# PIH Health Good Samaritan Hospital

Hospital in Los Angeles, CA. Verified from the hospital's own policy.

PIH Health Good Samaritan Hospital likely gives free care to households with a yearly income up to $15,960 for 1 person, $21,640 for 2, $27,320 for 3, $33,000 for 4, $38,680 for 5 or $44,360 for 6. It likely gives a discount 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.

The hospital makes the final decision.

| Household size | Free care if yearly income is up to | Discount if yearly income is up to |
|---|---|---|
| 1 | $15,960 | $63,840 |
| 2 | $21,640 | $86,560 |
| 3 | $27,320 | $109,280 |
| 4 | $33,000 | $132,000 |
| 5 | $38,680 | $154,720 |
| 6 | $44,360 | $177,440 |

Dollar amounts use the 2026 federal poverty guidelines.

## Discount steps

- 0% to 100% of poverty level, patient pays $0
- 101% to 125% of poverty level, patient pays $100 per inpatient day or outpatient surgery; $35 per outpatient non-surgery or ER visit (or less, see notes)
- 126% to 138% of poverty level, patient pays $200 per inpatient day or outpatient surgery; $50 per outpatient non-surgery or ER visit (or less, see notes)
- 139% to 150% of poverty level, patient pays $300 per inpatient day or outpatient surgery; $65 per outpatient non-surgery or ER visit (or less, see notes)
- 151% to 175% of poverty level, patient pays $400 per inpatient day or outpatient surgery; $80 per outpatient non-surgery or ER visit (or less, see notes)
- 176% to 185% of poverty level, patient pays $600 per inpatient day or outpatient surgery; $120 per outpatient non-surgery or ER visit (or less, see notes)
- 186% to 200% of poverty level, patient pays $800 per inpatient day or outpatient surgery; $150 per outpatient non-surgery or ER visit (or less, see notes)
- 201% to 225% of poverty level, patient pays $1,000 per inpatient day or outpatient surgery; $200 per outpatient non-surgery or ER visit (or less, see notes)
- 226% to 250% of poverty level, patient pays $1,200 per inpatient day or outpatient surgery; $225 per outpatient non-surgery or ER visit (or less, see notes)
- 251% to 275% of poverty level, patient pays $1,350 per inpatient day or outpatient surgery; $275 per outpatient non-surgery or ER visit (or less, see notes)
- 276% to 300% of poverty level, patient pays $1,500 per inpatient day or outpatient surgery; $325 per outpatient non-surgery or ER visit (or less, see notes)
- 301% to 325% of poverty level, patient pays $1,550 per inpatient day or outpatient surgery; $350 per outpatient non-surgery or ER visit (or less, see notes)
- 326% to 350% of poverty level, patient pays $1,600 per inpatient day or outpatient surgery; $375 per outpatient non-surgery or ER visit (or less, see notes)
- 351% to 375% of poverty level, patient pays $1,700 per inpatient day or outpatient surgery; $425 per outpatient non-surgery or ER visit (or less, see notes)
- 376% to 400% of poverty level, patient pays $1,850 per inpatient day or outpatient surgery; $500 per outpatient non-surgery or ER visit (or less, see notes)

## How to apply

- Call (562) 967-2875 and ask for financial assistance.
- [Application form](https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=bbe7323a-ab54-4946-849e-07435f47af32)
- [Financial Assistance Policy (FAP) AKA Charity Care/Uncompensated Care Program, E.85300.600 (last revised 7/1/2026)](https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae)
- 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 pay stubs, benefit check stubs, or tax returns, the application also asks for copies of checks and bank statements.
- Residency. Patients should live in the hospital's primary or secondary service area and have a doctor on its medical staff. Out-of-area patients seen in or admitted through the emergency department are also considered.
- Savings and property. The policy counts savings or property, not only income.
- Very large bills. Out-of-pocket costs over 10% of annual net family income in the prior 12 months; people facing catastrophically large bills are also eligible
- Languages. English, Spanish

## 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. Emergency and medically necessary hospital facility services at PIH Health Whittier, Downey, and Good Samaritan hospitals.

Not covered. All doctors bill separately and are not covered, including emergency room doctors, radiologists, pathologists, anesthesiologists, hospitalists, and surgeons. PIH Health Physicians is excluded.

## 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

Free care only at or below 100% of the poverty level. From 101% to 400% you pay a set amount per day or per visit, and the amount rises with income. You pay the lowest of the cash discount rate, 10% of your yearly income, or the table amount. The policy lists a charge cap for Whittier (16.2%) and Downey (20%) but none for Good Samaritan. CMS lists Good Samaritan as proprietary, but this is the PIH Health nonprofit system policy. HCAI's copy for Good Samaritan is the same policy text as Whittier and Downey. The policy table lists amounts at steps of the poverty level (125%, 138%, 150% and so on). We read each step as covering incomes up to that level. This policy still counts assets. It skips the first $10,000 of savings and half of the rest, and retirement accounts. California law since 2025 does not allow hospitals to count savings and other money assets, so ask about this if it comes up. The application asks for bank statements and the value of your home and cars. The policy gives no deadline to apply. If you apply within 240 days of the first bill, collections stop while they decide. Eligibility is checked again after 6 months. Appeals go in writing to the Uncompensated Care Committee. The phone number is PIH Health's system-wide Customer Service line, printed on the application form (an image, read by eye).

## Sources

- Free care level https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > Patient applications that show that family income at or below 100% of Federal Poverty Guidelines (FPL) will be approved for no-cost to the patient.
- Discount level https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > family income between 101 % and 400% FPL will be granted the lessor of the self-pay rate or discounts as outlined below.
- Discount steps https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > 400% $1,850 $500
- Insured patients https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > Insured and uninsured patients who demonstrate ability to pay part but not all of their liability.
- Asset test https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > Consider individual or family net worth including all liquid and non-liquid assets owned, less liabilities and claims against assets.
- Residency https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > Patient should reside in the hospital's primary/secondary service area and have a physician who is a member of the hospital's Medical Staff.
- Very large bills https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > those who have an out of pocket that exceeds 10% of their annual net family income in the prior twelve months
- What is not covered https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > this FAP applies only to hospital facility services and does not apply to emergency room physicians, radiologists, pathologists, anesthesiologists, hospitalists, surgeons or other physicians
- Documents https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > Recent pay stubs such as paychecks, General Relief, Social Security, pension, unemployment or disability check stubs, or tax returns
- Languages https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > The hospital's website includes a copy of the policy and applications in English and Spanish.
- Financial counseling phone https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=bbe7323a-ab54-4946-849e-07435f47af32
  > PIH Health Customer Service number 562.967.2875
- Facility list https://api.hdc.hcai.ca.gov/Public/Extract/Attachment?id=b860c079-feb6-4080-a3bb-f9ded1fe8bae
  > PIH Health Whittier Hospital (PHWH), PIH Health Downey Hospital - Downey (PHDH), and PIH Health Good Samaritan Hospital (PHGSH)

Last checked 2026-11-10.

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