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 resort.

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 and a 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.

Definitions

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

  • Catastrophic Charity: Financial assistance available to patients whose medical expenses exceed one-fourth (1/4) of their total household income.
  • Elective Services: Services that are not medically necessary but “desired” by the patient for other reasons beyond life threatening or debilitating in nature.
  • 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.
  • Financial Assistance: Reduction of patient’s account balance based on established criteria; discounted or free care granted pursuant to this policy.
  • Incomplete Application for Financial Assistance: An application that is missing requested information or documentation needed to process the application.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • Uninsured: Patients with no insurance or third-party assistance to help resolve their financial liability to healthcare providers.
  • 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.

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 Chief Medical Officer.
  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. Patients 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 and their spouses 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 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 debts, 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 an Application for Financial Assistance.
  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 assets 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 –

Augusta Health & Augusta Medical Group

01-12-2022 Financial Assistance Fee Schedule

HouseholdFPL100% (0 – 200%)60% (Not greater than 400%)60% (201% – 400%)
113,59027,18027,18154,360
218,31036,62036,62173,240
323,03046,06046,06192,120
427,75055,50055,501111,000
532,47064,94064,941129,880
637,19074,38074,381148,760
741,91083,82083,821167,640
846,63093,26093,261186,520
951,350102,700102,701205,400
1056,070112,140112,141224,280
1160,790121,580121,581243,160
1265,510131,020131,021262,040

AH Service Area

ZipcodeCityZipcodeCity
22812Bridgewater24440Greenville
22821Dayton24441Grottoes
22827Elkton24442Head Waters
22841Mount Crawford24445Hot Springs
22843Mount Solon24450Lexington
22920Afton24458McDowell
22932Crozet24459Middlebrook
22939Fishersville24460Millboro
22943Greenwood24463Staunton
22952Lyndhurst24464Montebello
22976Tyro24465Monterey
22980Waynesboro24467Mount Sidney
24401Staunton24469Fort Defiance
24402Staunton24472Raphine
24407Staunton24473Rockbridge Baths
24411Craigsville24476Steeles Tavern
24412Bacova24477Stuarts Draft
24413Blue Grass24479Swoope
24415Brownsburg24482Verona
24416Buena Vista24483Vesuvius
24421Churchville24484Warm Springs
24430Craigsville24485West Augusta
24431Crimora24486Weyers Cave
24432Deerfield24487Williamsville
24433Doe Hill24555Glasgow
24435Fairfield24578Natural Bridge
24437Fort Defiance24579
Natural Bridge Station
24439Goshen
  1. The financial assistance discount will be applied as follows:
  1. Augusta Health Services (Hospital Based)
    Uninsured patients who do not meet the criteria of this policy will receive an uninsured 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$100.00
100% financial assistance adjustment-100.00
Total balance due$ 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
100% financial assistance adjustment-100.00
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
  1. When determining patient eligibility, race, gender, age, sexual orientation, religious affiliation, or immigration 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).
  2. 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 provided 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 Application for Financial Assistance (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 Augusta Health Business Office.
    • Over the telephone by calling (540) 332-4600.
    • By mail, by sending a request to Augusta Health Business Office, 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 or 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 (3) months.
    • Proof of income for applicant (and spouse, if applicable), such as most recent pay stubs for the last three (3) months, unemployment compensation, alimony, child support, disability compensation, pensions, rental income, Supplement 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 patient, patient’s guarantor, or patient’s representative, will be notified of the decision, in writing.
  9. Financial Advocates are available to assist in the application process in person at the Augusta Health Business Office located at 189 Medical Center Circle, Fishersville, VA 22939, from 8:00 a.m. to 4:30 p.m., Monday through Friday, or by phone at (540) 332-4600.*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 (1/4) 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 an Application for Financial Assistance 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 / Charity 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 / Charity 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 / Charity Policy, Application for Financial Assistance, and Plan Language Summary of the Financial Assistance / Charity 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 Augusta Health 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 the Augusta Health Business Office, P. O. Box 1000, Fishersville, VA 22939.
    • To access the Financial Assistance / Charity Policy, the Plain Language Summary of the Financial Assistance / Charity Policy, or the Application for Financial Assistance, please use the following website address: 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 / Charity 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 Plain Language Summary) can be obtained within the facility and by mail.
    • Posting information about financial assistance (Including Policy, Application and Plain Language Summary) 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 (i.e., phone calls, face-to-face).
    • Ensuring designated staff members are knowledgeable of the Financial Assistance / Charity Policy and can answer patients’ questions or refer patients to the program.
    • Notifying local physician practices and representatives of the 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 Plain Language Summary of our Financial Assistance / Charity Policy to local physician offices and community agencies, including all Augusta Medical Group offices.
    • Inclusion of financial assistance information with billing statements 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 they include all information required.
    • A visit to each physician practice and registration point within the hospital to ensure each point of entry has access to the updated Financial Assistance / Charity Policy, as well as an updated Application for Financial Assistance, 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 reimbursement rates of the payers being used to calculate an average of “amounts generally billed” (AGB) does not fall below that of what a patient who qualifies for financial assistance is being billed.
  2. The Financial Assistance / Charity 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 an Application for Financial Assistance, 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 Application for Financial Assistance process. For 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 / Charity Policy and actions to be taken if an application is not submitted or the outstanding balance is not paid.
  5. Patient accounts granted presumptive eligibility will be reclassified under the Financial Assistance / Charity 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. Plain Language Summary

  1. In accordance with Section 501(r) charity requirements, below is considered the “Plain Language Summary” of the Augusta Health and Augusta Medical Group Financial Assistance / Charity 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 8:00 a.m. until 4:30 p.m. 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 / Charity Policy and/or Application for Financial Assistance, patients can:
    • Visit the website: https://www.augustahealth.com/business-office/financial-assistance
    • Visit the Augusta Health Business Office located at 189 Medical Center Circle, Fishersville, VA 22939
    • Send a request by mail to the Augusta Health Business Office, P. O. Box 1000, Fishersville, VA 22939.
    • Call the Augusta Health Business Office at (540) 332-4600.
  • Application for Financial Assistance
  • Plain Language Summary of the Financial Assistance / Charity Policy

References

None

Revision Notes

  • May 27, 2021 – Placed on new Policy Template.
  • June 22, 2021 – Minor typographical changes made.

Addendum A

Financial Assistance Application

Addendum B

Learn More