Financial Assistance Program Policy

Definitions

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): For hospitals, 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 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.