Plain Language Summary of Charity Care and Financial Assistance Policy

Overview

Flagler Hospital is committed to offering financial assistance to people who have health care needs and are not able to pay for care. You may be able to get financial assistance if you are not insured, underinsured, not eligible for a government program, do not qualify for governmental assistance (for example Medicare or Medicaid), or who are approved for Medicaid but the specific medically necessary service is considered non-covered by Medical Assistance. Flagler Hospital strives to make sure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. This is a summary of the Flagler Hospital’s Charity Care and Financial Assistance Policy.

Availability of Financial Assistance

You may be able to get financial assistance if you do not have insurance, are underinsured, or if it would be a financial hardship to pay in full the expected out of pocket expenses for services at Flagler Hospital. Please note that there are certain service exclusions that are not typically eligible for financial assistance, including, but not limited to transplants, cosmetic services and other services.

Eligibility Requirements

Financial assistance is generally determined by a sliding scale of total household income based on Federal Poverty Guidelines. When total household income is less than 200% of FPG, a 100% discount from gross charges will be applied. With respect to uninsured individuals, when the total household income between 201% and 300% of FPG, a 75% discount will be applied. When the total household income is between 301% and 400% of FPG, an 85% discount will be applied respectively.
With regard to balances after insurance payment (underinsured), when the total household income is less than 200% of FPG, a 100% discount from gross charges will be applied. Underinsured individuals with a total household income between 201% and 300% of FPG, a 25% discount from gross charges will be applied. When the total household income is between 301% and 400% of FPG, a 10% discount will be applied respectively. Otherwise, uninsured self-pay patients who do not qualify for financial assistance will be given an automatic discount of 50%.

Federal Poverty Guidelines Chart *Effective as of January 2016

Number of People in Your Family Unit
Below 200% of FPG May Qualify for Free Care
Over 200% but Below 400% of FPG May Qualify for Reduced Priced Care
1
$23,760
$23,760 - $47,520
2
$32,040
$32,040 - $64,080
3
$40,320
$40,320 - $80,640
4
$48,600
$48,600 - $97,200
5
$56,880
$56,880 - $113,760
6
$65,160
$65,160 - $130,320
7
$73,460
$73,460 - $146,920
8
$81,780
$81,780 - $163,560
More than 8
Add $8,320 (Per Person)

Eligibility Requirements - Continued

No person eligible for financial assistance under the FAP will be charged more for medically necessary care than amounts generally billed to individuals who have insurance covering such care (AGB). Flagler Hospital determines AGB based on all claims paid in full to Flagler Hospital by Medicare and private health insurers (including payments by Medicare beneficiaries or insured individuals themselves), over a 12-month period, divided by the associated gross charges for those claims. If an individual has sufficient insurance coverage or assets available to pay for care, he/she may be deemed ineligible for financial assistance. Please refer to the full policy for a complete explanation and details.

Where to Find Information

There are many ways to find information about the FAP application process, or get copies of the FAP or FAP application form. To apply for financial assistance you may:
  • Download the information online at flaglerhospital.org, key words financial assistance
  • Request the information in writing by mail or by visiting the Flagler Hospital Business Office at 2155 Old Moultrie Rd., Suite 103 St. Augustine, FL 32086
  • Request the information by calling (904) 819-4539

Availability of Translations

The Financial Assistance policy, application form, and the plain language summary are offered in English and Spanish. Flagler Hospital may elect to furnish translation aids, translation guides, or provide assistance through use of qualified bilingual interpreter by request. For information about Flagler Hospital’s Financial Assistance Program and translation services, please call a representative at (904) 819-4539.

How to Apply

The application process involves filling out the financial assistance form and submitting the form along with the supporting documents to Flagler Hospital for processing. You may also apply in person by visiting the Business Office at the address listed below. Financial assistance applications are to be submitted to the following office:
Business Office
2155 Old Moultrie Rd., Suite 103
St. Augustine, FL 32086
Requirement to Provide Estimates upon Written Request for All Patients - Florida Agency for Health Care Administration 395.301 (7) F.S.: A licensed facility not operated by the state shall notify each patient during admission and at discharge of his or her right to receive an itemized bill upon request, within seven days following the patient’s discharge or release from a licensed facility.
Requirement to Provide Estimates for the Uninsured - Florida Agency for Health Care Administration 395.301 (8) F.S.: Uninsured patients have a right to receive an estimate of charges prior to non-emergent services. Please consult with a Financial Counselor at (904) 819-4539 to help you with this request.