st. agnes hospital kev cai thiab kev ua haujlwm sau … · 2017. 12. 20. · tswv cuab kom ua raws...

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

SAU TXOG: TXOJ CAI TXOG KEV XA NQI THIAB KEV SAU NQI Nplooj 4 ntawm 8

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

SAU TXOG: TXOJ CAI TXOG KEV XA NQI THIAB KEV SAU NQI Nplooj 5 ntawm 8

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.

SAU TXOG: TXOJ CAI TXOG KEV XA NQI THIAB KEV SAU NQI Nplooj 6 ntawm 8

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

SAU TXOG: TXOJ CAI TXOG KEV XA NQI THIAB KEV SAU NQI Nplooj 7 ntawm 8

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/.

SAU TXOG: KEV CAI THEM NQI Nplooj 3 ntawm 9

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.

SAU TXOG: KEV CAI THEM NQI Nplooj 4 ntawm 9

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.

SAU TXOG: KEV CAI THEM NQI Nplooj 5 ntawm 9

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.

2.Tsevneegcovnyiajsiabtshaj175%FPLtiamsisyoglossistsawgdua200%FPLyuavtsimnyogtaucovnqiluv50%raucovnqikhomob.

3.Tsevneegcovnyiajsiabtshaj200%FPLtiamsisyoglossistsawgdua250%FPLyuavtsimnyogtaucovnqiluv25%raucovnqikhomob.

4.Tsevneegcovnyiajsiabtshaj250%FPLtiamsisyoglossistsawgdua300%FPLyuavtsimnyogtaucovnqiluv20%raucovnqikhomob.

SAU TXOG: KEV CAI THEM NQI Nplooj 6 ntawm 9

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

SAU TXOG: KEV CAI THEM NQI Nplooj 7 ntawm 9

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.

SAU TXOG: KEV CAI THEM NQI Nplooj 8 ntawm 9

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

SAU TXOG: KEV CAI THEM NQI Nplooj 9 ntawm 9

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.