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Patient Information - Billing - Financial Assistance - Application Process subpage_title_arrow

Application Process

Related Information
Here are some extra materials that may help you.

HealthTrust — Sliding Scale Discounts

  • In order to qualify for HealthTrust services, total family income is considered, including assets, liabilities and current medical debt. Additionally, funds residing in Health Savings Accounts or in Medical Spending Accounts must be fully exhausted in order to qualify for Health Trust services.
  • A "HealthTrust Application for Reduced Fee Services" must be completed in writing by the patient or someone serving in their interest. Completion of the application includes, but is not limited to, the following:
    • Employment information for all family members
    • Identification of Health Savings Accounts and/or Medical Spending Accounts and respective balances
    • Income information for all family members, including most recently filed federal tax returns and previous months' respective pay stubs
    • Documenting monthly expenses
    • Listing of all checking and savings accounts, including any retirement accounts and associated documentation
    • Listing of all other assets and liabilities for the family and associated documentation
  • To qualify for a reduction of greater than 50% of fees, evidence of application with the Department of Medical Assistance Services and/or the Social Security Administration programs must accompany the application.
  • The form must be signed and submitted to a Financial Counselor in the Patient Financial Services department at the address located on the form. By signing the form, the applicant is attesting that the information included with the form is a true and accurate representation to the best of his/her knowledge. Additionally, the signature grants Martha Jefferson Hospital permission to verify information with the sources.
  • An application will only be considered when all information, documentation and evidence of application to the Department of Medical Assistance Services and/or Social Security Administration, if appropriate, are received.
  • An interview may be deemed appropriate to complete the application process.
  • Approval notification will be delivered via mail or phone.
  • Applications and approval will remain in effect for a three month period from the date of application and will cover services rendered during this period. For services rendered outside of this period, the application must be updated and signed.
  • For reference, this chart shows eligibility criteria for charity care and discounts based on family income:

Payment Plan
  • To establish a payment plan for services rendered, the patient or responsible party must notify Martha Jefferson Hospital's Patient Financial Services Department to request the establishment of a payment plan.
  • The payment plan may not exceed 12 calendar months in duration.

Patients Responsibility

  • A request for financial assistance under this policy must be made by or on behalf of the patient. Patients may apply for, and will be encouraged to apply for financial assistance before or during the period of time services are rendered. Patients may also apply for financial assistance within a reasonable time after services are rendered.
  • To be considered for any option for which relief sought is greater than 50% of the their services, the patient or responsible party must cooperate to provide the information and documentation necessary to apply for other existing financial resources that may be available to pay for his or her health care, such as Medicaid, Medicare, etc.
  • To be considered for any option that is based on income determination, the patient or responsible party must provide the hospital with financial and other information needed to determine eligibility.
  • Patients who qualify for a partial discount must cooperate with the hospital to establish a reasonable payment plan, which takes into account available income and assets, the amount of the discounted bill(s), current medical debt payments and any prior payments.
  • Patients who qualify for partial discounts must make a good faith effort to honor the payment plans for their discounted hospital bills. Patients are responsible for communicating to the hospital any change in their financial situation that may impact their ability to pay their discounted hospital bill or to honor the provisions of their payment plans.
  • Patients who do not initially qualify for financial assistance after providing the requested information and documentation may re-apply if there is a change in their income, assets or family size.

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