Neurotech Financial Assistance Policy
It is the policy of Neurotech In-Home EEG Specialists (“Neurotech”) to provide care to indigent patients regardless of ability to pay. Neurotech's Financial Assistance Program assists patients with limited or no insurance coverage. The program is designed to assist patients who are unable to pay for their EEG diagnostic services. All medically necessary services provided by Neurotech are eligible for financial assistance.
Eligibility Information
A patient (or their representative) may request financial assistance before or after receiving services from Neurotech. Eligible patients must be residents of the United States. The eligibility determination shall be applied regardless of race, color, creed, age, sexual orientation, gender, ethnic origin, national origin, religion, or immigration status. Applications for financial assistance are administered on an individual, case-by-case basis, taking into consideration all of the patient's specific circumstances and needs.
The Application Process
All patients requesting financial assistance must complete a Financial Assistance Application. The applicant must provide thorough documentation that supports their family's current level of income, available assets, and proof of U.S. residency. Documents that prove the level of current income can include recent tax returns, pay stubs, W-2 forms, Social Security or disability statements, or business income and expense statements. If the applicant cannot provide any of these, he or she may still be able to apply for financial assistance. All applications, supporting documentation, and communication will be treated with the utmost patient confidentiality. Neurotech may ask that applicants apply for public assistance (Medicaid).
Patient Request for Financial Discounts
All patients (insured or uninsured) may apply for financial assistance based on sliding scale tied to the family size and family income. For insured patients, the discount will be applied to the patient's deductible, co-insurance, and/or co-payment.
Financial Assistance Decision and Notification Process
Neurotech uses poverty guidelines issued by the U.S. Department of Health and Human Services (the “FPL”) to determine a patient's eligibility for financial assistance. Financial assistance will be provided to patients when their gross family income is less than or equal to three and one quarter times the Federal Poverty Guidelines adjusted for family size. If the patient's income, adjusted for family size, is more than one and one quarter times the Federal Poverty Guidelines, Neurotech may consider certain assets and liabilities of the patient when determining ability to pay. The amount of the discount varies based upon the applicant's income and the size of the applicant's family.
Poverty Levels for 2022 as determined by HHS (48 Contiguous States and DC).
| Family Size | Poverty Level | Up to 125% of the FPL | More than 125% and up to 175% of the FPL | More than 175% and up to 225% of the FPL | More than 225% and up to 275% of the FPL | More than 275% and up to 325% of the FPL |
|---|
| 1 | $13,590 | $16,987.50 | $23,782.50 | $30,577.50 | $37,372.50 | $44,167.50 |
| 2 | $18,310 | $22,887.50 | $32,042.50 | $41,197.50 | $50,352.50 | $59,507.50 |
| 3 | $23,030 | $28,787.50 | $40,302.50 | $51,817.50 | $63,332.50 | $74,847.50 |
| 4 | $25,750 | $32,187.50 | $45,062.50 | $57,937.50 | $70,812.50 | $83,687.50 |
| 5 | $32,470 | $40,587.50 | $56,822.50 | $73,057.50 | $89,292.50 | $105,527.50 |
| 6 | $37,190 | $46,487.50 | $65,082.50 | $83,677.50 | $102,272.50 | $120,867.50 |
| 7 | $41,910 | $52,387.50 | $73,342.50 | $94,297.50 | $115,252.50 | $136,207.50 |
| 8 | $46,630 | $58,287.50 | $81,602.50 | $104,917.50 | $128,232.50 | $151,547.50 |
| Discount | | 100% | 75% | 50% | 25% | 10% |
Patients whose income exceeds 325% of the FPL may be eligible to receive discounted rates on a case-by-case basis based on their specific circumstances, such as catastrophic illness or medical indigence, at the discretion of Neurotech.
Applications should be sent to:
Neurotech, LLC
Attn. Carly Chasteen
626 W. Moreland Blvd
Waukesha, WI 53188
info@neurotecheeg.com
Fax (262) 754-0897
If, after receiving a discount, a patient cannot pay the entire remaining bill, Neurotech may offer a payment plan to the patient. The amount the patient will be required to pay will depend on his or her income level. If a patient is not eligible for Financial Assistance, Neurotech may offer the patient a payment plan on a case-by-case basis.
Download the application here (Acrobat PDF)