WeliaCare Charity Care

Last reviewed April 2023

Purpose

Welia Health is committed to their mission and vision in providing health care services to the communities we serve. As a result, Welia Health has a charity care program, WeliaCare, to assist persons with medical expenses incurred at Welia Health with limited ability to pay.

Definitions

1. Amounts Generally Billed (AGB) Limit
   • a. The average amount collected by Welia Health for providing emergency and other appropriate hospital-based medical services to individuals who have insurance covering those services, as defined by IRS Regulations 1.501(r)-1(b)(1). The amount generally billed is calculated by dividing the sum of the amounts of the all its claim for emergency and other medically necessary care that have been allowed by health insurers during the prior 12-months of the sum of the associated gross charges for those claims. The AGB percentage will be updated annually.

2. Income Limitation
   • The method of determining income shall include, but is not limited to, gross income plus nontaxable retirement income (i.e., Social Security), child support, unemployment compensation as well as any payments received for living expenses and “in kind” payments (i.e., use of property rent free). The value of food stamps and housing subsidies will be excluded from “in-kind” payment consideration. (See WeliaCare Program Check List for detailed description).

3. Asset Limitations
   • The following will be considered a liquid asset: checking and savings accounts, health saving accounts, money market accounts, certificates of deposits (CDs), value of stocks, bonds, and IRAs where the recipient is not assessed a penalty of early withdrawal of the funds (see WeliaCare Program Check List for detailed description).

4. Community Care
   • Discounts on all charges for medical services given to patients that are considered uninsured or medically indigent at the time of service.

5. Financial Assistance Program
   • The program to provide health care services free or a discount to individuals who quality by meeting income and asset guidelines. The Community Care Program is called WeliaCare.

6. Medically Necessary Care and Services
   • Medically necessary care and services include procedures and treatment for physical or mental conditions in accordance with professionally recognized standards of health care. Examples of non-medically necessary services are cosmetic procedures, birth control, non-emergency dental services, experimental or non-traditional care, test, or treatment; hearing aids, retail services such as pharmacy, optical shop and durable medical equipment. Welia Health reserves the right to determine on a case-by-case basis, whether the care or services meet the definition and standards of medically necessary.

7. Medicaid
   • Medical Assistance (MA) is a Medicaid program for people with low incomes. The income limit and calculations depend on your age and who lives with you. If you are pregnant, blind or have a disability, you may have different income limits. (https://mn.gov/dhs).

Eligibility guidelines

1. An accumulated self-pay balance of $250 or more.
2. Patient’s family income must be at or below 275% of the then-current federal poverty guideline or qualifies to file IRS Form 4029, Application for Exemption from Social Security and Medicare Taxes and Waiver of Benefits. See section J, WeliaCare Application process if the patient’s family has filed Form 4029.
3. A patient’s family liquid assets must be less than $20,000 to be eligible to receive free care under the WeliaCare program.
4. The eligibility period is for one year beginning with the first day of acceptance to the program. After this period the eligibility for further participation will be fully reassessed for further support upon the request of the recipient.
5. Patient must live in the state of Minnesota or Wisconsin to be eligible for the WeliaCare program.
6. Patients with Medicare A & B only are encouraged to apply for assistance with co-pays, deductible and non-covered services utilizing the services of the Seven County Senior Federation. Welia Health participates by forgiving patient owed balances when proof of eligibility is supplied by the patient in the form of a membership card with an expiration date after the date of service. Copies of the membership card must be presented by the patient prior to balances being forgiven. Patients must have both Medicare A & B to qualify for WeliaCare.
7. For patients receiving unemployment compensation, eligibility will be determined utilizing the prior year’s income tax filing. In situations where the patient feels the prior year’s income tax filing does not represent their current financial status due to a permanent loss of employment, a letter from the previous employer indicating a permanent job loss status will be required. Once the letter is received, unemployment compensation will be utilized to determine eligibility.
8. For those applicants not meeting the economic guidelines, Welia’s Business Office will help arrange a payment plan designed to meet the applicant’s financial requirements.

2023 Federal Poverty Guidelines (FPG)

Annual and Monthly Income Levels at the 275th Percentile

Family Size	Year	Month
1	$49,095	$3,341
2	$54,230	$4,519
3	$68,365	$5,697
4	$82,500	$6,875
5	$96,635	$8,053
6	$110,770	$9,231
7	$124,905	$10,409
8**	$139,040	$11,587

2023 Poverty Guidelines (FPG) annual income levels as published in the Federal Register of January 19, 2023.

**For families with more than 8 persons, add $14,135 annually for each additional person.

Exception

For catastrophic illness, exceptions to income and asset limitations may be approved on a case-by-case basis.

1. Available Healthcare Coverage
   • a. Patients are encouraged to take advantage of available healthcare coverage; however, Welia Health recognizes the premiums may be a hardship for the patient.  In such cases, patients are required to provide documentation regarding their minimum monthly insurance premium and personal information indicating why it is considered a hardship.  Examples of employer health insurance documentation would include a copy of the employer’s rate sheet or a letter from the employer’s Human Resource department. Patients should apply for coverage through MN-Sure if they are not offered coverage through their employer (the affordable Care Act 2010 mandates medical insurance coverage for individuals and families effective January 1, 2014.)  If patients feel coverage through MN-Sure is unaffordable, they should submit information detailing what plans and rates are available to them. Patients will be considered for WeliaCare if the minimum healthcare coverage premium is more than 20% of their monthly income.  

2. Factors Not Considered
   • a. The following factors will not impact nor be considered when an application is reviewed for financial assistance:  
     • Courtesy/administrative adjustments unrelated to ability to pay
     • Third Party payer contractual allowances
     • Medical write-offs
     • Bad debt, defined as care provided to patients unwilling to pay
     • Cases paid through charitable contribution, community services or outreach program

3. Reasons for Denial
   • a. Sufficient income
   • b. Sufficient asset level
   • c. Patient is uncooperative or unresponsive despite reasonable efforts to work with the patient.
   • d. Incomplete Charity Care application and required documentation despite reasonable efforts to work with the patient.
   • e. Procedures or visits deemed not medically necessary.
   • f. Medicaid spend down co-payments

4. WeliaCare Application Process
   • a. All patients desiring consideration under the Welia Health Charity Care program must apply for assistance in writing disclosing financial information that is considered pertinent to the determination of the patient’s eligibility for charity care.  Persons requesting assistance will be given a Charity Care application form.  
   • b. Completed WeliaCare application form is submitted to a Welia Health Patient Financial Representative located in the Business Office.
   • c. Applications for charity care must include verification of income and the value of liquid assets.  Verification may be obtained from one or more of the following forms of documentation:
     • A copy of the previous year’s IRS Federal 1040 form(s) prepared for the family.  The previous year’s Income Tax filing is acceptable up to February 15th of the current year.  Current year’s income tax filing is required after February 15th.  Dependents over the age of 18 will be included in family size calculation only if they are list on the tax return.  If self-employed, a copy of the completed Schedule A – Itemized Deductions and Schedule C – Profit or Loss from Business, is also required.
     • A copy of the most recent four pay stubs with year-to-date earnings for the patient or guarantor and spouse.
     • Copies of the most recent detailed bank statements for the household (savings, checking, health saving and money market accounts).
     • A copy of the Social Security gross income information award letter.
     • A copy of forms approving or denying unemployment or worker’s compensation benefits.
     • A copy of monthly pensions or income from retirement plans.
     • Written verification from public welfare agencies or any other governmental agency, which can attest to the patient’s income status for the patient or guarantor.
     • Denied Medicaid application request and documentation indicating MNSure premiums.
     • The application is reviewed and approved or denied based on the above guidelines by the Director of Revenue Cycle or CFO within 30 days of a completed application being provided to Welia Health.
   • d. The application is reviewed and approved or denied based on the above guidelines by the Director of Revenue Cycle or CFO within 30 days of a completed application being provided to Welia Health.
   • e. Persons will be notified of the decision of eligibility for the WeliaCare Program by letter.  A family membership card (one card per family) is included for all members that qualify.

• WeliaCare Application Process for Patients Qualified to File Federal Form 4029
  • a. All patients who file a Form 4029 and desire consideration under the Welia Health Charity Care program must apply for assistance in writing by completing the Personal, Dependent Children and signature sections and submitting a copy of the most recent Form 429.
    • Once the application has been approved the applicants will qualify for a discount to remain in effect for up to one year.  The discount applied will be 30% to gross charges for services received.  An additional 10% prompt pay discount is available for payments in full if received within 45 days from the date of the first letter.

ADDENDUM A – ENTITY NAMES NOT COVERED UNDER THE WELIACARE POLICY

1. Minneapolis Heart Institute
2. Consulting Radiology

ADDENDUM B – PROVIDERS COVERED UNDER WELIA HEALTH

TEMPORARY STAFF:

• Pappas, Charles
• Urbach, Jonathan
• Felzenberg, Emily
• Floyd, Alicia
• LeMaire, Jayden
• Arens, Carissa
• Scuderi, Joseph
• Cassady, Diane
• Godin, Elizabeth
• Sit, Nathan

LOCUM:

ACTIVE STAFF:

• Allen, Matthew G.
• Bostrom, Randall A.
• Dahlen, Donald A.
• Donner, Peter J.
• Gaalswyk, Ryan J.
• Kroschel, Kathleen M.
• Kroschel, Ryan R.
• Lind, Joseph B.
• Niskanen, Brian D.
• Olen, Jessica M.
• Schultz, Matthew D.
• Schwinghamer, Jack D.
• Weeks, Robert M.

ASSOCIATE STAFF:

• Alapati, Subba
• Al Maluli, Hayan
• Amin, Kathan
• Annen, Michael
• Asaithambi, Ganesh
• Belson, Patrick
• Bonner, Wendell, R.
• Dirks, Timothy
• Dombeck, Teague
• Dondlinger, Steven
• Dubay, Rachel
• Esse, Katherine
• Feierabend, Siegfried
• Fraser, Robert
• Gao, Wangcai
• Giannakidis, Dimitrios
• Hamid, Nadira
• Hall, Christopher
• Hanson, Sandra
• Hoj, Kenneth
• Horst, Brian
• Hryniewicz, Katarzyna
• Hyun, Eric
• Jeyakumar, Arthie
• Kuhnlein, Ryan
• Lerner, David
• Maurer, Kyle
• Massaquoi, Reyanna
• McKenna, Kim
• Mello, Ryan
• Meyer, Russell
• Nigam, Gaurav
• Piroso, Ettore
• Samara, Michael
• Severnak, Todd
• Stokman, Peter
• Thacker, Tapan
• Thomson Treat, Ruth
• Torseth, John
• Watt, Douglas
• Weber, Brennan
• Willardsen, Darin
• Uricchio, Joseph
• Zimbwa, Peter

CONSULTING STAFF:

• Althoen, Morgan
• Amin, Vinit B.
• Argentieri, Jennifer A.
• Lin, Sopo
• Arms, Joseph
• Arslanlar, Norman
• Bae, Richard Y.
• Baillargeon, Amanda
• Bennett, Mosi K.
• Bergman, Danielle M.
• Binder, Curtis L.
• Blackwell, Charles D.
• Bodeau, Geoffrey R.
• Bradley, Steven M.
• Brandt, Donald E.
• Buckler, Joshua
• Burns, Durand E.
• Cabuay, Barry M.
• Cady, Michael T.
• Cady, Rachel S.
• Caldwell, Douglas P.
• Campbell, Alex R.
• Carolan, Patrick L.
• Cavalcante, Joao
• Chahla, Saydi
• Chamberlain, Marydee C.
• Chandrabalan, Amee N.
• Cheng, Victor
• Chu, Matthew C.
• Chung, Willis C.
• Clary, Andrew M.
• Copelan, Alexander
• Conway, Andrea
• Delgado, Josser E.
• DePompolo, Anna M.
• Dorn, David P.
• Doyscher, Mark W.
• Dryden, Sarah
• Durand, David A.
• Eckman, Peter M.
• Edelman, Kevin R.
• Engstrom, Bjorn I.
• Farris, Paul A.
• Frankwitz, Alicia A.
• Gebhard, Thomas
• Golding, Daniel
• Gowda, Naveen K.
• Groebner, Nathan J.
• Gross, David A.
• Hafferman, Susan K.
• Halverson, Jennifer R.
• Halvorson, Ronald D.
• Harris, Kevin M.
• Hassell, Douglass S.
• Hauck, Samuel J.
• Hetzel, Thomas M.
• Hick, Karen L.
• Hirschman, David A.
• Hite, Stephen H.
• Holien, Chad A.
• Hollander, David S.
• Houghland, Mark A.
• Hudson, Mark J.
• Hurrell, David G.
• Huynh, Jimmy
• Hyde, Brenda
• Ibach, Thomas J.
• Inampudi, Subbarao
• Jahangir, David A.
• Jahangir, Kayleen
• Jay, Desmond B.
• Jha, Vaishali
• Jibben, Celeste
• Johnson, Terry A.
• Kampa, John P.
• Kane, Jon P.
• Karow, Jillian A.
• Kayan, Yasha
• Keig, William C.
• Keszler, Jason L.
• Kharbanda, Anupam B.
• Klatzko, Martin D.
• Klucar-Stoudt, Adrianna M.
• Knickelbine, Thomas
• Kocken, Paula F.
• Kurisko, Stanley D.
• Larson, Tom D.
• LeBlanc, Justin W.
• Lee, Peter U.
• Leidig, Fritz
• Lesser, John R.
• Lin, David
• London, Michelle S.
• Longley, Deborah G.
• Madhok, Manu
• Magnuson, Jeffrey E.
• Manger, Philip
• Massin, Brandon
• Masood, Moeen
• Matson, Thomas C.
• Meyer, Brendan M.
• Miedema, Michael D.
• Miller, Andrew
• Miller, Lisa A.
• Mills, David J.
• Milner, Donna M.
• Mooney, Michael R.
• Morrell, David S.
• Mullin, Thomas M.
• Nelson, Dana L.
• Nelson, Joel
• Nelson, Thomas M.
• Newell, Marc C.
• Nobrega, John M.
• Ogbogu, Kene G.
• Orlandi, Quirino G.
• Ortega, Henry W.
• Osayomore, Amadin O.
• Pappas, Anastasios A.
• Parker, Robin J.
• Parker, Trudi
• Patterson, Matthew C.
• Peterson, Jeffrey J.
• Plouff, Robert T.
• Qualey, Bradley J.
• Rathousky, Phillip
• Reid, Samuel R.
• Ricke, Tracy L.
• Romans, David
• Roohani, Pezhman
• Rudser, Annalisa K.
• Rust, Paul R.
• Santos, Edward Rainier G.
• Saxena, Retu
• Schnellinger, Mark G.
• Schroeder, Brian
• Shelton, Jack B.
• Sicoli, Robert A.
• Sidney, Scott D.
• Skrypek, Thomas M.
• Soloff, Erik
• Sondag, Matthew J.
• Steely, John W.
• Stoeckeler, Joel
• Strauss, Craig E.
• Street, Kellee A.
• Swenson, Alice D.
• Tamene, Ashenafi M.
• Tarrel, Ronald M.
• Thiessen, Norma L.
• Tillotson, Christopher L.
• Todd, Adam J.
• Tortorelis, Dean G.
• Tran, Huy Q.
• Van Tyn, Marlieke
• Veldman, Sara B.
• Waters, Kurtis A.
• Weimerskirch, Debra A.
• Whitcomb, Valerie T.
• Wu, Betty C.
• Wyatt, Billy D.
• Yapundich, Robert
• Yost, Robert A.
• Youn, Albert H.
• Zenker, Paul N.
• Zubkov, Alexander

ALLIED HEALTH PROFESSIONAL STAFF:

• Albrecht, Ryan
• Anderson, Nicole
• Axtell, Amber
• Smothers, Maria
• Titus, Sophia
• Backlund, Hans
• Benson, Chelsea L.
• Bjorklund, Jordan
• Bojado, Lisa D.
• Burk, Aimee M.
• Clapper, Nathan C.
• Coleman, Renee L.
• Cook, Breanna M.
• Danielson Anderson, Darla R.
• Detert, Jenifer K.
• Deutschlander, Heidi S.
• Dowell, Cherie
• Dvorak, Joseph
• Dvorak, Kati J.
• Fortier, Joseph
• Frazier, BethAnn
• Gerding, Carly
• Gilbertson, Elizabeth
• Giller, Nicholas G.
• Hamiel, Matthew J.
• Herges, Erika
• Herges, Jill A.
• Houglum, Jenny A.
• Huseby, Amy L.
• Kempf, Beth
• Kennedy, Alana
• Koski, Shannon M.
• Krogstad, Brian N.
• Kroll, David W.
• Lange, Todd D.
• Lind, Patricia R.
• Maul, Tawney
• McDaniel, Amy M.
• Moore, Sandra J.
• Mork, Gordon, Troy
• Mork, Joseph T.
• Naumann, Whitney M.
• Paschke, William P.
• Patterson, Ashley
• Penrose, Kelli J.
• Perreault, Julie A.
• Peterson, Jennifer L.
• Schoenecker, Jody
• Shierts, Erin
• Sickler, Benjamin C.
• Smith, Elisa M.
• Sterk, Anthony J.
• TenNapel, Scott A.
• Thompson, Brent J.
• Tomann, Sarah M.
• Turnblom, Daniel H.
• Valentine, Corey E.
• Voss, Dustin P.
• White, Rebecca J.
• Winn, Cara
• Woods, Robert M.

Section	WeliaCare Charity Care	Effective Date	April 2023
Contact	Business Office; Finance	Last Review	April 2023
Approved by	Governing Board Policy & Procedure Committee	Next Review	October 2024
Reference		Approval Date	May 17, 2023 May 4, 2023
Destination	Organization-Wide

WeliaCare Charity Program