Financial Assistance Policy

This Financial Assistance and Charity Care Policy documents the commitment of Bristol Hospital and Health Care Group, Inc. DBA Bristol Health, to provide financial assistance to eligible uninsured patients who do not have the ability to pay for all or a portion of their health care expenses for emergency and other medically necessary health care services, and to ensure that such financial assistance is made available in accordance with all applicable state and federal statutes and regulations and consistent with the mission of Bristol Health.



“AGB” means amounts generally billed for emergency or other medically necessary care to individuals who have insurance coverage.  
“EMTALA” means the Emergency Medical Treatment and Active Labor Act, 42 USC §1395dd.
“Family” means, 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.
“FAP” means the Financial Assistance Program described in this Financial Assistance and Charity Care Policy.
“FPG” means Federal Poverty Guidelines established by the United States Department of Health and Human Services in effect at the time of the determination.
“Gross Charges” means the organization’s published charges. 
“Medically Necessary Health Care Services” means services required to identify or treat a medical condition, illness or injury, based on the patient’s symptoms, diagnosis or treatment of the underlying condition, in accordance with professional standards of medical care generally accepted in the medical community.
“Uninsured” is defined by the State of Connecticut as an individual who is liable for one or more hospital charges whose income is at our below 250% of the FPG and who (A) has applied for and been denied  eligibility for any medical or health care coverage provided under the Medicaid program due to failure to satisfy income or other eligibility requirements, and (B) is not eligible for coverage under the Medicare or CHAMPUS programs, or under any Medicaid or health insurance program of any nation, state, territory or commonwealth, or under any other governmental or privately sponsored health or accident insurance or benefits program, including but not limited to, worker’s compensation and awards, settlements or judgments arising from claims, suits or proceedings involving motor vehicle accidents or alleged negligence.  For purposes of this Policy, Bristol Health may consider a patient as uninsured for partial assistance up to 400% of FPG.


It is the policy of Bristol Health to provide financial assistance to eligible patients who have difficulty paying for emergency and other medically necessary health care services. Regardless of eligibility for such financial assistance, Bristol Health will provide care, without discrimination and without regard to payor source, for emergency medical conditions in accordance with EMTALA and Bristol Hospital’s emergency medical treatment policy. This policy is designed to provide the appropriate level of financial assistance to the greatest number of eligible patients who are truly in need while at the same time ensuring that Bristol Health has the resources available to serve its community.  As a result, this policy will cover medically necessary, non-emergency health care services only for U.S. citizens who have resided in Bristol Health’s primary and secondary service areas for at least one (1) year, subject to limited exceptions described in the “Patient Eligibility” section below. 


This policy applies to Bristol Hospital and the following affiliates within Bristol Health: Bristol Hospital Multi-Specialty Group, Bristol Hospital EMS LLC, Bristol Health Inc. DBA Ingraham Manor, and Bristol Homecare & Hospice Agency, Inc.  Also, a list of Bristol Health providers who provide emergency and other medically necessary care is attached in Appendix A. The list indicates if the provider is covered under the FAP.  If the provider is not covered under the FAP, patients should contact the provider’s office directly. 


Uninsured patients who are U.S. citizens and have resided for at least one (1) year in Bristol Health’s primary or secondary service area are eligible to apply to the FAP for financial assistance.  Bristol Health’s primary and secondary service areas consist of the following towns:  Bristol, Plainville, Plymouth, Terryville, Burlington, Farmington, Southington, Harwinton, Thomaston and Wolcott.  In addition, uninsured lawful non-U.S. citizen residents who meet the five (5) year residency requirement for Connecticut Medicaid and who have resided in the identified service areas for at least one (1) year may also apply to the FAP. 
Any patient who does not fall into any of the categories described above may qualify for financial assistance if the patient receives EMTALA services and is determined to be eligible for financial assistance based on review of income, assets and other criteria set forth in this policy.  Except for the specific services required in an EMTALA encounter, a self-insured patient who is not a U.S. citizen or lawful non-U.S. citizen resident meeting Connecticut Medicaid eligibility requirements, or who resides outside Bristol Health’s primary or secondary service area, or has resided in the primary or secondary service area for less than one (1) year will not be considered for financial assistance. 
A patient with insurance where the insurance company does not include Bristol Health as a participating provider will be considered as self-pay.  As such, a deposit of 33% of estimated charges will be required before the patient is registered or scheduled for a non-emergency service, and financial assistance will not be provided. 
Financial assistance is not considered to be a substitute for patient responsibility.  Patients are expected to cooperate with Bristol Health’s FAP application procedures and to contribute to the costs of their care based on ability to pay.  Individuals with the financial capacity to purchase health insurance will 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.  Patients should also apply for governmental programs including Medicaid to assure access to health care services and may only apply for FAP if such assistance is denied.


The FAP applies to emergency and other medically necessary inpatient and outpatient health care services.  The FAP is not available for elective, cosmetic and uncovered bariatric procedures or other procedures and costs that are not considered medically necessary under generally accepted medical standards.  In addition, the FAP is not available for ancillary fees for items and services such as private duty nursing, convenience fees such as television and telephone charges and other discounts and reductions that are not described in this policy. 


Financial assistance for services eligible under this policy may be made available to the uninsured patient on a full or partial basis based on family size and federal poverty levels (FPL) using the FPG in effect at the time of the determination. An uninsured patient whose income is less than or equal to 250% of FPL and meets all other criteria for eligibility, will be entitled to a 100% discount. Eligible uninsured patients with income up to 400% of FPL will be entitled to a sliding scale discount set forth in Appendix B.
No individual determined to be eligible under the FAP will be charged more for emergency or medically necessary health care services than the AGB (amounts generally billed) to individuals who have insurance to cover their care.  Appendix B describes how Bristol Health has calculated the AGB and the AGB percentage used for the current year.  Bristol Health calculates AGB annually and may revise the AGB percentage based on the calculation.  The AGB percentage is applied to reduce charges before any discount on the sliding scale is applied under the FAP. 
All patients must submit an application following the procedures outlined below in order to be considered for financial assistance.
Uninsured Catastrophic Medically Indigent:  An uninsured patient who is determined to be unable to pay their bills due to catastrophic medical expenses that exceed at least 50% of the annual gross family income may be eligible for discounts on a case by case basis.  The patient will be required to submit a financial assistance application along with other supportive documentation, such as medical bills, drug and medical device bills and other evidence relating to high medical bills not exclusive to Bristol Health.


In order to be considered for financial assistance, the patient must complete a Financial Assistance Application and provide certain financial information and other documentation that may be requested for determination of eligibility under the FAP. 
Bristol Health will attempt to assist all patients registered as “self-pay” with identifying and securing coverage, and/or establishing a payment plan for amounts determined to be a patient responsibility prior to receipt of medically necessary health care services and will provide any self-pay patients who may not be able to secure coverage or pay for the service with information about the FAP and the application process.   
All patients requesting consideration for financial assistance will be required to apply for Medicaid coverage or another available government supported insurance program.  If the patient balance is under $230 the patient may apply for financial assistance without applying for Medicaid coverage.
All applications must include the following documentation:

  1. Proof of legal residency status (e.g. social security card or driver’s license) and proof of residency for at least one year in Bristol Health’s primary or secondary service area:  Bristol, Plainville, Plymouth, Terryville, Burlington, Farmington, Southington, Harwinton, Thomaston and Wolcott  
  2. All sources of income, including spousal income, at the time of application and any other documentation sufficient to show annual gross household income (Note that if loss of income is due to patient’s personal choice, the patient may not qualify for financial assistance).
  3. Assets including checking and saving accounts bank statements.  In order to be considered, assets must be below $7,500 for an individual and $15,000 for a family.  Assets do not include the primary residence or vehicles required for commuting to employment.
  4. Most recent complete 1040 tax return with supporting schedules and W-2[s]
  5. Investment accounts
  6. Other documents:
    • Four (4) most recent weekly paystubs, or two (2) bi-weekly paystubs, including the employer’s name
    • A statement from the employer on company letterhead stating gross wages for last four (4) weeks and that the employer does not offer health/medical insurance
    • If self-employed, self-employment worksheet and all 1040 forms and schedules (C,D,SE,K etc.)
    • Social Security confidential form 2458 or copy of check, or bank statement or SSA-4926SM.
    • Pension or annuity check stubs
    • Workers compensation or disability statement with benefits and period covered
    • DOL form or printout for Unemployment Compensation benefits
    • HUSKY Health self-employment income verification form
  7. Proof of identity that can include, but is not limited to, documents that contain a photograph or other identifying information, such as, name, age, sex, race, height, weight, eye color and address. Acceptable documents include:
    • Driver’s license issued by a state or territory
    • Identification card issued by a school, military, a federal, state or local government, a military dependent card or U.S. Coast Guard Merchant Marine
    • Clinic, doctor, hospital or school record for children under 19 years of age
    • Two documents that provide information that is consistent with the applicant’s identity such as, but not limited to, high school and college diploma, marriage or divorce records, property deeds, rental agreements
    • A finding of identity from a federal or state agency, if the agency has verified the identity
    • An affidavit signed, under penalty of perjury, by another person who can reasonably testify to a person’s identity, if no other documentation is available
The application period begins the day of admission for inpatient services and the date that care is provided for outpatient services and ends 180 days after the day of admission for inpatient services, or 180 days after the date of service for outpatient services.  The patient/guarantor has 30 days from the date a request for financial assistance is made to present all required forms of documentation for consideration. A Financial Assistance application will be considered a “complete application” when the following criteria have been met:
  • The application has been received in the Patient Financial Counseling Department.
  • The patient/guarantor or an authorized representative has signed the application.
  • All questions on the application have been answered.
  • Income verification and other documentation that is sufficient to make an eligibility determination has been provided.

If the Financial Assistance application is not complete, a Financial Counselor will send one follow-up letter to the patient. This letter will indicate the information that is necessary to process the application.
The applicant/guarantor must provide the required documentation within 30 days of receipt of the follow-up letter. If the information is not received within this time frame, the application will be denied. A letter with the reason for denial will be sent to the applicant and the patient account will be placed back in standard billing proceedings.
Bristol Health will stop sending billing statements to anyone who has requested an application for financial assistance for up to 30 days following the request.  If the application is not submitted within 30 days, billing statements will resume.  Once the application is submitted, billing statements will not be sent while the application is being considered and will resume only if the application is denied.


A complete application will be evaluated by a Financial Counselor to determine eligibility.  In addition to review of the completed application, best practices available at that time will be used to assess patient income from all sources including self-employed gross income, assets, liabilities and potential unreported insurance. 

  1. If all eligibility criteria have been met, a letter of approval will be sent to the applicant/guarantor that will indicate the eligibility period and percentage of discount.
  2. If all eligibility criteria have not been met, a letter of denial will be sent to the applicant/guarantor with the reason for the denial and instructions on the appeal process.  
  3. The applicant/guarantor will have thirty (30) days from the date of the denial letter to submit an appeal and provide documents to support the appeal.  The Chief Financial Officer will make the final decision on the appeal, and the applicant/guarantor will be notified of the outcome.
  4. Applications that have been approved and processed will be maintained in a central file in the Financial Assistance Office.  
  5. An approved application will be valid for 180 days from the date of the application.  If services continue beyond 180 days, a new application for financial assistance must be submitted.

Presumptive Eligibility:  There are instances when an uninsured resident patient who has received medically necessary services may appear eligible for financial assistance discounts, but there is no approved 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 financial assistance.  In the event there is no evidence to support a patient’s eligibility for financial assistance, Bristol Health could use outside agencies and sources to estimate income amounts for determining financial assistance eligibility and potential discount amounts.  Once determined, due to the inherent nature of the presumptive circumstances, the patient may receive a sliding scale discount up to a 100% write-off of the account balance based on individual circumstances and levels of authorization defined separately.  Examples include:

  1. State-funded prescription programs 
  2. Homeless or received care from a homeless clinic
  3. Participation in Women, Infants and Children programs (WIC) 
  4. Food stamp eligibility
  5. Subsidized school lunch program eligibility
  6. Eligibility for other state or local assistance programs that are unfunded (e.g., Medicaid spend down)
  7. Low income/subsidized housing is provided as a valid address 
  8. Patient is deceased with no known estate.


Insured patients are expected to pay in full and charges will not be waived. The actions that Bristol Health may take in the event of nonpayment are set forth in a separate Billing and Collection Policy that can be found on the Bristol Health website. Members of the public also may obtain a free copy of the Billing and Collection Policy by using the contact information set forth below.


Bristol Health makes this policy, application form and plain language summary of this Policy widely available on its website in English and Spanish. Bristol Health implements additional measures to widely publicize the policy in communities served. Among other things, Bristol Hospital will post a notice of the availability of financial assistance at all registration points and other visible locations throughout the Hospital, including the emergency room.  Also, a conspicuous notice will be printed on all Bristol Health bills and statements informing patients and families of the availability of financial assistance.


To learn more about the Bristol Health's FAP, obtain a copy of the FAP Application, or obtain assistance with the FAP process, please contact Bristol Health as follows: 
Telephone:     860-585-3135
By Mail:           Bristol Health
                        Attn:  Financial Counselor
                        41 Brewster Road, Bristol, CT 06010
In Person:       Bristol Health Counseling on Level E of main campus
REFERENCES: Internal Revenue Code 501(c)(3)
                           Internal Revenue Code 501(r)
                           Conn. Gen. Stat. §19a-673 et seq.

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