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Effective Date: March 31, 2020
The purpose of this FAP is to set forth a fair and equitable process for providing financial assistance for emergency and medically necessary hospital care provided at Wellstar to patients who are uninsured or have limited or no means to pay for their care.
It is Wellstar's 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 as 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.
Certain services provided at a Wellstar hospital by a physician, physician assistant, nurse anesthetist or other professionals employed by Wellstar or otherwise part of a Wellstar Hospital medical staff, are not covered under this Wellstar FAP. Specifically, services provided in the departments/providers listed in Job Aid 5, Appendix A, are not covered by this FAP.
Financial Assistance eligibility will be extended to Qualifying Patients who receive emergency and Medically Necessary Care. Other medical services rendered by and at Wellstar may be reviewed on a case-by-case basis after the appropriate approval process.
The Wellstar Financial Assistance Program is intended to assist patients in paying for necessary healthcare services. Wellstar establishes Indigent, Charity, and Discount programs which meet State Health Planning Agency Requirements. Annually, Wellstar completes the State Health Planning Survey, which reports all Wellstar Indigent/Charity activity to the state. OCH requires that Wellstar complies with the following:
The Department of Community Health (DCH) Medical Assistance program allows hospitals to "coordinate" their ICTF program with an existing program of care for the Medically Indigent provided that no patients are rendered ineligible for services without charge or at a reduced charge who would have been eligible if the variance had not been granted.
To determine indigent or financial assistance (charity care) status, Wellstar may use a full and complete FAP application, review credit reports, other publicly available information to evaluate patient/guarantor income and assets, use an automated system or technology, executive administrative evaluation, or internally available information to determine eligibility. If a patient/guarantor does not apply for Financial Assistance under this FAP, or we are not otherwise informed of one's eligibility, normal collection activities will ensue which may include up to the use of ECAs. Wellstar may, at its sole discretion, elect to utilize automation or technology to determine probable eligibility, prior to any account going to bad debt or during the application and/or notification periods as defined above. The level of automation logic currently in use at Wellstar varies based on the specific configurations for each hospital patient accounting system and is subject to change. In general, the use of technology and proprietary information available allows for the determination of a modeled assessment to reasonably determine financial capability, financial need or payment ability and is evaluated through the use of a consistently applied algorithm that is proprietary in nature by the service provider. The output of the evaluation for these types of services is provided as a gradient measure such as an alpha, numeric or color score with a defined scale providing a low, medium, high and unable to determine assessment outcome. This evaluation is commonly referred to throughout the healthcare industry as Propensity to Pay (P2P) scoring. Wellstar Health has determined that a low ability and low propensity to pay, with a medical credit score of less than 600 (indicated in the system as a color (red), represents probable evidence that the patient qualifies for Indigent Care. Wellstar may seek further information to qualify the patient, however, further qualification or proof is not required under the FAP.
Other special circumstances may qualify a patient for full Indigent or sliding scale discounts at the discretion of the Wellstar. Special circumstances may include but are not limited to:
Wellstar provides notice of the availability of Financial Assistance Program via:
In addition, Wellstar will provide notice of the FAP, and FAP Application to community stakeholders who participated in the CHNA.
Language translations of the FAP, Plain Language Summary and FAP Application, at a minimum will be provided for those languages which have been determined to meet the 5-percent/1000-person threshold under the HHS Safe Harbor as reasonably determined by Wellstar.
In certain situations, Wellstar may utilize third-party assistance to help identify and/or assist patients that qualify for financial assistance based on publicly or privately available programs. Examples of such programs include but are not limited to:
A patient may qualify for financial assistance under this FAP if they meet one of the following guidelines based on income or expenses and they are not eligible for other private or public health coverage so long as the patient has complied with the requirements of the policy governing Wellstar financial assistance, this FAP.
A patient is eligible to receive a Minimum Charitable Allowance under this FAP.
In addition to the Minimum Charitable Allowance, patients may be eligible for additional charitable allowances, under this FAP, based upon household income and in certain situations, if qualifying assets do not exceed an amount equal to 200% of their billed charges for services rendered. For purposes of this policy, "Qualifying Assets" will:
Patients not eligible for additional charitable allowances, based on assets may be eligible for financial assistance through an exception-based review if their allowable medical expenses have depleted the family's resources so that they are unable to pay for eligible services (Medical lndigency).
Exception-based discounts may be issued on a sliding scale from 0-100% at the discretion of Wellstar. The following two qualifications must both apply:
If the patient has third party insurance which would have covered the qualifying services, the patient is responsible for complying with the conditions of coverage for their third party insurance. Failure to do so, when the patient could have reasonably complied, may result in a denial of eligibility under this Financial Assistance Program.
Patient cooperation with Wellstar is necessary in identifying and determining alternative sources of payment or coverage from public and private payment programs. As such, a patient (or his or her guardian or family member) must provide any or all of the following that are applicable, when requested.
Provide two of the following if unable to provide a copy of the most recent Federal Income Tax Return or as further requested by Wellstar in the course of the application or application verification process:
The patient/guarantor is expected to pay any amount of their account that is not eligible for write-off under this FAP. Failure to do so may result in a reversal of any Financial Assistance Program discounts. Those who fail to pay the remaining balance after adjusting the bill for Financial Assistance will become delinquent and be subject to normal collection procedures.
However, in no event will the charges for a FAP eligible patient exceed the specific AGB as defined by Wellstar FAP and related procedures.
Please refer to Wellstar's SBO Collections and Bad Debt Procedure for an explanation of expectations regarding payment of out of pocket responsibility. Please refer to Wellstar's Charity Care Eligibility and Financial Assistance Table I & II.
All uninsured patients are entitled to the Minimum Charitable Allowance (MCA), as defined in this policy.
Further charitable allowances are provided to individuals who meet the following Household Income (HI) guidelines.
Patient Payment Responsibility
Still, further charitable allowances are again provided to individuals who meet the Qualifying Assets test noted above and the following Household Income (HI) guidelines.
Patient Payment Responsibility*
* For patients with insurance coverage, the patient pay responsibility will be the insurance co-pay, co-insurance and deductible, subject to further possible charitable allowances based upon Medical lndigency, capped in all cases at a percentage of gross charges, up to the AGB.
Any federal government or state government programs where a discount is given due to patient care via Medicare, Medicaid, pending Medicaid application vendors, DFCS, county health programs, city programs or ordinances, or any other government program, provided at Wellstar will be considered by the FAP department for the remaining self-pay balance. Patients must still follow all FAP procedures, must fill out a FAP application when requested, must qualify under the FAP guidelines, and provide all necessary documentation as requested by Wellstar under this Financial Assistance Policy.
All patient self-pay balances after any other non FAP discounts are eligible to apply for financial assistance under this FAP. However, any patients who choose to utilize Wellstar's Cash-Pay Rate or "Pay in Full Option" options are not eligible for the Wellstar FAP.
If a patient qualifies for financial assistance under this FAP for a specific service or hospital stay, an applicable retroactive Financial Assistance Program write-off will be applied to all patient balances for any services up to six (6) months prior to the application approval date. Other balances may be considered at the discretion of Business Office staff/management. FAP approval is valid for six (6) months from application approval date for future qualified services.
In the event a patient or any member of the patient's immediate family pays all or part of his or her bill for services rendered, and that payment is specifically identified for the service which is subsequently determined to qualify for free or discounted care under this policy, Wellstar will provide refunds to the individual who issued the payment that resulted in a patient payment amount made in excess of the amount the individual is personally responsible for paying based upon AGB.
In the event any patient believes their application for Financial Assistance Program was not properly considered in accordance with this FAP, or they otherwise disagrees with the application of this FAP in their case, a patient may submit a written request for reconsideration to the Vice President, Revenue Cycle, and then to the Chief Financial Officer of Wellstar, who will be the final level of appeal.
Any decisions made under this policy, including the decision to grant or deny financial assistance under this FAP, will be based on an individualized determination of financial need, and will not take into account race, color, national origin, citizenship, religion, creed, gender, sexual preference, age, or disability.
Financial Counselors, upon discovery of the patient's financial circumstances during the patient interview, will advise the patient of the Financial Assistance Program and the availability of financial assistance under this policy.
Patients will be informed of available assistance through a standard message placed on the patient's bill, as well as through a handout available at the hospitals', through the Business Office and/or through the Wellstar website.
The Financial Assistance Program's availability and referral numbers will be placed within any notification on Wellstar's website, the patient's bill, or the available handout.
Notice of availability of financial assistance and instructions for patient screening will be posted in the emergency rooms, and the main registration departments of the Wellstar hospitals, as well as in the offsite business office and other outpatient sites, as appropriate.
Patient, or a patient's guardian or legal conservator, may apply under this FAP by calling the Wellstar Single Billing Office and requesting an application at the Wellstar Financial Assistance Program website or from a Wellstar financial representative.
If assistance is needed, with the application, please contact:
A patient may apply for multiple outstanding balances on the same application. Financial Assistance Program applications may be submitted within 240 days following the patient's date of service and/or post-
Wellstar will review Financial Assistance Program applications bi-weekly upon receipt for approval. Balances approved will be submitted for write-off to a transaction code assigned to Financial Assistance Program and will follow the signature authority of the Wellstar adjustment approval guidelines. In the event the application is lacking the required information, patient will be notified in writing and be given 30 days to provide the additional information.
Any recoveries to an account which has qualified and was classified under an originating transaction other than charity will have the amount of the recovery or adjustment reversed so that appropriate amounts are reconciled with the Financial Assistance Program. Recording of Financial Assistance Program adjustment codes will be used to ensure the diminished Charity Care is reflected properly in the accounting records.
On an individual patient basis, the staff or management member of the Wellstar Business Office may complete an internal Financial Assistance Program Application to include a full explanation of:
The enrollment, participation or referral from a program, provider or clinic which has substantially similar approval criteria to that of the Wellstar's FAP and has been approved by Wellstar.
Provided through direct education from customer service representatives and self-pay vendor representatives in response to patient phone calls. All patient contact is logged electronically.
As the result of the harmonization to the Epic Electronic Medical Record for all discharges on or after February 25, 2018 all Wellstar facilities use the same AGB percentage.
For dates of discharge prior to February 25, 2018 the AGB percentage is determined by the facility location, as indicated below:
Details of the procedures used in the calculation of the AGB percentage are defined in the Calculation of Amounts Generally Billed (AGB) and is available by request to Wellstar Business Office between the hours of 8:00 AM and 4:30 PM, Monday through Friday at (678) 838-5750.
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 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 take up 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.
Asset 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 only for remaining balances after any payments have been received from third parties. This "award" will, at a minimum, be sufficient such that the hospital will not charge any patient eligible for assistance, more than the AGB. This is otherwise known as the Minimum Charitable Allowance.
Billed Charges: Charges for services by Wellstar as published in the Charge Description Master (CDM).
Business Office: Department which is part of Wellstar 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% 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.
View the current Wellstar CHNA
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 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 or reporting method 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 (FPC): 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 Care: 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 125% of the FPG. Qualified hospitals are required by law to operate a program under which patients may receive "care without charge", otherwise referred to as ICTF Qualified Care or Indigent Care.
Indigent Care: Medically necessary hospital care provided to a family whose household income is 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% 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-l (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 hospital 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 Assets: 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 the patient's monetary assets, including cash, stocks, bonds, commodities, cash investment equivalents, savings accounts or other bank accounts, but excluding IRS qualified retirement plans and deferred-compensation plans. Certain real property or tangible assets (primary residences, principle automobiles, etc.) will not be included in "Qualifying Assets;" however, additional residences in excess of a single primary residence, automobiles in excess of the principle automobile and recreational vehicles will be included. "Qualifying Assets" will not include the principal amounts of funds contained within an IRS recognized retirement account, such as an IRA, 401k or403b 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. Including any settlement or proceeds received from an entity although paid directly by the patient, the patient's representative or third-party administrator.
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.
This replaces all previous Financial Assistance Program (FAP) Policies & Procedures and all previous versions shall automatically terminate upon the effective date set forth above.