Fairview Charity Care

Getting help paying your hospital bills

The Charity Care program covers charges for most Fairview hospitals. You may qualify if your income is at or below 300 percent of the Federal Poverty Guidelines (see chart below).

Before applying for the Charity Care program, you may be asked to first apply for help with the county or state. If you currently have no coverage and are a Minnesota resident, please visit the MNsure website or call 1-855-366-7873. If you are not a Minnesota resident, visit your state's health care reform website. If you have coverage and are not sure if you're eligible for additional coverage through the Affordable Care Act, contact our office at 612-672-6724.

Services covered

The Fairview Charity Care program covers charges for most Fairview hospital-based and clinic-based services. It does not cover charges for:

Care that is not needed (care not approved by a Fairview doctor or trial treatments)
Care not offered at Fairview
Services given at Fairview by independent providers
Services not billed by Fairview
Services related to transplant

Fairview's Charity Care Program does not include care received in free-standing ambulatory service centers. This is covered under Fairview's Charity Care Program. Fairview has a number of financial assistance programs.

If you do not know whether the care you are seeking is covered by Fairview Charity Care, please ask us. If you have questions, call 612-672-6724 or (toll-free) 866-417-3560. Or if you are in the Range/Hibbing area, call 218-362-6624 or toll-free 877-390-6624.

Income guidelines

If you qualify for the program, 50 percent up to 100 percent of your bill may be paid depending on your gross annual income, family size and asset guidelines. You must comply with all the terms of the program when you apply, and we also ask you to follow the rules set by your insurance plan.

Income Limits by Family Size
Family size	Annual Gross Income (200% FPL) up to 100% benefit	Annual Gross Income (300% FPL) up to 50% benefit
1	$25,520	$38,280
2	$34,480	$51,720
3	$43,440	$65,160
4	$52,400	$78,600
5	$61,360	$92,040

Asset guidelines

If a family has total assets in bank accounts or stock assets totaling more than $15,000 they are not eligible for Financial Assistance. If total assets, including retirement, exceed $500,000 they are not eligible for Financial Assistance.

How to apply

Thank you for your interest in Fairview’s Hospital Charity Care program.

To apply, review the instructions below and complete our Charity Care application form. The application is also available Spanish, Somali, Vietnamese, Hmong, Russian and Karen.

Step 1: Complete and sign this form.

List the names and birth dates for each family member applying for the program. If you do not list them on the form, they will not be included.
If your spouse is also applying for this program, both of you must sign the form.
Your family includes a spouse, dependent children and any person for whom you have legal guardianship.

Step 2: Attach these items to the form. We will keep your records confidential (private). Please include records for all adults in your household.

A copy of your most recent 1040 Federal Income Tax form. Do not include W2 forms.
Records of income are to include copies of the two most recent payroll stubs. (Example: pay stubs that show your year-to-date earnings.)
Copies of bank statements for all checking and savings accounts for the last 30 days. Include the last statement for any CDs (Certificates of Deposit).
Records of all retirement savings: employee pension plans, 401K plans, 403b plans, annuities, IRAs.
Record of current balances in all health savings accounts (HSA).
Optional: a letter explaining any recent events that might affect your ability to pay your medical bills.

Step 3: Return the form with the above records to the following address:

Patient Financial Services
Attn: Charity Care
400 Stinson Blvd NE
Minneapolis, MN 55413

Step 4: If you have applied for insurance coverage via MNsure or the Affordable Care Act, send the application results.

You will keep receiving bills until we have your complete application. This includes the records listed above. If there are legal fees related to your account, you are not eligible for charity care.

Financial Assistance Policy

The Financial Assistance Policy is available in the following languages: English, Spanish, Somali, Vietnamese, Russian, Hmong and Karen.

Financial Assistance Plain Language Summary

The Financial Assistance Plain Language Summary is available in the following languages: English, Spanish, Somali, Vietnamese, Russian, Hmong and Karen.

Provider Lists

Fairview has a list of all provider groups that provide emergency and medically necessary services to patients at a Fairview Hospital facility. The list identifies which providers are and are not covered by Fairview’s Financial Assistance Policy.

Fairview Health System Covered Provider List
Fairview Health System Non-Covered Provider List

Amount Generally Billed (AGB)

Following a determination of financial aid eligibility, a financial aid-eligible individual will not be charged more than the amount generally billed (AGB) to individuals who have insurance for emergency or medically necessary care.

English, Amharic, Arabic, Chinese, Hmong, Karen, Oromo, Russian, Somali, Spanish, Vietnamese.

Billing and Collections Policy

The billing and collections policy is available in the following languages: English, Spanish, Somali, Vietnamese, Russian, Hmong and Karen.

What is Senior Partners?
Senior Partners is a partnership between Fairview and the Senior Community Services available to qualifying Minnesota residents enrolled in Medicare part A and B. This program helps with charges that Medicare does not cover, like deductibles. Applications for enrollment can be found at www.aeoa.org or by calling 1-800-662-5711, ext. 7337 (toll free).