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Patient Financial Assistance Policy

Financial Assistance Application

Follow this link to download a Cottage Health Financial Assistance Program Application

This policy will establish eligibility requirements and the application process for patient financial assistance (charity care) at the three Cottage Health hospitals in a manner that is consistent with the values of excellence, integrity and compassion and is compliant with all State and Federal Regulations. The Cottage Health Patient Financial Assistance policy (Charity Care/Emergent) and application covers technical services rendered at:

  1. Santa Barbara Cottage Hospital
  2. Santa Ynez Valley Cottage Hospital
  3. Goleta Valley Cottage Hospital

This policy does not cover services rendered by Emergency Department physicians, Hospitalists, Internists, Radiologists or Radiology groups, Anesthesiologists or Anesthesia groups, Pathology, or other physician services rendered by the following medical staff departments: Cardiovascular Services; Family Practice ; Internal Medicine; Neurology/Neurosurgery; OB/GYN; Oncology; Ophthalmology; Orthopedic Surgery; Otolaryngology; Pediatrics; Psychiatry; Pulmonary/Critical Care; General Surgery; or Urology.


The Financial Assistance Program guidelines/definitions will be reviewed periodically by the Finance Committee Board of Directors.

Services Covered
Medically necessary services defined by the State of California as any service that is reasonable and necessary to prevent significant illness or disability, relieve severe pain or save someone’s life.

Services Not Covered
Cosmetic Surgery and the COPE program are not covered by this policy. Patients who require an elective or non-emergent medical procedure but do not have third-party insurance, Medicare, Medi-Cal or other government-sponsored insurance (collectively known as “health insurance coverage”) that covers the services provided, may qualify for financial assistance under the Non-Emergent Charity Care Policy, 8560.74. Patients receiving services at Cottage Residential Center and Cottage Rehabilitation Hospital will apply for financial assistance through the Non-Emergent Charity Care Policy, 8560.74

Patient Notification of Financial Assistance Availability
Patients who do not present with evidence of a third-party insurer will receive a notification of available financial assistance during the admission process and can obtain and receive assistance with applications for Covered California and/or Medi-Cal prior to discharge. All patient registration and payment areas will post information on financial assistance programs. All billing notices sent to the patients will contain information on financial assistance programs. All notifications will comply with Assembly Bill 774, Hospital Fair Pricing Act (AB774) and the Internal Revenue Service Regulation Section 501(r).

Application and Documentation for Financial Assistance
Eligibility for financial assistance is based upon completion of the required application and presentation of required documentation. Patient Financial Counselors will be available to assist patients with filling out the application for financial assistance in person or by phone. Patients may be denied if they do not produce the required documentation.


Family Members: Assembly Bill 774 defines a patient’s family for persons 18 years and older as a spouse, domestic partner, and dependent children under 21 years of age, whether living at home or not. For persons under 18, Assembly Bill 774 defines a patient’s family as parent(s), caretaker relatives, and other children less than 21 years of age of the parent or caretaker. If a student applying for assistance is claimed as a dependent on the family tax return, then the entire family income must be considered. Family size should directly correspond with the number of dependents listed on the current year tax return. If not available, or the number of dependents does not correspond with the current year tax return, the patient/responsible party must provide one or more of the following documents:

  • Birth Certificate
  • Baptismal Record
  • U.S. Immigration Form
  • Guardianship Papers

Household Income: Household gross income will include the patient/responsible party’s gross income as well as other adult members listed in the household. Acceptable income source documents are listed below.

  • Patient/responsible party is required to provide prior six (6) months’ paycheck stubs as written proof of family income. Copies of these documents will be made and the originals will be returned to the patient/responsible party. The family’s total income will be computed by taking the last six (6) months income and multiplying by two (2).


  • Patient/responsible party may provide the most current income tax return.
  • Account statements may also be requested to determine total monetary assets such as bank account statements and publicly-traded stock.

Extraordinary Collection Activity (ECA): Actions taken to collect a bill that requires a legal or judicial process, including wage garnishment, property liens, arrests, foreclosures on real property, civil lawsuits, and reporting adverse information to credit reporting agencies or credit bureaus.

Other Required Documents

  • Driver’s License or Photo Identification issued by a government entity
  • Medi-Cal Denial Letter

Eligibility Requirements for Financial Assistance


A self-pay patient is someone who does not have health insurance coverage for the services provided. This may include patients who are eligible for Medi-Cal but whose eligibility dates may not cover the entirety of the hospital stay. Dates of service outside of the eligibility period may be considered self-pay. Eligibility for financial assistance (both free care and discounted care) for self-pay patients is based on the household income and monetary assets of the patient or the patient’s guarantor. Patients will be eligible for 100% charity care coverage if their household income is less than or equal to 350% of the Federal Poverty Level (FPL) and they meet the monetary asset guidelines. Discount percentages and income levels can be found on the Patient Financial Assistance Calculation form and are based on FPL guidelines.

A patient’s monetary assets will also be considered when determining eligibility. Using assets to determine eligibility is limited to monetary assets such as bank accounts and publicly-traded stock. Retirement plans, deferred compensation plans qualified under the Internal Revenue Code, and nonqualified deferred compensation may not be considered. The first $10,000.00 of a patient’s assets may not be considered. In order to be eligible for financial assistance, a patient’s remaining monetary assets may not exceed the amount owed to the hospital.

Patients who have some form of third-party insurance that has provided payment but are unable to pay their portion of the discounted or non-discounted bill may be eligible for financial assistance. Eligibility is based on the self-pay criteria above. 

Catastrophic Eligibility
A patient who has a catastrophic medical experience is defined as a patient with a balance of over $25.000, that may or may not have a third-party insurer and their income exceeds financial eligibility guidelines. Patients with catastrophic accounts can receive a discount of 70%. A patient is eligible for catastrophic financial assistance if their income is less than four (4) times the amount owed and they meet the monetary guidelines above.

Presumptive Charity Eligibility
Patients that are homeless, undocumented, not locatable with questionable financial resources, or where it is unreasonable to expect documentation from but are believed to qualify for financial assistance, may be approved by the Director of Patient Business Services and/or Vice President of Finance dependent on the account balance.

Special Circumstances
The Director of Patient Business Services and Vice President of Finance may negotiate financial assistance with patients under special circumstances in order to ensure that all members of our community have access to medical care.

Non-Discriminatory Application of this Policy
Any decisions made under this Policy, including the decision to grant or deny financial assistance, shall be based on an individualized determination of financial need, and shall not take into account age, gender, race, social or immigrant status, sexual orientation or religious affiliation.

Notification Period

The period in which the Cottage Health hospitals must notify patient of the financial assistance program (FAP) starts with the date care is provided and ends 120 days after the date of the first statement. During the notification period, the Cottage Health hospitals will not engage in extraordinary collection activity (ECA) until the end of the notification period (unless FAP eligibility has been determined).

After 120 days, if no FAP application is received, the hospital can begin collection activity.  The hospitals have met notification if a patient submits an application.  If a patient contacts the hospital(s) within 120 days from the date of the first statement, the hospital(s) must accept the financial assistance application and stop any ECA.


Any patient who qualifies for financial assistance and has made a payment on the account will receive a refund.  Accounts under $1,000.00 that are refunded within 90 days of the approval will have a flat fee of $5.00 added to the refund.  Account refunds that are over $1,000.00 will include an interest payment of 5% per annum due from the date the application was approved to the date the refund was processed by Patient Business Services.

Emergency Physician Services

An emergency physician, as defined in Section 127450 of the California Health Code, who provides emergency medical services in a hospital that provides emergency care, is also required by law to provide discounts to uninsured patients or patients with high medical costs who are at or below 350% of the federal poverty level and in accordance with AB774 guidelines and subsequent amendments.


Approvals for financial assistance will be based upon account balance, as shown below.

Amount Approver
Under $75,000 Supervisor
$75,001 - 100,000 Director
Over $100,000 Vice President Finance

Patient Business Services Review Procedure

  1. If a patient does not present with third-party insurance, the patient will be given a Notice of Financial Assistance and Preliminary Application. This application should be forwarded to Eligibility Services.
  2. A daily report will be created for all inpatients and emergency department patients who accumulate charges over $500 who do not provide proof of third-party insurance.
  3. The daily report will be reviewed by Eligibility Services to determine patient eligibility for government-sponsored insurance programs and to assist with the government program application process.  Patients will also be assisted in applying for the CH Patient Financial Assistance Program and other applicable assistance.
  4. A Medi-Cal eligibility worker is on site at SBCH to help facilitate with Covered California and Medi-Cal applications while the patient is in the hospital.
  5. If the patient requests financial assistance after they have left the hospital:
    • Patient will be pre-screened for Medi-Cal/CenCal eligibility by utilizing the Medi-Cal or evaluation forms.
    • Patient Financial Counselor will mail the FAP application and information to patient.
  1. Completed applications for CH Patient Financial Assistance Program will be sent to Customer Service, Patient Business Services.  If a patient applies for financial assistance for an account in bad debt status, the account will be placed on a 30-day hold with the collection agency.  After the 30-day hold, if all appropriate documentation has not been received, collection activity will resume.
  2. The Patient Financial Counselor will complete the current year’s Patient Financial Assistance Calculation form to determine the discount the patient is eligible for and will route the application to the Supervisor for approval.
  3. The Supervisor will verify the eligibility determination as identified below and route for final approval based on amount of account (see Approval and Appeals).
    • Approved 100%: Patient’s/responsible party’s income and family size qualify them for 100% assistance. The application, along with supporting documentation, will be forwarded to the Director for review and approval. The Director will review, approve, or deny application.  Approval will be documented in the Account Comments, the charity adjustment will be applied and an approval letter to the patient will be sent. Any self-pay discounts will be reversed. The application will be scanned into the patient’s business folder.
    • Discount/Approved for less than 100%: Patient’s/responsible party’s income and family size qualify them for a discount based upon sliding scale guidelines. A self-pay discount of 30% will be applied to the account’s remaining balance to determine the final account balance. After obtaining approval, the account will be adjusted accordingly. The patient is eligible for a 180-day interest-free payment plan. If the patient needs longer than 180 days to complete the payments, the account will be referred to Financial Credit Network to establish an acceptable payment plan, compliant with Assembly Bill 774, for the remaining balance.  The application will be scanned into the patient’s business folder.

      If a patient is not approved for 100% financial assistance and has a change in their financial circumstances, the patient may submit supplementary documentation for consideration for additional financial assistance.

    • Denied: Patient/responsible party has completed the application process and does not qualify for any assistance.  Patient will receive a reduction in charges that is consistent with Self-Pay Discount Policy 8550.72. Patient will be offered six (6)-month payment plan and be referred to Financial Credit Network to establish an acceptable payment plan with patient/responsible party.  The application will be scanned into patient’s business folder.
    • Appeal Process: If the application is denied, the patient can send an appeal to:

Patient Business Services Director
Financial Assistance Appeal
Santa Barbara Cottage Hospital
PO Box 689
Santa Barbara, CA 93102

Financial Assistance Application

Follow this link to download a Cottage Health Financial Assistance Program Application

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