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Financial Assistance Program Policy

Revised: 02/22/2018


Policy Summary

The mission of the WellStar Health System (WellStar) is to create and deliver high quality healthcare services that improve the health and well-being of the individuals we serve. WellStar’s vision is to deliver world-class healthcare. To eliminate financial barriers for WellStar’s hospital patients with limited means to pay for medically necessary services provided in the hospital or in hospital outpatient facilities, WellStar provides various levels of financial assistance to eligible patients under its Financial Assistance Program (FAP) policy. This policy only covers qualifying hospital services and may include services already performed and billed.


How to Qualify for FAP

Step 1: Determine if household is within Federal Poverty Level (FPL) and FAP program guidelines.

WellStar provides a Minimum Charitable Allowance (MCA) for all uninsured individuals, equal to the difference between the charges for medically necessary services and the federally defined “Amounts Generally Billed (AGB)”.

Further additional levels of financial assistance are determined by both FPL and FAP policy guidelines. FPL is federally defined as the minimum amount of gross income (before taxes) that an individual or family needs for food, clothing, transportation, shelter and other necessities. WellStar considers individuals or families at 125 percent FPL or below have by its definition, limited means to pay for medically necessary hospital services, and as a result, provides for additional financial assistance above the MCA to these individuals, such that they will receive 100% free hospital care. For individuals or families between 126 percent and 200 percent of FPL, WellStar provides additional financial assistance up to 97% of the federally defined AGB. For individuals between 201 percent and up to the maximum 300 percent FPL, additional financial assistance maybe provided, dependent on their household income level and whether they meet the “Qualifying Assets” test.

Below, in the first column is Family Size in the FAP table, find the number that applies – from an individual living alone to the number of spouse, parents and their children under age 21 living in the same household. The number includes minor children living with a legal guardian. Then, match the total household income range listed on that line to establish a FAP category. Patients not FAP-eligible based on income guidelines alone may be able to receive financial assistance if necessary medical expenses have depleted the family’s income and resources (medical indigency). Also, WellStar or a third-party will try to assist patients in determining if sources of insurance or financial assistance are available through government-sponsored or other community benefit programs to help reduce healthcare costs.


Patient Guide to WellStar FAP - Household Income Less Than 300% FPL


Family
Size
125% or less FPG
Category 1
126% - 200%
Category 2
201% - 250%
Category 3
251% - 300%
Category 4
1
$0 - $15,175
$15,176 - $24,280
$24,281 - $30,350
$30,151 - $36,420
2
$0 - $20,575
$20,576 - $32,920
$32,921 -$41,150
$41,151 - $49,380
3
$0 - $25,975
$25,976 - $41,560
$41,561 - $51,950
$51,951 - $62,340
4
$0 - $31,375
$31,376 - $50,200
$50,201 - $62,750
$62,751 - $75,300
5
$0 - $36,775
$36,776 - $58,840
$58,841 - $73,550
$73,551 - $88,260
6
$0 - $42,175
$42,176 - $67,480
$67,481 - $84,350
$84,351 - $101,220
7
$0 - $47,575
$47,576 - $76,120
$76,121 - $95,150
$95,151 - $114,180
8
$0 - $52,975
$52,976 - $84,760
$84,761 - $105,950
$105,951 - $127,140
*
$5,400
$8,640
$10,800
$12,960

*For each additional family member, for family size over eight (8), there are incremental increases in salary range qualifiers for discounts.


Step 2: Complete a WellStar FAP application with supporting financial documentation.

To be considered for the FAP, uninsured or underinsured patients must complete an application and disclose any sources of insurance and/or means of payment to establish proof of need. A completed FAP application includes all required supporting documents such as bank statements, tax returns and other income verification information to help WellStar determine eligibility for full financial assistance (indigent care) or partial financial assistance(charity care).

Applications are available on our Policies, Privacy & Financial Help page and upon request at hospital and hospital outpatient facility registration and/or discharge areas. Applications may be submitted within 240 days following the service date or the first post-discharge statement. In the event an application is lacking required information, the patient will be notified in writing and given 30 days from the date of the notification to resubmit. FAP status is communicated within 30 days of receiving a completed application. If approved, the level of FAP is effective for 6 months. Patients will be responsible for paying any reduced amount remaining based upon FAP policy. For application assistance, WellStar financial counselors are available onsite or patients may call 470-245-9998. Please address completed applications and any other FAP-related correspondence to: WellStar SBO FAP Department, 805 Sandy Plains Road, Marietta, GA 30066.


Policy Statement

It is the WellStar Health System (WellStar) policy to provide medically necessary hospital care at no cost to qualified patients of WellStar, and to significantly discount medical care costs to others who cannot afford the full cost of hospital care, including but not limited to, those WellStar patients faced with financial hardship due to medical misfortune.

WellStar is committed to providing financial assistance to patients who have sought medically necessary care at WellStar hospitals but have limited or no means to pay for that care. Our Financial Assistance Program (FAP) refers to what is commonly known was Charity Care. WellStar follows the generally accepted accounting principles for the accounting of our charity care provided. WellStar will provide emergency hospital medical care to all individuals, regardless of their insurance coverage, their ability to pay for these services or their eligibility under this FAP.

It is also the policy and practice of WellStar to adhere to any and all applicable Federal, State, and Local laws and any contractual obligations which may be associated with the contents and subject matter contained in this document.

Allowable Medical Expenses: The total of family medical bills that if paid, would qualify as deductible medical expenses for Federal income tax purposes without regard to whether the expenses exceed the IRS-required threshold for taking the deduction. Paid and unpaid bills may be included.

Amounts Generally Billed (AGB): The amounts generally billed (AGB) is the amount charged for emergency and other medically necessary hospital care to individuals who have insurance covering such care. WellStar uses the “look-back”, or retrospective method of allowed amounts for all claims with a primary coverage through Medicare and commercial insurers, to determine AGB, which is allowed for by the Federal Government. This calculation is further explained in the procedure LD-24-02.

Amounts Generally Billed Percentage: Means the percentage derived by dividing the AGB by the applicable gross charges that a hospital facility uses for any emergency or other medically necessary hospital care it provides to an individual who is eligible for assistance under the WellStar FAP.

Amounts Generally Billed Implementation Period: Final regulations define that a hospital may to take up to 120 days after the end of the 12-month period used in calculating the AGB.

Application Period: A period of 240-days following the first post-discharge billing statement that was provided to an eligible FAP patient after individual care has been provided and the patient has left the service facility in which represents the regulatory time period for application submission.

Assest Statement: Is a summation net worth, excluding any possessions such as a car, house, or other valuables.

Award: The dollar amount, or discount off of charges which will be given, once it is determined that the patient/guarantor is deemed eligible for partial or full benefit. Please note that the award, if approved, will be granted for remaining balances after any payments have been received from any source. This “award” will, at a minimum, be sufficient such that the hospital will not charge any patient eligible for assistance, more than the amounts generally billed to individuals who had insurance covering such care.

Billed Charges: Charges for services by WellStar Health as published in the Charge Description Master (CDM).

Business Office: Department which is part of WellStar Health and is responsible for billing, collection and payment processing.

Charges: Total charges for any hospital inpatient stay or outpatient service, procedure, or group of services.

Charity Care: Patients or guarantors who qualify for free or discounted care based on the WellStar FAP and has income greater than 125% of the Federal Poverty Guideline (FPG).

Community: Community is defined geographically, by WellStar hospitals’ intersecting 90 percent catchment areas irrespective of county lines, and statistically, by the demographics and determinants of health reported in the WellStar Health System CHNA.

Community Health Needs Assessment (CHNA): Refers to a state, tribal, local, or territorial health assessment that identifies key health needs and issues through systematic, comprehensive data collection and analysis.

  • The current CHNA for Kennestone, Cobb, Paulding, Douglas and Windy Hill Hospitals’ can be located at www.wellstar.org/about-us/pages/default.aspx#chna.
  • The current CHNA for West Georgia medical Center can be located at http://www.wghealth.org/about-us/community-needs-assessment/.
  • The CHNA for Atlanta Medical Center (AMC), AMC South Campus, North Fulton, Sylvan Grove and Spalding hospitals’ will be completed in accordance with IRS regulations governing New, Newly Acquired or Newly Subject to Section 501(r) Hospital Facilities and is currently not available.


Discount: A discount off of total charges for individuals above and beyond those reductions covered by this FAP. These discounts may include prompt payment, packaged or bundled payment, selected services as defined and approved by WellStar which conclude with a patient responsibility amount of less that total billed charges.

Discounted Care: Medical bills which are sent by WellStar Health, and which receive a discount from the full, billed charges.

Extraordinary Collection Actions (ECA): Actions taken by a hospital against an individual related to obtaining payment of a bill for care that engage in a legal or judicial process unrelated to actions specifically excluded by the regulations, involve selling an individual’s debt to another party, the deferral or denial of (or the requirement of a payment before providing) medically necessary hospital care because of the individual’s non- payment of one or more bills for previously provided care, or involve reporting adverse information about an individual to consumer credit reporting agencies or credit bureaus (collectively, "credit agencies"). WellStar does not use ECA for those individuals qualifying under this FAP, unless any residual patient pay responsibility remain unpaid in compliance with WellStar’s Billing and Collection policy.

Family Unit: The Family Unit consists of individuals living alone; and spouses, parents and their children under age 21 living in the same household. A Family Unit may include minor children living with a legal guardian. The child, legal guardian, and the legal guardian’s Family Unit living in the same household may comprise a Family Unit.

Federal Income Tax Return: The form which is submitted to the IRS for purposes of reporting taxable income. The form must be a copy of the actual, signed and dated form submitted to the IRS.

Federal Poverty Guideline (FPG): Guidelines set by the Federal Government which establishes income levels for households living above or below defined poverty or subsistence annual incomes.

Financial Assistance Program (FAP): Commonly known as, Charity Care, a program which may prospectively and /or retroactively establish the qualification for reductions issued to the amount owed by a patient for the bills sent by WellStar Health under the authority of this FAP.

Financial Class: A technology term used for the purposes of associating specific payor categorization within a patient accounting system generally associated to a specific type or product of coverage used in the management and / or facilitation of account management.

Guarantor: A Guarantor is an individual whom signed the financial guarantee and/or individual who is financially responsible under the Laws of the State of Georgia or appropriate legal governing body.

Hospital: A facility that is required by a state to be licensed, registered or similarly recognized as a hospital as described in the Department of the Treasury; Internal Revenue Service; Section 501(c)(3) that operates one or more hospital facilities in accordance with Section 501(r)(2)(A)(i).

Household Income (HI): Income of all family members who reside in the same household as the patient, or in the household which the patient claims on their tax returns or other government documents as their home address.

ICTF Qualified: ICTF Qualified hospitals serve a “disproportionate number of low-income patients with special needs,” or serve “Medically Indigent” persons “with an income no greater than 200% of the Federal Poverty Guideline”(FPG). Qualified hospitals are required by law to operate a program under which Patients may receive “care without charge or at a reduced charge.”

Indigent Care: Family makes 125% of FPG or less.

Intelligent Software: Software applications which provide “presumptive eligibility for Charity” for hospital provided services.

IRC 501(r)(5): Is a Federal statute that requires a hospital to limit the amounts charged for emergency and other medically necessary hospital care that is provided to individuals eligible for assistance under the organization’s financial assistance policy to not more than the AGB to individuals who have insurance.

IRC 501(r)(6) Is a Federal statute that requires a hospital to forego ECA against an individual before the organization has made reasonable efforts to determine whether the individual is eligible for assistance under the hospital organization’s financial assistance policy.

Medically Necessary Care: Are Hospital services or supplies that the treating physician determines are needed for the diagnosis or treatment of a medical condition and meet the standards of good medical practice. Examples of hospital services not considered to be medically necessary hospital services include: hyperbaric services, cosmetic services*, dental surgery, tubal ligation*, vasectomy* and vaso-vasectomy*, retail pharmacy, laboratory outreach services and services deemed out of network by an individual’s insurance company*.

Further, Medically Necessary Care under this FAP does not include the professional fees charged by physicians and other providers for their services, even if those services were rendered at a WellStar hospital. In accordance with Georgia Health and Safety Code, emergency physicians who provide emergency hospital medical care and physicians not employed by WellStar, are required by law to provide discounts to uninsured patients or patients with high hospital medical costs who are at or below 300 percent of the FPG. Detailed policies for emergency physician discounts and physicians not employed by WellStar will be maintained by the individual physicians or their representative networks. A list of covered and non-covered providers is provided in Appendix A. Any additional questions related to covered and non-covered providers and services can be directed to the WellStar Business Office at 805 Sandy Plains Road, Marietta, GA 30066, Attention: SBO FAP Department.

[*If these services are rendered at a WellStar hospital due to emergent patient care or classified as medically necessary as deemed by a physician and in accordance with the definition provided previously in this FAP, then these services may qualify under this FAP, but will be determined on a case by case basis by the WellStar Business Office. WellStar operates in compliance is compliant with the Emergency Medical Treatment Active Labor Act (EMTALA) as outlined in the policies: PAS-01-800-01, EMTALA/COBRA Guidelines AMC-RI.280 Medical Treatment and Labor Act EMTALA, Patient Access Services - Financial Clearance Policy 8220-1(WGMC) and Emergency Department – Plan of Care Policy 6231-001 (WGMC).]

Minimum Charitable Allowance: For uninsured patients, this amount is that charity care discount that is arrived by taking 100% and subtracting the specified AGB Percentage from this amount, then multiplying this remaining percentage by the gross charges for services rendered.

Notification Period: A period of 120-days following the first post-discharge billing statement that was provided to an eligible CFA / FAP patient after individual care has been provided and the patient has left the service facility.

Out-of-Network: Hospital services are out-of-network if WellStar is not contracted with an individual’s insurance benefit plan.

Out-of-Pocket Costs: Costs which the patient pays for out of personal funds and/or income.

Patient: All inpatients and outpatients.

Payment Plan: Plan which sets a series of equal payments over an extended period of time to satisfy the patient- owed amounts of bills sent by WellStar.

Qualifying Assests: Monetary assets which are counted toward the patient‟s income in determining if the patient will meet the income eligibility for the program. For purposes of this Policy, “Qualifying Assets” will mean 50% of the patient‟s monetary assets in excess of $10,000, including cash, stocks, bonds, savings accounts or other bank accounts, but excluding IRS qualified retirement plans and deferred-compensation plans. Certain real property or tangible assets (primary residences, automobiles, etc.) will not be included in “Qualifying Assets;” however, additional residences in excess of a single primary residence will be included, as will recreational vehicles. “Qualifying Assets” will not include the principal amounts of funds contained within an IRS recognized retirement account, such as an IRA, 401K or 403B retirement accounts.

Qualifying Patient: Patient who meets the financial qualifications for the Community Financial Assistance program as defined in the WellStar Community Financial Assistance Policy and related Job Aides inclusive of Table I and / or Table II and has not been otherwise excluded through policy.

Third Party Insurance: An entity (corporation, company health plan trust, automobile med pay benefit, etc.) other than the patient which will pay all or a portion of the patient‟s medical bills

Under-Insured: Persons who have some level of insurance, but coverage is inadequate to resolve an average healthcare claim. Coverage may include but not be limited to auto accident, supplemental only, cancer only, and some personal indemnity policies. Under-insured classification does not apply to high deductible health plans as those plans relate to prompt payment or payment plan discounts.

Uninsured: Persons who do not have insurance of any kind, who have been verified as not being able to qualify for alternative payment sources such as crime victims, disability, Medicaid, or other third party liability such as third party injury cases where a hospital lien is filed. Note that patients must divulge all sources of primary, secondary, auto, liability, supplemental, and all alternative sources of insurance and means of payment before being considered for financial assistance under this FAP. WellStar will try to assist all uninsured patients in determining if previously unknown sources of insurance or assistance are available, prior to approving FAP applications.