Schedule H (Form 990) - Hospitals Page 7
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Schedule H (Form 990) 2017
Page
Part V
Facility Information (continued)
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Name of hospital facility or letter of facility reporting group
Yes
No
Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged
22
to FAP-eligible individuals for emergency or other medically necessary care.
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service
a
during a prior 12-month period
The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and
b
all private health insurers that pay claims to the hospital facility during a prior 12-month period
c
The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in
combination with Medicare fee-for-service and all private health insurers that pay claims to the hospital
facility during a prior 12-month period
d
The hospital facility used a prospective Medicare or Medicaid method
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During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility
provided emergency or other medically necessary services more than the amounts generally billed to
individuals who had insurance covering such care? .
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If “Yes,” explain in Section C.
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During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross
charge for any service provided to that individual?
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If “Yes,” explain in Section C.
Schedule H (Form 990) 2017
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