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Jones Memorial Hospital / Financial Assistance

Financial Assistance

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Would you like to pay your hospital bill on-line? Take advantage of this convenient way to pay using our secure server! If you have questions, please contact the JMH Business Office at (585) 596-4037 for assistance.

NYS Surprise Bill

Read more information about pricing, insurance plans, and providers that bill the patient separately from the hospital.


Contact the JMH Patient Financial Consultant or the Navigator to find out what your options are!

To apply for financial assistance, print and complete our Sliding Fee Application. Then return it to Jones Memorial Hospital, Patient Financial Consultant, 191 N. Main Street, Wellsville NY 14895.

Health Insurance Coverage for the Uninsured Population (HICUP) and the Patient Financial Assistance Policy


Financial Assistance is intended to assist those low-income individuals who do not otherwise have the ability to pay full charges or need assistance with co-insurances and deductibles for medically necessary services. This policy incorporates the requirements of New York State Public Health Law 2807-K which took effect on January 1, 2007. When patients are unable to meet their obligations, and they demonstrate the need, the hospital will assist the patient (guarantor) in accordance with its not-for-profit charitable mission. This assistance can be in the form of financial counseling, payment arrangements or the offering of financial aid. Should the patient (guarantor) not be able to demonstrate a true need, and no effort is being made to settle their account(s), the hospital will have no recourse but to recommend that the account be turned over to a collection agency. The hospitals catchment area for medically necessary services qualifying for financial aid includes the counties of Allegany, Cattaraugus, Steuben Livingston and Wyoming in New York and Potter and McKean counties in Pennsylvania. Financial aid for emergency medical services is available to any qualifying resident of New York State or the hospitals catchment area. Care for emergency medical conditions is provided, without discrimination, regardless of whether an individual is eligible under this policy.


Financial assistance is offered to each patient with a household income (HI) less than or equal to 300-percent of the Federal Poverty Level (FPL) if such individual has no insurance or has exhausted his or her health insurance benefits for emergency, other medically necessary Hospital care or medical clinic care and is unable to pay the full charges for those services. Financial assistance is available to eligible patients regardless of their immigration status, race or language.

Discount Calculation

All uninsured patients receiving services at Jones Memorial Hospital and the Jones Memorial Physician Practices will receive a 50-percent discount prior to the financial assistance process. The Financial Counselor will make the appropriate adjustment to the patient account. All adjustments over $1,000 will be approved of by the Director of Patient Accounting.

The determination of the level of discount for which a patient may be eligible under this policy is based on such individual’s household income (HI) as a percentage of the Federal Poverty Level (FPL). Jones Memorial Hospital has determined that Medicare is its “highest volume” payor. Therefore, patient responsibility will not exceed the rate of reimbursement Jones Memorial Hospital would have received from Medicare.

  • HI at or below 100-percent of the FPL will receive 95-percent discount of charges, leaving the patient responsibility the greater of 5-percent of Medicare rate or
    • Inpatient care will require a payment of $150 per discharge
    • Ambulatory surgery visits will requirement a payment of $150 per procedure
    • MRI testing will require a payment of $150 per procedure
    • Adult ER/Clinic care will require a payment of $15 per visit
    • Pre-natal and pediatric ER/Clinic care will be at no charge
  • HI from 101-percent to 125-percent of the FPL will receive a 90-percent discount, leaving patient responsibility of 10-percent of Medicare rate
  • HI from 126-percent to 150-percent of the FPL will receive an 80-percent discount, leaving patient responsibility of 20-percent of Medicare rate
  • HI from 151-percent to 175-percent of the FPL will receive a 65-percent discount, leaving patient responsibility of 35-percent of Medicare rate
  • HI from 176-percent to 200-percent of the FPL will receive a 45-percent discount, leaving patient responsibility of 55-percent of Medicare rate
  • HI from 201-percent to 225-percent of the FPL will receive a 25-percent discount, leaving patient responsibility of 75-percent of Medicare rate
  • HI from 226-percent to 250-percent of the FPL will receive a 5-percent discount, leaving patient responsibility of 95-percent of Medicare rate
  • HI from 251-percent to 300-percent of the FPL will be responsible for paying 100-percent of Medicare rate

The Federal Poverty Level (FPL) will be periodically adjusted as it is published. When applicable, a New York State surcharge will be added to patient balances due.


In order to qualify for financial assistance the patient or their representative must apply within 90 days of the date of service or within 90 days of being first notified of their balance. The patient will be required to submit documentation substantiating his or her household income (HI). Household income (HI) includes income earned by the patient and all of the patient’s family members living at the same address as such individual from the following sources: wages (including self-employment earnings), Social Security benefits, unemployment benefits, workers’ compensation, alimony/child support, military family allotments, rent, interest, dividends and pensions/IRA distributions/annuities, etc. As a condition of seeking financial assistance, patients will also be required to apply for Medicaid (Traditional Medicaid, Family Health Plus, Child Health Plus and Prenatal assistance programs) unless it is clear that the patient will not be found eligible.

The application will be available in the primary language of the service area (English). Jones Memorial Hospital contracts with an external vendor to provide interpreter services, if necessary.

Once Jones Memorial Hospital has received a completed application and documentation, patient may disregard any bills until a determination is made. Payment deposits are not required. Accounts will not be sent to collection while an application is pending. The hospital prohibits collections from a patient who is determined to be eligible for Medicaid at the time services are rendered. All applications will be approved or denied in writing within 30 days of receipt of complete application. If approved, the applicant will qualify for financial assistance for 180 days following the date of application and financial assistance will be applied to all unpaid balance up to 90 days prior to the date of application.

Appeal Process

Should a patient not agree with the determination issued by Jones Memorial Hospital regarding their application for financial assistance, they may appeal the decision.

  • Step I. Patient may request a review, in writing, within 15 days of receipt of the denial letter. A review of the application will be conducted by the Director of Patient Accounting. A decision will be made within 15 days of the request for review/appeal and the patient will be informed, in writing, if the appeal is sustained or overturned.
  • Step II. If the patient still disagrees with the determination, they will have 15 days from the date of the first level appeal decision letter to submit a second level appeal, in writing, to Jones Memorial Hospital. A review of the case will be conducted by the CFO. A decision will be rendered within 15 days of the request for the second level review. The patient will be notified in writing.
  • Step III. A third and final level of appeal may be submitted, in writing, within 15 days of the determination letter from the second level of appeal. This final review will be conducted by the CEO. The final decision will be made, in writing, within 15 days of the receipt of the third level appeal request.


Jones Memorial Hospital will incorporate flexible payment plans as appropriate. A monthly payment capped at 10-percent of the patient’s/household’s total gross income can be required by the hospital on a monthly basis. Multiple bills for the same family or household will be combined and capped at 10-percent of the total monthly gross.

Nonpayment of the agreed upon monthly amount will be considered a default of payment. The patient will receive a series of statements from the hospital requesting payment. If no activity takes place on the account, a final bill is sent to the patient (guarantor) stating that the account will be turned over to an outside collection agent within 30 days. If an account remains unpaid and there is no visible attempt by the patient (guarantor) to pay the account, the hospital will have no recourse but to refer the account to outside collection.

Outside collection agencies are required to comply with this policy. Contracted collection agencies must obtain the hospital’s written consent before commencing legal action. The hospital prohibits the forced sale or foreclosure of a patient’s primary residence in order to collect an outstanding bill. Jones Memorial Hospital prohibits any accelerated collection efforts.

For further clarification of Jones Memorial Hospital’s collection procedures please review policy # C-01.


Jones Memorial Hospital will make paper copies of this policy and the application for financial assistance available upon request without charge, both in the hospital and by mail. The hospital will inform and notify visitors to the hospital about this policy through conspicuous public displays. The hospital will inform and notify residents of the community about this policy in a manner reasonably calculated to reach those members of the community who are most likely to require financial assistance. The hospital will also make this policy and the sliding fee financial assistance application on the hospital’s website. In addition, hospital staff is available weekdays during normal business hours at (585) 596-4040 to provide additional information regarding this policy and the application process.

Internal Audit

An internal audit will be conducted annually by the Corporate Compliance Officer to ensure compliance with this policy.