Hospital Financial Assistance Program

Hospital Financial Assistance Program (FAP)


Alliance Community Hospital (ACH) provides services without charge or at a reduced rate to patients who cannot afford to pay for hospital care.  To be eligible, patients must complete a financial assistance application and family income must be at or below 300% of the federal poverty level income guidelines. Federal poverty guidelines are updated annually. This policy meets the guidelines of Ohio’s Hospital Care Assurance Program (HCAP) as well as the IRS Regulation under IRC Section 501(r) that hospitals must meet in order to retain their tax-exempt status. 


  • Assistance is limited to acute hospital services that are deemed emergent or medically necessary.  ACH determines medical necessity by the list of “covered revenue codes” as defined in Appendix I of the Ohio Department of Medicaid Office of Benefits Hospital Billing Guidelines:
  • Financial assistance is only available for services at Alliance Community Hospital.  Professional fees are not included.  Specifically, balances for physician offices (Alliance Community Medical Foundation, Alliance Medical Associates), radiology fees (Foundation Radiology Group), anesthesia fees (Anesthesia Associates of Alliance), Community Care Center, Alliance Visiting Nurse, Alliance Hospice, etc. are not covered by the hospital’s financial assistance policy.
  • Patients or their representatives must complete a financial assistance form for eligibility. Hospital may obtain information orally if patient cannot complete application in writing.
  • Gross income for all members of the family must be reported.  The definition of “family” shall include:
  • Gross income is income from employment of jobs, self-employment, public assistance, Social Security, unemployment compensation, Worker’s Compensation, pension, inheritance, disability, child support, alimony, interest earned, and rental income BEFORE TAXES.
  • The income reported on the application earned in the three months prior to hospital services will be projected as a year of income.  The lower of the projected year of income or the actual 12 months of income preceding the hospital services will be used to determine eligibility.
  • Third party coverage is always primary to financial assistance.  Patients with third party coverage must comply with all of the requirements of their coverage such as pre-certification, prior authorization and referrals as a condition of eligibility for financial assistance.
  • Patients must indicate the date of service for which they are requesting assistance.  In the case of maternity services, patients must indicate an approximate date of service.
  • The Patient Financial Services office will determine eligibility and will mail a formal eligibility determination letter to the patient.
  • Parent(s) Spouse(s) Children, natural or adoptive, under  age  18 living in the home



  1. Applications will be given to the colleague(s) responsible for eligibility determinations.
  2. Eligibility determination will be made in accordance with the following policies:

a)      Hospital Care Assurance Program – HCAP

b)      Hospital Financial Assistance Policy to include IRS 501( r ) regulations


Alliance Community Hospital is required to provide emergent or medically necessary healthcare without charge to persons who cannot afford to pay for care.


Individuals are eligible for medically necessary healthcare at no cost if their family does not exceed the Federal Poverty Income Guidelines.  See schedule below.


If an individual has health insurance coverage provided by their employer, self-insured, or Medicare, etc. they would receive medically necessary services at no cost or a reduced cost if they are not paid by the plan and qualify for financial assistance.  If it appears that they may be eligible for assistance from Federal or State agencies, they may be asked to apply to these agencies before a request for financial assistance is finalized.   


Individuals are eligible for medically necessary healthcare at a reduced cost if their gross family income does not exceed 300% of the Federal Poverty Income Guidelines.  Patients that are at or below the poverty guidelines will qualify for a 100% reduction according to the Hospital Care Assurance Program (HCAP).  The code to be used for this adjustment is ASPHCAP.  Patients that have a household income between 100% and 300% of the Federal Poverty Guidelines may qualify for a reduction of 50% to 75% of total charges.  The code used for these charity adjustments is ASPCHAR.


Size of Family

Maximum Income For Care at 100% Reduction - No Cost (ASPHCAP)

Maximum Income For Care at 75% Reduction (ASPCHAR)

Maximum Income For Care at 50% Reduction (ASPCHAR)













For each additional family member add







HCAP Application

Hospital Financial Assistance Policy
Plain Language Summary




Questions regarding financial assistance should be directed to the Patient Financial Services at 330-596-7584 between the hours of 8 a.m. and 4 p.m. Monday through Friday.

  • To request a copy of the FAP or FAP application form please contact Patient Financial Services or visit our website at
  • A paper copy of our policy can be obtained at our facility located at 200 East State Street, Alliance, Ohio 44601 in the Patient Financial Services Office, the Admitting/Registration area, or in the Emergency Department.
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