RES 1267laitnRESOLUTIONNO.
A RESOLUTION adopting an Ambulance Billing Debt
Forgiveness Policy.
WHEREAS,it is the policy of the City of Camas that the provision of emergency medical
services is not conditioned upon ability to pay,and
WHEREAS,the City Council desires to adopt a policy providing for cancellation of all or
a portion of debt owed to the City for emergency medical services for those with no means or
inadequate means to pay.
NOW,THEREFORE,BE IT RESOLVED BY THE COUNCIL OF THE CITY OF
CAMAS AS FOLLOWS :
Section I
The City hereby adopts the Ambulance Billing Debt Forgiveness Policy attached hereto as
Exhibit "A "and by this referenced incorporated herein.
Section II
ADOPTED by the Council of the City of Camas at a regular meeting this day of March,
2013 .
SIGNED :
ATTEST:4
Clerk
APPROVED as to form:
City Attorney
Exhibit “A”
CITY OF CAMAS
AMBULANCE BILLING DEBT FORGIVENESS POLICY
Policy -
It is the policy of the City of Camas that ability to pay is never a condition of emergency medical
services.All aspects of emergency medical services will be provided to all patients without
discrimination of those with no means or inadequate means to pay.A patient that cannot pay
for emergency medical services may apply for debt forgiveness based on income eligibility.
Definitions -
Income Eligibility is the qualifying income level as determined by the current year Health
and Human Services Federal Poverty Guidelines.
Debt Forgiveness is canceling all or a portion of debt owed to the City of Camas for
emergency medical services rendered.
Procedures -
After receipt of an application for debt forgiveness,the finance department ascertains whether
the applicant claiming to need financial assistance actually meets income eligibility criteria
using documentation provided by the applicant.Such documentation may include the most
recently filed federal tax returns,payroll check stubs,unemployment compensation and
Medicaid eligibility.Other financial resources available to the patient including medical
insurance,government programs and third party liability insurance will be reviewed and
included in the ability to pay.The city will review each application,approve or deny each one
and notification will be sent to the applicant .
Full debt forgiveness will be provided to a patient or responsible party with a gross
family /household income at or below 100%of current published Federal Poverty Guidelines,
adjusted for family size.If the patient can be claimed as a dependent,the parent or guardian
income will be considered in the income eligibility.Partial debt forgiveness will be provided for
a patient or responsible party with a gross family/household income between 101%and 200%
of the current year published Federal Poverty Guidelines according to the sliding scale below:
Debt Forgiveness
Income as a Percentage of Federal Poverty
Level *
Percentage of Debt Forgiveness
100%or below 100%
101%to 133%75%
134%to 166%50%
167%to 200%25%
Greater than 200%0%
*See Addendum A for poverty levels and number of persons in household.Addendum A to be
updated annually based on current year Federal Poverty Guidelines.
Under some circumstances debt forgiveness may be provided to a patient or responsible party
with a gross family /household annual income greater than 200%of the Federal Poverty
Guidelines.If circumstances such as extra -ordinary non-discretionary expenses,future earning
capacity or the ability to make payments over an extended period of time may be taken into
consideration.All members of the finance committee must be in agreement of any debt
forgiveness allowed under these circumstances.
Reasonable payment arrangements,consistent with the eligible responsible party's ability to
pay,will be extended for amounts not eligible for debt forgiveness.Up to ten monthly
payments without interest may be arranged;additional months could be considered especially
with consistent payment history.The finance department reserves the right to revoke any debt
forgiveness and assign all unpaid balances to collections if an extended payment agreement is
in default.
Addendum A
Full or Partial Debt Forgiveness Schedule Based on
2013 Health &Human Services Federal Poverty Guidelines
100%
Forgiveness -
Income Range
100%or below
Poverty
Guideline
75%
Forgiveness -
Income Range
101%-133%
Poverty
Guideline
50%
Forgiveness -
Income Range
134%-166%
Poverty
Guideline
25 %
Forgiveness -
Income Range
167%-200%
Poverty
Guideline
Persons in
Family /Household
$0 -$11,490 $11,491 -$15,282 $15,283 -$19,073 $19,074 -$22,9801
$11,491 -$15,510 $15,511 -$20,628 $20,629 -$25,747 $25,748 -$31,0202
$15,511 -$19,530 $19,531 -$25,975 $25,976 -$32,420 $32,421 -$39,0603
$19,531 -$23,550 $23,551 -$31,322 $31,323 -$39,093 $39,094 -$47,1004
$23,551 -$27,570 $27,571 -$36,668 $36,669 -$45,766 $45,767 -$55,1405
$27,571 -$31,590 $31,591 -$42,015 $42,016 -$52,439 $52,440 -$63,1806
$31,591 -$35,610 $35,611 -$47,361 $47,362 -$59,113 $59,114 -$71,2207
$35,611 -$39,630 $39,631 -$52,708 $52,709 -$65,786 $65,787 -$79,2608
For each additional person in family/household add :
$4,020 $5,437 $6,673 $8,040Add
For example :a family/household of 2 members with an income of $25,000 will qualify for debt
forgiveness of 50%of the ambulance billing as the patient's income is above $20,629 and below $25,747
per year .