Charity Care Policy

Renville County Hospital and Clinics is committed to providing a comprehensive range of medical care in its non-profit, primary care facility. Its health services, as well as active outreach specialties, are developed to meet individual needs and improve the health status of the people it serves.


Renville County Hospital and Clinics Charity Care has been developed to ease the cost of services provided by RCHC to patients who do not have the financial means to pay for all or a portion of the charges and who meet eligibility requirements. Charity Care excludes elective care and cosmetic procedures that do not lead to a direct medical benefit.


Renville County Hospital and Clinics Charity Care will be applied equally, a patient account will be considered for Charity Care on an individual basis without regard to sex, age, race, color, national origin, sexual orientation, disability or source of income.
Renville County Hospital and Clinics will distribute information and applications for charity care at the time of registration, in the patient’s admission packet and with the patient’s bill.


The criteria for determining the amount of Charity Care is primarily based on adjusted gross annual income guidelines. These guidelines include:

  • Individual or family income
    Income data is based upon information supplied by the patient or someone acting on the patient’s behalf. Such data will be verified with income tax statements, social security statements and pay stubs.
  • Family Unit Size
    Family size will be determined by the individual’s most recent tax return.
  • Other sources of payment
    Charity Care is the last resort of payment for patients in need of care. Eligibility for all other sources of payment will need to be exhausted prior to granting Charity Care. This means the patient will need to complete a Medical Assistance application and be denied coverage prior to being considered for Charity Care. The appropriate amount of Charity Care is determined in relation to amounts due after applying all other resources. The patient’s ability to pay and the resources available for services to a patient may change over time. For example:

    • A patient may have agreed to a payment plan that was reasonable in relation to the circumstances at the time, but subsequent events such as a change in employment status or another need for healthcare services could change the patient’s ability to pay.


The following is a summary of the steps generally used to determine eligibility or verify applicant information:

  • RCHC identifies and informs any uninsured, underinsured, or self-pay patients of payment options.
  • Patient completes an application/determination of eligibility form.
  • Patient completes financial statement that includes income and liabilities.
  • Patient supplies documentation of resources (i.e. W-2 pay stubs, tax forms, etc.) and outstanding obligations (i.e. bank statements, loan documents, etc.).
  • RCHC will verify payments from other payment sources.
  • RCHC will attempt to secure federal, state or local funding if appropriate.
  • The Business Office Manager will interview the patient to assess if the patient has the ability to pay in full, has the ability to pay reasonable monthly installments, or qualifies for General Relief.
  • RCHC will consider federal poverty guidelines and family size.
  • After the initial determination of insufficient funds, income, and healthcare benefits, the application becomes eligible for final review by the determining committee comprised of a Renville County Human Service employee, RCHC Administrator, CFO and Business Office Manager.
  • The Business Office Manager will notify the patient the extent of Charity Care granted. Patients who do not qualify will be advised of their option to have their initial determination reviewed.
  • The Administrator and Board of Directors will designate a monetary value specifically set aside for Charity Care annually. The annual amount determined by the Board will not be exceeded in granting Charity Care.
  • Charity Care policies do not eliminate personal responsibility. All patients are expected to contribute to their care based on the individual ability to pay.

Charity Care Benefit Calculation

Patients that qualify for Charity Care will receive a reduction in the balance owed, as long as funds are available in the yearly designation of Charity Care. The amount of Charity Care will be based on the patient’s ability to pay and the size of the outstanding balance. Income guidelines for annual gross income are based on 100% of federal poverty guidelines plus 10%.

If the patient’s verified income is equal to or less than the annual gross income guidelines, they may qualify for a Charity Care reduction of the outstanding balance owed. Patients who meet the federal poverty guidelines generally qualify for federal, state or local programs.

2018 Maximum Annual Income Amounts for each Sliding Fee Percentage Category

Family Size 100% 90% 70% 50% 30% 10% 0%
1 $12,140 $16,146 $16,753 $18,210 $24,280 $30,350 $36,420
2 $16,460 $21,892 $22,715 $24,690 $32,920 $41,150 $49,380
3 $20,780 $27,637 $28,676 $31,170 $41,560 $51,950 $62,340
4 $25,100 $33,383 $34,638 $37,650 $50,200 $62,750 $75,300
5 $29,420 $39,129 $40,600 $44,130 $58,840 $73,550 $88,260
6 $33,740 $44,874 $46,561 $50,610 $67,480 $84,350 $101,220
7 $38,060 $50,620 $52,523 $57,090 $76,120 $95,150 $114,180
8 $42,380 $56,365 $58,484 $63,570 $84,760 $105,950 $127,140
For each additional person, add $4,320 $5,746 $5,962 $6,480 $8,640 $10,800 $12,960

Renville County Hospital and Clinics Request for Determination of Eligibility for Charity Care

Please answer each question in detail. Along with your completed application please provide verification of income which includes:

  • A copy of your most recent year income tax statement, or
  • Copies of your last four pay stubs or unemployment earnings, veteran benefits, social security, retirement, injury compensation funds, child support or disability, or
  • If self-employed, your last quarterly estimated tax report
  • Applicant * Required
  • Date Format: MM slash DD slash YYYY
  • Address
  • Spouse’s Name
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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