Mt. Ascutney Hospital and Health Center

Billing Questions/Financial Information

Mt. Ascutney Hospital and Health Center is dedicated to serving our patients, to the best of our ability, in a fiscally responsible manner. As a not-for-profit community hospital, and in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), we treat everyone seeking essential medical care, regardless of their ability to pay. 

However, it does cost money to run the hospital, and we kindly ask that you work with us to make sure that we have all the proper information regarding your insurance company/third-party payer and that you are willing to take responsibility, if you are financially able, for your portion of your hospital bill.


Do you need assistance to pay your bill for emergency or medically necessary care at Mt. Ascutney Hospital and Health Center?

MAHHC offers free or discounted care for emergency or medically necessary services provided to patients within our service area who qualify and are residents or to non-residents who experience a medical emergency while in our service area.

Generally, financial assistance will be available to help with balances you owe if:

  • You have no insurance or you are under-insured.
  • You are not eligible for insurance coverage or other governmental assistance, and either of the following is true:
    • Your family income is at or below 300% of the Federal Poverty Limit; issued by the Department of Health and Human Services (HHS), updated on a yearly basis, or;
    • If you believe that your assets, liquid assets, or other available resources are not enough to cover the cost of your care.

In addition to your completed application, we may require documents verifying your income, assets and medical expenses to determine whether you qualify for assistance. If you do not qualify for financial assistance, you may still be eligible for the prompt pay discount. You can fnd information below about how to get a copy of the full MAHHC Financial Assistance Policy which describes these potential discounts in more detail.

MAHHC Financial Policy

Patients without insurance cannot be charged any more than amounts generally billed to patients who have insurance covering the same care. MAHHC applies a discount to the FAP eligible patient’s gross charges to all balances where there is no insurance, or to medically necessary services processed by insurance carriers resulting in a balance, which the patient is expected to pay. This discount doesn’t apply to any co-payments, co-insurance, deductible amounts, pre-payment or package services which already refect any required discounts or any non-covered services per our policy.

How do I apply for financial assistance?

Windsor Community Health Clinic Patient Advocates and our Financial Counselors can assist you in identifying and applying for insurance coverage or other resources and with completing an application for financial assistance. If you have a remaining balance after exhausting all other coverage options, you may be eligible for financial assistance. An application can be requested in person, over the telephone or obtained via the web link below. At your request, a financial application form or copy of the Financial Assistance Policy will be mailed to you at no charge. Also, these documents and this brochure summary of the policy are available on this page and can be printed in alternative languages by contacting the public relations offce at (802) 674-7327. Translation and sign language services can also be arranged by request through any MAHHC clinical or clerical staff.

Do you need assistance completing an application?

You can get help in the following ways:

Receive in-person assistance by going to the following locations

Mt. Ascutney Hospital and Health Center
289 County Road
Windsor, VT 05089

Ottauquechee Health Center
32 Pleasant Street
Woodstock, VT 05091

Mt. Ascutney Hospital Ophthalmology
80 S. Main Street
Hanover, NH 03755

Call one of our Financial Counselors at

(802) 674-7471 or Windsor Community Health Clinic at (802) 674-7213

Please send completed applications to:

ATTN: Customer Service Department
Mt. Ascutney Hospital and Health Center
289 County Road
Windsor, VT 05089


Please see our policies below for guidance and an application for assistance in paying your bill.
MAH Credit and Collection Policy
Financial Assistance Application

Insurance Information
Mt. Ascutney Hospital files insurance claims on your behalf. This does not release you from responsibilities for charges billed to your account. Your insurance contract is between you and your insurance company. Regardless of the type of insurance you carry, your bill is ultimately your responsibility. Some portion of the bill that is not paid by your insurance carrier is charged directly to you. Examples include co-payments, deductibles and non-covered services, i.e. plastic surgery.

If You Do Not Have Insurance
If you do not have insurance, you may qualify for State Assistance (Medicaid) or for help through assistance programs offered by Mt. Ascutney Hospital and Health Center. Please note, that in order to qualify for financial assistance from the hospital, you must complete a financial disclosure form and meet certain eligibility requirements. To find out more about financial assistance programs see our policies above or review our Financial Assistance Policy brochure.

For more information on Vermont health programs, you can link to the web site, Another resource available is the Vermont Drug Price Finder which you can access at

Bills for Hospital Services
Hospital services including inpatient stays, laboratory, radiology, physical therapy, occupational therapy, the Miller Therapeutic Pool, oncology services and chemotherapy, and emergency room visits generate bills from the hospital. Depending on the services you received, you may get more than one bill. Once your insurance company has paid your bill(s), if there is a balance due, you will receive a statement. If your insurance company pays your bill in full, and you would like to have an itemized statement, you must request one. Statements show payments received from your insurer and any payments due from you.

Physicians’ Bills
Charges for physicians’ services are not included in your hospital bill. Most of the physicians involved in your care send separate bills. You may receive bills, for example, from your hospitalist, primary care physician, anesthesiologist, surgeon, or radiologist.

If you Have Questions About Your Bill
If you have any questions about your hospital bill and you are an inpatient, please contact your case manager. Patients who are discharged, as well as outpatients should call the hospital’s Customer Service Department at (802) 674-7471. Please have your insurance card with you when you call. If you wish to speak to someone about setting up a payment plan, please call (802) 674-7319.



To establish a policy for the administration of Mt. Ascutney Hospital and Health Center’s (MAH) financial assistance for healthcare services program. This policy outlines the following with respect to all emergency or other medically necessary care provided by all MAH facilities:

  • eligibility criteria for financial assistance
  • method by which patients may apply for financial assistance
  • basis for calculating amounts charged to patients eligible for financial assistance under this policy and limitation of charges for emergency or other medically necessary care
  • MAH’s measures to publicize the policy within the community served

This policy is intended to comply with the requirements of VT, the Internal Revenue Code Section 501(r) and the Patient Protection and Affordable Care Act of 2010 and will be changed from time to the extent required by applicable law.


For purposes of this policy, "financial assistance" requests pertain to the provision of emergency and other medically necessary care provided in any MAH facility by MAH or any provider employed by MAH.


Financial assistance (also known as “affordable care”): The provision of healthcare services free or at a discounted rate to individuals who meet the criteria established pursuant to this Policy.

Presumptive financial assistance: The provision of financial assistance for medically necessary services to patients for whom there is not a completed MAH Financial Assistance Form due to lack of supporting documentation or response from the patient. Determination of eligibility for assistance is based upon individual life circumstances demonstrating financial need. Presumptive financial assistance is not available for balances after Medicare.

Family: As defined by the U.S. Census Bureau, a group of two or more people who reside together and who are related by birth, marriage, or adoption.

  • The state law regarding marriage or civil union and the federal guidelines are used to determine who is included in a family.
  • In the case of applicants who earn income by caring for disabled adults in their homes, the disabled adult will be counted as a family member and their income included in determination.
  • The Internal Revenue Service rules that define who may be claimed as a dependent for tax purposes are used as a guideline to validate family size in granting financial assistance.

Household: A group of individuals primarily residing in the same household who have a legal union (blood, marriage, adoption), as well as unmarried parents of a shared child or children. A patient's household includes the patient, a spouse, a dependent child, unmarried couples with a mutual child dependent living under the same roof, same sex couple (married or civil union), parents claimed on adult child’s claim on a tax return.

Family Income: As defined under the federal poverty guidelines as published annually by the U.S. Department of Health and Human Services ("FPL"), based on:

  • earnings, unemployment compensation, workers’ compensation, Social Security, Supplemental Security Income, public assistance, veterans’ payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources;
  • noncash benefits (such as food stamps and housing subsidies) do not count;
  • pre-tax income;
  • the income of all family members (Non-relatives, such as housemates, do not count).

Uninsured patient: A patient with no insurance or other third party source of payment, whose out-of- pocket expenses nevertheless exceed his/her ability to pay in as determined according to this Policy.

Gross Charges: The total charges at the organization's full established rates for the patient’s healthcare services

Emergency medical conditions: As defined within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd), a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

  • placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
  • serious impairment to bodily functions, or
  • serious dysfunction of any bodily organ or part

Medically necessary: As defined by Medicare with respect to healthcare items or services, reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.


MAH is committed to providing financial assistance to persons who have healthcare needs but do not have the financial means to pay for services or balances that are their responsibility. MAH strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. A patient can apply for financial assistance any time before, during, and after service is provided, including after an account has been referred to an outside collection agency.

MAH will provide care for emergency medical conditions and medically necessary services to individuals regardless of their ability to pay or eligibility for financial or government assistance, and regardless of age, gender, race, social or immigrant status, sexual orientation or religious affiliation.

Financial assistance is not considered to be a substitute for personal responsibility. Patients are expected
to cooperate with MAH procedures for obtaining financial assistance or other forms of payment, and to contribute to the cost of their care based on their individual ability to pay. Individuals with the financial capacity to purchase health insurance are required to do so, as a means of assuring access to health care services, for their overall personal health, and for the protection of their individual assets.

MAH will not impose extraordinary collections actions, such as sending to collections or other legal actions, for any patient without first making reasonable efforts to determine whether that patient is eligible for financial assistance. Any exceptions must be approved by the Chief Financial Officer. For information on actions MAH may take in the event of nonpayment, including extraordinary collection actions and reasonable efforts to determine eligibility for assistance, please refer to our credit and collections policy. Copies of the Credit and Collection Policy are available online or can be requested at the Patient Financial Services Offices or can be mailed to you by calling 802-674-7471.

A. Eligibility Criteria for Financial Assistance. In order to qualify for financial assistance under this Policy, a patient must meet the following criteria:

  • Be in our service area, see attachment B, or a non-resident who receives emergency treatment at MAH.
  • Be uninsured or, underinsured, ineligible for any government health care benefit program, and unable to pay for their care as outlined in the Credit and Collections Policy, based upon a determination of financial need under this Policy.
  • Have gross Family Income, inclusive of all members of the patient’s household, during the past 12 months of less than 300% of FPL. These guidelines will be updated annually. The guidelines are set up with a prorated scale of assistance based on income
  • Ownership, Liquid Assets and Assets with limited liquidity will be considered for each application for assistance totaling over $10,000. Ability to satisfy the obligation through these assets will be determined. Assets such as Retirement Accounts, Real Estate, and others will be considered to be available resources.
  • For purposes of determining value of assets, assets includes but is not limited to: savings, alimony, certificates of deposit, IRA’s, stocks, bonds, 401ks, and mutual funds. In calculating the amount of assets for purposes of qualifying a patient for charity above, (i) savings (which includes savings accounts, alimony, or certificate of deposit) are sheltered up to 100% of FPL, (ii) retirement accounts (which includes IRA’s, stocks, bonds, 401ks and mutual funds) are sheltered up to $100,000, equity in a primary residence is sheltered up to $200,000 for applicants up to age 54, and (iv) equity in a primary residence is sheltered up to $250,000 for applicants age 55 or older. When dividends are noted on a tax return, the source of the dividends will be requested along with a recent market value statement. Documentation of all trust fund payments and ability to access funds is required.
  • Demonstrate compliance with the requirements to apply for qualified health plan coverage the New Hampshire or Vermont Healthcare Exchange Program if eligible for these programs.

Exceptions to this requirement may be approved by senior leadership for good cause on a case by case basis. "Good cause" will depend on facts and circumstances, and may include:

  • Those that missed the open enrollment period and do not fall into a life changing event category outside of open enrollment.
  • Those for whom the financial burden will be greater for the patient to enroll in a qualified health plan than not to do so.

If there is no interaction with the patient concerning financial assistance, or the patient is unable to complete the application procedures required under this Policy, such patients may nevertheless be considered for eligibility for presumptive financial assistance.

B. Method by Which Patients May Apply for Financial Assistance

1. MAH will explore alternative sources of payment from federal, state or other programs and assist patients in applying for such programs. With respect to any balances remaining after such other sources have been exhausted, MAH will conduct an individual assessment of a patient's financial need in order to determine whether an individual qualifies for assistance under this policy, using the following procedures:

  •  A patient or guarantor is required to submit an application on a form approved by MAH management, and provide such personal, financial and other information and documentation as required for MAH to determine whether such individual qualifies for assistance, including, but not limited to, documentation to verify Family Income and available assets or other resources. If MAH is unable to obtain an application or any required supporting documentation from the patient or the patient’s guarantor, MAH may consider whether the patient is eligible for presumptive financial assistance;
  • In lieu of an application and supporting documentation from the patient, staff may use any of the following to support a recommendation for approval of a financial assistance application:
    • MAH may utilize one or more vendors to screen individuals for eligibility using publicly available data sources that provide information on a patient’s or guarantor’s capacity and propensity to pay;
    • Current eligibility for Medicaid;
    • Current statement from a Federal or State housing authority;
    • Verification from a homeless shelter or a Federal Qualified Health Center;
    • Verification of incarceration with no source of payment from the correction facility;
    • or
    • For an individual patient, a patient's verbal attestation of income and assets, in lieu of a written income verification, may be accepted with respect to one (1) account only, provided that the balance on such account is less than $1,000.

2. It is preferred, but not required, that a request for financial assistance and a determination of financial need occur prior to rendering non-emergent medically necessary services. However, a patient may be considered for financial assistance at any point in the collection cycle. An approved financial assistance application applies to all balances for which the patient has applied for charity, in addition to emergency and other medically necessary care provided for a period of time, dates of service prior to receipt of the financial assistance application, including balances placed at a collection agency, and any services provided before or on the expiration date listed on the acknowledgement letter as long as the service is not listed on the Financial Assistance Policy Exclusions Job Aid (linked below). After that time, or at any time additional information relevant to the eligibility of the patient for financial assistance becomes known, MAH will re-evaluate the individual's financial need in accordance with this Policy.

MAH: MAH recognizes decisions made by the following assistance programs without requesting copies of applications. All applicable co-pays or other patient responsibility amounts should be requested in accordance with requirements of such programs.

  • NH Health Access Network Card for insured patients only  Good Neighbor Health Clinic
  • Manchester Community Health Center
  • Nashua Area Health Clinic
  • Mobile Community Health
  • Teen Health Clinic
  • Current Medicaid eligibility if not retroactive to cover past services

3. It is the goal of MAH to process a financial application and notify the patient of a decision in writing within 30 days of receipt of the completed application.

4. Appeals Process: If MAH denies partial or total financial assistance then the patient (or his/her agent) can appeal the decision within 30 days. The patient must write a letter to the Director of Eligibility and Enrollment to explain why the decision made by MAH was inappropriate. The appeal letter will be reviewed by MAH and a final decision will be sent to the patient within 30 days of the receipt of the request for appeal.

C. Determination of Amount of Financial Assistance

All insurance payments and contractual adjustments as well as the uninsured discount are taken prior to the financial assistance adjustment being applied. See MAH Uninsured Patient Discount Policy: Revenue Management Division. If an individual is approved for financial assistance, the amount of such assistance to be provided for applicable care will be as follows:

  • Family income at or below 225% of FPL will receive 100% financial assistance;
  • Family income between 226% - 250% of FPL will receive a 75% discount,
  • Family income between 251% - 275% of FPL will receive a 50% discount, and
  • Family income between 276% - 300% of FPL will receive a 25% discount.
  • As discussed above, patients whose family income exceeds 300% of FPL may be eligible to receive a discount based on the self-pay balance. Discounts will be granted such that the total self-pay bill does not exceed 10% of 2 years gross income, plus 10% of assets in excess of the sheltered asset calculation described earlier in the Policy. Any discounts other than those described above must be approved by the Financial Assistance Appeals Committee based on a written appeal from the patient or responsible party.
  • Patients meeting criteria for Presumptive Financial Assistance, will receive 100% financial assistance.

Patients without insurance, including uninsured patients who qualify for financial assistance under this Policy, may not be charged any more than the amount generally billed to patients who have insurance covering the same care. MAH applies a discount against gross charges to all balances for patients who have no insurance, resulting in a discounted balance which the patient is expected to pay. The discount is based on the “prospective Medicare” method as described under applicable regulations implementing Section 501(r) of the Internal Revenue Code. This discount is applied prior to billing the patient and prior to applying any financial assistance adjustments. This discount doesn’t apply to any copayments, coinsurance, deductible amounts, pre-payment or package services which already reflect any required discount, or to services classified as non-covered by all insurance companies.

D. Communication Regarding the MAH Financial Assistance Policy to Patients and Within the Community

Referral of patients for financial assistance may be made by any MAH staff member or agent, including physicians, nurses, financial counselors, social workers, case managers, chaplains, and religious sponsors. A request for financial assistance may be made by the patient or a family member, close friend, or associate of the patient,

Information regarding financial assistance from MAH is from MAH, including but not limited to this policy, a plain language summary of this policy, an application form and information concerning D- MAH's patient collection policies and procedures, will be available to the public and to MAH patients through at least the mechanisms described below:

  • On the MAH website,
  • Posted in patient care areas,
  • Available on Information Cards in the registration and admitting departments,
  • Available in other public spaces as determined by MAH,
  • Provided in the primary languages spoken by the population serviced by MAH; translation
  • services are utilized as needed.
  • If the balance is approved, the patient is sent a letter indicating approval.

E. Financial Assistance Appeals Process

  • If the balance is not approved, the patient will be sent a denial letter or if requested, a copy of the application highlighting the reason for disapproval. A letter outlining the formal appeals process is also sent with every denial or those letters providing only a partial reduction.
  • A committee of three MAH Leaders not involved in the original process will review the appeal and make recommendations on all denial appeals.

F. Charity Determination Levels

Approval levels are as follows:

  • Less than $500 – Financial Counselor
  • Less than $1000.00 - Supervisor
  • Less than $10,000 – Manager
  • $10,000 - $50,000 – Conifer Directors
  • Over $50,000 –Director of Revenue Management


Staff Education

  • Staff education regarding fall assessment and fall prevention plan of care shall occur during the new employee orientation process and be reinforced as appropriate.

Patient Education

  • Educate and involve the patient, family and/or significant other regarding fall risk reduction including
  • home safety measures.
  • Provide age appropriate fall risk education hand-out as needed.
  • Patient and family education shall be documented in the designated patient/family interdisciplinary teaching document.


  • This policy will be implemented and disseminated through the organization and will be published in the organizations Policy Library. Access to this document is open to all.
  • It is the responsibility of the departmental managers to ensure all staff working in financial assistance area are aware of this policy.
  • Departmental managers are responsible for ensuring staff receives training to support the implementation of this policy.
  • Monitoring of staff competence will form part of the individual’s annual performance review and where necessary, additional training will be provided.


  • N/A


  • Financial Assistance, Affordable Care