Financial Assistance Programs

Financial Assistance Programs

Community Memorial Hospital has had a long-standing commitment to share responsibility for providing care to all members of our community, regardless of their ability to pay. The following charity care information outlines our commitment to providing free and significantly discounted care to patients due to financial hardship.

Free Care – Hospital Care Assurance Program (HCAP)

When medically necessary, CMH will provide free hospital care for Ohio residents with family incomes under 100% of the federal poverty income limits (FPL). This does not include professional fees, or charges that are covered by Medicaid, Disability, or other health insurance.Documentation is required. Refer to our HCAP Policy for complete details.

A patient is eligible for HCAP if:

  1. The patient is not a recipient of the Medicaid program.

  2. The patient is a resident of Ohio.

  3. The patient is a current recipient of the disability assistance (DA) program, or its successor program.

  4. The patient’s individual or family income is at or below the current federal poverty income guideline issued by the Department of Health and Human Services.


    The 2013 poverty income guidelines are (Effective January 24, 2013):

    Family Size Income Guideline
    1 $11,670
    2 $15,730
    3 $19,790
    4 $23,850
    5 $27,910
    6 $31,970
    7 $36,030
    8 $40,090

    Add $3,960 for each additional person if the family unit has more than eight members.

Charity Care

Free medically necessary hospital care for patients with family incomes between 101% and 200% of FPL.

Proof of income documentation is required as follows:

  1. A completed Charity Care application with a patient or guarantor’s signature AND hard copy proof of income, such as most recent pay stubs, bank statements, or a letter from the applicant’s employer supporting the income. If this information is unavailable, then,

  2. A completed Charity Care application inclusive of the patient or guarantor’s signature AND Federal income tax returns or W2’s from the most recent year supporting the income.

  3. If the patient/family report zero income on the application then a statement of wage earnings for all adults in the household will be required for the 12 months prior to the date of service. This can be obtained from the patient’s local Department of Job and Family Services Office.

  4. Applications for charity care must be received within 12 months of the date of service. Untimely applications may be denied.


Special Circumstances/Hardship Cases/Catastrophic Care

Full or partial discounts are considered on a case-by-case basis when a patient’s unusual financial situation, medical debt, or other unusual circumstances prevent them from qualifying for charity care programs or applying for public assistance.


Other Payment Options

Financial Counseling is always available. Our staff can assist you with pre-payment arrangements for planned expenditures. This may be through self pay pre-paid packages or discounts on prompt payment of accounts.

Early Payment Discount

Underinsured or uninsured patients who can pay their balance in full within 30 days may be eligible for an Early Payment Discount. Please contact the Business Office for more information (419) 542-5590.

Pre-Payment Option

Uninsured patients who are having elective surgeries may qualify for a discounted pre-payment option. This option allows the patient to pre-pay for elective procedures such as hernias, appendectomies, and knee replacements in advance of the procedure. Please contact the Business Office for more information (419) 542-5590.

Payment Plan

All patients who have unpaid balances are invited to call the business office to set up payment plans. Payment plans can be arranged for up to of two years and with a minimum payment of $25.00 per month. Please contact the Business Office for more information (419) 542-5590.

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208 N. Columbus | Hicksville, OH 43526 | (419) 542-6692

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