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201710296

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UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Fiscal Affairs

Financial Assistance Policy (2.16)

Financial Assistance Policy (2.16) - Policies, Administrative, UW Health Administrative, Fiscal Affairs

2.16

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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).
Policy Title: Financial Assistance Policy
Policy Number: 2.16
Effective Date: September 28, 2017
Chapter: Fiscal Affairs
Version: Revision
I. PURPOSE
Consistent with our mission to advance health without compromise through Service, Scholarship,
Science, and Social Responsibility, UW Health is committed to providing financial assistance to
uninsured and underinsured individuals who are in need of emergency or medically necessary treatment
and have a household income up to 500% of the Federal Poverty Guidelines (FPG). The eligibility criteria
for financial assistance and the procedures for receiving financial assistance outlined in this policy set
forth the parameters for UW Health’s Community Care program, and will ensure that UW Health has the
financial resources necessary to meet its commitment to providing care to the greatest number of patients
with the greatest financial need in its Dane County community and surrounding areas. In addition, this
policy establishes a fair and consistent method for the review and completion of requests for Community
Care for UW Health’s patient population.

In accordance with the Affordable Care Act (ACA), any patient eligible for financial assistance under
UW Health’s Community Care program will not be charged more for emergency or medically necessary
care than the amount generally billed (AGB) to insured patients. In addition, the Community Care
program ensures that the University of Wisconsin Hospitals and Clinics Authority, a component of UW
Health, will meet its statutory obligation to provide comprehensive, high-quality health care to the
medically indigent.

II. DEFINITIONS

The following terms are meant to be interpreted as follows within this policy:

A. Amount Generally Billed (AGB): The amounts generally billed to insured patients for
emergency or other medically necessary care, determined as described in Appendix A of this
policy.
B. Community Care: UW Health’s internal name for its Financial Assistance Program. The
Community Care program is not a form of health insurance and cannot be used to subsidize
premiums.
C. Emergency Care: Immediate care provided by a hospital facility for emergency medical
conditions that is necessary to prevent putting a patient’s health in serious jeopardy, serious
impairment to bodily functions, and/or serious dysfunction of any organs or body parts.
Emergency Care is deemed to be medically necessary.

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D. Gross Charges: The full, established price for medical care that UW Health consistently and
uniformly charges patients before applying any discounts, contractual allowances, or deductions.
E. Medically Necessary: Those services required to identify or treat an illness or injury that is either
diagnosed or reasonably suspected to be necessary, taking into account the most appropriate level
of care. Depending on a patient’s medical condition, the most appropriate setting for the provision
of care may be a home, a physician’s office, an outpatient facility, or a long-term care,
rehabilitation or hospital bed. In order to be medically necessary, a service must:
1. Be required to treat an illness or injury;
2. Be consistent with the diagnosis and treatment of the patient’s conditions;
3. Be in accordance with the standards of good medical practice; and
4. Be that level of care most appropriate for the patient as determined by the patient’s
medical condition and not the patient’s financial or family situation.
The term “medically necessary” does not include services provided for the convenience of the
patient or the patient’s physician, or elective health care. For purposes of this policy, UW Health
reserves the right to determine, on a case-by-case basis, whether the care and services meet the
definition and standard of “medically necessary” for the purpose of eligibility for financial
assistance.
F. Presumptive Eligibility Determination: The process by which UW Health may use previous
eligibility determinations and/or information from sources other than the individual to determine
eligibility for financial assistance under this policy.
G. Eligibility Area: Includes UW Health’s primary service community, Dane County, as well as
some zip codes within Columbia, Green, Iowa, Jefferson, Lafayette and Rock counties. UW
Health will provide documentation of its Eligibility Area upon request.
H. Underinsured: Insured patients whose out-of-pocket medical costs exceed their ability to pay.
I. Uninsured: Patients with no insurance or third-party assistance to help resolve their financial
liability to healthcare providers for a particular service.
J. Urgent Care: Medically necessary care to treat medical conditions that are not immediately life-
threatening, but could result in the onset of illness or injury, disability, death, or serious
impairment or dysfunction if not treated within 12–24 hours.
K. UW Health: UW Health is comprised of three separate entities: the University of Wisconsin
Hospitals and Clinics Authority, the University of Wisconsin Medical Foundation, Inc., and the
University of Wisconsin School of Medicine and Public Health. Each of these three entities is
responsible for enforcement of this policy with its employees and agents.

III. POLICY ELEMENTS

UW Health provides financial assistance only when: (a) it deems care to be medically necessary and
eligible for coverage under this policy; (b) it determines patients have met all eligibility criteria; (c) it
determines it is the appropriate provider for the level of care; (d) the patient’s residence is within the
Eligibility Area of UW Health (as defined above); and (e) patients have first diligently sought assistance
from other financial assistance programs (such as Medicaid or insurance through the public marketplace).
For persons residing outside of the Eligibility Area who seek care at UW Health, UW Health may, in its
sole discretion, opt to provide financial assistance under special circumstances (e.g. the service can be
provided only by UW Health medical staff/technology or patients are eligible for financial assistance
under Swedish American Hospital’s financial assistance policy). As described within this policy, UW
Health offers both free care and discounted care, depending on individuals’ family size, income and type
of health care service.

Uninsured and underinsured patients who do not qualify for free care may receive a sliding scale discount
off of the gross charges for their medically necessary services based on their family income as a percent
of the Federal Poverty Guidelines. These patients are expected to pay their remaining balance, and may

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work with a UW Health Revenue Cycle representative to set up a payment plan based on their financial
situation.

If the Covered Services are Emergent Services or services that UW Health is otherwise required to
provide under EMTALA, then UW Health will provide such Covered Services without requiring any
advance deposit or prepayment. For all other Covered Services, UW Health may require an advance
prepayment. From time to time UW Health may make exceptions to this policy as deemed appropriate by
the UW Health Vice President of Revenue Cycle (in consultation with the UW Health Chief Financial
Officer).

IV. PROCEDURE
A. Eligibility for Community Care:
1. Services eligible for Community Care include all emergency and other medically necessary
care provided by UW Health, as described in Appendix B. UW Health will not charge
patients who are eligible for financial assistance more for emergency or medically necessary
care than the amounts generally billed (AGB) to insured patients. To the extent permitted by
governmental or private insurers, deductibles, co-insurance, or co-payments may be eligible
for consideration under Community Care.
2. Eligibility for financial assistance may be determined at any point in the revenue cycle.
3. In order to be eligible for Community Care, patients must meet the following criteria:
a. The patient and/or patient representative must cooperate with UW Health to explore
alternative means of assistance if necessary, including Medicare, Medicaid, group health
insurance, the health exchange marketplace and other forms of insurance. Patients will be
required to provide necessary information and documentation when applying for financial
assistance or other private or public payment programs. Additionally, any uninsured
patients who are believed to have the financial ability to purchase health insurance may
be encouraged to do so to help ensure healthcare accessibility and overall well-being.
b. The patient is unable to pay based on his or her individual financial situation.
c. The patient and/or patient representative cooperates with UW Health’s policies and
procedures.
d. The patient must have primarily resided in the Eligibility Area for at least a year.
Internationally traveling/visiting patients who seek non-emergent treatment from UW
Health are not eligible for Community Care.
e. The patient must have either annual household incomes below 500% of the Federal
Poverty Guidelines, or have excessive medical debt (greater than 50% of gross income).
f. The patient or patient representative must submit a completed Financial Statement
(including all documentation required by the application), or meet presumptive eligibility
requirements.
4. When determining eligibility, UW Health does not discriminate on the basis of race, color,
national origin, gender, age or disability.
5. If UW Health determines that patient meets the criteria described above, UW Health
determines the amount of a patient’s Community Care support using an income-based sliding
scale.
6. Patients not eligible for financial assistance include the following:
a. Specific patient populations that have a current Memorandum of Understanding or Single
Case Agreement with UW Health
b. Patients who are eligible for coverage or payment for services under any other health or
accident insurance program, including workers’ compensation, third-party liability, and
motor vehicle insurance”
c. Patients who are members of insurance plans that deem UW Health to be “out of
network,” UW Health may reduce or deny the financial assistance that would otherwise

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be available to Patient based upon a review of Patient’s insurance information and other
pertinent facts and circumstances.
d. Patients receiving any Category 3 Excluded services or items listed on Appendix B
B. Assistance for Patients Not Eligible for Financial Assistance:
Uninsured patients who are not eligible for financial assistance may be provided a self-pay
discount.
C. Applying for Financial Assistance:
1. A Patient may qualify for financial assistance through presumptive eligibility or by applying
for financial assistance by submitting a completed Financial Statement. The financial
statement and instructions are available online at www.uwhealth.org/communitycare, by
mail, in person at all admission/registration desks, and at all UW Health business office
locations. (Appendix C)
2. Patients will be asked to attest that all information provided is true. If any information is
determined to be false, all discounts afforded to the patient may be revoked, making them
responsible for full charges for the services rendered.
3. Complete a financial statement and provide the following supporting documentation:
a. Proof of income for applicant (and spouse/domestic partner if applicable);
i. Most recent pay stubs
• If paid weekly (every week) – 4 most recent, consecutive stubs needed
• If paid bi-weekly (every 2 weeks) – 2 most recent, consecutive stubs
needed
• If paid monthly (every month) – most recent stub
• Letter from employer stating weekly, monthly or annual earnings
ii. Unemployment earnings statement
iii. SSI/SSDI income information (including minor children)
iv. Annuity information
v. Pension information
vi. Any other sufficient information on how patient/family is currently supporting
themselves
vii. Copy of most recent federal tax return (including all applicable schedules)
b. Bank statements - 2 most recent
c. Evidence of other assets, as described on the financial statement
4. Individuals who cannot provide the documentation listed above, have questions about or
would like help completing the Financial Statement, may contact a Revenue Cycle
representative either in person or over the phone. UW Health has English and Spanish
speaking Revenue Cycle representatives as well as the use of a Language Line to assist
patients with their questions or to provide copies of the Financial Assistance policy and
Financial Statement and Instructions. (Appendix C).
5. The completed Financial Statement will be reviewed by a Revenue Cycle representative to
verify:
a. That all health or other insurance coverage has been exhausted, including any potential
third party liability settlements.
b. Eligibility for government and other programs. If eligible, assistance will be provided in
applying for coverage.
c. Resources available other than income, e.g. home, land, vehicle(s), personal possessions.
d. Future earnings potential.
e. Other financial obligations, e.g. child support, alimony.
f. Possible use of appropriate gift funds.
6. Patients qualified for consideration for partial assistance under the UW Health Community
Care Policy shall cooperate with UW Health by providing all information and documentation

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necessary to establish a reasonable agreement and/or payment plan. Patients must notify UW
Health of any positive or negative changes in their financial situation when scheduling
subsequent visits.
7. External sources may be utilized, including credit or medical recovery score, to verify
eligibility. Other sources could include: TransUnion, Zillow, or Access Dane.
8. Depending on the supporting documentation provided, financial statements may be approved
on a one time basis for all outstanding balances, and/or may be approved prospectively for up
to six months after the date of submission of the completed financial statement.
D. Appeals of denials or partial Community Care awards.
Patients or their representatives may appeal UW Health’s decisions regarding eligibility for
financial assistance.
1. If financial assistance is denied, an appeal can be filed within 20 calendar days of the date of
the letter notifying the applicant of the denial or partial award. Send a letter to UW Health –
Community Care, Attention: Community Care Appeals Committee, Administrative Offices
Building, 7974 UW Health Court, Middleton, WI 53562, outlining why the application
should be reconsidered and providing additional supporting information.
2. All appeals will be considered by UW Health’s Community Care Appeals Committee and
decisions of the committee will be sent in writing to the individual that filed the appeal.
E. Determining Discount Amount:
1. Once eligibility for financial assistance has been established, UW Health will not charge
patients who are eligible for financial assistance more than the amounts generally billed
(AGB) for emergency or medically necessary care. Patients who have a household income at
or below 500% of the Federal Poverty Guidelines (FPG) may receive free or discounted care
as illustrated on Appendix D.
2. Patients with excessive medical debt (greater than 50% of income) are also eligible for larger
Community Care discounts under this policy, as described on Appendix D.
3. Category 2 Services/Items are discounted for all patients eligible for Community Care at the
AGB, regardless of family income (see Appendix B). All Category 2 Services/Items and
related follow-up care must be prepaid before they will be scheduled.
4. Category 3 Services/Items are not eligible for Community Care.
F. Presumptive Eligibility:
1. Absent sufficient information to support financial assistance eligibility, UW Health may opt
to refer to or rely on external sources and/or other program enrollment resources to determine
eligibility in the event that:
a. Patient is homeless;
b. Patient is eligible for state or local assistance programs;
c. Patient is eligible for a state-funded prescription medication program;
d. Patient is deceased and without an estate;
e. Patient files bankruptcy; and/or
f. Patient receives care from a partner community clinic primarily serving an uninsured
population and is appropriately referred to UW Health for further treatment.
2. External sources utilized to determine presumptive eligibility may include credit or medical
recovery scores available through TransUnion, Zillow, or Access Dane.
3. UW Health also uses an outside source to determine a propensity to pay score to help identify
patients who may be eligible for financial assistance under this policy. UW Health may use
previous financial assistance eligibility determinations as a basis for determining eligibility in
the event that the patient does not provide sufficient documentation to support an eligibility
determination.
4. Presumptively eligible approvals apply to outstanding balances only and not to any future
balances. These accounts are approved for 100% discount.


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G. Eligible Providers:
1. In addition to care delivered by UW Health, emergency and medically necessary care
delivered by the providers listed in Appendix E to this policy, are also covered under this
policy. Members of the public may readily obtain Appendix E free of charge online at
www.uwhealth.org/communitycare, by mail, in person at all admission/registration desks and
at all UW Health business office locations. Refer to Appendix C for more details.
H. Communication of Financial Assistance Program:
1. UW Health communicates the availability and terms of its financial assistance program to all
patients, through means which include, but are not limited to:
a. Notifications on patient bills/statements;
b. Posted policies on the organization’s website;
c. Brochures available to patients at all UW Health locations;
d. Notices on UW Health information monitors;
e. The UW Health new patient packet; and
f. Designated staff knowledgeable on the financial assistance policy to answer patient
questions or who may refer patients to the program.
2. Requests for financial assistance can be made by a patient, their family members, friend or
associate, but will be subject to applicable privacy laws.
I. Patient Business Services Contact Information:
1. UW Health has English and Spanish speaking Revenue Cycle representatives as well as the
use of a Language Line to assist patients with their questions regarding the Financial
Assistance program or for requests of a copy of the UW Health Financial Assistance
Guidelines. Individuals, who cannot provide the documentation listed above, have questions
about or would like help completing UW Health’s application, may contact a Revenue Cycle
representative either in person or by phone. Reference Appendix C - Patient Business
Services Contact Information.
J. Regulatory Requirements:
1. In implementing this policy, UW Health shall comply with all other federal, state, and local
laws, rules, and regulations that may apply to activities conducted pursuant to this policy.

V. FORM

UW Health Financial Statement

VI. REFERENCES

UW Health Administrative Policy 2.26-Financial Screening for Solid Organ Transplant
UW Health Clinical Policy 5.1.1-Emergency Assessment at UW Health Facilities
UW Health Administrative Policy 2.33-Billing and Collection Policy

Related Law
Wis. Stat. s. 233.04(3b)(a)(1)
26 .F.R. 501(r)-4
Appendices
A. Amount Generally Billed
B. Financial Assistance Categories of Services
C. Patient Business Services Contact Information
D. Financial Assistance Adjustment Levels
E. Eligible Providers Other than UW Health



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VII. COORDINATION

Sr. Management Sponsor: SVP, Chief Financial Officer
Author: VP, Revenue Cycle

Approval Committee: UW Health Administrative Policy and Procedure Committee
University of Wisconsin Hospitals and Clinics Authority Board

SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer