WeliaCare Charity Care (plain language)
Last reviewed April 2023
Welia Health is committed to its mission and vision in providing healthcare 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. Our financial assistance program is called WeliaCare.
- Eligible patients are those who qualify for the program by meeting the income and asset guidelines.
- Must pertain to medically necessary care provided by Welia Health.
- Services must be billed by Welia Health to be eligible for the program.
- Application must be completed and returned with supporting documents.
- This is not an insurance program.
Program qualifications and discounts
- An accumulated self-pay balance of $250 or more.
- 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, and the amount generally billed (AGB) based on the 12-month lookback period for all payors described in Reg § 1.501(r)-5(b)(3).
- For additional information about the AGB limits, see full WeliaCare Charity Care policy.
- Patient must live in the state of Minnesota or Wisconsin to be eligible for the WeliaCare program.
How to apply for WeliaCare and obtain copies
The applicant will be required to provide the following information to determine eligibility:
- 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.
- Copies of four most recent 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 (if applicable).
There are three ways to receive a WeliaCare application and the WeliaCare Charity Care policy:
- Download a copy of the WeliaCare application and policy.
- Pick up an application and policy from the Patient Financial Representative at Welia Health, 301 Hwy 65 S, Mora, MN 55051.
- Contact our business at 320.225.3340 and request a free copy of our application and policy to be mailed to you.
Return completed application with the required documents to:
Attn: Patient Financial Representative
301 Hwy 65 S
Mora, MN 55051
- If you do not have insurance, you may qualify for medical assistance through your county or state.
- Before any appointment at Welia Health, check with your insurance company for coverage requirements, including if a referral or prior authorization is required.
- Welia Health will bill your insurance for charges related to your visit. You will be responsible for any remaining balance.
- Patients determined to be eligible for financial assistance will not be charged more than the amounts generally billed (AGB) for emergent and medically necessary care to patients who have insurance.
- If you are unable to pay your balance in full or have questions regarding your bill, please contact Welia Health’s Business Office at 320.225.3340.
- A collection agency and Revenue Recapture are used when balances go unpaid.
|Section||WeliaCare Charity Care||Effective Date|
|Contact||Business Office||Last Review||New|
|Approved by||Policy & Procedure Committee||Next Review||October 2023|
|Reference||Approval Date||March 2023|