Purpose: To provide financial assistance for emergency and medically necessary healthcare services received as an inpatient or outpatient from the Hospital in a fair, consistent, respectful and objective manner to indigent, medically indigent, uninsured or underinsured patients. This policy contains GPHA recommendations. Effective October 16, 2013

  2. The Financial Assistance Program employs a sliding scale discount that takes into consideration a patient’s household income and qualifying assets. (See Appendix A)
  3. 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) must be less than 300% of the Federal Poverty Level (FPL) to qualify for financial assistance discounts. Financial assistance discounts are subject to the limitations on Qualified Assets described in section E.5 and E.6.
  4. Financial Assistance determination will be consistent among patients, regardless of sex, race, creed, disability, sexual orientation, national origin, immigration status or religious preference.
  5. Financial Assistance is secondary to all other financial resources available to the patient including employer-based insurance coverage, commercial insurance, government programs, third-party liability and household qualified assets.
  7. In the case of emergency or other medically necessary care, a patient who is eligible for assistance under this Program will not be charged more than the amounts generally billed (AGB) for third party fee-for-service beneficiaries(individuals who have third party insurance for care). This discount is determined utilizing the look back method after the Medicare Cost report have been completed five months after the fiscal year and final settlements are added to fiscal year data for all third party fee-for-service collections to determine the AGB. The new AGB will be applied effective the first day of the seventh month after the end of the fiscal year-end. Current AGB % is 78.84.
  8. In the case of all other medical care, a patient who is eligible under this program will be charged an amount less than the gross charges. (99%)

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

  1. Posting the Financial Assistance Program, Financial Assistance Application and a summary of the policy on the Greenwood County Hospital website at the following location:
  2. Providing paper copies of the program, application and summary of the program upon request in admissions and patient financial services at Greenwood County Hospital.
  3. Posting notices about the program in the emergency department, admitting areas and business office of Greenwood County Hospital.
  4. Distributing a plain language summary of the program and offering a Financial Assistance application to patients before discharge from the hospital.
  5. Informing patients about the program in person or during billing and customer service phone contacts.
  6. Providing a summary of the program in the patients’ monthly billing statement.
  8. All qualifying applicants will be granted Financial Assistance for medically necessary services in accordance with the qualifications and guidelines herein set forth.
  9. An application for financial assistance can be initiated by a patient in person at admissions or at patient financial services; over the phone by calling 785-284-2121; through the mail at Greenwood County Hospital, 100 W. 16th Eureka, KS 67045; or via the Greenwood County Hospital website

It is ultimately the patient’s responsibility to provide the necessary information to qualify for financial assistance. There is no assurance that the patient will qualify for financial assistance.

  1. The Financial Assistance process begins at the time of service (during pre-admission, admission or at time of discharge.)
  2. The application process includes completion of a “Personal Financial Statement for Financial Assistance” and providing verification documents.

Verifiable information may include, but is not limited to, the following:

  1. Individual or family income (income tax return with copies of earnings statements – W-2 forms, 1099 forms, etc. for past 2 years)
  2. Copies of most recent 90 days of payroll stubs, Social Security checks, or unemployment checks.
  3. Copies of most recent 60 days of bank statements
  4. Current trust fund statements
  5. Mortgage statements
  6. Annual property tax statements
  7. In the absence of income, a letter of support from individuals providing for the patient’s basic living needs
  8. County tax appraisal statement
  9. Documentation of employment status
  10. Household family size
  11. Credit history reports
  12. Denial letter from Medicaid
  13. Previous or current returns from collection agencies with documentation regarding inability to pay
  14. Business Office knowledge of individual or family background
  15. Business Office previous experiences

Note: The object 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 worth financial assistance will not be granted.

  1. After the application for Financial Assistance has been completed, account(s) being considered for Financial Assistance will be put in a “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. 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).
  2. The application period for completion of a financial assistance application is available for a minimum of 240 days from the date Greenwood County Hospital provides the patient with the first billing statement for patient services.
  3. Should a patient’s account be transferred to a collection agency and subsequently a completed financial assistance application is received and approved, the Hospital will:
  4. Suspend all extraordinary collection actions (ECA)
  5. Make and document a determination regarding qualification
  6. Notify the individual in writing of the eligibility determination and the basis of the determination (including the assistance for which the individual is eligible.)
  7. If the Hospital determines an individual is eligible for an FAP discount the Hospital will do the following:
  8. Provide the patient with a billing statement that indicates the amount owed and shows or describes how the patient can obtain information regarding the amounts generally billed (AGB) for the care and how the facility determined the amount that the individual owes.
  9. 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.
  10. Takes all reasonably available measures to reverse any ECA taken against the individual to collect the debt as issue; such measures shall include but not be limited to: vacating any judgments, lifting any liens or levy’s on the individuals property and remove from the individuals credit report any adverse information that was reported to a reporting agency or credit bureau.
  11. The Hospital Business Office will continue to work with the patient or guarantor to resolve remaining account balances. Patients or guarantors are responsible to make mutually acceptable payment plan arrangements with the Hospital within 30 days of receiving a written notice of determination regarding their Financial Assistance application.
  12. Actions Greenwood County Hospital may take in the event of nonpayment of a bill for medical care are described in the collections policy. Patients may obtain a free copy of the collections policy by calling 785-284-2121 or on the Greenwood County Hospital website
  13. 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 account(s) to a collection agency.
  15. Financial Assistance discounts are determined based on a sliding-fee scale and are subject to income and assets. To obtain Financial Assistance, the patient or guarantor must establish that the household income is below 300% of the most recent Federal Poverty Level (FPL) at the date of service.

Discount provided per FPL income is identified in the Poverty Sliding Scale 2012 document (see Appendix A).

  1. Allowances may be made for extenuating circumstances based on each person’s unique life circumstances and mitigating factors. The amount of assistance provided by the Hospital may be more than outlined in the guidelines, but never less.
  2. “Household Income” includes all pre-tax income, however derived, for all persons 18 years old and over who reside in the household.
  3. “Household Assets” will be considered in the final determination of eligibility for Financial Assistance. Household Assets that will be considered include all cash and non-cash assets owned by all members of the household who are 18 years and over who reside in the household. Household assets include but are not limited to:
  4. Cash held in savings accounts, checking accounts, safe deposit boxes, or in the household;
  5. Value of trust (including living trust) the patient or guarantor has interest or ownership in, and includes equity in real estate;
  6. Cash value of stocks, bonds, treasury bills, mutual funds, certificates of deposit and money market accounts;
  7. Cash value of life insurance policies;
  8. Personal property held as an investment, such as jewelry, coin collections, etc.;
  9. Vehicles, other than a family automobile of reasonable value used as the primary source of transportation;
  10. Boats, campers, trailers, farm machinery and equipment;
  11. Lump sum or one-time receipts of funds, such as inheritances, lottery winnings, and insurance settlements;
  12. Value or equity in real property such as residence, rental property, business property and farming property.
  13. A patient who is otherwise eligible for Financial Assistance will have the amount of Financial Assistance reduced by the amount that the patient’s “Qualified Assets” exceed the amount of the bill(s) for which the patient otherwise would be responsible after the deduction of financial assistance discount based on income.
  14. “Qualified Assets” are determined by calculating one-quarter of the amount that remains after $25,000.00 is deducted from the total value of a patient’s net household assets. For example, Qualified Assets = (Household Assets-Household Debts – $25,000) X (25%).
  15. 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. The Hospital will retain the incomplete application and send written documentation outlining the information needed, and instructions on submitting the necessary paperwork.
  16. The Hospital’s Business Office Manager or his/her designee will process the Financial Assistance application and determine the appropriate discount.
  17. The Hospital’s Business Office will send a written notice of determination to the patient or guarantor within 30 days of receiving the completed application (including all required documentation).
  18. 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.
  20. Approval and authorization of Financial Assistance discounts will be based on the following: (or the Hospital’s alternative Board of Trustee’s adopted policy)
  21. $0 to $750 – Business Office Manager or designated Representative
  22. $ 750 to $2,000 – Business Office Manager
  23. $2,001 to $4,000 – Administrator
  24. $4,001 to $25,000 – Vice President of Regional Operations or Representative
  25. $25,000 or higher – Board of Trustees or Representative for Managed Hospitals; GPHA CFO for Leased Hospitals

Federal Poverty Level (FPL):

Poverty thresholds that are issued each year in the Federal Register by the Department of Health and Human Services (HHS)

Refers to person financially responsible for patient’s account balance(s).

Indigent:Refers to patient that has no financial resources to pay obligation.

Medically Indigent:
Refers to situation where payment of obligation will create financial hardship.

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 untreated, would pose a threat to the patients ongoing health status.


Household Annual Wages: $50,000
Other Household Income: $2,000
Total Household Income: $52,000
Other Medical Indebtedness:$5,000
Hospital AR: Patient Responsibility: $12,000

Cash on hand: $3,300
Cash in banks: $5,000
Stocks & Bonds: $0
Mutual Funds, Money Market, etc.: $0
Cash Value of Life Insurance: $0
Real Estate Value: $85,000
Farming Real Estate Value: $0
Vehicles Value (not primary vehicle): $9,000
Jewelry & other personal property: $0
Other Assets: $0
Qualified Assets: $1,325
Total Assets: $102,300

Credit Card Debt: $5,000
Medical Debt – other than hospital: $5,000
Real Estate Debt: $48,000
Vehicle Debt – $2,000
Other Debt – $0
Hospital AR: Patient Responsibility: $12,000

Total Liabilities: $72,000Calculation from information above was uploaded into the “Poverty Sliding Fee Schedule” worksheet: Charity, W/O: $6,314, Amount Due: 5,686.


Plain Language Summary: The Greenwood County Hospital Financial Assistance Program (FAP) exists to provide eligible patients partially or fully discounted emergentor medically-necessary hospital care. Patients seeking Financial Assistance must apply for the program, which is summarized below.

Eligible Services:
Emergent and/or medically necessary healthcare services provided by Greenwood County Hospital.

Eligible Patients:
Patients receiving eligible services, who submit a Financial Assistance Application (including related documentation/information),and who are determined eligible for Financial Assistance by Greenwood County Hospital.


Financial Assistance Application may be obtained/completed/submitted as follows:

  • Obtain an application at Greenwood County Hospital’s admissions desk or at patient financial services.
  • Request to have an application mailed to you by calling 785-284-2121.
  • Request an application by mail at Greenwood County Hospital, 100 W. 16th Eureka, KS 67045
  • Click here to download the Financial Assistance application from the Greenwood County Hospital.


Generally, patients are eligible for financial assistance based on their income level and assets (See Appendix A of the Financial Assistance Program at Eligible patients will not be charged more for emergency or other medically necessary care that Amounts Generally Billed (AGB) than those patients who have insurance.


Applicant Last Name, First (and spouse if filing jointly)

Date of Birth

Social Security Number (for all applicants)

Number of People in Household

How many of the total househould occupancy are over 18 with an income?

Applicant Street Address

City, State, Zip Code

Applicant’s Hospital/Clinic Account Number and Balances:

Has the Patient applied for Medicaid? If not, why?

Current Checking Account Balance:

Current Savings Account Balance:

Currnet Cash on Hand for everyone over 18:

Monthly Income from any of the following:

  • Paycheck Amount:
  • Disability Amount:
  • State Assistance and/or Medicare Amount:
  • Food Stamps Amount:
  • Child Support Amount:
  • Other Amount:

PLEASE READ BEFORE SIGNING:I CERTIFY that the information I have provided is true and accurate to the best of my knowledge. I will independently or with the assistance of hospital personnel apply for ANY or ALL ASSISTANCE which may be available through federal, state, and local government and private sources to help pay this hospital bill. I understand that if I do not cooperate with my hospital provider in providing requested information, my application may be denied for possible financial assistance. I hereby grant permission and authorize any accredited agent of the Medicaid program to disclose to my hospital provider ALL information regarding the status of my Medicaid application and if the application is not approved and the reason for disapproval. I UNDERSTAND that if any information I have given proves to be untrue, my hospital provider will reevaluate my financial status and take whatever action becomes appropriate. To qualify for assistance, most recent year’s tax return for anyone’s income included on this form along with several pay stubs from any other sources must accompany the application. Additional supporting documentation may be requested. Supporting documentation can include but is not limited to, a current W-2, notarized letter of support, etc (Please see Financial Assistance Program Policy). Requests for assistance may be denied if supporting documentation is not provided and if required meeting with the Business Office is not held. Any unpaid balance will be eligible for further collection action.

For assistance with this application, please call the Business Office at (620) 583-7451.

Signature of Applicant:

Date Completed

Signature of Co-Applicant:

Date Completed