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Financial Assistance Policy

Purpose

Consistent with our mission to provide high quality health and wellness services for the community, Augusta Health and Augusta Medical Group are committed to providing free or discounted care to individuals who are in need of emergency or medically necessary treatment and have a household income below 400% of the Federal Poverty Level (FPL) Guidelines, as the payer of last resource.

In accordance with the federal Patient Protection and Affordable Care Act (PPACA) and section 501(r) of the Internal Revenue Service code, all other uninsured patients will not be charged more than the amount generally billed to commercially insured patients for emergency or medically necessary care.

Policy

Free care is provided only when care is deemed medically necessary and after uninsured or underinsured financial assistance eligible patients have been found to meet all qualifying criteria.

Patients seeking financial assistance may be assisted with applications for other means of payment (e.g., Medicaid, other local funding programs) BEFORE approval for financial assistance.

Uninsured patients who do not qualify for Augusta Health's financial assistance program (e.g., due to their household income) will receive a discount of 50% for Augusta Health services & 35% discount for Augusta Medical Group services on gross charges for medically necessary services to ensure they do not pay more for care than commercially insured individuals. These patients are expected to pay their remaining balance for care, and may work with financial advocates to set up an acceptable payment plan based on their financial situation.

Uninsured patients who are believed to have the financial ability to purchase health insurance are encouraged to do so in order to ensure healthcare accessibility and overall well-being.

Procedure

Augusta Health and Augusta Medical Group will follow the guidelines set forth in this policy when determining patients' eligibility for financial assistance.

I. Eligibility for Financial Assistance

  1. Patients who are deemed financial assistance eligible will not be charged more than amounts generally billed to insured patients for emergency or medically necessary care.
  2. In order to be deemed eligible for financial assistance, patients must meet all of the applicable criteria set forth in this policy.
  3. Services eligible for financial assistance include: emergent or urgent care, services deemed medically necessary by Augusta Health and/or Augusta Medical Group, and, in general, care that is non-elective and needed in order to prevent death or adverse effects to the patient's health.
  4. Services considered "elective" and/or "medically indicated" do not qualify for financial assistance under this policy, unless otherwise approved by the Augusta Health medical director.
  5. Uninsured patients must be residents of the Augusta Health service area (See addendum "B") in order to qualify for financial assistance. Under special circumstances, such as unplanned emergency admissions, patients who reside outside the Augusta Health service area may qualify for financial assistance.
  6. Patients with Out-of-Network insurance coverage are not eligible for Financial Assistance. Governmental plans and plans that do not meet Minimum Essential Coverage as defined by the Internal Revenue Service are not considered to be Out-of-Network, even if Augusta Health is not one of the designated facilities or providers in the plan or the plan does not have a provider network unless the plan denies the service as not authorized.
  7. Patient with health insurance coverage must agree to use that coverage before financial assistance may be considered. That includes securing pre-authorization for scheduled services, when applicable.
  8. Patients who may be eligible for coverage through other means, such as Medicaid, Medicare, or Workers Compensation, but either refuse to cooperate with Augusta Health in applying for such programs or fail to comply with established eligibility processes will not be eligible for financial assistance for that episode of care.
  9. Patients/guarantors who decline Group Health Insurance (GHI) coverage available to them through their employers are not eligible for financial assistance under this policy.
  10. All liquid assets (cash, checking, savings and money market accounts, matured certificates of deposit, mutual funds and bonds that may be cashed without penalty and other easily convertible investments) held by the patient or guarantor in excess of $15,000.00 must be applied to the indebtedness owed to Augusta Health/Augusta Medical Group before financial assistance will be considered. Retirement funds will not be included.
  11. Healthcare Scoring Eligibility: Uninsured patients will be screened for financial assistance eligibility. This screening may occur prior to or after the service is provided while still in the Application Period. Outside resources may be used to determine the patient's qualification for presumptive financial assistance. Eligibility may be determined on the basis of individual life circumstances that may include qualification through:
    1. Free clinic or indigent health access programs, including Augusta Regional Clinic (Free Clinic) and other regional free clinics and Federally Qualified Health Centers (FQHCs).
    2. Eligibility for other state or local assistance programs that are unfunded (Medicaid spend-down; other Medicaid non-covered services).
    3. Identification that the patient is homeless.
    4. Third party evaluation to determine ability to pay prior to transfer to bad debt, based on a patient's healthcare scoring financial information, which may include but is not limited to income, assets, or credit score. The patient may still be responsible for partial payment given the absence of a financial assistance application.
  12. Uninsured patients who have a household income below 201% of the current Federal Poverty Level (shown in the table below) and available liquid assets of less than or equal to $15,000 may receive free care.

    ​Uninsured patients who have a household income from 201% to 400% of the current Federal Poverty Level and available liquid assets of less than or equal to $15,000 may qualify for a reduction of 60% of total charges.

    Uninsured Patients with a Household Income above 400% of the current Federal Poverty Level are not eligible for Financial Assistance under this Policy; however, these patients may be eligible for the Catastrophic Discount.
  13. Insured patients who have a household income equal to or below 200% of the current Federal Poverty Level and available liquid assets equal to or less than $15,000 are eligible for a full, 100% write-off of any remaining patient responsibility balance after insurance has paid on Covered Services under this Policy.

    Insured patients who have a household income from 201% to 400% of the current Federal Poverty Level and available liquid equal to or less than $15,000 are eligible for a reduction of 60% of any remaining patient responsibility balance after insurance has paid on Covered Services under this Policy.
    Federal Poverty Level Guidelines – 2018
    Family Size 12 Month Income
    1 $12,140
    2 $16,460
    3 $20,780
    4 $25,100
    5 $29,420
    6 $33,740
    7 $38,060
    8 $42,380

    *If there are more than eight individuals in the family, add $4,320 for each additional member.

  14. The financial assistance discount will be applied as follows:
    1. Augusta Health Services (Hospital Based)

      Uninsured patients who do not meet these income requirements will receive a discount of 50% on gross charges for medically necessary and emergency care that they receive.

      Example #1: An uninsured patient who does not qualify for financial assistance

      Total charges $100.00
      Uninsured adjustment $ 50.00
      Total balance due $ 50.00

      Example #2: An uninsured patient who qualifies for 100% financial assistance

      Total charges $100.00
      Uninsured adjustment $50.00
      100% financial assistance adjustment $ 50.00
      Total balance due $ 0.00

      Example #3: An uninsured patient who qualifies for 60% financial assistance

      Total charges $100.00
      Uninsured adjustment $50.00
      60% Financial assistance adjustment $ 30.00
      Total balance due $ 20.00
    2. Augusta Medical Group Services (Physician Based Locations)

      Uninsured patients who do not meet the criteria of this policy will receive an uninsured discount of 35% on gross charges for medically necessary and emergency care that they receive.

      Example #1: An uninsured patient who does not qualify for financial assistance

      Total charges $100.00
      Uninsured adjustment $ 35.00
      Total balance due $ 65.00

      Example #2: An uninsured patient who qualifies for 100% financial assistance

      Total charges $100.00
      Uninsured adjustment $35.00
      100% financial assistance adjustment $ 65.00
      Total balance due $ 0.00

      Example #3: An uninsured patient who qualifies for 60% financial assistance

      Total charges $100.00
      Uninsured adjustment $35.00
      60% Financial assistance adjustment $ 39.00
      Total balance due $ 26.00
  15. When determining patient eligibility, race, gender, age, sexual orientation, religious affiliation, or immigration or social status are not taken into account. Accounts will be considered for financial assistance when the application is received within 240 days of the first invoice date for the rendered service(s).
  16. Augusta Health may refer to or rely on external sources and/or other program enrollment resources if uninsured patients lack documentation that supports eligibility. For example, free care may be provide when we are able to determine that:
    • Patient is homeless
    • Patient is eligible for other state or local assistance programs that are unfunded
    • Patient is eligible for Supplemental Nutrition Assistance Program-SNAP (formerly known as Food Stamps) or subsidized school lunch program
    • Patient is eligible for a state-funded prescription medication program
    • Patient's valid address is considered low-income or subsidized housing
    • Patient receives free care from a community clinic and is referred to hospital for further treatment

II. Applying for Financial Assistance

See Addendum A for the application form.

  1. Determinations for eligibility for discounted care will require patients to submit a complete financial assistance application (including all documentation required by the application) and may require appointments or discussion with hospital financial advocates.
  2. To apply for financial assistance, patients must submit a complete application (including supporting documents) either by mail to Augusta Health Business Office, P.O. Box 1000, Fishersville, VA 22939, or in person at 189 Medical Center Circle, Fishersville, VA 22939, within 240 days of the first invoice date for the rendered service(s).
  3. An approved application will cover applicable services provided to the patient 240 days prior to and 180 days following the date on which the application is approved. After an approved application is expired, a new application with current supporting documentation must be submitted if the patient still needs financial assistance.
  4. Applications can be accessed:
    • At the facility at all registration and access points on the main hospital campus, at all Augusta Medical Group physician offices, and at the Business Office
    • Over the phone by calling (540) 332-4600
    • By mail, by sending request to P.O. Box 1000, Fishersville, VA 22939
    • Online at https://www.augustahealth.com/business-office/financial-assistance
  5. To be considered eligible for financial assistance, patients must fully cooperate with Augusta Health and its affiliates to explore alternative means of assistance, if necessary, including eligibility for Medicare and Medicaid. Patients will be required to provide necessary information and documentation when applying for hospital financial assistance or other private or public payment programs.
  6. Applications returned requesting additional information will be held for 30 days from the date the letter was mailed to the applicant requesting the information. If the information is not received within 30 days, the application will be considered withdrawn and will be denied.
  7. In addition to completing an application, individuals should be prepared to supply the following documentation:
    • Most recent bank statements for the last three months
    • Proof of income for applicant (and spouse if applicable), such as most recent pay stubs for the last three months, unemployment compensation, alimony, child support, disability compensation, pensions, rental income, Supplemental Security Income-SSI, or sufficient information on how patients are currently supporting themselves
    • Copy of most recent federal income tax return
    • In some cases, information on available assets or other financial resources
    External, public sources such as credit/healthcare scores may also be used to verify eligibility.
  8. The patients or the patient's guarantor, or representative, will be notified of the decision, in writing.
  9. Financial Advocates are available to assist in the application process in person at 189 Medical Center Circle, Fishersville, VA 22939 from 8:00am – 4:30pm, Monday through Friday, or by phone at (540) 332-4600.

    Representatives at several community agencies are also able to assist with completing the financial assistance application, and their contact information is as follows:

    All-Tran Health, Inc.
    78 Medical Center Drive
    Fishersville, VA 22939
    (540) 332-4619
    Augusta Regional Clinic (Augusta Free Clinic)
    342 Mule Academy Road
    Fishersville, VA 22939
    (540) 221-6123

    *Note: Augusta Health and Augusta Medical Group have access to qualified foreign language interpreters who can assist patients who are unable to speak English, as well as qualified sign language interpreters to assist patients who are deaf or hard of hearing.

III. Determining the Financial Assistance Adjustment

Individuals eligible for financial assistance under this policy shall not be charged more than the amounts generally billed (AGB) to individuals who have insurance. This value shall be calculated using the "look-back" method based on actual paid claims. The current AGB is 50% for Augusta Health and 35% for Augusta Medical Group. The AGB is updated annually.

IV. Catastrophic Charity Eligibility

Individuals whose household income exceeds 400% of the federal poverty guidelines, and/or have a catastrophic illness resulting in expenses that are greater than one-fourth of their annual income, may be eligible for a catastrophic charity adjustment.

V. Actions in the Event of Non-Payment

The collection actions Augusta Health and Augusta Medical Group may take if a financial assistance application and/or payment is/are not received are described in a separate billing and collections policy.

In brief, Augusta Health and Augusta Medical Group will make certain efforts to provide uninsured patients with information about our financial assistance policy, such as including a summary of that information with billing statements, before we or our collection vendors take certain actions to collect your bill (these actions may include charging of interest, some civil actions, or reporting of outstanding debt to credit bureaus).

For more information on the steps Augusta Health and Augusta Medical Group will take to inform uninsured patients of our financial assistance policy and the collection activities we may pursue, please see Augusta Health's billing and collections policy.

VI. Communication of Financial Assistance

  1. The financial assistance policy, financial assistance application, and summary of the financial assistance policy are available free of charge at our facility, by mail, and online.
    • To access any of these documents at the facility, please visit the Business Office at 189 Medical Center Circle, Fishersville, VA 22939
    • To have a hard copy of any of these documents mailed to you, please call (540) 332-4600 or mail a request to Augusta Health Business Office, P.O. Box 1000, Fishersville, VA 22939
    • To access the Financial Assistance Policy, the summary of the Financial Assistance Policy, or the Financial Assistance Application, please visit https://www.augustahealth.com/business-office/financial-assistance
  2. Augusta Health/Augusta Medical Group communicate the availability of financial assistance through means which include:
    • Posting signs within waiting rooms and check-in desks, as well as emergency rooms, urgent care centers, and physician offices
    • Creating a document that summarizes the financial assistance policy, which is given to patients by hospital team members at discharge and sent with patient statements
    • Ensuring free copies of financial assistance documents (policy, application, and summary) can be obtained within the facility and by mail
    • Posting information about financial assistance (including summary, application, and policy) on the Augusta Health's website: https://www.augustahealth.com
    • Providing information about the policy and how to apply during verbal communication about the patient's bill (e.g., phone calls, face-to-face)
    • Ensuring designated staff are knowledgeable of the financial assistance policy and can answer patients' questions or refer patients to the program
    • Notifying local physician practices and representatives of community and social service agencies, including Augusta Medical Group, and other non-affiliated community physician offices about the availability of financial assistance at Augusta Health and how interested individuals can apply
    • Providing brochures and copies of the summary of our assistance policy to local physician offices and community agencies, including all Augusta Medical Group offices
    • Inclusion of financial assistance information with billing statement for uninsured and underinsured patients

VII. Misrepresentation

Augusta Health and August Medical Group may deny an application for financial assistance and/or may reverse previously applied discounts if we learn that previously provided information to support a conclusion was false or inaccurate. In addition, we may elect to pursue legal actions, including criminal charges, against persons who we believe knowingly misrepresented their financial condition, including those who accept financial assistance after an improvement in their financial circumstances which was not made known to Augusta Health.

VIII. Ensuring Compliance

  1. On an annual basis, the Director of Patient Financial Services or designee and/or the Corporate Controller or designee, will perform an audit to include:
    • A random sampling of billing statements to ensure it includes all information required
    • A visit to each physician office and registration point within the hospital to ensure each point of entry has access to the updated financial assistance policy, as well as updated financial assistance applications, and that staff are informed on how to inform patients of each
    • An audit of the website to ensure the application and policy are still easily accessible
    • A look-back analysis to ensure the then reimbursement rates of the payers being used to calculate an average of "amounts generally billed" does not fall below that of what a patient who qualifies for financial assistance is being billed
  2. The Financial Assistance Policy is subject to periodic review and may be revised at any time, as business needs require. The Augusta Health Board of Directors must approve any changes to this policy.

IX. Determination of Financial Need of Non-Responsive Patients and Guarantors

  1. We understand that certain patients may be unable to complete a financial assistance application, comply with requests for documentation, or are otherwise non-responsive to the application process. As a result, there may be circumstances under which a patient's qualification for financial assistance is established without completing the formal assistance application. Under these circumstances, Augusta Health may utilize other sources of information to make an individual assessment of financial need. This information will enable Augusta Health to make an informed decision on the financial need of non-responsive patients by utilizing the best estimates available in the absence of information provided directly by the patient.
  2. We may utilize a third-party to conduct an electronic review of patient information to assess financial need. This review utilizes a healthcare industry-recognized model that is based on public record databases. This predictive model incorporates public record data to calculate a socio-economic and financial capacity score that includes estimates for income, assets, and liquidity. The electronic technology is designed to assess each patient to the same standards and is calibrated against historical approvals for Augusta Health financial assistance under the traditional application process.
  3. The electronic technology will be deployed prior to bad debt assignment after all other eligibility and payment sources have been exhausted. This allows us to screen all patients for financial assistance prior to pursuing any extraordinary collection actions. The data returned from this electronic eligibility review will constitute adequate documentation of financial need under this policy.
  4. When electronic enrollment is used as the basis for presumptive eligibility, the highest discount of full free care will be granted for eligible services for retrospective dates of service only. If a patient does not qualify under the electronic enrollment process, the patient may still be considered under the financial assistance application process. To patients not qualifying through this process, we will provide them with a written notice informing them that financial assistance is available. It will include a plain language summary of the financial assistance policy and actions to be taken if an application is not submitted or the outstanding balance paid.
  5. Patient accounts granted presumptive eligibility will be reclassified under the financial assistance policy. They will not be sent to collection, will not be subject to further collection actions, will not be notified of their qualification, and will not be included in the hospital's bad debt expense.

X. Plan Language Summary

  1. In accordance with 501(r) charity requirements, below is considered the "Plan Language Summary" of the Augusta Health and Augusta Medical Group Financial Assistance Policy which will accompany all billing statements and be presented to patients during all financial discussions.
  2. Consistent with its mission to provide high quality health and wellness services for the community, Augusta Health and Augusta Medical Group are committed to providing free or discounted care to individuals who are in need of emergency or medically necessary treatment and have a household income below 400% of the Federal Poverty Level (FPL) Guidelines. Individuals who qualify for financial assistance will not be charged more than the average amounts generally billed to commercially insured patients, for emergency or medically necessary care.
  3. Financial Advocates are available at (540) 332-4600, Monday through Friday, from 8:00am until 4:30pm to discuss the application process.
  4. Augusta Health will not pursue extraordinary collections actions against an individual without first using reasonable efforts to determine if such individual is eligible for financial assistance.
  5. For a free copy of the entire Financial Assistance Policy and/or an Application for Financial Assistance, patients can:

XI. Definitions

The following terms are meant to be interpreted within this policy as follows:

  1. Financial Assistance: Reduction of patient's account balance based on established criteria; discounted or free care granted pursuant to this policy.
  2. Incomplete Financial Assistance Application: An application that is missing requested information or documentation needed to process the application.
  3. Catastrophic Charity: Financial assistance available to patients whose medical expenses exceed one-fourth of their total household income.
  4. Presumptive Eligibility: A determination that a patient is presumed eligible for Financial Assistance based on information other than that provided by the patient or responsible party through the regular financial application form.
  5. Emergency Care: Immediate care which is necessary to prevent serious jeopardy to a patient's health; serious impairment to bodily functions, and/or serious dysfunction of any organs or body parts.
  6. Medically Necessary: Hospital services or care rendered to a patient, both inpatient and outpatient, in order to diagnose, alleviate, correct, cure, or prevent the onset or worsening of conditions that endanger life, cause suffering or pain, cause physical deformity of malfunction, threaten to cause or aggravate a handicap, or result in overall illness or infirmity.
  7. Medically Indicated: Services that are not medically necessary but rather are indicated as needed for a quality of life improvement but not necessarily life threatening or debilitating.
  8. Elective services: Services that are not medically necessary but "desired" by the patient for other reasons beyond life threatening or debilitating in nature.
  9. Urgent Care: Services necessary in order to avoid the onset of illness or injury, disability, death, or serious impairment or dysfunction if not treated within 12 hours.
  10. Liquid Assets: The applicant's household cash or cash equivalent assets, such as savings and checking accounts, investments, and trust accounts that can be withdrawn, with or without penalty, for use in paying for medical care.
  11. Underinsured: Patients who have limited private or public healthcare coverage, for whom it would be a medical hardship to pay out-of-pocket expenses for medical services provided by Augusta Health.
  12. Uninsured: Patients with no insurance or third-party assistance to help resolve their financial liability to healthcare providers.
  13. Out-of-Network: Certain insurance carriers or third party administrators may reduce or eliminate the provision of benefits unless care is provided by designated facilities or providers. In cases where Augusta Health is not one of the designated facilities or providers, or the plan does not have a provider network, any care provided is considered to be out-of- network.

Addendum A

Financial Assistance Application

Addendum B

Augusta Health Service Area

Zip Code

City

22812

Bridgewater

22821

Dayton

22841

Mount Crawford

22843

Mount Solon

22920

Afton

22932

Crozet

22939

Fishersville

22943

Greenwood

22952

Lyndhurst

22976

Tyro

22980

Waynesboro

24401

Staunton

24402

Staunton

24407

Staunton

24411

Craigsville

24412

Bacova

24413

Blue Grass

24415

Brownsburg

24416

Buena Vista

24421

Churchville

24430

Craigsville

24431

Crimora

24432

Deerfield

24433

Doe Hill

24435

Fairfield

24437

Fort Defiance

24439

Goshen

24440

Greenville

24442

Head Waters

24445

Hot Springs

24450

Lexington

24458

McDowell

24459

Middlebrook

24460

Millboro

24463

Staunton

24464

Montebello

24465

Monterey

24467

Mount Sidney

24469

Fort Defiance

24472

Raphine

24473

Rockbridge Baths

24476

Steeles Tavern

24477

Stuarts Draft

24479

Swoope

24482

Verona

24483

Vesuvius

24484

Warm Springs

24485

West Augusta

24486

Weyers Cave

24487

Williamsville

24555

Glasgow

24578

Natural Bridge

24579

Natural Bridge Station