EFFECTIVE DATE: January 24, 2018


Purpose: To provide finanCial assistance for emergency and medically necessary healthcare services received
I as an inpatient or outpatient from GWCH in a fair, consistent, respectful, and objective manner to indigent, 5 medically indigent, uninsured or underinsured patients.


  1. The Financial Assistance Program (F AP) employs a sliding scale discount that takes into consideration a patient’s household income and number of occupants.
  2. Eligible patients are people who have received emergency and medically necessary services, and are indigent, medically indigent, uninsured or underinsured. The patient’s household income (as defined below) 5 must be less than 200% of the Federal Poverty Level (FPL) to qualify for financial assistance discounts.
  3. Financial Assistance determination will be consistent among patients, regardless of sex, race, creed, disability, sexual orientation, national origin, immigration status, or religious preference.
  4. Financial Assistance is secondary to all other financial resources available to the patient, including ~ employer-based insurance coverage, commercial insurance, government program, and third-party liability.



The following measures are used to publicize the Program to the community and patients:

  • Posting the Financial Assistance Program, Financial Assistance Application and a summary of the Policy on the GWCH website at the following location: wwwgwchorg
  • Providing paper copies of the Program, application and summary of the Program upon request in the GWCH Billing Office.
  • Posting notices about the Program in the admitting areas.
  • Informing patients about the Program in person or during billing and customer service phone contacts.
  • Articles in local newspapers as well as local PSA’S as appropriate through current media outlets.



  1. All qualifying applicants will be granted Financial Assistance for medically necessary services in accordance with the qualifications and guidelines set forth.
  2. An application for financial assistance can be obtained by a patient in as follows:
    • In person at admissions
    • Upon Discharge from GWCH
    • In the GWCH Business Office after the date of service
    • Over the phone by calling (620) 5 83-745 1
    • Through the mail at 100 W. 16th Street, Eureka, KS, 67045.


  3. The application process includes completion of a Financial Assistance Application and providing verification documents. verifiable information may include, but is not limited to the following:
    • a.) Individual or family income (income tax return with copies of earnings, statements -W-2 forms, 1099 forms, etc.)
    • b.) Copies of the most recent 90 days of payroll stubs, Social Security Checks, or unemployment checks. 0.) C0pies of the most recent 60 days of bank statements.
    • d.) Current trust fund statements
    • e.) In the absence of income, a letter of support from individuals providing for the patient’s basic living needs.
    • f.) Documentation of employment status
    • g.) Household family size
    • h.) Denial letter from Medicaid
    • i.) Previous or current returns from collection agencies with documentation regarding inability to pay
    • j.) Business Office knowledge of individual or family background
    • k.) Business Office previous experiences

    NOTE: The object of requiring this documentation is to document the need for financial assistance. If a patient or the person who has financial responsibility for emergency and medically necessary services is unwilling or unable to provide all necessary and pertinent information to make a conscientious and fair determination of their financial net work worth; financial assistance WILL NOT BE GRANTED.

  4. Once the application has been completed and the required documentation has been assembled, the patient or the person who has financial responsibility will need to bring everything to the GWCH Business Office. At that time, an appointment will need to be set up with a Business Office representative to review the application packet. Financial documents will be reviewed with the patient or the financial representative along with existing insurance, the status of Medicaid applications, and the discussion of entering into a contract payment plan. The contract payment plan will need to be completed at the time of this meeting regardless of if the ‘ i application for the PAP is approved. Once the meeting is held, the account will then be considered for Financial Assistance.
  5. Once the application for PAP and the required Business Office Meeting has been held, the account will be put in “hold” status while the application is being reviewed (no longer than 30 days). The hold status will prevent account(s) from proceeding through the collection process, including assignment to a collection agency.
  6. Once the Financial Assistance application has been processed and approved/denied, the Hospital will send written notice to the patient and/or person having financial responsibility for the account(s).
  7. The application and the required Business Office meeting must be completed within 180 days from the date GWCH provides the patient with the first billing statement for patient services.
  8. Should a patient’s account be transferred to a collection agency and subsequently a completed financial ! assistance application is received and approved and the mandatory Business Office Meeting completed, the Hospital will:
    • a.) Suspend all extraordinary collection actions (ECA)
    • b.) Make and document a determination regarding qualification
    • c.) Notify the individual in writing of the eligibility determination and the basis of the determination (including the assistance for which the individual is eligible.)
  9. If the Hospital determines an individual is eligible for an FAP discount the Hospital will do the following:
    • a.) Send a letter detailing the current balance, the sliding fee discount applied, the balance going forward, the agreed upon payment plan that was determined during the meeting with the Business Office, and estimated pay off date.
    • b.) If the patient or guarantor has made payments to the hospital facility (or any other party) for the care in excess of the amount he or she is determined to owe as an FAP eligible individual, refunds those excess payments.
    • c.) Takes all reasonable available measures to reverse an ECA taken against the individual to collect the debt.
    • d.) The HOSpital Business Office will continue to work with the patient or guarantor to resolve remaining account balances. If a patient needs to change the previously agreed upon Contract Payment plan, then the Business Office will need to be contacted.
    • e.) If there is a remaining balance after the PAP discount is applied and the patient or guarantor does not make any payments, the account will be eligible to be sent to collections.
    • f.) If the patient or guarantor fails to initiate or complete the Financial Assistance process, the Hospital may elect to begin collection activity, including possible transfer of the account(s) to a collection agency.



  1. Financial Assistance discounts are determined based on a sliding-fee scale and are subject to income and household occupancy. To obtain Financial Assistance, the patient or guarantor must establish that the household income is below 200% of the most recent Federal Poverty Level (FPL) at the date of service.
  2. Allowances may be made for extenuating circumstances based on each person’s unique life circumstances and mitigating factors.
  3. “Household Income” includes all pre-tax income, however derived, for all persons 18 years old and over who reside in the household.
  4. Incomplete Financial Assistance applications, or undocumented information within the application, may cause the Hospital to deny the assistance until the completed application or documentation is provided. Not scheduling and completing the required Business Office meeting will also result in a denial of assistance. The Hospital will retain the incomplete application and send written documentation outlining the information needed, and instructions on submitting the necessary paperwork.
  5. The Hospital’s Business Office Manager or his/her designee will process the Financial Assistance application, schedule the required meeting, and determine the appropriate discount.
  6. The Hospital’s Business Office will send a written notice of determination to the patient or guarantor within30 days of receiving the completed application (including all required documentation).
  7. Patients or their representatives can appeal a denial of Financial Assistance by providing additional information regarding eligibility determination or an explanation of extenuating circumstances, to the Business Office Manager of the Hospital within 30 days of receiving the written denial notificatiOn. The party making the appeal will be notified in writing of the final decision made by the Business Office Manager and Administrator.



  • 1. Approval and authorization of Financial Assistance discounts will be based on the following:
  • a.) $0 – $5,000: Business Office Manager
  • b.) $5,000 or higher: Member of Administration Team and Business Office Manager ~
  • f.) If the patient or guarantor fails to initiate or complete the Financial Assistance process, the Hospital may elect to begin collection activity, including possible transfer of the account(s) to a collection agency.



  1. Federal Poverty Level (FPL): Poverty thresholds that are issued each year in the Federal Register by the Department of Health and Human Services (HHS).
  2. Guarantor: Refers to person financially responsible for patient’s account balance(s).
  3. Indigent: Refers to patient that has no financial resources to pay obligation.
  4. Medically Indigent: Refers to situation were payment of obligation will create financial hardship.
  5. Medically Necessary Services: Refers to inpatient or outpatient healthcare services provided for the purpose of evaluation, diagnosis, and/or treatment of an injury, illness, disease or its symptoms, which if left untested, would pose a threat to the patients ongoing health status.