Financial Assistance Application

Provider Listing

Federal Poverty Income Guidelines

Policy Statement:

Western Reserve Hospital is committed to providing financial assistance responsive to the needs of the community, regardless of race, age, gender, color, ethnic background, national origin, citizenship, primary language, religion, disability, handicap, education, employment or student status, disposition, relationship, insurance coverage, community standing, or any other discriminatory differentiating factor.

Healthcare Financial Assistance (“HFA”) is a program that is fully funded by Western Reserve Hospital. It covers patients without health insurance and those with only partial insurance coverage (i.e. the uninsured and underinsured) who meet the income and other eligibility criteria described herein.

Related Policies:                                               

Western Reserve Hospital offers other options for uninsured or underinsured patients who do not qualify for financial assistance under this HFA policy. For further information, please see the following Western Reserve Hospital policies:

Commitment to Provide Emergency Medical Care:

Western Reserve Hospital provides care, without discrimination, for emergency medical conditions to all individuals regardless of whether they can pay or are eligible for assistance under this HFA policy. Western Reserve Hospital  will not engage in actions that discourage individuals from seeking emergency medical care, such as by demanding that emergency department patients pay before receiving treatment for emergency medical conditions or by permitting debt collection activities that interfere with the provision of emergency medical care. Emergency medical services, including emergency transfers, pursuant to the Federal Emergency Medical Treatment and Labor Act are provided to all Western Reserve Hospital patients in a non-discriminatory manner. 

Services Eligible for HFA:

This HFA policy applies to all emergency and other medically necessary care provided by the Western Reserve Hospital, as well as certain other providers delivering emergency or other medically necessary care in Western Reserve Hospital’s facilities. Attached is a list of providers, other than the Western Reserve Hospital, delivering such care in Western Reserve Hospital facilities, that specifies which providers are covered by this HFA policy and which are not covered (see Attachment A). 

The following services are not covered under this HFA policy:

  • Items deemed “not medically necessary”.
  • Cosmetic surgery (identify by diagnosis & procedure done, etc.)
  • Bariatric charges. 

HFA Eligibility Criteria:


  • To apply for HFA, a patient or family member must complete an application (see Attachment B) including gross income for a minimum of 3 months (up to 12 months) prior to the date of application or date of service. Proof of income may be requested from patients requesting financial assistance consideration.
  •  Third party income scoring may be used to verify income in situations where income verification is unable to be obtained through other methods. 


  • There are situations where individuals may not have reported income but have significant assets available to pay for healthcare services. In these situations, Western Reserve Hospital may evaluate these assets as cash available to meet essential living expenses, which includes healthcare expenses. 

Health Savings Accounts

  • Western Reserve Hospital requires proof that Health Savings Account and/or Medical Savings Account funds have been depleted prior to providing healthcare financial assistance. 

Federal Poverty Guidelines

  • HFA eligibility is based upon expanded income levels of up to 400% of FPG and is prorated on a sliding scale. (See Attachment C). Approval is based upon the number of family members and family income.
  • If a dependent is disabled and over the age of eighteen, he/she will be included in family size. 

Health Insurance Marketplace (Exchange) Participation

  • If a patient has elected not to enter the marketplace/exchange, financial assistance may not be extended until they do so. Exceptions to this policy include patients discharged to a SNF, patients who are deceased with no estate, and patients who have documented homelessness.
  • Healthcare financial assistance may be offered once the patient meets the requirement for insurance. 

Geographic Area

  • Patients who live in the community served by a Western Reserve Hospital (Summit, Portage, and Medina counties) will be offered healthcare financial assistance. For those patients living outside of the geographic area, extenuating circumstances must be documented and approved by the PFS Manager. 

Self-Pay Balances after Insurance

  • For patients who have self-pay balances after insurance, payment will be required based on a sliding scale given their current household income (see Attachment C).
  • Upon receipt of the signed application, the information will be reviewed, income verified, and an eligibility determination will be made. 

Presumptive Eligibility

  • When a patient is personally unable, does not have a family member or executor or does not have an assigned power of attorney to complete patient’s application, the patient may be presumed to be eligible for financial assistance. Patients discharged to a SNF, patients who are deceased with no estate, and patients who have documented homelessness, may fall into this application exception and qualify as presumptive eligibility.  Patients determined to have presumptive financial assistance eligibility have no patient liability.
  • Western Reserve Hospital shall utilize available resources (e.g. technology solutions, service organizations, etc.) to obtain such information as credit score in order to assist in determining whether a patient is presumed eligible for financial assistance. 


  • Patients/guarantors shall cooperate in supplying all third party information including Motor Vehicle or other accident information, requests for Coordination of Benefits, pre-existing information, or other information necessary to adjudicate claims, etc. 
  • While the application is being processed, Western Reserve Hospital will request that patients who may be Medicaid-eligible apply for Medicaid. In order to receive healthcare financial assistance, the patient must apply for Medicaid and be denied for any reason other than the following:  
    • Did not apply;
    • Did not follow through with the application process;
    • Did not provide requested verifications. 

Accuracy of Application

  • Financial assistance may be denied under this HFA policy if there is reasonable suspicion of the accuracy of an application. If the patient/guarantor supplies the needed documentation and/or information requested to clarify the application, the financial assistance request may be reconsidered. Reconsideration will be reviewed and handled on a case-by-case basis. 

Application Process for HFA: 

  • Application forms (see Attachment B) are made available in Pre-Registration, Admission / Registration, and several alternative registration sites to facilitate early identification and initiation of the application process. Application forms may also be obtained by contacting Western Reserve Hospital as indicated on Page 5.
  • Western Reserve Hospital may accept verbal clarifications of income, family size or any information that may be unclear on an application.
  • Inpatients will be required to complete an application for each admission unless the patient is readmitted within 45 days of discharge for the same underlying condition.
  • Approved outpatient applications are effective for 90 days from initial date of service.
  • An inpatient application can also be used to cover outpatient services for the patient in the 90-day period immediately following the first day of the inpatient admission.
  • Applications will be valid retrospectively for a period of 3 years prior to the date of application regardless of inpatient or outpatient status. 

Financial Assistance for Catastrophic Situations: 

Western Reserve Hospital defines Catastrophic Situations as incurred medical expenses that result in patient responsible debts of greater than 25% of the gross annual family income.

  • Financial assistance for a catastrophic situation is available in accordance with Western Reserve Hospital’s Financial Aid Catastrophic Policy. 

Basis for Calculating Amounts Charged to Patients: 

Following a determination of eligibility under this policy, a patient eligible for financial assistance will not be charged more for emergency or other medically necessary care than the amount generally billed (AGB). At least annually, Western Reserve Hospital calculates an AGB percentage based on the Look-back Method (as defined by Treasury Regulations under section 501(r) of the Internal Revenue Code of 1986, as amended). Members of the public may obtain the current AGB percentage for any Western Reserve Hospital (and a description of the calculation) in writing and free of charge by contacting Western Reserve Hospital as indicated on Page 5.

  • Western Reserve Hospital does not bill or expect payment of gross charges from individuals who qualify for financial assistance under this policy. 

Actions Taken in the Event of Nonpayment:

  • The actions that Western Reserve Hospital may take in the event of nonpayment are described in a separate Billing and Collections Policy. Members of the public may obtain a free copy of this separate policy from the Western Reserve Hospital PFS by contacting Western Reserve Hospital as indicated on Page 5. 

Measures to Widely Publicize the HFA Policy:

  • Western Reserve Hospital makes this HFA policy, application form, and plain language summary of the policy widely available on its website, and implements additional measures to widely publicize the policy in communities served.
    • Website
    • Signage in all registration areas.
    • Statement of Financial Assistance Program on each patient statement
    • Financial Assistance Programs referenced in each personal contact phone call.
    • Western Reserve Hospital also accommodates significant presenting populations (greater than1000) within our community that have limited English proficiency by translating this HFA policy, all related billing and collection policies, the application form, and plain language summary of the policy into the primary language(s) spoken by such populations. 

Self-Pay Cash Price

  • Patients who do not qualify for financial assistance or choose not to apply may request to pay the Self-Pay Upfront Cash Price of 55% of gross charges.  Payment arrangement must be made with a Financial Counselor prior to services.  The Self-Pay Upfront Cash Price does not apply to patients who qualify for financial assistance.


Financial counselors are available to answer your questions about payment arrangements, insurance coverage, Medicare and other financial inquiries.

For more information about financial counseling, please call (330) 971-7597.


Contact Western Reserve Hospital Patient Account Services at (330) 255-3101. 

Representatives are available Monday through Friday from 9:00 a.m. to 12:00 p.m. and from 1:00 p.m. to 4:30 p.m.

Notice to Ohio Residents—Ohio Hospital Care Assurance Program (HCAP): Western Reserve Hospital  provides, without charge to the individual, basic, medically necessary hospital-level services to individuals who are residents of Ohio, are not Medicaid recipients, and whose income is at or below the federal poverty line. Covered services are inpatient and outpatient services covered under the Ohio Medicaid Program, with the exception of transplantation services and services associated with transplantation. Recipients of Disability Financial Assistance qualify for assistance. Ohio residency is established by a person who is living in Ohio voluntarily and who is not receiving public assistance in another state. Requests for financial assistance for Ohio residents are processed for HCAP first, and then are otherwise subject to the provisions of this HFA policy.