobrawsliAgnesianKevCaiPabThemNqi. LuvNqiRauCovTsisMuajInsurance:Luvnqiraucovtswvcuablossiscovlavnqiyogtsismuajkevpovhwmthemnqikhomob.Covnqiluvraucovtsismuajinsuranceyeejyograwslicovnqixatawm(AGB). B. KEVPOMZOORAUCOVNQIKHOMOB Agnesianyeejmobsiabraukevpabthemnqiraucovtswvcuabtsimnyogtxaislossiscovlavnqi,uasyogcovtsismuajinsurancelossistsismuajinsurancetxausthiabraucovyuavthemtsistaustagnrhocovnqikhomobtsimnyoglosntawmAgnesian.Yogpomtiasibtugneegyeejthemtauscovnqicesyeejyuavuarawscaikomnwsthemcovnqikhomob.KevsaunqirautxojcainoyuavsivrautxhuatustswvcuabtxawmnwsmuajinsurancelostsismuajthiabyuavuarawslitxojcailijchojthiabrawsliAgnesianlubhomphiaj. Agnesianyuavqhiakommeejraucovtswvcuab,lossistuslavnqikhomob,qhiatxogcovkevpabthemnqi,thiabqhiatiastauthemnqilicas.Qhovnoyuavuarawslilubcaijnujnqi.Agnesianmuajtxojcaitxhobyuamneegthemnqikhomobuantejnwstuajrautsevkhomoblubchavkhocovmuajxwmkubceevlossisyuavtsismuajkevsaunqiyogtiasyuavcuamtshuamraunwstxojkevpabthaummuajxwmkubceevntawd. Txhuacovlusqhiatxognwstejnyiajlossispovhwmthemnqikhomoblosntawmtustswvcuablossistuslavnqi,yuavtsisqhiaraulwmtusneeg.

SAU TXOG: TXOJ CAI TXOG KEV XA NQI THIAB KEV SAU NQI Nplooj 3 ntawm 8

1. PomTseebTxogKevThemTausNqi: Agnesianyuavsivcovkaujruamlossaibsebqhovtseebtiastustswvcuabyuavthemtauslicas. Rau tej tus tswv cuabpeb yuav xa nws cov nqi rua lwm lub chaw saunqithiabnwsthemlicasraulawvlosAgnesianyeejyuavxamtiasnwsthemrauAgnesiankomxaustaunwscovnqikhomob.Pebyeejyuavxacovnqikhomobraulwmlubchawrawslilubsijhawmraukevcailijchoj.Yogtiasuatauthiabtsiskim,Agnesianyuavuahaujlwmnrogcovtswvcuabkomkhotaucovteebmeemlawvmuajnroglawvlubinsurance.YogtustswvcuabtxojhaujlwmqhiarauAgnesiantxognwslubinsuranceuasnwsmuajraulubcaijnwstxaiskevkhomob.

2. KevKhoTswvCuabCovNqi:Thaumtwgpomtiasibtugtswvcuablossistuslavnqi,kevthemnqiyuavyogli

cas,Agnesianyuav(ib)qhiatustswvcuab,lossistuslavnqi,txogcovyuavmuajlicasraunwsxavkomnwsthemtascovnqi,thiab(ob)qhiatxogtxojkevcaithemnqi,daimntawvtsonperaukevpabthemnqi,covntsiablussauyoojyim,thiabkevcairaukevthemnqiyustuskheejthiabkevsaunqi.Yogtiastustswvcuablossistuslavnqiyuavthemtsistaucovnqiuantejpebcaug(30)hnub,mamliqhiaraulawvtxogkevthemlicaskomlawvthemtauraulawvcovnqi,ibyamraucovthemrawssijhawm,thiablossiskevpabthemnqi.Yuavqhialiqhiatauraucovtswvcuab,lossistuslavnqi,txogAgnesiantxojkevcaithemnqithiabyuavqhiatxogyuavuadaimntawmthovkevpablicas.CovhaujlwmnoyoglosntawmAgnesianCovPabQhiaTxogKevThemNqi(FinancialCounselors).

3. LusQhia:Agnesianyuav xa tsawgkawgpebdaimntawvqhianqi rau covneeg tau themnqi los sismuab

emailrauqhiaraupebzaumkawg.Tiamsis,yuavtsisxacovnqituaj lawmtomqabtus lavnqitauxanwsdaimntawvthovkevpabthemnqirawslitxojkevcaithemnqilossisyogthemtaglawm.Yogtuslavnqitxojhaujlwmqhiaqhovchawnyobraulubcaijtuajtxaiskevkhomoblossisthaumtsivtsev.Yogtiastsismuajqhovchawnyobtseeb,txhaistautiaspebualipebuataulawm.Txhuacovntawvqhianqiyuavmuaj,tiamsistsisyogcovnoxwb:

a.Covnqiraukevkhomob;b.Covnqitauthemlosntawmtustswvcuablossistuslavnqi;c.Tsabntawmqhiameejrautustswvcuablossistuslavnqitxogtiasmuajcovkevpabthemnqirawsli

kevcaithemnqithiabmuajtusxovtoojrauchavpabthiabwebsiteuasluamtaucovntawvno,ntxivlidaimNtawvThovKevPabThemNqi.

d.NtawmcovntawvnqixatawmyuavmuajibdaimntawvqhiarautustswvcuablossistuslavnqitxogECAuasnwsuatauyogtiastustswvcuablossistuslavnqiyuavtsisthovraukevpabthemnqirawslikevcaithemnqilossisthemqhovnqirawslilubsijhawm.Muajdaimntawvqhiacovntsiablussauyoojyimtxogcovkevcaithemnqinrograudaimntawvnqi.

4. KevPabThemNqi:Daimntawvqhiatxogkevpabthemnqiyeejmuajraucovtswvcuabthiabcovneegtxais

kevpablosntawmAgnesian.AgnesianFAP,DaimNtawvThovKevPabThemNqi,thiabdaimntawvqhiacovntsiablussauyoojyimtxogFAPyuavluamtauntawmAgnesianlubwebsite.Covntawvluamqhiatxogtejnomuabtauyognugtxog,tsisthemdabtsi.

Covntawvqhiatxogkevpabthemnqi,thiabcovlusqhiatxogAgnesianFAPthiabqhiatxogtiasyuavualicasthiajliyuavtaukevpablosntawmAgnesian,qhiatauraucovtswvcuabthaumlawvtuajtsevkhomoblossisthaumlawvyuavmustsev.Covlusqhiatxogkevpabthemnqilosmuaj,tsisthemdabtsi,thaumibtugtswvcuabnugtxogthiabpebyeejmuablorautejlubchawhauvlubtsevkhomobthiabchavtostxaisneeg,nyobrauhauvlubtsevkhomobthiabchavtxaiscovneegmobxwmkubceev,thiabyuavmuabtsonrogtustswvcuabcovntawvnqixatuaj.

5. ThemNqiRawsCaij:Tauthemcovnqitagnrho,uastseemtshuavthem,uantej30hnubntawmthawjhnub

xathawjdaimntawvnqituaj.Yogtiastustswvcuabthemtsistaus,lossistuslavnqi,themtsistautagnrhorawslubsijahwmntawd,tejzaumlaijlubsijhawmraukevthemnqikomntevzograwsliqhovnqitseem


tshuavtshemtomqabluvnqiraucovtibneegtsimnyogtxaiskevpabthemnqi.MamliuakevthemnqiuasobleegpomzoontawmAgnesianthiabtustswvcuab.Covkevcaintawmkevthemnqiyuavyoguarawslitusneegthovnwscovnqikhomobuastseemtshuav,covnyiajnwskhwvraucuabyigrauiblubxyoosthiablwmyam.Yogtiaspomzoo,yuavtsisraugthempajraucovnqithemrawssijhawm.

CovtswvcuabtauqhiarauAgnesianyogtiaslawvhovthemtsistaucovnqilicastomqabtwbthamtagtiaspomzootxogkevthemnqilawm.Yogtiastustswvcuabtsistxuaslustuajcestejzaummuajfeemcovnujnqinoraugxatawmraulubchawmsaunqi(collectionagency).YogtiasAgnesianibtugtswvcuabuasyeejmuajcovnqithemrawssijhawmlawmtautxaiskevpabntxivtimAgnesianthiabtaumuajlwmcovnqithem,tustswvcuab,lossistuslavnqirautustswvcuabkevthemnqitejzaumtauhloovraucovnqitshiab.Kev themnqiyeejmuaj raucov tswvcuab, los sis cov lav lawvcovnqi, covuas tsimnyog txais tsawgdua100%kevpabthemnqi,tiamsisthemtsistautagnhrocovnqi.Kevthemnqiyograwslicovkevcaicovtswvcuablossiscovlavnqiuastsistsimnyogtxaiskevpabthemnqi.Yogtiascovnqitshuavthemthiablossiscovnqithemtsistsimnyograupebkevthemnqi,tustswvcuablossistuslavnqitauuadaimntawvtxaisnyiajntawmlubtuamtsevtxaisnyiajbank.

C. YOGTIASTSISTHEMCOVNQICESYUAVMUABCOVNQIXATAWMRAULWMTXOJKEVSAUNQILAWM

1. YuavUaLiCasThaumTsisThemNqi:Pebyuavtsisxacovnqikhomobraulubchawsaunqi,lossisECA,uantej120hnubntawmthawjhnubxadaimntawvnqitawmyogtiasAgnesianyeejualiuataulawmkompaubtiassebibtugtswvcuabpuastsimnyogtxaistxojkevpabthemnqi.Lubcaij120hnubnotejzaumyuavsaiduayogtiastaupomzootxaiskevpabthemnqi,tauuakevthemnqitiavthiabtustswvcuabthiabtuslavnqipomzoo,thiabtustswvcuablossistuslavnqitsisthemrawslikevthemnqilawm.Yuavtsismaujkevsaunqirauibtugtswvcuabyogtiasnws,lossistuslavnqi,taumuajpovthawjqhiatiasnwstaumusthovMedicaidlawm,lossislwmcovpovhwmthemnqikhomob,uastejzaumyuavlosthemraucovnqithiabrauyogtiastseemsaibsebnwspuastsimnyog.

UantejxaibtugtswvcuabcovnqimusrauiblubchawsaunqiAgnesianyuavualiuataukomqhiatxogcovkevpabthemnqithiabyuavxalitsawgkawgpeb(3)daimntawvnqirautustswvcuablossistuslavnqi.TxhuadaimntawvnqiyuavmuajcovlusqhiameejtxogAgnesiantxojkevcaithemnqi,xovtoojhukommuajneegpab,thiabwebsiteyoglicas.Yogtiaskevtxuaslustsistaunrogtustswvcuablossistuslavnqi,thiabchawnyobtsisyogescovntawvxalostsispom,covnqiyuavraugxaraukevhaiskomthemnqi(collectionagency).Uantej240hnubntawmthawjhnubxadaimntawvnqi,yogtiasibtugtswvcuab,lossistuslavnqi,tauthovtxojkevpabthemnqi,daimntawvthovkevpabthiabcovkevsaunqiyuavtsotsegraulubcaijlossaibsebpuastsimnyogtxaiskevpab.YogtiastusthovkevpabhovtauCommunityCarelawmces,nwstsistauthemcovnqitsimnyogtsisthem.Yogtiastustswvcuabtsistaukevpabthemnqilossistauqhovnqithemtsawgzog,pebyuavkomnwsthemcovnqi.Yogtiastsisthemcovnqilossisthamtsishaumtxogyuavthemnqilicas,pebyuavmuabcovnqixaraukevsaunqilawm.Yogtiassautsistxhijraudaimntawvthovkevpab,Agnesiantau(ib)txotagnhrocovkevsaunqi,(ob)sauntawvrautheneegqhiatxogtiastseemtshuavdabtsirauFAPlossisdaimntawvthovkevpabthiajlitiavraudaimntawvthov(peb)qhiaAgnesiantusxovtoojlossischawnyoblossiskevtxuaslusraulawv.Daimntawvuathovkevpabyuavnyobli30hnubntawnhnubtimxatsabntawvrautustsonpethovtxaiscovlusqhia.Yogtiastustsonpetsistebtuajthaum30hnubntawd,yuavtsispomzoomuabkevpab.Covthovkev


pabthemnqiyuavtaucovnyiajthimrovqabraulawvyogtiaslawvthemtshajlicovnujnqiuastustswvcuablossistuslavnqitauthemthaumlubcaijpomzoomuabkevpabthemnqirauhauvAgnesianFAP.Thimnyiajyog$5.00lostshaj.Rawslitxojcaino,txojkevpabthemnqifeemntauzausyuavtsispabraucovnqiseemthauminsuranceuantawvtaglawmvimtiastustswvcuabtsisuacovntawvkomtiavpubntsibkwskhomob(referral),lossisyogtiaskevpabtsisyograwslitustswvcuabdaimntawvcoglusnrognwslubinsurancecesyoglicovnqithemntawdyuavtsisthimrovqab.KevsaunqiyogibtxojkevsivrauAgnesianthaumxavtaucovtswvcuablossiscovlavnqithem(ib)covnqitsistaumuajleejtwgthemtshaj120hnublawmraucovneegtsistauthovkevpabthemnqi,(ob)covtswvcuablossiscovlavnqitsisuarawslipomzooraukevthemnqi,lossis(peb)tustswvcuablossistuslavnqitsiskoomtesthemcovnqikomtag.Tsawgkawgli30hnubuantejhaiskomtustswvcuabthemnqirawsliECA,Agnesianyuavmuabtsabntawvqhiatxogkevpabthemnqirautustswvcuablossistuslavnqitxogyamnwsthovtau,qhiatiasyuavthovkevpabthemnqilicas,thiabyuavmuabtauFAPqhovtwg.TsabntawvlinoyuavqhiacovECAuasAgnesianlossislwmlubchawpomzooraulawvhaiskomthemcovnqikhomob,thiabqhialubcaijkawguastaupibuacovECA.Lubcaijtauuatiavyuavtsumyogtxhobsaitshajpebcaug(30)hnubtomqabxatsabntawvtawmrautustswvcuablossistuslavnqi.DaimntawvsaucovntsiablussauyoojyimtxogkevcaithemnqiyuavnyobnrogAgnesiancovntawvthiabyuavualiuataucianeegqhiarautusneegtxogAgnesianFAPthiabtustswvcuabyuavualicasthiajuataurauFAP.CovlustomqabnoqhiatxogtiastejzaumECAAgnesianuataukomtaunyiajthemcovnqikhomob:(ib)xacovnqitsisthemraulubchawqhianeegtsisthemnqirauteevcia(creditreporting)(creditreportingagencies,(ob)cojmushaisplaub,(peb)uantawvrauneegevraulawvtejavlossistsev,lossis(plaub)haiskomlubhaujlwmthemraucovnqitsistauthem.

2. CovChawSauNqi (CollectionAgencies):Tej zaumyuav siv cov chaw saunqi los hais komcov tswv cuab

themcovnqi.Qhovnotejzaumyuavuatejyamno,lossislwmyamthiab,xwslilubchawsaunqi(collectionagency)yuavhuxovtoojtuaj,yauvxantawvtuaj,thiabnrhiavcovneeguastsisthemcovnqikhomob.Yuavtsismuabcovnqiraulubchawsaunqithaum120hnubtomqabxathawjdaimnqi,tiamsisyuavtsisualinoyogtiastustswvcuablossistuslavnqitsisthemnqilinwstauhais.

Uantejyuavmuabxaraulubchawsaunqisabnraud,yuavsaibtxhuatusneegcovnqisebAgnesianpuastauualilawvuataukompaubtiassebtustswvcuablossistuslavnqipuastsimnyograukevpabthemnqi.Tomqabsaibtejnotaglawm,cesyuavraugmuabcovnqixaraulubchawsaunqisabnraud.Txhuacovneeguasraugxamusraulubchawsaunqitauuarawslicovkevpabthemnqi.Agnesiantsispomzookomneeghutuajthabplaub,haislubphem,haislussaibtsistaus,haisluscuav,haislusdaglossishaislusyuamkevlosntawmcovkwslijchojsaunqi,chawsaunqi,lossiscovsawvcevraulawvsaunqithiablawvcovneeguahaujlwm.Agnesianyuavtsispomzookomtibneegthabplaub,haislusphem,hais lus saib tsis taus, dag los sis hais lus yuamkev los sis coj tus cwj pwmphem los ntawmcovneeguahaujlwmsaunqintawmcovtswvcuab.TxhualubchawsaunqiuahaujlwmrauAgnesianyuavmuajdaimntawvcoglusqhiatiastxojkevuahaujlwmsaunqiyograwsliAgnesiancovkevcaithiabtauuarawslicovkevcailijchojraulubxeevthiabtsoomfwv.Tsawgkawg,daimntawvcoglustaumuajtejnorauhauv:

a.YogibtugneegtauuadaimntawvthovFAPtomqabtwbxanwsmusraulwmlubchawsaucovnqitiamsishovyoguantejlubcaijdaimntawvthovlubcaijtag,lawvyuavtxoECAkomtxhobsaunqilawm.


b.YogibtugneegtauuadaimntawvthovFAPtomqabtwbxanwsmusraulwmlubchawsaucovnqitiamsishovyoguantejlubcaijuadaimntawvthovlubcaijtagthiabhovpomzootiasnwstsimnyogtauFAPlawm,lawvtauualinokomrawssijhawm.1. Uacovhaujlwmraws lidaimntawvcog luskomtibneegtsis tau them, thiabkom lawvtxhob

muajqhovfeemthem,komnwsthiablubtsevkhomobuatxhobtauthemtshajnwstauthemrawsliyogtsimnyogtaukevpabnyobrauFAP.

2. Yogmuajfeemrauthiabtusneeg(tsisyoglubtsevkhomob),muajtxojcaiua,yeejualiuataukomhloovcovECArovqab(dualimuabcovnqimuagraulwmlubchawlossislwmlubECA)uasyogcovkomtusneegthem.

3. Yogtiascovnqintawdraugmuagraulwmlubchawlawmthaumlubsijhawmthovkevpab,mamlimusmuab ib daim ntawv cog lus los ntawm tog ntawd kommuaj tag nrho cov lus sau rautshoojno.

YuavmuabdaimntawvpomzooAgnesianKevXaNqi thiabKevSauNqi thiabCovCaiPabThemNqi:PabThemNqiKhoMobrautxhualubchawsaunyiajuahaujlwmnrogAgnesiancovneeguaskevthemnqiyustuskheejkomthiajlimuajfeemuasyoguarawscovkevcai.TausaunpetxaiscovkevcaithiabpomzooraucovkevcaiyuavyogibqhovtauuakompaubtiasyuavuarawslicovkevcaithiabyuavkhawsciarauhauvAgnesian.Yogtiasibtugtswvcuab,lossisibtuslavnqi,uantawvthovraukevpabthemnqiuantejtomqab240hnubntawmthawjhnubtxaisdaimntawvtawmtsevkhomoblossis30hnubthomqabtauxadaimntawvqhiatiascovnujnqixaraulubchawsaunqilawm,mamlipomzooraudaimntawvthovthiabkevsaunyiajmamlimuab txokomtxogpaub tiaspuasyuav tsimnyog.Yog tias tus thovntawd taukevpabdawb,yuav tsismuajkevhaiskomnwsthemnqintxivlawmrauqhovcovnqiuastsimnyogthemraulawm.Yogtiastusthovntawdtsimnyogtaucovnqiluvlawm,lossistsistaukevpabthemnqi,muajcovkaujruamtustswvcuabuatau,lossistuslavnqi,komhaiskhocovnqikhomobkomthemtauyogtsisuacesyuavmuabxaraulwmcovkevsaunqilawm.

3. Lubchawqhianeeg tsis themnqi rau teevcia (CreditReporting):Agnesianyuav tsis tsocai rau lawvcovchawsaunqimusraucovchawqhianeegtsisthemnqirauteevcia(creditreporting).

Rautejlubsijhawm,Agnesianyuavuarawskevcailijchojsaunqi,lossismuabraulawvcovchawsaunqi,komtaucovnqitsistauthem.LubchawsaunqiyuavtsismuajcaipibsaunqirauAgnesiancovtswvcaub,lossistuslavnqi,lossismushaisplaubtautostxogli120hnubtomqablubsijhawmuantawvthovtwbdhaulawmthiabAgnesiantauualiuatausaibsebtustswvcuabpuastsimnyogtxaiskevpabthemnqi.Yogtiasmushaisplaubtagtauraugthemcovnqilawm,tejzaumyuavualino:txiavnyiajtimhaujlwm,tsorauyuscovtsevlossisavevcovnqi,thiabtsorauinsurancethemyogtiashaiscovplaubtaguasmaujfeemraucovkhomoblosntawmAgnesianuasyogtseemtshuavnqitsistauthem.Agnesianyuavnrogcovtawmtswvyimthamtaguantejmuabcojmushaisplaub.Txhuacovnqiyuavcojlossaibibqhozujzusthiabmamlixamtxogtustswvcuablossistuslavnqinyobzoolicas.CovthawjcojtimAgnesianmamlisaibtxhuacovkevsaunqiuasmuajfeemsebyuspuastxaussiabthemnqi,thiabsebcovnqipuastsimnyogmusraukevhaisplaub.

4. CovNqiTsoRauVajTseLossisAvEvRauCovTswvCuabUasTauTagSimNeejThiabNwsTsisMuajPojNiamlossisibtusTxiv:TejzaumAgnesianyuavmuabcovnqiraucovtsevlossisavevyogtiastustswvcuabtautagsimneej,yogtiastustswvcuabtsismuajpojniamlossisibtugtxiv.Tustswvcuabuastagsimneejlawm,tuspojniamlossistustxivyogtuslavAgnesiancovnqiuastseemthemtsistautag,yeejyogxamtiasnwsyogtusthemcovnqiyogtiasAgnesiantsistautxaisDaimNtawvCogLusTxogKevSibFaibCuabYeej


CuabTamqhialosntawmtustswvcuabtiasnwstustxivlossistuspojniamtsislavuantejtusneegtxaiskevpabkhomob.

D. KEVQHIAUAHAUJLWMYuavmuajkevqhiauahaujlwmraucovneeguahaujlwmsaunqi.Covneeguahaujlwmsaunqiraukevthemnqiyustuskheejyuavkawmtxogkevnrogtswvcuabhaislus,kawmkevsablaj/sibkhothiabkawmkevsaunyiaj.KevqhiauahaujlwmyuavqhiatxogfeemntauAgnesianCovKevCaiRauKevPabThemNqi/SauNqithiabkevkoomteskomsaibtausthiabpabtxhuatustswvcuab.KevqhiauahaujlwmyuavqhiatxogyuavhaiscovluslicasthaumhaistxogkevsaunyiajthiablwmyamtauhaiskomcovtswvcuabpaubtxogAgnesiancovkevcai.E. KEVSAIBXYUASCOVCHAWSAUNYIAJCovchawsaunyiajsabnraudyuavuahaujlwmsawvcesrauAgnesianyuavmuajkevsaibxyuastaslikommuajfeemtiaslawvuarawslitxojcaino.F. MUABTAUCOVKEVCAIMuajntawvqhiatxogAgnesianCovKevCaiPabThemNqi,thiabAgnesianKevCaiRauKevThemNqiYusTusKheejthiabKevCaiSauNqiyeejmuajobpebtxojkevmuabtauraucovneeguastuajtxaiskevpabntawmAgnesian.SaibTshooj1yogxavpaubntxiv.G. KEVTSWJYogtauhaiscovlusphem,thabplaub,daglossislwmyamcwjpwmphemntawmAgnesiancovneeguahaujlwm,covneeguahaujlwmraucovchawsaunyiajlossiscovkwslijchojyuavraugkevkhorawscovkevcaikhocovneeguahaujlwmtsiszoo.H. TSISQHIARAULWMTUSAgnesianyuavtivthaivcovtswvcuabcovntaubntawv,txoglawvtejnyiajtxiagthiablawvtejntaubntawvkhomob.

SAU TXOG: TXOJ CAI TXOG KEV XA NQI THIAB KEV SAU NQI Nplooj 8 ntawm 8 KevCaiRauKevThemNqiYusTusKheejthiabKevCaiSauNqi

Tshooj1MUABTAUCOVKEVCAIMuajntawvqhiatxogAgnesianCovKevCaiPabThemNqi,thiabKevCaiRauKevThemNqiYusTusKheejthiabKevCaiSauNqiyeejmuajobpebtxojkevmuabtauraucovneeguastuajtxaiskevpabntawmAgnesian.

1.CovtswvcuabthiabcovlavnqithovtaucovntawvtxogcovKevCaiPabThemNqi,covKevCaiRauKevThemNqiYusTusKheejthiabKevCaiSauNqi,DaimNtawvThovKevPabThemNqi,thiablossisCovNstiabLusSauYoojYimyogsauemailtuajrau:

AgnesianHealthcareFinancialCounseling430E.DivisionStreetFondduLac,WI54935

2.CovtswvcuabthiabcovlavnqithovtaucovntawvtxogcovKevCaiPabThemNqi,covKevCaiRauKevThem

NqiYusTusKheejthiabKevCaiSauNqi,DaimNtawvThovKevPabThemNqi,thiablossisCovNstiabLusSauYoojYimyoghuxovtoojrau920-926-4841.

3.CovtswvcuabthiabcovlavnqimuabtaucovntawvtxogKevCaiPabThemNqi,covKevCaiRauKevThemNqi

YusTusKheejthiabKevCaiSauNqi,thiabDaimNtawvThovKevPabThemNqi,thiablossisCovNstiabLusSau Yooj Yim yogmus saib rauhttp://www.agnesian.com/patient-visitor-resources/on-line-services/patient-billing-information

4.CovtswvcuabthiabcovlavnqithovtaucovntawvtxogcovKevCaiPabThemNqi,covKevCaiRauKevThem

NqiYusTusKheejthiabKevCaiSauNqi,DaimNtawvThovKevPabThemNqi,thiablossisCovNstiabLusSauYoojYimyogtuajrautimcovchawnyobhauvqabno:

a. St.AgnesHospital,430E.DivisionStreet,FondduLac,WI

b. FondduLacRegionalClinic,420E.DivisionStreet,FondduLac,WI

c. ConsultantsLaboratory430E.DivisionStreet,FondduLac,WI

d. RiponMedicalCenter,845ParksideStreet,Ripon,WI

e. WaupunMemorialHospital,620W.BrownStreet,Waupun,WI

AGNESIAN HEALTHCARE COV KEV CAI THIAB KEV KHIAV HAUJLWM CLW1/02, FDLRC1/02, RMC10/12, SAH10/91, WMH1/02)

SAU TXOG: KEV CAI PAB THEM NQI

Chav: Thawj Coj - Bonnie Schmitz

Nplooj 1 ntawm 9

TSIM THAUM HNUB TIM NO: 10/25/91 (Txoj cai no yog hloov rau daim St. Agnes Hospital Administrative Policy No. 5, "Community Care Program".) TXOJ CAI:

MuajfeemrauTxhuatustswvcuabrauSt.AgnesHospital(tomqabno,yuavyoglubnpetiasAgnesian)uastautxaiskevpabkhomoblosntawmSt.AgnesHospital,RiponMedicalCenter,WaupunMemorialHospital,FondduLacRegionalClinicslossisConsultantsLaboratory.

QhiameejPebtxojkevpabyeejmuajfeemntauraucovtibneegnyobpuagncigpeb.Covtibneeguahaujlwmraupeblosyogcovnyobzepeb.Covtswvcuablosyogpebcovphoojywg.Pebnyobraulubzosuassibkoomteszoo,sibhlubliibtseneeg,thiajliuarauyuspomraulubchawuahaujlwmtiaspebsihlubliibtseneeg.Vimtiaspebmuajkevmobsiablinopebcovphoojywgthiabcovnyobzepebyuavnojqabhaushuvzoodua.

AgnesianHealthCarelubhomphiajyogmuabkevpabzookomuaraulwmtusmuajkevCiaSiab,KevNojQabHausHuvraucovpebpabpebyuavuatauzoofwmcovhluasmusraucovlaus.Lubhomphiajnoyogqhovyuavtuavpebtxojkevuahaujlwmrautxhualubcaij.

AgnesianHealthCareyeejmobsiabkoomtesnrogkojkevnojqabhaushuv.Qhovnotxhaistiaspebyeejlojhlobtaslis,nhriavkevpabkhomobtshiab,thiabyuavmuajkevpabntxivraucovtibneeguasmobheevraupeblubzejzos.

Vimpebyogiblubchawuaspablubzejzos,pebyeejtxhobtxwmkoomteskompabcovtibneeghauvzejzoskomcooblicoobtau.Pebcovkwskhomobthiablwmcovneeguahaujlwmyeejyuavkoomtesnrogkoj,txhawbkojkomkojmuajfeemraukojkevnojqabhaushuvthiab.Lawvyuavqhiakojtxogcovkevkhomobtseemceebthiabmuabtswvyimraukojkomualubneejnojqabhuashuvzoodua.Thaummuabkevpabkomhaumpeblubhomphiaj,Agnesianyeejkoomteskommuabkevpabthaummuajmobxwmkubceevthiabpabtejyammoblojtxawmtustswvcuabmuajlostsismuajinsurancelossisnyiaj.Qhovkevcaithemnqiyogibqhotauuarawslitsoomfwvthiablubxeevcovkevcairaucovzospebuahaujlwmrau.CovtswvcuabtsimnyogtxaiskevpabrautxojcainoyuavtaucovnqiluvraucovkwskhomobtsimnyoghauvAgnesian.Kevpabthemnqiraukevcainoyuavuarawsliqhovkevciasiabtiascovtswvcuabyuavkoomtesnrogcovkevcaitswjkevthovkevpabthiablwmcovchawuaspabthemnqikhomobraucovpejxeem.Agnesianyuavtsisxaivntsejmuagrawslihnubyug,pojniamlossistxivneej,haivneeg,kevntseeg,ximtawvnqaij,yogtusneegtsistaus,nyiamuapojniamlossistxivneej,tuajtxawvtebchaws,lossisyoglostsisyogpejxeemthaumlostxiavtximtxogkevpabthemnqi. TXHAIS LI CAS

Covlustxhaishauvqabntawmnoyograutxhualunyobrautxojcaino.FeemNtauCovNqiRaugLiCas(AGB):Covnqiuasfeemntauraugyogcovnqithaumtuajrauchavkhomobxwmkubceevlossiskhomoblojraucovtswvcuabthiablossistuslavnqi.Raucovtswvcuabtsimnyogtau,covnqiyuav

SAU TXOG: KEV CAI THEM NQI Nplooj 2 ntawm 9

tsistshajcovnqinyobrauLookBackMethodqhiameejrau§1.501(r)-5(b)(3)rauInternalRevenueCode.TheLookBackMethodyogibqhovlaijrawslicovtibneegthemAgnesianHealthcareyavtaglosuasmuajMedicarenqi-rau-kevpabtagnrhonrogcovneeguasmuajinsurancelawvtuskheejlostimhaujlwm.CovnyiajthemyuavmuajfeemnrograuAGBthaumlaijyuavpaubtiasyuavmuajcovnqinpaumlicasrawslixyootaglos.Covnqiuasyustauthem(co-insurance,co-paymentsthiabdeductibles)yuavmuabcojloslaijnrograucovMedicarenqi-rau-kevpabuakenrogcovnqixaraucovinsurancehaujlwmlossiscovyusyuav.Covnqitauthemtagnrhoraucovnqikhomobyuavmuablaijnrograwstagnrhocovtibneeg.QhovAGByuavlaijrawsliqhovThimRovQabrauiblubxyoouantej45hnubtomqabhnubxausrauxyookawg,thiabpibrauthaumhnub120rauhnubxaustomqabibxyoo.QhovNqiTauRaugThemFeemNtauRawsFeemPuaAGBlaijqhovthemfeempuatxhualubxyoosuantej45hnubraulubxyoos,thiabqhiameejnyobrauTshoojCrautxojcaino.LubCaijUaNtawvThov:Covcaijuantawvthovyuavtxaisthiabsaibraukevpabthemnqi.Daimntawvthovkevpabyuavpibrauthaumhnubtimtxaiskevpabthiabxausrau240hnubtomqabthawmhnubxadaimnqitawm.KevLuvNqi:Kevpabthemnqiuaspabluvcovnqi,raucovkevpabkhomobuastsimnyoblosntawmAgnesian,yeejlaijrawslicovnyiajtxiag,raucovtswvcuabtsimnyogtau,lossiscovlavnqi,uasmuajnyiajrauibtsevneegrauiblubxyoontawm166rau300%feempuarawsTsoomFwvPomTiasTxomNyemthiabmuajcovcuabyeejcuabtamuastsawgdua$2,000rauibtugtsevneeg.MuajMobXwmKubCeev:YogqhiameejrauTshooj1867rauSocialSecurityAct(42U.S.C.1395dd).Lolus"muajmobxwmkubceev"txhaistautiasyogibqhomobuascialimobloj(ibyamlimobheev)esyogtiastsistaukevpabkhomobraunocesyuavmuajfeemlino:

1.Uarautusneegntawd(lossis,haisraucovxeebtub,kevnojqabhaushuvrautuspojniamlossistusmenyuam)yuavmuajteebmeemloj,

2.Uaraulubcevyuavmoblojuatsistaus,lossis3.Lubcevlossistejsiabntswslossislwmqhovchawraulubcevyuavmobloj,lossis4.Raucovpojniamxeebtubuasmobplabyugmenyuam:

a.Yoghloovmuajcaijkompabtaunwshloovraulwmlubtsevkhomobuantejnwsyug,lossisb.Yoghloovtsevkhomobyuavuateebmeemrauleejniamlossisrautusmenyuamuastsistauyug.

TsevNeeg:TxhaistaulosntawmU.S.CensusBureau,tiasyogibpabneeguasmaujoblossiscoobtshajuasnyobuakethiabuassibtxheebvimmuajtibtugleejniamlossisleejtxivlossissibyuavlossisuantawvmuajcaisaibxyuastusneeg.Yogtiasibtugneegsivtusneegntawdraunwscovsetiasnwstutusneegntawd,rawsliInternalRevenueServicecovkevcai,tejzaumlawvyeejyogibtuguastseemtoslwmtuspabnwsxwbthaumcojnwslossaibsebpuastsimnyogtxaiscovkevpabrautxojcaino.TsevNeegCovNyiaj:Covtsevneegcovnyiajlaijrawslitxhuatusneeglaustaunyiajntaulicasthiabcovuasnyiajsauraucovserautsoomfwv(federaltaxreturn).Raucovtswvcuab18xyoorovhauv,tsevneegcovnyiajyoglawvniamthiabtxivthiablossiscovneegtulawv.CovtsevneegcovnyiajyogsaibsivrawsliCensusBureauqhia,kujmaujfeemlaijrawslicovneegtxomnyemuasyogtsoomfwvtxojcai:

1.Xamtiasnyiajnocesyognyiajuahaujlwm,nyiajpoobhaujlwm,nyiajraugmobtimhaujlwm,nyiajSocialSecurity,nyiajSupplementalSecurityIncome,nyiajxyuamqhaub,nyiajtubqubrog,nyiajthemvimmuajtusneegtagsimneej,nyiajlaus,paj,nyiajlajluam,nyiajxaubtsev,nyiajthemrawskevcai(royalties),nyiajmuagcuabyeejcuabtam,nyiajtsotsegrauyuslosntawmlwmtus(trusts),nyiajraukevkawmntawv,nyiajyugpojniamlossistustxiv,nyiajyugmenyuam.

2.Yuavtsisxamcovkevpabuastsisyognyiajntsuab(xwslinyiajmuasnojthiabnyiajpabrauyusthemnqixaubtsev);

3.Sivcovnyiajuastsistautxiavse;4.Tsisxamcovnyiajlagluamuastauthiabpoob.

TxomNyemRawsLiTsoomFwvPom:Qhovyustxomnyemrawslitsoomfwvpom(FPL)yogsivcovnyiajtxiaglawvyeejmuabcojlosntsuasrauntawmibtsevneegrawsmuajcoobleejlicasthiajlipaubtiasleejtwgtxomnyemhauvlubtebchawsUnitedStates.TejlubsijhawmFederalRegisternyobrauUnitedStatesDepartmentofHealthandHumanServicesyeejmuabkhotshiabrawstxojkevcaitshooj(2)ntawmtshooj9902ntawmTitle42ntawmUnitedStatesCode.CovkevcairauFPLnyobrauntawmhttp://aspe.hhs.gov/POVERTY/.


KevPabThemNqi:Kevpabmuajraucovtswvcuabuastsimnyog,covuasyuavraugkevnyuajraunyiajtxiag,komtxotaumentsislossistagnrhocovnqikhomobthaummuajxwmkubceevlossiscovmoblojthaumtuajhauvAgnesian. PabDawb:Pomzootxotagnhro100%covnqikhomoblosntawmAgnesianraucovtswvcuabtsimnyog,lossiscovlavnqi,yogcovnyiajtxiagraulawvtsevneegyoglossistsawg165%ntawmFPLthiabmuajcuabyeejcuabtamtsawgduabli$2,000rauibtugtseneeg.TusLavNqi:Tusneegmuajtxojhaujlwmdualitustswvcuablosthemtustswvcuabcovnqikhomob.NqiTauThemTagNhro:Covnqiuaslaijrawslicovnqikhomobuantejluvcovnyiajtawm.TsisMuajTsevNyob:RawsliTsoomFwvtautxhaislawm,thiabtauteevcovntawvraupejxeempomrauFederalRegisterthaumlub12hlisntujhnubtim5,2011nyobrauHUD:Ibtugneeglossisibtsevneeguastsismuajtiblubtsevuasnwstaupwtxhuahmo,txhaistautiastusneegntawdlossistsevneegntawdpwrautejlubchawnraumzoovlossisrautejlubchawtsisyograutibneegpwlossisnyobraucovtsevpubneegtsismuajvajtsepwxwbvimtsuasyogpwibntusxwb.Covneegnolosyeejyogcovuastwbtawmntawmlubtuamtsevuasnwstaunyobli90hnublostsawgduauasnyobraucovtuamtsevpabcovneeguasraugxwmkubceevlossiscovchawsuastsisyograutibneegnyobuantejlawvmusraulubtuamtsev.YamMobLojTauTxaisKevPabKhoMob:YogtxhaislosntawmMedicaretiasyogcovkevpablossiscovkhoomuastsimnyogthiabtaumuabkompaublossiskhocovmobrauibtugneegmuajmoblossisraugmob.MedicareNqi-Rau-KevPab(FFS):InsurancethemnqikhomobuasnyobrauhauvMedicarePartAthiabPartBnyobrauTitleXVIIIhauvtxojcaiSocialSecurityAct(42USC1395c-1395w-5).KevThemNqi:TxojkevthemnqirawscaijuaspomzoolosntawmAgnesianthiabtustswvcuab,lossistuslavnqi,raucovnqitauthem.Txojkevthemnqiyuavyograwslintawmtustswvcuabtaunyiajntaulicas,covnyiajtauthemntaulicas,thiabnwsthemlicasyavtagloslawm. YeejXavTiasTejZaumYeejTsimNyog:Nyobrautejtusneeg,covtswvcuabmuajinsurancetsistxauscestejzaummuajqhovuaspebxavtiasnwsyeejtsimnyogtxaiskevpabthemnqivimnwsmuajnperautejqhovtxheejtxheemlossislwmyamqhiaraupebpaub,tsisyoglosntawmtustswvcuab,kompaubntsuamxyuassebnwscovnyiajtxiagyoglicas.InsuranceUasYogTimHaujlwmlosyogYuavYusTusKheej:Covchawuastsisyogxuamqhaubcovinsurancethemnqikhomob,ntxivlicovchawuasmuajkevkhomobnyobrauMedicareAdvantageuastsisyogxuamkhaubli.LubCaijTsimNyog:Yogtiasthovtaucovkevpabthemnqilawmcesyuavtaukevpabtxogliraulubhlis.Kevpabyuavmaujraulubcaijdhauloslawmthiabraucovnqiuastsimnyogpab6lubhlisuantejuadaimntawvthovkevpab.LuvNqiRauCovTsisMuajInsurance: Covtswvcuabuastsismuajlwmcovkevpabthemnqikhomobyuavtauluvnqiraucovtsismuajinsurance,raucovkevpabtsimnyogtaulosntawmAgnesianrautxojcaino,rauthaumlubsijhawmluvcovnqi.TusTswvCuabUasTsisMuajInsurance:Ibtugtswvcuabuastsismuajlwmlubchawthemcovnqikhomoblosntawmiblubinsurance,qhovERISAplan,TsoomFwvKevPabThemNqiKhoMob(licovMedicare,Med,SCHIP,thiabCHAMPUS),NyiajRaugMobTimHaujlwm,lossislwmcovchawuasyuavpabthemcovnqikhomob.TusTswvCuabUasTsisMuajInsuranceTxaus:Ibtugneeg,uasmuajinsurancelosntawmhaujlwmlossisyognwsyuavnwslossistautimxuamqhaub,yuavnyuabraunwsthemcovnqikhomoblosntawmAgnesian. KEV KHIAV HAUJLWM:

A. KEVPABTSIMNYOGTAUCovkevpabnyobrauAgnesiantxojkevcaithemnqitauyogibqhovkhomobzoothiabuarawslifeemntaucovkwskhomobua.Covmuajcesyoglino:

1.Kevpabkhomobrauthaummuajxwmkubceev,thiabkevpabrauchavkhomobxwmkubceevpabkomtustswvcuabqhovmobkomrovloszoomentsis.

2.Kevpabkhomobraucovmoblojlawmtiamsistsisyogtuajrauchavxwmkubceev.


3.Yamkhomobtauua,xwslicovpwraurauhauvtsevkhomoblossiscovtuajntsibkwskhomobtxaiskevntsuamxyuas,saibsebmobdabtsi,thiablossistxaiskevkhomobvimraugmoblossismuajmob,thiabcovkevpabkhomobrawsliMedicarelossislwmcovinsurancethemhuua"covkevkhomobuasthemrau."

4.CovkwskhomobuahaujlwmrauAgnesianyeejthemrautxojcaino.ThovsaibrauTshoojFkomtautagnhrocovkwskhomob.

Kevpabuastsistsimnyogtxaiskevpabthemnqiyogcovno:1.Covkevkhomobuastsistsimnyogtaukho,thiabcovkevpabuasMedicaretsisthemlossisyogMedicare

pomtiasyogibqhouastsistaukho.2.KevpablosntawmcovkwskhomobuastsisuahaujlwmrauAgnesian(xwslicovuaraulawvtuskheejthiab

lossistsisyogAgnesiancovkwskhomob,tshebthaujneegmob,lwmyam.)Yeejxavkomcovtswvcuabhuraucovkwskhomobnugseblawvpuasmuajkevpabthemnqikhomoblossisseblawvpuaspubyusmajmamthem.SaibTshooj3komtautagnhrocovkwskhomobuastsismuajnperaupebthemrautxojcaino.

3.SaibTxhoojAkomtautagnhrocovkevpabuastsisthemrau.B. KEVKOOMTESNROGRAUKEVNTSUAMXYUASCOVTAUUARAULUBZEJZOSTXOGKEVNOJQABHAUSHUVTaumuajkevntsuamxyuascovkevpabxavtau(CHNA)raulubzejzosuasAgnesianuahaujlwmrau.Pomtiasneegrogyogibqhovteebmeemlojheev.Txojkevnpajpabraulubzejzospomtiasyogneegphaisplab(bariatricsurgery)yuavpabneegtxhobrog,tiamsiskevphaisplabtsisyogibqhovkevpabtsimnyogtauraukevpabthemnqilossistsisluvnqiraucovneegthemlawvtuskheej.C. NTSUASKEVTSIMNYOGLICASKevpabthemnqiyuavmuajraucovtsismuajinsurancethiabcovtsismuajtxauslossistuslavnqi,uastsimnyograwslicovqhiahauvqabno.CovkevsaibpuastsimnyograukevcaithemnqitauuarautxhuaAgnesiancovchawuahaujlwm.Agnesianmuajtxojcailoshloov,kholossispauvtxojcaikomhaumthiabyogtaukho.Covthovkevpabthemnqitaunyob3lubhlisraulubnroogFondduLac,DogelossisGreenLake.ThovsaibrauTshoojEkompaubcovZipCodeuaspebuahaujlwmrau.Muajtejlubcaijuastibneeguastsisnyobraulubzostiamsistuajnyogibntusxwblostejzaumlawvtxaistaukevpabkhomobxwmkubceevthiabpebyeejsaibibtugtxawvibtugsebpuastsimnyog.Covchawthemnqikhomob(covinsurancetimhaujlwm,MedicalAssistance,IndigentFunds,VictimsofViolentCrimes,thiablwmyam)taucojlossaibuantejsebpuastsimnyograukevpabthemnqiesAgnesianthiajlipaubzootswjcovchawthemnqikhomobyogtiasmuabtaukevpabthemnqi.Yogtiastejzaumibtugtswvcuabyuavtsimnyogtxaiskevpab,Agnesianmamlihaiskomnwsmusntsiblubchawuasyuavpabtaunwsthiabraunwsmusuatiavcovntaubntawv.Covneegtsonpethovraukevpabtauhaistxhuaqhovchawsuaslawvmuajnpethemnqikhomobkomlawvthemlilawvthemtautagcesmamlixamsebpuastsimnyogtxaiscovkevpabthemnqi.QhovnoyogcovkevthemnqikhomoblosntawmlubXeev(Stateprogram)uasnwstsimnyogtautiamsishovtsisthemcovnyiajthemrawssijhawmraukevpabntawd.Covtibneegthovraukevpabthemnqitxojhaujlwmyogmusthovcovinsurancerauxuamqhaubthiabcovinsurancetimhaujlwmlossiscovyusthemyustuskheej.Covtswvcuab,lossiscovlavnqi,uastsisxavkoomtesmusthovraucovinsuranceuasAgnesianpomzoorauyusmusthov,cesmuajfeemuasyuavtsispomzoorauyustxaiscovkevpabthemnqi.Covtswvcuabtauthemraucovnqirawslilawvthemtausrawslitxojkevcaino.Covtswvcuab,lossiscovlavnqi,uastsimnyogtauMedicaid,taumusthovMedicaidlossismuabdaimntawvlosntawmMedicaidtiasMedicaidtsiskampablawvmuabuantejrau(6)lubhlisuasthovrauAgnesiankevpabthemnqi.Covtswvcuab,lossiscovlavnqi,taukoomtesnrograudaimntawvthovkevpabrawslidaimkevcaithovkevpabthemnqi.


ThaumAgnesianlosntsuassebibtugtswvcuabpuastsimnyograukevpabthemnqiyogsaibnwstsevneegcovnyiaj,cuabyeejcuabtam,thiabcovkevkhomobnwstautxais.Agnesiantxojkevpabthemnqiyeejmuajrautxhuatustswvcuabuastsimnyogtxaisrawslitxojkevcaintawmno.Covkevpabthemnqiyogibqhouasmuabtauraucovtswvcuab,lossiscovlavnqi,rawslilawvcovnyiajtxiagthiabtauuarawslicovtsoomfwvthiablubxeevcovkevcailijchoj.Kevpabthemnqiyograucovtswvcuabtsimnyog,yogtiascovkevpabyograwslicovntawvcoglusntawmnwsthiabnwslubinsurance.Kevpabthemnqifeemntauzausyuavtsispabraucovnqitustswvcuabtauthemrau(co-payment)rawslilawvlubinsuranceyogtiastustswvcuabtsisuarawslilawvlubinsurancehaiskomtauuaxwsliyogtsisuacovntaubntawvtsocaikuajkwskhomob(referralslossisauthorizations).Feemntauzaus,covnqitshuavtauthem(outofnetwork)yogtsiskuajcovkwskhomobmuajnperauinsuranceyogibqhosaibibtugzujzus.Covtswvcuabuassivtaucovnqiraukevuase,covuasmuajnyiajtseglosthemnqikhomobxwsliHealthSavingsAccount,losqhovHealthReimbursementArrangementlossisqhovFlexibleSpendingAccount,yuavtausivcovnyiajtsegntawdtagtsomamlimuabtxojkevpabthemnqirau.AgnesianmuajtxojcaitshemcovkevpabluvnqiyogtiastaupomtiastaumuajneeguatxhaumcovkevcainyobrauAgnesian.D. KEVPABTHEMNQIThaumsaibxyuastustswvcuabtsevneegcovnyiajtxiag,cuabyeejcuabtam,thiabkevkhomobtautxais,covtswvcuabtsimnyogtejzaumtxaistaucovno.LuvNqiRauCovTsisMuajInsurance: Covtswvcuabuastsismuajlwmcovkevpabthemnqikhomobyuavtaukevluvnqiraucovtsismuajinsurancerauthaumlaijcovnqiuastsistauluv.Qhovnomuajfeemraucovtswvcuabuastsismuajinsurancethemnqikhomobthiablossislwmkevthemnqikhomob.Covtswvcuablossiscovlavnqi,yogtiasluvnqiraucovtsismuajinsurance,tsistaumuabcojraukevtsimnyograukevpabthemnqinyobrauntawmno.KevPabDawbTagNhro:QhovnqiAgnesianHealthcareyuavkomthemnyobntawmkevcaithemnqiraucovtsismuajinsurancelossiscovmuajinsurancetsistxaus,lossiscovlavnqi,uastsevneegcovnyiajyogtsawgdua165%ntawmkevtxomnyemrawslitsoomfwvpomuasmuajcuabyeejcuabtamtsawgdua$2,000rauibtugneeg.KevLuvNqi:QhovnqiAgnesianyuavluvraukevcaithemnqiraucovtsismuajinsurancelossiscovmuajinsurancetsistxaus,lossistuslavnqi,uastsevneegcovnyiajyog165%tiamsistsawgdua300%ntawmkevtxomnyemrawslitsoomfwvpomuasmuajcuabyeejcuabtamtsawgdua$2,000rauibtugneeg.Yuavluvnqi,rawslicovnyiajtxiaghauvqabno,rawsliibtsevneegcovnyiajrautustswvcuab,lossistuslavnqi:

1.Tsevneegcovnyiajsiabtshaj165%FPLtiamsisyoglossistsawgdua175%FPLyuavtsimnyogtaucovnqiluv75%raucovnqikhomob.





KevThemNqi:Tauthemcovnqitagnrho,uastsistauthem,uantej30hnubntawmthawjhnubxathawjdaimntawvnqituaj.Yogtiastustswvcuabthemtsistaus,lossistuslavnqi,themtsistaustagnrhorawslubsijahwmntawd,tejzaumlubsijhawmraukevthemnqikomntevzograwsliqhovnqitseemtshuavtshemtomqabluvnqiraucovtibneegtsimnyogtxaiskevpabthemnqi.MamliuakevthemnqiuasobleegpomzoontawmAgnesianthiabtustswvcuab.Covkevcaintawmkevthemnqiyuavyoguarawslitusneegthovnwscovnqikhomob,covtsevneegcovnyiajrauiblubxyoosthiablwmyam.Yogtiaspomzoo,covnyiajthemrawssijhawmyuavtsistauthempaj.CovtswvcuabtauqhiarauAgnesianyogtiaslawvhovthemtsistauscovnqilicastomqabtwbthamtagtiaspomzootxogkevthemnqilawm.Yogtiastustswvcuabtsistxuaslustuajcestejzaummuajfeemcovnujnqinoraugxatawmraulubchawmsaunqi(collectionagency).E. YEEJXAVTIASTEJZAUMYEEJTSIMNYOGAgnesiantotaubtiastxhuatustswvcuabyuavsautsistaudaimntawvthovkevpabthemnqilossisyuavmusmuabtsistaucovntaubntawvpovthawj.Tejzaumyuavmuajtejtustswvcuabuasyuavtsimnyogtaucovkevpabthemnqiuastsistauuadaimntawvthovkevpab.LwmyamuasqhiatxogtustswvcuabrauAgnesiantejzaumyuavsivtaulostxiavtximtiascovnqintawdyuavthemtsistauvimtejzaumyeejtsimnyog.Qhovxavtiastejzaumtsimnyogyogibqhouataurawslilwmcovkevpabnwstxaislossistejyamhauvnwslubneejxwsli:

1.Covtswvcuablossiscovlavnqiuastauuantawvthemtsistaulawvcovnujnqi(bankruptcy).Raucovtibneeguastauuakevthemtsistaulawvcovnujnqi(bankruptcy)lawm,qhovnqiuastseemtshuavthemrauhnubnwsthovtaukevtsisthemnqi(bankruptcy)yuavyogqhovuaspubmuabtshemtawm.

2.Covtswvcuablossiscovlavnqiuastautagsimneejtsismuajtsevlossisav.3.Covtswvcuablossiscovlavnqiuastsismuajtsevnyob.4.Covnqiuasxarovtuajlosntawmlubchawsaunqitiaslawvsautsistauvimcovlussausaumno.5.CovtswvcuablossiscovlavnqiuastsimnyogtxaisStateMedicaidcovkevpabthemnqi,yuavtsimnyogtxais

kevpabraucovnqiuasyogcovseemtauthemlossiscovuaslawvtsiskamthemrau.AgnesianyeejtotaubtiasmuajibcovtswvcuabyuavtebtsistauAgnesiantxogthovkevpab.Yogmuajlino,tejzaumAgnesianyuavsivlwmkevsaibxyuaskevtsimnyograuibtugneegkevthemnqi.CovyuavpaubtxognoyuavpabAgnesiantxiavtximtxogtusneeguashaistsistaulusthaumthovkevpab.Tejzaumyuavpomzooraucovtswvcuabthaumlawvtseemuacovntawvthovkevpabthemnqi.Agnesianyuavsauntawvraucovtswvcuabuastsistsimnyogtxaiskevpabthemnqiqhiaraulawvpaubtiaslawvyuavtsistaucovkevpabthemnqilawm.Tsabntawvnoyuavmuajcovntsiablussauyoojyimtxogtxojkevcaithemnqithiabyuavualicasyogtiastsisuadaimntawvthovkevpablossistsisthemcovnqi.Covtswvcuabuastejzaumtsimnyogyuavtautxojkevpabthemnqiyuavmuajnpenyobraucovneeguastwbtautxaislawm.Lawvyuavtsisraugxaraukevsaunqi,yuavtsisrauglwmkevsaunqi,yuavtsissauntawvqhiatxogtiastsimnyogdabtsi,thiabyuavtsismuajnperaulubtsevkhomobtiasyogtusneegtsisthemnqi.Raucovtswvcuablossiscovlavnqiyogtiaslawvtsimnyogvimsivtauntaubntawvlosntawmcovchawqhiatxogkeebkwmthemnqi(creditagencies)lossisqhialawvcovnyiajtxiag.F. KEVPABKHOMOBTHAUMXWMKUBCEEVRawslitxojkevcaitsoomfwvpabcovtibneegmuajmobxwmkubceevFEDERALEMERGENCYMEDICALTREATMENTANDLABOR(EMTALA),tsispubtsevkhomobsaibxyuassebnwspuasmuajnyiajthemraulawvuantejlawvmuabkevpabkhomobrauthaummuajkevkhomobxwmkubceev.TejzaumAgnesianyuavnugkomtustswv


cuabthemnwsqhovfeemuasnwstauthem(xwslicovco-payments)rauthaumlubcaijnwstxaiskevpab,yogtiasnugnoyuavtsiscuamtshuamraunwskevkhomoblossiskevpabraunwsyogmuajmobxwmkubceev.G. COVNQIXARAUTUSTSWVCUABUASTSIMNYOGRAUKEVPABTHEMNQICovnqixarautustswvcuabthem,lossistuslavnqi,uastsimnyograukevpab.Raucovtswvcuabuastsismuajinsuranceestsimnyogtau,covnqiyuavtsistshajcovnqinyobrautxojcaihuuaLookBackMethod.QhovLookBackMethodyogibqhovlaijrawslicovtibneegthemAgnesianyavtaglosuasmuajMedicareFee-for-Servicetagnrhonrogcovneeguasmuajinsurancelawvtuskheejlostimhaujlwm.CovnyiajthemyuavmuajfeemnrograuAGBthaumlaijyuavpaubtiasyuavmuajcovnqinpaumlicasrawslixyootaglos.Covnqiuasyustauthem(co-insurance,co-paymentsthiabdeductibles)yuavmuabcojloslaijnrograucovMedicarenqi-rau-kevpab(MedicareFee-for-Service)uakenrogcovnqixaraucovinsurancehaujlwmlossiscovyusyuav.Covnqitauthemtagnrhoraucovnqikhomobyuavmuablaijnrograwstagnrhocovtibneeg.QhovAGByuavlaijibzaugibxyoos.Qhovfeemlaijyuavsivrau120hnubtomqabxyootaguasAgnesiansivloslaijcovfeempuarauAGB.CovtswvcuabuastsimnyogtxaiskevcaithemnqiyuavtsistauraugthemtagnhrocovnqilaijraukevkhomobtsimnyogthaumlawvthovtaukevcaithemnqilosntawmAgnesian.CovnqiluvyuavmuajrawslidaimntawvtshoojCraukevcaino.

KevlaijnqiraucovtsismuajinsurancetsimnyograucovthovFA:NqiTauThemTagNhroYog $1,000.00AGB%rautustswvcuab 35%LuvNqi $350.00AGBTagNhroYog $650.00LaijqhovluvnqirawsliTsoomFwvkevcaixamtiasyogkevtxomnyemraucovnqitshuavtxog$650(TagNhroAGB)

CovqauvqhiatxogyuavlaijnqiraucovtsimnyograucovthovFA:NqiTauThemTagNhroYog $1,000.00Insurancethem/luvnqikhomob $300.00QhovTusTswvCuabTauThem $700.00AGB%rautustswvcuab 35%

LuvNqi $350.00 Nqi–NqiLuv=AGBtagnhro $350.00

LaijqhovluvnqirawsliTsoomFwvkevcaixamtiasyogkevtxomnyemraucovnqitshuavtxog$350.(AGBTagNhro)

H. THOVRAUKEVPABTHEMNQIYuavkomtsimnyogtxaiskevpabthemnqiyuavsaibrawslicovnyiajtxiagraulubsijhawmtsonpethovkevpab.Feemntau,taumuajntawvpovthawjraudaimntawvthovkevpabthemnqi.Yogtiastsismuajcovntawvpovthawj,tejzaumAgnesianyuavnugkommuablwmyamntawv.Yuavtaumuabpovthawjqhiatiasyeejtsimnyogtxaiskevpabthemnqi.Covntawvtomqabnoyogcovuassivtauuapovthawjlosntawmcovtswvcuab,lossistuslavnqi,kompaubtiasnwstsimnyoglicas:

1.LuamcovntawvseFederal(daim1040),thiabtagnhrocovntawvuasenrog,rautsaibno.Yogtiastsistauuase,cestauuadaimntawv4506T.

2.DaimNtawvPovThawjQhiaTxogTauNyiajLiCas-luamdaimtwtshev(30hnubdhau)lossislwmdaimntawvpovthawj.

3.Povthawjraunyiajtxiag,xwslinyiajpoobhaujlwm,raugmobhaujlwm,themyugpojniamlossistustxiv,nyiajlaus,nyiajlwmtustsotsegrauyus,nyiajtubqubrog.


4.Daimntawvtimlubchawtsonyiaj(bankstatement),raucheckingthiabsavingthiabdebittibsi.Covntawvtomqabnoyogcovuassivtauuapovthawjlosntawmcovtswvcuab,lossistuslavnqi,sebnwspuasyuavtsimnyog:

1.Muajnyiajthemnqirautimbank(Checkingaccount)2.Muajnyiajtsegtimbank(Savingsaccount)3.Muajnyiajtaupajtsegtimbank(Moneymarketaccounts4.Covntawvpovthawjtsonyiaj(Certificatesofdeposit)5.Nyiajthemrauyustaslubneej(Annuities)6.Nyiajtsegsivthaumtsisuahaujlwm(Non-retirementinvestmentaccounts)7.Nyiajlaus,nyiajtsegtimhaujlwmthemthaumlaus,nyiajIRA,401K.8.Vajtselossisav9.Lwmcovcuabyeejcuabtam

Covntawvthovraukevpabthemnqixatautuajtxog240hnubtomqabhnubtimxanqi.Yogtiasdaimntawvthovsautsistxhij,lossisyogtiastseemtshuavlwmyamntxiv,daimntawvthovkevpabyuavciaqhibrau30hnubrauntawmhnubxatsabntawvnugraucovntawvxavtauntxivntawd.Yogtiastustsonpethovkevpabtsistebtuaj30hnubntawd,yuavtsispomzoomuabkevpab.RaulubsijhawmuasuadaimntawvthovKevPabThemNqi(FAA)notseemcojlossaibxyuaslawm,yuavtxotxhuakevsaunqi.DaimFAAyuavmuabteevtsegrautustswvcuabcovntaubntawv.KevxanqitseemyuavuahaujlwmliqubraulubcaijtseemsaibthiabtxiavtximtxogdaimntawvFAA.YogdaimntawvFAA,yeejuatxhijlawm,taupomzooraunocesmamlimuabrauibtugneeguahaujlwmrauAgnesianthiabyuavmuabteevtsegrautustswvcuabcovntaubntawvthiabcovnqilosyuavmuabtxorawslicovpomzoo.Yuavtauxacovntawvthovkevpabthemnqirauqhovchawnyobntawmno:

AgnesianHealthcareHealthSystemCommunityCareDepartment

430E.DivisionStreetFondduLac,WI54935

Yogtiastsispomzoomuabkevpabthemnqi,tustswvcuablossistuslavnqi,rovthovduayogtiasnwscovnyiajtxiagtauhloov.I. KEVTXIAVTXIMSIABPUASTSIMNYOG,KEVTHOVKOMROVMUABLOSSAIBDUATHIABKEVSIBKHOTauxacovntawvqhiatxognwskevtxiavtximtagraunwskevthovFAAuantejpebcaug(30)hnubntawmhnubnwsuatiavdaimntawvthov.CovthovkevpabthemnqiyuavtaucovnyiajthimrovqabraulawvyogtiaslawvthemtshajlicovnujnqiuastustswvcuablossistuslavnqitauthemthaumlubcaijpomzoomuabkevpabthemnqirauhauvAgnesiantxojkevcaithemnqi.Tejzaumcovnyiajthimnoyuavtshaj$10lossistshaj.Rawslitxojcaino,txojkevpabthemnqifeemntauzausyuavtsispabraucovnqiyustauthem(co-payment)lossiscovnqitshuavuasinsurancethemtaglawmvimtiastustswvcuabtsisuacovntawvpubntsibkwskhomob(referral),lossisyogtiaskevpabtsisyograwslitustswvcuabdaimntawvcoglusnrognwslubinsurancecesyoglicovnqithemntawdyuavtsisthimrovqab.Covtswvcuabmuajcaicojlostxiavtximduayogsauntawvtuajuantej30hnubntawmhnubtxaisdaimntawvtxiavtxim:

AgnesianHealthcareHealthSystemAttn:CommunityCareManager

430E.DivisionStreetFondduLac,WI54935


Covntawvsauthovkommuabcojlostxiavtximduayuavtauxatuajuantej30hnubntawmhnubtxiavtximthawjzaug.TusuahaujlwmsaibxyuashuuaDirectorofRevenueCyclemamlisaibdaimntawvthovsebpuasyuavhloovlicas.KevtxiavtximlicaslosntawmtusthawjsaibxyuasDirectorofRevenueCycle.J. LubCaijTsimNyogKevtxiavtximpomzooraukevpabthemnqiyuavmuajfeempabrautxogli6lubhlisthiabyuavpabrauyogmusrauchavpabkhomobxwmkubceevlossistejyamkhomoblojntawmhnubtimpomzooraukevpablosthemraucovnqiqubthiabcovnqiuastaumuabxatawmraulwmlubchawsaunyiajtiamsisyuavtsisualinoyogtiastauthemcovnqitaglawm.Yogtiascovnyiajtxiagtauhloovlossislwmtusneegyuavpabthemcovnqitauhloovlubsijhawmtxiavtximthiabtausaibxyuasntxiv.K. QHIATXOGKEVPABTHEMNQICovlusqhiatxogAgnesiantxojkevcaithemnqithiabqhiatxogyuavhurauAgnesianthiablwmyam,thiabyogthemnyiajtaulicas,yuavmuabdaimntawvnoloraulubtsevkhomobqhovchawtostxais,thiabrauchavpabthaummuajxwmkubceev.Covlusqhianolosmuabtaulosntawmtsevkhomobcovtawmtswvyimtxogkevthemnqi(financialcounselors).Agnesiandaimntawvqhiatxogtxojkevcaithemnqi,daimntawvthovthiabdaimntawvqhiatxogcovntsiablussauyoojyimrautxojkevcaimuajnyobraulubwebsite:www.agnesian.com.Covlusnomuabpubdawb,yogtiashurautusqhiatswvyimthemnqitusxovtooj(920)926-4841lossis(800)486-4157.Yogkojxavtaukevpabuadaimntawvthovkevpabthemnqi,kojhurau(920)926-4841thiabnrogtusuahaujlwmpabneeg(CommunityCareRepresentative)tham.CovlusqhiatxogAgnesiantxojkevpabthemnqiyuavmuabtxhaistauraulwmhomluskomlwmhaivneegtotaubthiab.Covlusqhiatxogkevpabthemnqi,thiabcovntawvlorauhauvcovtsevkhomobyuavmuabtxhaisrauntauhomlusuasyogcovlussivlitsawgtshaj1,000lossis5%ntawmcovneegnyobzelubtsevkhomob.Ntxivmus,AgnesianyuavmuajcovntawvqhiatxogcovkevcaithemnqithiabkevpabthemnqiluamrautxhualubhliAgnesianxacovnqithemthiabcovntawvsaunyiaj.CovlusqhiatxogAgnesiantxojkevcaithemnqiyeejmuabtau,txhualubsijhawm,yogtiastustswvcuabthovkommuab.L. TXOJCAIQHIATIASTAUYAMTAUMUAJAgnesianHealthcareyuavuarawslitsoomfwv,lubxeevthiablubzejzoscovkevcailijchoj,thiabyuavqhiatxogtejyamtauqhiauasyuavmuajfeemlicasrautxojkevcaino.Agnesiantauuarawstxojkevcaiteevciatxogcovmuajfeemraukevpabthemnqikomqhiatautxogkevpabno.CovlusqhiatxogkevpabthemnqiyuavmuajrawstxojkevcaiqhiatxhualubxyoosrauIRStsabntawv990ScheduleH.M. KEVKHAWSNTAUBNTAWVAgnesianyuavkhawstxhuacovntaubntawvraukevpabthemnqithiajlimuajkevtswjthiabuataurawslicovkevcailijchoj.

Saib Rau/Hnub Hloov: 9/1992, 4/1994, 7/1997, 8/1997, 1/2002, 12/2004 DO, 8/2006, 4/2007, 9/2007, 1/2008, 11/2008, 1/2010, 2/2011 hloov 10/2012, 1/2014 hloov, 1/2015 hloov, 6/2016 hloov

TshoojAAgnesianHealthCareKevCaiPabThemNqi

TsisPabThemCovNqiNoCovkevpabntawmnoyuavtsisnyobrautxojKevCaiPabThemNqi.Yuavtsisluvnqintawmtxojcairaucovno:

• TxhuaCovKevPabKhoMobRauNeegZooNkaujZooNraug,rautxhuacovkevpabcuamthiabcovkhoomyuav.

• Covkhoqhovtsocuabyeejraulubqhovmuagkompomkev(Premiumlensimplant)• Tsotshuajkhoraucovleegntshavuasntsuabntsuabntawmtxhaisceg(Sclerotheropy

rauspiderveins)• Kevpabkhoqhovmuagthiabkhoomrauqhovmuag• LubNtsawsPobNtsegKomHnovLusthiabcovkhoomsiv• CovLoQhovMuagKomPomKev(ContactLenses)• KevKuajPobTxhaDabKaum(ChiropracticServices)• IntegratedHealthServices• Sam(Vasectomies)• Kevpabkommuajmenyuamthiabkuaj(Fertility)• KevTivThaivTxhobMuajMenyuam• KevKuajMuajMobLosNtawmNiamLossisTxiv(GeneticTesting)

TshoojBAgnesianHealthCareKevCaiPabThemNqi

QhiaTxogCovKwsKhoMobUasTsisNyobRauKevPabCovkwskhomobntawmnoyuavtsisnyobrautxojKevCaiPabThemNqi.AgnesianHealthCaretsisyogtustswvlossistsisyogtuskhiavcovchawqhiahauvqabno,yogliyuavtsismuajfeemrautxojcaipab.

• RadiologyAssociatesofFoxValley• FondduLacPathology• NeuroscienceGroup• LakelandNeurology• TXHUAAmbulancelossisLifestar(Helicopter)Services• TXHUAtuskwskhomobuasmuajnpenroglwmlubtuamtsevkhomob

TshoojCAgnesianHealthCareKevCaiPabThemNqi

FeemNtauCovNqiRaugLiCasCovnqiuasfeemntauraugyogcovnqithaumtuajrauchavkhomobxwmkubceevlossiskhomoblojraucovtswvcuabthiablossistuslavnqi.Raucovtswvcuabtsimnyogtau,covnqiyuavtsistshajcovnqinyobqhiarauLookBackMethodqhiameejrau§1.501(r)-5(b)(3)rauInternalRevenueCode.QhovLookBackMethodyogibqhovlaijrawslicovtibneegthemnqiyavtaglosuasmuajMedicareFee-for-Servicetagnrhonrogcovneeguasmuajinsurancelawvtuskheejlostimhaujlwm.CovnyiajthemyuavmuajfeemnrograuAGBthaumlaijyuavpaubtiasyuavmuajcovnqinpaumlicasrawslixyootaglos.Covnqiuasyustauthem(co-insurance,co-paymentsthiabdeductibles)yuavmuabcojloslaijnrograucovMedicarenqi-rau-kevpab(MedicareFee-for-Service)uakenrogcovnqixaraucovinsurancehaujlwmlossiscovyusyuav.Covnqitauthemtagnrhoraucovnqikhomobyuavmuablaijnrograwstagnrhocovtibneeg.YuavlaijtusnqiAGBkomtxhobtshajibzaugrauiblubxyoouantej45hnubtomqabxyookawg,thiabyuavpibrau120hnubtomqabxyookawg. QhiaKevPab: Luv%

• ConsultantsLaboratoryofWisconsin 63%• FondduLacRegionalClinics 61%• RiponMedicalCenterKevPabKhoMobRauCovPwTsevKhoMob

(InpatientServices) 35%• RiponMedicalKevPabKhoMobRauCovPwTsevKhoMob

(InpatientServices) 48%• SaintAgnesHospitalKevPabKhoMobRauCovPwTsevKhoMob

(InpatientServices) 58%• SaintAgnesHospitalKevPabKhoMobRauCovPwTsevKhoMob

(InpatientServices) 54%• WaupunMemorialHospitalKevPabKhoMobRauCovPwTsevKho

Mob(InpatientServices) 41%• WaupunMemorialHospitalKevPabKhoMobRauCovPwTsev

KhoMob(InpatientServices) 55%

TshoojDAgnesianHealthCareKevCaiPabThemNqi

LuvNqi(TsoomFwvTebChawTxomNyemNtau)

AGNESIAN HEALTHCARE COMMUNITY CARE QHIA RAWS NYIAJ TXIAG

2016 TSOOM FWV QHIA RAWS COV TXOM NYEM

Coob Li Cas 100%

125%

150%

165%

175%

200%

250%

300%

1 Ib lub xyoo $11,770 $14,713 $17,655 $19,421 $20,598 $23,540 $29,425 $35,310

Txhua hli $981 $1,226 $1,471 $1,618 $1,716 $1,962 $2,452 $2,943

2 Ib lub xyoo $15,930 $19,913 $23,895 $26,285 $27,878 $31,860 $39,825 $47,790

Txhua hli $1,328 $1,659 $1,991 $2,190 $2,323 $2,655 $3,319 $3,983

3 Ib lub xyoo $20,090 $25,113 $30,135 $33,149 $35,158 $40,180 $50,225 $60,270

Txhua hli $1,674 $2,093 $2,511 $2,762 $2,930 $3,348 $4,185 $5,023

4 Ib lub xyoo $24,250 $30,313 $36,375 $40,013 $42,438 $48,500 $60,625 $72,750

Txhua hli $2,021 $2,526 $3,031 $3,334 $3,536 $4,042 $5,052 $6,063

5 Ib lub xyoo $28,410 $35,513 $42,615 $46,877 $49,718 $56,820 $71,025 $85,230

Txhua hli $2,368 $2,959 $3,551 $3,906 $4,143 $4,735 $5,919 $7,103

6 Ib lub xyoo $32,570 $40,713 $48,855 $53,741 $56,998 $65,140 $81,425 $97,710

Txhua hli $2,714 $3,393 $4,071 $4,478 $4,750 $5,428 $6,785 $8,143

7 Ib lub xyoo $36,730 $45,913 $55,095 $60,605 $64,278 $73,460 $91,825 $110,190

Txhua hli $3,061 $3,826 $4,591 $5,050 $5,356 $6,122 $7,652 $9,183

8 Ib lub xyoo $40,890 $51,113 $61,335 $67,469 $71,558 $81,780 $102,225 $122,670

Txhua hli $3,408 $4,259 $5,111 $5,622 $5,963 $6,815 $8,519 $10,223

9 Ib lub xyoo $45,050 $56,313 $67,575 $74,333 $78,838 $90,100 $112,625 $135,150

Txhua hli $3,754 $4,693 $5,631 $6,194 $6,570 $7,508 $9,385 $11,263

10 Ib lub xyoo $49,210 $61,513 $73,815 $81,197 $86,118 $98,420 $123,025 $147,630

Pom Zoo Rau: 100% 75% 50% 25% 20%

TshoojEAgnesianHealthCareKevCaiPabThemNqi

QhiaCovChawNyobUasPabTauCovtswvcuabthiablossiscovLavNqiuasnyobraucovzipcodentawmno(CovChawAgnesianMuajKevPab)yuavmuajfeemthovtauKevPabThemNqirawstxojcaino:54923Berlin 53050Mayville53919Brandon 53949Montello53006Brownsville 53057MountCalvary53009Bryon 54960Neshkoro 53010Campbellsport 53065Oakfield53019Eden 54963Omro 54932Eldorado 54964Pickett 53931Fairwater 54968Princeton54935FondduLac 53956Randolph54936FondduLac 54970RedGranite54937FondduLac 54971Ripon53933FoxLake 54974Rosendale54941GreenLake 53079SaintCloud54932Horicon 53091Theresa53939Kingston 54979VanDyne53048Lomira 53963Waupun53049Malone53946MarkesanAgnesianHealthcaremuajkevpabkhomobraucovchawno;tiamsis,covntawvthovkevpabuasnyobraucovzipcodesauhauvnoyuavtausaibxyuassebkevpabkhomobyoguantejthovtaukevpabthemnqiraucovchawqhia.Kevpabkhomob:PsychiatricAssociatesrauBeaverDam,AgnesianHealthcareDialysisrauBeaverDam,HospicethiabOncologyrauBerlin.53916BeaverDam 54966Plainfield54930Coloma 54982Wautoma53925Columbus 54984WildRose54943Hancock 54986Winneconne54901OshkoshAgnesianHealthcare’sBehavioralHealthmuajntawvcoglusnrograucovnroogAdams,Calumet,Dodge,GreenLake,Jefferson,Marquette,Shawano,Washington,thiabManitowoc

komlawvtxaiscovtibneeguastxaiskevpabnyuajsiabtawmtswvyimpabcovpuashlwbuaspwtimtsevkhomob.Tejlubsijhawmmuajlwmlubchawrauibtugneegmustxaiskevpabyogtiastsismuajlubchawzedua;xwslilubnroogShawano.Tejzaumyuavpubrauibcovtibneeguasnyobraucovzipcoderaulubcaijtxaiskevpabkhomobraulubtsevkhomobuasyoglubpabtauthiabyograucovxaraucovkwskhomobkuajtejhommob,hloovtsevkhomobthiabthaummusrauChavKhoThaumMuajXwmKubCeev.SamaritanClinictsuaspabcovtibneegnyobrauFondduLacthiabDodgeCounty.09/20/2007,08/10/2011,10/03/2012,01/16/2014

TshoojFAgnesianHealthCareKevCaiPabThemNqi

QhiaTxogCovKwsKhoMobNyobRauKevPabCovkwskhomobsauntawmnoyogcovnyobrautxojKevCaiPabThemNqi.

• FondduLacRegionalClinicProviders• LwmcovkwskhomobxanqilosntawmAgnesianHealthCare.

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