UVA Health Financial Assistance Policy: Northern Virginia & Culpeper

This policy applies to patient care at these locations:

  • UVA Health Culpeper Medical Center (CPMC)
  • UVA Health Haymarket Medical Center (HAMC)
  • UVA Health Prince William Medical Center (PWMC)
  • UVACH Medical Group
  • UVA Health Cancer Center Gainesville


It is the policy of UVA Community Health (UVACH), which includes UVA Health Culpeper Medical Center (CPMC), UVA Health Haymarket Medical Center (HAMC), UVA Health Prince William Medical Center (PWMC), UVACH Medical Group, and UVA Health Cancer Center Gainesville, to ensure access to needed healthcare services for all.

UVACH treats all patients, whether insured or uninsured, with dignity, respect, and compassion throughout the admissions, delivery of services, discharge, and billing and collection processes.

This policy is drafted with the intention of satisfying the requirements in Section 501(r) of the Internal Revenue Code of 1986, as amended, regarding financial assistance and emergency medical care policies, limitations on charges to persons eligible for financial assistance, and reasonable billing and collection efforts, and should be interpreted accordingly.


This policy is to be used by all UVACH acute care facilities and does not cover elective procedures.


Amounts Generally Billed (AGB) – Amounts Generally Billed refer to amounts generally charged to patients for urgent and medically necessary services who have health insurance for those services. The costs of patients who are eligible for financial assistance will be limited to a maximum of the amounts generally billed ("AGB") for such services.

These charges are based on the average amounts allowed by Medicare and commercial payers for emergency and other medically necessary care. Allowable amounts include both the amount to be paid by the insurer and the amount, if any, that the individual is personally responsible for paying. CPMC, PWMC, and HAMC AGBs are calculated using the retrospective method under 26 CFR §1.501(r). For more information on the AGB discount, see Appendix A.

Assets – The total value of what you own, including bank and retirement accounts, home, car, etc. Additionally, countable assets include the liquidated value of land (including farmland), equity in recreational vehicles, boats, second homes, etc. Assets included in the formula for financial assistance consideration will be the amount less than $50,000.

Bad Debt – Cancellation of Accounts Receivable as uncollectible, but still considered an outstanding balance.

Cosmetic – Surgeries whose primary purpose is to improve appearance.

Disproportionate Share Hospital (DSH) – A hospital that serves a high number of low-income patients and receives payments from the Centers for Medicaid and Medicare Services to cover the costs of providing care to uninsured patients.

Eligible Services – The services provided by UVACH facilities that are eligible under this financial assistance policy shall include:

  • Emergency medical services provided in an emergency room setting
  • Non-elective medical services provided in response to life-threatening circumstances in a non-emergency room hospital setting
  • Medically necessary services

Emergency Medical Condition – A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child
  • Serious impairment to bodily functions
  • Serious dysfunction of any bodily organ or part

Extraordinary Collection Actions (ECA) – Actions taken by a hospital facility against an individual related to obtaining payment of a bill for services covered under the facility’s financial assistance program.

Federal Poverty Guidelines – The Federal Poverty Level is used by the U.S. government to define the poverty level of a patient and his/her family for purposes of this Policy. It is based on a family's annual cash income, rather than its total wealth, annual consumption, or its own assessment of well-being. The poverty guidelines are updated annually in the Federal Register by the U.S. Department of Health and Human Services in effect at the time of such determination.

Flat Rate – A predetermined fee for certain services patients elect to have that are paid for by the patient at the time the services are performed.

Guarantor – The patient, caregiver, or entity responsible for payment of a health care bill.

Head of Household – The individual listed on a tax return as “Head of Household”.

Homeless – An individual without permanent housing who may live on the streets; stay in a shelter, mission, abandoned building, or vehicle; or in any other unstable or nonpermanent situation. An individual may be considered to be homeless if the person is “doubled up” with a series of friends and/or extended family members greater than 90 days.

Household Income – Gross cash or cash equivalents earned by or provided to an individual. Items not considered as income are noncash benefits and public assistance, such as food and housing subsidies and educational assistance.

Household Family Members (“Dependents”) – Individuals “residing” in a household which are claimed on the tax return of the Head of Household.

Medical Eligibility Vendor/Medical Assistance Advocacy – Advocacy vendor contracted by UVACH to screen patients for government programs and UVACH Financial Assistance.

Medically Necessary Services – Healthcare services needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine. In any of those circumstances, if the condition produces debilitating symptoms or side effects, then it is also considered medically necessary to treat.

Non-Eligible Services – The following healthcare services are not eligible for financial assistance under this policy:

  • Services provided as a result of an accident. These charges are subject to all legal instruments required to ensure third-party liability payment, even if these instruments are filed after the initial eligibility for the Patient Financial Assistance Program has been approved. If third-party coverage exists, UVACH will collect the balance owed from the third-party payer. In the event a balance remains after insurance the patient may apply for financial assistance. Insured patients that are within the income and resource threshold (at or below 400% of the Poverty Guidelines and assets at or below $50,000), may apply for financial assistance as long as it does not conflict with a contract between the insurance company and UVACH.
  • Elective non-medically necessary procedures, such as cosmetic and flat rate procedures, and patients with insurance who choose not to use their insurance, durable medical equipment, home care, and prescription drugs.

Regulatory Requirements – By implementing this policy, UVACH shall comply with all other federal, state, and local laws, rules, and regulations that may apply to activities conducted pursuant to this policy.


The rationale for this procedure is UVACH screens to identify individuals and their family members who may qualify for federal, state, or local health insurance programs or the UVA Community Health Patient Financial Assistance Program (“FAP”). Application of this policy to any individual patient is contingent upon satisfactory completion of the application for financial assistance with all necessary documentation. Any patient who refuses to satisfactorily complete the financial assistance application including the supporting documentation is not eligible for financial assistance under this policy (provided the patient has received the notifications required by the regulations under Section 501(r)). UVACH may not deny financial assistance under its FAP based on an applicant's failure to provide information or documentation unless that information or documentation is described in the FAP or FAP application form. See Appendix B for information regarding how patients may obtain a financial assistance application.

UVACH will provide, without discrimination, care for emergency medical conditions and/or labor to individuals regardless of whether they are FAP-eligible. UVACH will not engage in any actions that would discourage individuals from seeking emergency medical care and has an EMTALA policy in place that prohibits any delay in examination or treatment in order to inquire about a patient’s insurance or payment status. The UVACH EMTALA policy also sets forth procedures for accepting appropriate transfers of patients with emergency medical conditions from other facilities.

UVACH expects all patients to be screened for federal, state or local insurance programs prior to being screened for UVACH FAP. Because the FAP is not a substitute for personal responsibility, persons seeking financial assistance through the Program are expected to cooperate with UVACH’s procedures for determining eligibility and to contribute to the cost of services to the extent of their individual ability. Patients are expected to provide appropriate and timely information to UVACH to obtain financial assistance. Individuals with the financial capacity to purchase health insurance shall be encouraged to do so, as a means of assuring access to broader healthcare services and for their overall personal health. If a patient elects not to bill his/her insurance for a particular procedure or date of service, that visit will not be eligible for FAP.

In certain situations, applicable state law may impose additional or different obligations on hospital facilities in such states. The intent of this policy is to satisfy both the Federal and state law requirements in such states. Accordingly, certain provisions are only applicable in certain states as noted below.

Eligibility Criteria

UVACH provides primary health services to any individual seeking care and does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of inability to pay; whether payment for those services would be made under Medicare, Medicaid, or CHIP; the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity.

Amounts Charged to Patients

The FAP provides 100% financial assistance for Eligible Services to uninsured and insured patients with an annual gross family income at or below 200% of the current Federal Poverty Guidelines (FPG) as adjusted annually and assets at or below $50,000 as established and defined in this policy. UVACH also offers a discounted rate to patients whose family gross income is between 201% and 400% of the FPL and with assets at or below $50,000. (Appendix C).


An FAP-eligible person will not be charged more than the AGB for emergency or other medically necessary care. UVACH AGB is market adjusted annually and is based on the look-back method utilizing Medicare and commercial rates, including co-payments and deductibles (Appendix D). UVACH also offers a self-pay discount to uninsured patients who do not qualify for financial assistance.

Period of Admissibility

Patients can apply for financial assistance up to 240 days after the first billing statement date. If the patient is approved for financial assistance, their coverage is valid for 5 years prior and 365 days post their application signature date. Patients approved for financial assistance that return for services during their 240-day approval timeframe will be screened for federal, state, or local health insurance programs upon each visit. The UVACH financial assistance program is not insurance.

Participating Providers

Certain medically necessary and emergency care services are provided by non-UVACH providers who are not employees of UVACH who may bill separately for medical services and who may not have adopted this financial assistance policy. See Appendix E for details regarding the full list of providers who provide emergency or other medically necessary care and who have not adopted UVACH’s financial assistance program.

Procedural Guidelines

See Appendix F for the procedural guidelines.

This policy is approved by the UVACH Board of Directors. For more information on billing and collections, please see our Billing and Collections Policy.


Appendix A: UVA Health Culpeper Medical Center (CPMC) AGB Discount

UVA Health Culpeper Medical Center (CPMC) AGB Discount: For more information about the AGB discount, call customer service: 540.829.4320 or 540.829.4330 (Local).

UVA Health Haymarket Medical Center Discount: For more information on the AGB discount, call UVA Haymarket Medical Center (HAMC): 571.284.1517

UVA Health Prince William Medical Center (PWMC): AGB Discount For more information about the AGB discount, call UVA Prince William Medical Center (PWMC):  703.369.8020

Appendix B: Obtaining Financial Assistance Information

Patients may obtain a financial assistance application from our Financial Assistance page, a registrar or financial counselor located at one of our hospital facilities, or by calling customer service at the following numbers:

Appendix C: Adjustment Percentages

UVA Health Culpeper Medical Center (CPMC) Adjustment Percentages

Assets <=$50,000 and Gross Income: Adjustment
<=200% FPL 100%
201%-300% 85%
301%-400% 75%

UVA Health Haymarket Medical Center (HAMC) Adjustment Percentages

Assets <=$50,000 and Gross Income: Adjustment
<=200% FPL 100%
201%-300% 85%
301%-400% 75%

UVA Health Prince William Medical Center (PWMC) Adjustment Percentages

Assets <=$50,000 and Gross Income: Adjustment
<=200% FPL 100%
201%-300% 85%
301%-400% 75%

UVACH Medical Group Adjustment Percentages

Assets <=$50,000 and Gross Income: Adjustment
<=200% FPL 100%
201%-300% 85%
301%-400% 75%

Appendix D: Amounts Generally Billed

Location AGB
UVA Health Culpeper Medical Center (CPMC) 31.6%
UVA Health Haymarket Medical Center (HAMC) 27.0%
UVA Health Prince William Medical Center (PWMC) 32.9%

Appendix E: Participating Providers

For a full list of physicians who provide emergency or other medically necessary care and who have not adopted UVACH’s financial assistance program, please visit our Financial Assistance page.

Appendix F: Procedural Guidelines

These guidelines are provided to assist personnel in accomplishing the goals of this policy. While following these procedural guidelines, personnel are expected to exercise judgment within their scope of practice and/or job responsibilities.

Eligibility Process

The following process will be used to determine eligibility for financial aid:

  • The patient or other designated representative completes and signs an application. The purpose of the application is to record the data necessary to verify the patient's eligibility for financial assistance.
  • External data sources can be used to provide information about a patient's or their guarantor's ability to pay (such as credit score).
  • Patients must have an account balance or service scheduled with UVACH before applying for financial assistance. Eligibility can be determined at any time during the income cycle.
  • Patients who refuse to participate and cooperate with our medical eligibility providers will not be eligible for financial assistance under this policy.
  • The financial aid applicant will be notified by mail if additional information is needed. The letter will advise the applicant to return the information within 30 working days of receipt of the letter. If the requested information is not received within 30 business days, no further action will be taken in relation to the applicant's financial aid application.
  • Requests for financial assistance will be processed promptly and UVACH will make reasonable efforts to notify the patient of approval or denial within 14 days of receipt of all information required to complete the application.

Income Verification, Assets, and Resources

The following documents can be used to verify the family's income:

  • Complete tax returns for the patient's household for the most recent calendar year.
  • If the patient is self-employed, a copy of the latest financial statement; If desired, you can add a patient's business address or quarterly number along with the previous year's business tax return and the patient's individual tax return
  • The last three pay stubs or a statement from the company
  • Current letter of unemployment benefits or workers' compensation stating the denial or entitlement to benefits and the amount received
  • Current Social Security letter, disability notification letter, or full bank statement for Social Security direct deposits
  • Current Pension Status
  • SNAP Letter
  • Court document or letter from the non-custodial parent stating the amount of child support received
  • Rental agreement or documentation evidencing gross rental income
  • Documentation listing the value of stocks, bonds, certificates of deposit, health savings accounts (HSAs), or any other property the patient may own
  • Full copy of any checking, savings, or money market accounts

Other income or asset resources will be evaluated, including resources from savings, checking, and retirement accounts as well as certificates of deposit (CDs). Health Savings Accounts (HSA’s) will be evaluated and any monies available will be required to be used on health care expenses before any financial assistance funding can be granted. A copy of all household members’ bank statements will be requested. If the applicant has not provided this documentation, UVACH will send the applicant a letter requesting additional information. If any documentation is still not provided, financial assistance will be denied.

Although proof of income is requested for consideration of the Patient Financial Assistance Program, some Local System DSH regulations may require proof of income. Such regulations will be handled on a case-by-case basis to ensure compliance with Local System DSH programs.

Financial Assistance Program Communication

UVACH will make reasonable efforts to ensure that information about our program and its availability is clearly communicated and made widely available to the public. Individuals may obtain a copy of our Financial Assistance Application and Policy at our Financial Assistance page. UVACH will also provide the website address to any individual who may ask.

Individuals may also obtain and receive assistance in completing the Financial Assistance Application from any of our registration areas, financial counselors, or cashier’s offices. The financial counselors or cashier’s offices are located within the patient registration areas. Individuals may stop at any of our information desks located within each hospital to ask for assistance in locating the financial counselors or cashier’s offices.

Individuals may obtain a free copy by mail of our Financial Assistance Application and Policy by calling our CPMC customer service department at 540.829.4320 or 540.829.4330 (Local). The PWMC and HAMC customer service department can be reached at 703.369.8020 (PWMC) or 571.284.1517 (HAMC).