# Good Samaritan Hospital

Hospital in San Jose, CA. Verified from the hospital's own policy.

Good Samaritan Hospital likely gives free care to households with a yearly income up to $63,840 for 1 person, $86,560 for 2, $109,280 for 3, $132,000 for 4, $154,720 for 5 or $177,440 for 6. We have not found a discount for incomes above the free care level.

The hospital makes the final decision.

| Household size | Free care if yearly income is up to | Discount if yearly income is up to |
|---|---|---|
| 1 | $63,840 | not found |
| 2 | $86,560 | not found |
| 3 | $109,280 | not found |
| 4 | $132,000 | not found |
| 5 | $154,720 | not found |
| 6 | $177,440 | not found |

Dollar amounts use the 2026 federal poverty guidelines.

## Discount steps

- 0% to 400% of poverty level, patient pays $0 (entire patient balance written off) for uninsured and underinsured patients
- 401% to null% of poverty level, patient pays May get an uninsured discount or Patient Liability Protection sliding-scale discount; scale not stated in this policy

## How to apply

- Call (800) 307-7135 and ask for financial assistance.
- [Application form](https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=4d691d68-ee80-42bf-b295-335354058f1b)
- [Charity and Discount Program Policy for California Patients with Family Incomes Below 400% FPL (HCA PARA.PP.OPS.016CA, effective 10/16/24)](https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=0ffe863b-3762-43cd-ac1f-5f07010582fe)
- We do not have the deadline yet. Apply as soon as you get a bill, and ask the billing office to pause collections while you apply.
- Bring recent income tax return, or two of: recent pay stubs, W-2, 1099 forms, last 3 months of bank statements, current credit report.
- Savings and property. The policy looks at income only, not savings or property.

## If you have insurance

Insured patients can also apply for help with deductibles and copays.
Keep your insurance. Financial assistance covers bills from this one place only.

## What is covered

Covered. Medically necessary services at HCA acute-care hospitals in California, including emergency and outpatient care.

Not covered. Your insurance or any other payer must pay its share first. Services that are not medically necessary are not covered. Emergency doctors bill separately and have their own write-off duty under state law.

## State program in California

### Hospital Fair Pricing Act (Health and Safety Code 127400 et seq.)

Every licensed general acute care, acute psychiatric, and special hospital in California must have a charity care policy and a discount payment policy. A patient can ask for help if they are uninsured (self-pay) or have high medical costs, and their family income is not more than 400% of the federal poverty level. Hospitals may choose to help people with higher incomes. With a discount, the bill is capped at about what Medicare or Medi-Cal would pay, whichever is greater. You can apply at any time, even after a bill goes to collections. Immigration status does not affect eligibility.

Income levels in the program are discount up to 400% of poverty level.

Applies to each licensed general acute care hospital, acute psychiatric hospital, and special hospital in California.

How to apply. Apply to the hospital's financial assistance office. Each hospital's policies and applications are posted on its website and on HCAI's Hospital Fair Pricing Policy Lookup (https://hcai.ca.gov/affordability/hospital-fair-billing-program/hospital-fair-pricing-policy-lookup/).

> Is a self-pay patient OR a patient with high medical costs; AND Patient's family income is not more than 400 percent of the federal poverty

Source https://hcai.ca.gov/affordability/hospital-fair-billing-program/hospital-bill-complaint-program/frequently-asked-questions/, checked 2026-11-10

### Hospital Bill Complaint Program (HCAI)

A free state program at HCAI. If a hospital wrongly denied you financial assistance, did not tell you about its programs, or sent you to collections the wrong way, you can file a complaint online (English and Spanish) or by mail (many languages). You must have applied to the hospital first for HCAI to review an eligibility decision. If HCAI finds you paid too much, the hospital must refund you within 30 days. It covers problems on or after January 1, 2022. It does not handle general billing disputes, price transparency, Good Faith Estimates, or bills from emergency room doctors.

Applies to complaints about any hospital covered by the Hospital Fair Pricing Act.

How to apply. File online through the Patient Complaint Portal (https://hcai.ca.gov/affordability/hospital-fair-billing-program/hospital-bill-complaint-program/should-i-file-a-complaint/) or mail the Patient Complaint Form to Department of Health Care Access and Information, Hospital Bill Complaint Program, 2020 West El Camino Avenue, Suite 1101, Sacramento, CA 95833.

> If you believe you were wrongly denied financial assistance, you may file a complaint with the Hospital Bill Complaint Program.

Source https://hcai.ca.gov/affordability/hospital-fair-billing-program/hospital-bill-complaint-program/, checked 2026-11-10

### Emergency physician discount rule

Most hospital policies cover only the hospital's own bill. Emergency room doctors often bill separately. California law also requires an emergency physician to give discounts to uninsured patients and patients with high medical costs whose family income is at or below 400% of the federal poverty level. Ask the doctor group's billing office for its discount policy. HCAI's complaint program does not handle emergency doctor bills.

Income levels in the program are discount up to 400% of poverty level.

Applies to emergency physicians who provide emergency medical services in a California hospital that provides emergency care.

How to apply. Ask the emergency physician group named on the bill for its discount payment policy.

> an emergency physician who provides emergency medical services in a hospital that provides emergency care is also required by law to provide discounted care

Source https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=c7bdd7eb-bcc0-4a84-bcab-a21b5e578d9c, checked 2026-11-10

## Notes

This is HCA's California policy for its acute-care hospitals. It does not list hospitals by name. If you have no insurance or not enough insurance and your family income is at or below 400% of the poverty level, the whole balance you owe is written off. You need to send proof of income. Above 400% of the poverty level, HCA says you may get help from its uninsured discount or its Patient Liability Protection program, a sliding scale based on income. That scale is not in this policy and has no stated income limit, so the discount limit is left blank. Applications are accepted at any time. The letter asks for it within 14 days and says review takes 21 business days. Homeless or undocumented patients and some Medicare savings program members can get the write-off without full paperwork. To dispute a denial, send a written request with documents to the hospital CFO or HCA's Operations Support Director. The phone number is HCA's customer service line printed on the application. The policy's own appendix prints a different number, 800-307-8016. The policy is dated 10/16/24. HCAI lists it with an effective date of 12/12/2025. HCAI lists Mission Oaks Hospital in Los Gatos under this hospital's license.

## Sources

- Free care level https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=0ffe863b-3762-43cd-ac1f-5f07010582fe
  > uninsured and underinsured patients who have a Family Income within 0-400% of the FPL will have the entire patient balance processed as charity write-off.
- Discount steps https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=0ffe863b-3762-43cd-ac1f-5f07010582fe
  > Uninsured and Underinsured patients with a Family Income above 400% FPL may be eligible for other financial assistance
- Insured patients https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=0ffe863b-3762-43cd-ac1f-5f07010582fe
  > have no (uninsured) or insufficient (underinsured) third party payer coverage for the services
- Asset test https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=0ffe863b-3762-43cd-ac1f-5f07010582fe
  > Monetary Assets shall not be considered in determining eligibility for charity care.
- What is not covered https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=0ffe863b-3762-43cd-ac1f-5f07010582fe
  > The charity write-off cannot be applied to any account with any outstanding payer liability.
- Documents https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=4d691d68-ee80-42bf-b295-335354058f1b
  > The preferred supporting documentation is your recent Income Tax Return.
- Financial counseling phone https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=4d691d68-ee80-42bf-b295-335354058f1b
  > Phone: 800-307-7135
- Facility list https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=0ffe863b-3762-43cd-ac1f-5f07010582fe
  > HCA-affiliated, non-partnership, acute-care hospitals ("Hospitals") in California.

Last checked 2026-11-10.

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