Charity Care and Financial Assistance Policy
Flagler Hospital is committed to providing charity care to persons who
have healthcare needs and are uninsured, underinsured, ineligible for
a government program, or otherwise unable to pay, for medically necessary
care based on their individual financial situation. Consistent with its
mission to deliver compassionate, high quality, affordable healthcare
services and to advocate for those who are poor and disenfranchised, Flagler
Hospital strives to ensure that the financial capacity of people who need
health care services does not prevent them from seeking or receiving care.
Flagler Hospital will provide, without discrimination, care for emergency
medical conditions to individuals regardless of their eligibility for
financial assistance or for government assistance.
Accordingly, this written policy:
Includes eligibility criteria for financial assistance – free and
discounted (partial charity) care.
Describes the basis for calculating amounts charged to patients eligible
for financial assistance under this policy.
Describes the method by which patients may apply for financial assistance.
Describes how the hospital will widely publicize the policy within the
community served by the hospital.
Limits the amounts that the hospital will charge for emergency or other
medically necessary care provided to individuals eligible for financial
assistance to the amount generally billed (received by) the hospital for
commercially insured or Medicare patients
Charity is not considered to be a substitute for personal responsibility.
Patients are expected to cooperate with Flagler Hospital’s procedures
for obtaining charity or other forms of payment or financial assistance,
and to contribute to the cost of their care based on their individual
ability to pay. Individuals with the financial capacity to purchase health
insurance shall be encouraged to do so, as a means of assuring access
to health care services, for their overall personal health, and for the
protection of their individual assets.
In order to manage its resources responsibly and to allow Flagler Hospital
to provide the appropriate level of assistance to the greatest number
of persons in need, the Board of Directors establishes the following guidelines
for the provision of patient charity.
For the purpose of this policy, the terms below are defined as follows:
Charity Care: Healthcare services that have been or will be provided but
are never expected to result in cash inflows. Charity care results from
a provider's policy to provide healthcare services free or at a discount
to individuals who meet the established criteria.
Family: Using the Census Bureau definition, a group of two or more people
who reside together and who are related by birth, marriage, or adoption.
According to Internal Revenue Service rules, if the patient claims someone
as a dependent on their income tax return, they may be considered a dependent
for purposes of the provision of financial assistance.
Family Income: Family Income is determined using the Census Bureau definition,
which uses the following income when computing federal poverty guidelines:
Includes earnings, unemployment compensation, workers’ compensation,
Social Security, Supplemental Security Income, public assistance, veterans’
payments, survivor benefits, pension or retirement income, interest, dividends,
rents, royalties, income from estates, trusts, educational assistance,
alimony, child support, assistance from outside the household, and other
Noncash benefits (such as food stamps and housing subsidies) do not count;
Determined on a before-tax basis;
Excludes capital gains or losses; and
If a person lives with a family, includes the income of all family members
(Non-relatives, such as housemates, do not count).
Patient: person receiving services, guarantor signing for financial responsibility
or the person supporting or acting on patient’s behalf.
Uninsured: The patient has no level of insurance or third party assistance to assist
with meeting his/her payment obligations.
Underinsured: The patient has some level of insurance or third-party assistance but still
has out-of-pocket expenses that exceed his/her financial abilities.
Gross charges: The total charges at the organization’s full established rates for
the provision of patient care services before deductions from revenue
Emergency medical conditions: Defined within the meaning of section 1867 of the Social Security Act (42
Medically necessary: As defined by Medicare (services or items reasonable and necessary for
the diagnosis or treatment of illness or injury).
A. Services Eligible Under This Policy: For purposes of this policy,
For purposes of this policy, “charity” or “financial
assistance” refers to healthcare services provided by Flagler Hospital
without charge or at a discount to qualifying patients. The following
healthcare services are eligible for charity.
Emergency medical services provided in an emergency room setting.
Services for a condition which, if not promptly treated, would lead to
an adverse change in the health status of an individual.
Non-elective services provided in response to life-threatening circumstances
in a non-emergency room setting; and
Medically necessary services, evaluated on a case-by-case basis at Flagler
B. Eligibility for Charity:
Eligibility for charity will be considered for those individuals who are
uninsured, underinsured, ineligible for any government health care benefit
program, and who are unable to pay for their care, based upon a determination
of financial need in accordance with this policy. The granting of charity
shall be based on an individualized determination of financial need, and
shall not take into account age, gender, race, social or immigrant status,
sexual orientation or religious affiliation.
[Flagler Hospital will also determine any charity assistance when a patient
is in litigation or has a pending settlement. If a patient fails to cooperate
or provide all requested documents once again it will be up to Flagler
Hospital’s discretion to determine any charity assistance.]
Method by Which Patients May Apply for Charity Care:
Financial need will be determined in accordance with procedures that involve
an individual assessment of financial need; and may:
Include an application process, in which the patient, the patient’s
guarantor or supporting person/persons are required to cooperate and supply
personal, financial and other information and documentation relevant to
making a determination of financial need (such as but not limited to tax
returns, bank statements, proof of assets etc…)
Include the use of external publically available data sources that provide
information on a patient’s or a patient’s guarantor’s
ability to pay (such as but not limited to credit scoring, tax and property
Include reasonable efforts by Flagler Hospital to explore appropriate alternative
sources of payment and coverage from public and private payment programs,
and to assist patients to apply for such programs;
Take into account the patient’s available assets, and all other financial
resources available to the patient; and
Include a review of the patient’s outstanding accounts receivable
for prior services rendered and the patient’s payment history.
Patients will be asked to certify all information provided is true. If
any information is determined to be false or the patient fails to cooperate
with any alternative source of payment all discounts afforded to the patient
may be revoked, making the patient or patient’s guarantor responsible
for the full charges for services rendered.
It is preferred but not required that a request for charity and a determination
of financial need occur prior to rendering of non-emergent medically necessary
services. However, the determination may be done at any point in the collection
cycle. If the last financial evaluation occurred within the past 30 days
prior to a subsequent time of service that financial evaluation will suffice
as proof in determining financial assistance for that subsequent service.
Flagler Hospital’s values of human dignity and stewardship shall
be reflected in the application process, financial need determination
and granting of charity. Requests for charity shall be processed promptly
and Flagler Hospital will provide a letter of charity approval at the
patient’s request. If the patient complies with all application
requirements and is found not eligible for charity Flagler Hospital will
mail the patient a charity denial letter and list the reason for the denial.
Each charity application will be reviewed and signed off by the Business
Office Supervisor. If charity eligibility is determined and the financial
assistance adjustment is applied to the patient’s account, Flagler
Hospital’s Director of Patient Financial Services will review each
collective batch of accounts and adjustments and then sign off on the
top of the batch page indicating review and approval. A summary sheet
of the monthly charity write-off totals will be forwarded to the CFO for
notification and review. These actions will suffice that all requirements
under this policy have been met.
D. Presumptive Financial Assistance Eligibility.
There are instances when a patient may appear eligible for charity care
discounts, but there is no financial assistance form on file due to a
lack of supporting documentation. Often there is adequate information
provided by the patient or through other sources, which could provide
sufficient evidence to provide the patient with charity care assistance.
In the event there is no evidence to support a patient’s eligibility
for charity care, Flagler Hospital may use outside agencies in determining
estimate income amounts for the basis of determining charity care eligibility
and potential discount amounts. Once determined, due to the inherent nature
of the circumstances, the only discount that can be granted is a 100%
write off of the account balance. Presumptive eligibility may be determined
on the basis of individual life circumstances that may include:
State-funded prescription programs;
Homeless or receives care from a homeless clinic;
Participation in Women, Infants and Children programs (WIC);
Food stamp eligibility;
Subsidized school lunch program eligibility;
Eligibility for other state or local assistance programs that are unfunded
(e.g., Medicaid spend-down, Medicaid exhausted benefits, Medicaid SLMB and QMB);
Low income/subsidized housing is provided as a valid address; and
Patient is deceased with no known estate.
Additionally, Flagler Hospital has contracted with a Third Party Vendor
who will also be utilized to identify potential Presumptive Charity accounts
utilizing their own proprietary scoring system. Vendor will send a series
of statements/letters for a 120 day timeframe as part of its standard
collection practices. All true self-pay accounts will be reviewed and
scored. The accounts that are deemed to be Presumptive Charity will be
identified via this process. Presumptive Charity accounts will be identified
separately by the vendor on the monthly close/return report that is received
by the hospital. These particular accounts will then be adjusted off to
charity (using a specific presumptive charity adjustment code) rather
than sending to a primary bad debt collection agency.
All patient payments received before the account was deemed eligible for
presumptive charity will be refunded for that episode of care.
E. Eligibility Criteria and Amounts Charged to Patients:
Services eligible under this Policy will be made available to the patient
on a sliding fee scale, in accordance with financial need, as determined
in reference to Federal Poverty Levels (FPL) in effect at the time of
Following a determination of financial-assistance eligibility, an individual
will not be charged more than the amounts generally billed (AGB) for emergency
or other medical care provided to individuals with insurance covering
At Flagler Hospital the AGB is determined through the “Look-back
method” which is calculated as follows:
The AGB is calculated by reviewing all past claims that have been paid
in full to the hospital facility for medically necessary care by Medicare
fee-for-service together with all private health insurers paying claims
to the hospital in a prior 12-month period. This amount can include co-insurance;
copayments and deductibles.
The AGB for emergency or medically necessary care provided to a financial
assistance-eligible individual is determined by multiplying gross charges
for that care by one or more percentages of gross charges (called "AGB
The percentages are calculated at least annually by dividing the sum of
certain claims paid to the hospital facility by the sum of the associated
gross charges for those claims.
Multiple AGB percentages may be calculated for separate categories of care
(for example, in-patient verses out-patient care; or care provided by
different departments) or for separate items or services.
Patients who do not have insurance coverage will be given an automatic
discount of 50% off of total charges. In special cases, a larger discount
may be granted. See “Section F” below which contains the patient
discount matrix. Discounted balance amounts need to be paid timely and
in accordance with any established payment plan guidelines. Failure to
pay on amounts owed may result in the account being sent to a primary
collection agency. Patients will receive billing statements reflecting
the discounted amount.
Patients whose family income is at or below 200% of the FPL are eligible
to receive free medical care, including mental health services.
Patients whose family income is above 201% but not more than 400% of the
FPL are eligible to receive services in accordance with the Discount Matrix
below. Patients who qualify for financial assistance under this policy
will be billed amounts no greater than the amounts generally billed to
(received by the hospital for) commercially insured or Medicare patients
for their medical and mental health care.
Additionally, patients may be eligible to receive discounted rates for
medical and mental health care on a case-by-case basis based on their
specific circumstances, such as catastrophic illness or medical indigence,
at the discretion of Flagler Hospital. To be approved by the CFO and Patient
Financial Services Director.
If Flagler Hospital determines that a patient qualifies for free care but
may be eligible for another alternative pay source/coverage, the patient
will be asked to fully cooperate in the process and resolution of that
alternative pay source/coverage. During the determination period a discount
of 85% will be applied to the account, if alternative pay source\coverage
is received the adjustment will be reversed for payment. If the patient
is not cooperative in the financial process and the resolution of the
alternative pay source/coverage, Flagler Hospital will determine if there
will be any additional financial reduction on the account and also the
specific amount of that reduction.
After the application process and submission of
all requested and complete
proof of income and assets, the attached matrix will be followed for the appropriate adjustment amount.
F. Flagler Hospital – Medical Patient Discount Matrix
(Balance After Insurance)
Up to 200% FPL
201% ‐ 300%
301% ‐ 400%
50% Automatic Self Pay
FLAGLER HOSPITAL – MENTAL HEALTH DISCOUNT MATRIX:
*Same as Medical Patient Discount Matrix
FINANCIAL ASSISTANCE SLIDING F.P.L. SCALE:
*See attached Federal Poverty Income Guidelines and Flagler Hospital Matrix
G. Communication of the Charity Program to Patients and Within the Community:
Notification about charity available from Flagler Hospital, which shall
include a contact number, shall be disseminated by Flagler Hospital by
various means, which may include, but are not limited to, the publication
of notices in patient bills and by posting notices in emergency rooms,
in the Conditions of Admission form, admitting and registration departments,
and the patient financial services office that is located off of the facility
campus, and at other public places as Flagler Hospital may elect.
Flagler Hospital shall also publish a summary of this charity care policy
on facility websites, in brochures available in patient access sites and
at other places within the community served by the hospital as Flagler
Hospital may elect. Such notices and summary information shall be provided
in the primary languages spoken by the population serviced by Flagler Hospital.
Referral of patients for charity may be made by any member of the Flagler
Hospital staff or medical staff, including physicians, nurses, financial
counselors, social workers, case managers, chaplains, and religious sponsors.
A request for charity may be made by the patient or a family member, close
friend, or associate of the patient, subject to applicable privacy laws.
Relationship to Collection Policies:
Flagler Hospital management shall develop policies and procedures for internal
and external collection practices (including actions the hospital may
take in the event of non-payment, including collections action and reporting
to credit agencies) that take into account the extent to which the patient
qualifies for charity, a patient’s good faith effort to apply for
a governmental program or for charity from Flagler Hospital, and a patient’s
good faith effort to comply with his or her payment agreements with Flagler Hospital.
For patients who qualify for charity and who are cooperating in good faith
to resolve their discounted hospital bills, Flagler Hospital may offer
extended payment plans, will not send unpaid bills to outside collection
agencies, and will cease all collection efforts.
A collection agency may be used to obtain payment. Flagler Hospital currently
uses outside vendors to attempt the collection of self-pay balances. You
will be contacted three times (via billing statements) during a 120-day
period reminding you of your bill(s). During this period, you will be
expected to pay your bill(s) in full, establish a payment plan or apply
for financial assistance
If the balance is unpaid after the 120-day period or a payment plan has
not been established, your account will be sent to a collection agency.
Your credit may be impacted if the balance is not resolved 60 days after
collection agency placement.
Flagler Hospital will not impose extraordinary collections actions such
as wage garnishments; liens on primary residences, or other legal actions
for any patient without first making reasonable efforts to determine whether
that patient is eligible for charity care under this financial assistance
policy. Reasonable efforts shall include:
a. Validating that the patient owes the unpaid bills and that all sources
of third-party payment have been identified and billed by the hospital;
b. Documentation that Flagler Hospital has or has attempted to offer the
patient the opportunity to apply for charity care pursuant to this policy
and that the patient has not complied with the hospital’s application
c. Documentation that the patient does not qualify for financial assistance
on a presumptive basis;
d. Documentation that the patient has been offered a payment plan but has
not honored the terms of that plan.
I. Regulatory Requirements:
In implementing this Policy, Flagler Hospital shall comply with all other
federal, state, and local laws, rules, and regulations that may apply
to activities conducted pursuant to this Policy.