DSA Free Documents & Tools

Below is a Financial Hardship Application Form that providers can use when considering waiving a patient’s copay due to financial hardship.

1️⃣ Have the patient complete the Financial Hardship Application Form. This ensures there is a documented request for assistance.
2️⃣ Review the 2025 Federal Poverty Guidelines (available for download below) to determine eligibility. Many healthcare institutions consider patients below 200-300% of FPL as eligible for assistance.
3️⃣ Assess the request individually – hardship waivers must not be routine and should be granted only after reviewing the patient’s financial situation.
4️⃣ Keep the completed form on file as documentation in case of an audit or compliance review.

Per Don’s recommendations, Medicare providers cannot routinely waive or reduce Medicare coinsurance or deductibles, as this could be seen as an inducement or a violation of the Anti-Kickback Statute and Civil Monetary Penalties Law (CMP). However, there are exceptions:

✔ Financial Hardship Waivers – A provider may waive or reduce cost-sharing if:

• The waiver is not routine and is based on an individual assessment of financial need.
• The provider does not advertise or actively promote the waiver.
• The patient requests assistance and demonstrates financial hardship.

✔ Federal Poverty Guidelines Consideration – While there is no strict 250% Federal Poverty Level (FPL) threshold under Medicare law, providers may use FPL guidelines (see guidelines PDF in the next section) as part of their hardship determination. Many healthcare institutions consider patients below 200-300% of FPL as eligible for assistance.

✔ Medicare & Medicaid Dual Eligibility – If a beneficiary qualifies for Medicaid or a Medicare Savings Program, Medicaid may cover their coinsurance/deductibles, so a discount may not be necessary.

⚠ The waiver must be based on genuine financial hardship and documented in the patient’s records.
⚠ Routine or blanket waivers are prohibited unless required by law (e.g., specific Medicare Advantage or Medicaid rules).