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To apply for financial assistance please complete this application and mail to:

Financial Assistance
125 Indigo Creek Dr.
Rochester NY 14626
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Financial Assistance & Charity Care


“The mission of Unity Health System is to make a positive difference in the lives and health status of individuals in the City of Rochester and Western Monroe County. We will educate our community, our providers and future health care professionals in order to offer the highest quality care to all members of our community, especially those who are underserved and most vulnerable.”

Unity Health System and its affiliates are committed to caring for patients 24 hours a day, seven days a week, 365 days a year, regardless of ability to pay.

The Charity Care Program has been developed to help the Health System meet the needs of our patients who are either uninsured or require assistance in meeting their financial obligations while maintaining the financial viability of the Health System. The following principles and guidelines explain how the Health System assists patients that cannot afford to pay for part or all of their essential Health Care services access the Charity Care Program.

  • Unity Health System believes that fear of a hospital bill should never get in the way of essential health services. This message will be proactively conveyed to prospective patients and local community service agencies.
  • We are committed to creating financial aid policies that are consistent with the mission and values of the Health System, that take into account each individual’s ability to contribute to the cost of his or her care, and the Health System’s financial ability to provide the care.
  • We will communicate our Charity Care policy in a manner that is clear, understandable, sensitive to the patients dignity and in a language appropriate to the communities and patients served. Designated staff is provided detailed training so that they are able to provide information and answer questions related to this program.
  • We are committed to implementing debt collection policies that reflect the mission and values of the organization.
  • Unity Health System will work with government, payers, consumer groups, employers and others to find solutions to expand access to health care coverage to all New York residents.
  • The Charity Care program does not eliminate personal responsibility. Eligible patients will be expected to access public or private insurance options in order to qualify for financial aid. However, all patients will be expected to contribute to their care based on their ability to pay.
  • The Health System maintains patient confidentiality in all aspects of its operations including this program.


Eligibility for Charity Care

Patients must be US citizens or non-residents residing in the country for a period of at least three months.

Insurance coverage

For patients without insurance, assistance with the application process for Medicaid, Family Health Plus and Child Health Plus is available. Patients must participate fully in all efforts to obtain any insurance for which they may qualify. Financial assistance is available to insured patients who require assistance in meeting their financial obligations related to deductibles, co-pays and coinsurance.

Covered Services

The Charity Care program covers all Health System medically necessary services. Cosmetic Services, Long Term Care Inpatient Services, television and telephone charges are excluded from the program. Park Ridge Living Center Transitional Care Center (TCC) stays are only eligible for Phase II Financial Assistance discounts. In addition, self pay balances as a result of a patient’s failure to comply with insurance company requirements are also not covered.

The provision of emergent or urgent health care is never delayed pending a Charity Care determination.

Qualifying Service Period

The program recognizes the benefit to patients when they are aware of their financial responsibilities for health care services prior to receiving services. Unity Health System will attempt to communicate the program to patients by using a variety of techniques such as written notice, signage and verbal communications. It is recognized, that is some cases, patients may not apply for Charity Care prior to services being rendered. Also, a patient’s circumstances may change after services are provided and they may wish to apply for the program at that time. In an effort to recognize these circumstances the “qualifying period” will go back six months and forward into the future for six months. It is understood that the six month future coverage can be reduced if the patients circumstances (i.e. employment, insurability, etc.) changes.

Financial Guidelines:

The Charity Care program is intended to assist patients who can not afford to pay in full for their care. A patient’s ability to contribute to the cost of his or her care will be considered. Charity Care is not a substitute for employer-sponsored, public or individually purchased insurance.

Charity Care assistance is determined in the following manner:

Through assessment of the responsible party’s annual household income and the number of people in the home, as a percentage of the Federal Poverty Guideline amounts for same size households. The financial guidelines will be updated annually in conjunction with the Federal Poverty updates published by the Deptartment of Health and Human Services. Patients falling within 400% of the guidelines will receive a discount from Health System charges. The discount amount for medical services will either follow the Unity Health System Financial Assistance fee scale or be equal to the Medicaid DRG, APG Base rate plus capital add-on or Medicaid fee schedule, whichever is less. The discount amount for dental services will follow the Unity Health System Financial Assistance fee scale.

Those patients who do not fall within 400% of the poverty guidelines will be required to submit additional information regarding income, liquid assets and expenses.

Consideration will be given to the size of the financial obligation. The program is generally designed so that patients are not expected to expend more that 20% of their income or 10% of assets (generally liquid) for qualifying healthcare obligations.

Patients who have exhausted their insurance benefits and/or exceed financial eligibility criteria but face extraordinary medical costs will be treated on a case-by-case basis.

The program does recognize the need to maintain certain levels of patient responsibility so that;

- The program or health services are not abused.
- The program has funding available.
- The Health System maintains its financial ability to provide care to the community.

Any bill amount remaining after application of the Charity Care discount is the responsibility of the patient. The patient will be assisted by the Hospital in making arrangements to satisfy any remaining balance on the account(s) by use of a payment plan.


The Health Systems procedure for implementation of the Charity Care program is as follows:

1. Communication
  • The Health System provides communications to the public regarding financial assistance that are written in consumer friendly terminology and in a language that is appropriate for our patients.
  • Information regarding the availability of the Charity Care program and a contact number is noted on patient bills and on department materials that are sent to patients prior to their scheduled date of service. Upon request, brochures are also available in registration areas.
  • Notices regarding the Health System Charity Care program are posted throughout the organization in key public access areas. These notices include instructions for obtaining applications and/or additional information.
  • Patients are educated about their responsibilities, their potential financial obligations, their obligations for completing eligibility documentation and the Health Systems bill collection policies through the registration or financial counseling process.
  • Facilitated Enrollers, Medicaid Liaisons, or Financial Counselors are available to provide assistance in applying for Medicaid, Family Health Plus and/or Child Health Plus for health care needs.

2. Staff Training
  • The Health System provides training to new staff members during the general orientation session. In addition, all existing staff members receive training through the Health System mandatory, annual training and exam.
  • Patient registration staff members receive additional training regarding the Charity Care program on an annual basis. These staff members are trained so they can generally explain the process and direct patients to an appropriate financial counselor or patient account representative for further assistance.
  • Financial Counselors and Patient Account Representatives receive detailed training about all aspects of the Health Systems Charity Care Program, policies and procedures in order to provide them with the information needed to implement the program.

3. Program Administration
  • Health System communications are written and verbally communicated in a way that is easily understood, respectful and promote appropriate access to care.
  • Documentation requirements are easy to follow and include items such as pay stubs, income declaration, tax returns, rent receipts and medical bills.
  • Applications are processed consistently, correctly and in a timely manner.

4. Application/Determination Process

  • Financial Counselors make every effort to interview all inpatients without full insurance coverage to determine insurance and/or Charity Care eligibility during the patients stay in the Hospital. In addition, any patient may contact a Financial Counselor or the Patient Accounting Department to learn more about the Charity Care Program. The procedure for contacting either of these areas is outlined in all published materials. In addition, all registration representatives are trained on how to direct patients to the appropriate area when questions arise related to Charity Care.
  • Upon receipt of the referral, the Patient Accounting Dept/Financial Counselor will conduct a financial assessment of the patient. If appropriate, the patient will be referred to a Medicaid Liaison/Facilitated Enroller to complete an application for Medicaid, Child Health Plus or Family Health Plus.
  • Medicaid Liaisons are available to assist patients throughout the Medicaid application/determination process. If necessary, Medicaid Liaisons are also available to assist with the fair hearing process.
  • Patients who are not eligible to apply for the above insurance or patients who are unable to obtain sufficient insurance coverage, are eligible to apply for Charity Care.
  • Charity Care applications may be submitted by patients, guarantors, guardians or Powers of Attorney. Applications will be accepted prior to, during or within six months of service date.
  • Once an application is received, the Financial Counselor/Patient Account Representative will determine eligibility and the qualifying discount amount. Additional documentation or information may be requested during this phase of the process.
  • Patients may be approved for Charity Care on an account by account basis or for a period of time up to six months. Patients will be required to update their financial information after six months if the need for Charity Care continues.
  • Charity Care applications are processed by the Patient Accounting Department timely and determinations are communicated to the patients within 10 business days of submission.
  • A patient or their representative may request reconsideration either by phone or in writing of a Charity Care determination if additional information is available that would change their application. A letter indicating the outcome of the reconsideration will be sent out within 10 business days of the request.
  • Bills will continue to be generated and mailed to patients during the application process however, payment will not be expected until the Charity Care determination is made as long as the patient submits required information within set timeframes.
  • Patients or their representatives who are unwilling to provide required documentation or comply with other aspects of the process are informed that they will not be eligible for Charity Care and that they are responsible for all Hospital charges related to their care.

Collection Policy
  • Unity Health System works with patients to establish a reasonable payment plan.
  • Patients or their representatives who do not fulfill their payment obligations within specified time periods will be referred to a collection agency for further collection activity.
  • Legal action, including the garnishment of wages, may be taken when there is evidence that the patient or responsible party has income and/or assets to meet their financial obligation.
  • Unity Health System will not force the sale or foreclosure of a patient’s primary residence to pay an outstanding medical bill when a patient is being considered for Charity Care.
  • The Health System maintains a written agreement with each collection agency it retains. These collection agencies are required to follow Health System guidelines when pursuing payment of an account. Accounts referred to collection agencies are subject to all standard collection practices.
  • In the event a patient/patient representative inquires about the Charity Care program during the collection agency process and are still within the eligible time frame to apply, the patient will be referred to the Patient Accounting Department for processing.

  • The Health System board is provided with detailed information regarding the Charity Care Program on an annual basis.
  • The board will determine if additional guidelines are needed.