States are adding their own rules requiring hospitals to screen patients for financial assistance before collecting bills, expanding on a federal requirement that already exists under the Affordable Care Act. These rules create a patchwork: some states mandate active screening, income thresholds vary by state, and several are tightening deadlines before hospitals can pursue debt collection. All nonprofit hospitals nationwide must maintain written financial assistance policies and apply them to applications submitted within 240 days of the first bill. But states including Washington, Oregon, New York, and Maryland are layering additional rules—often requiring hospitals to inform patients about assistance and to determine eligibility before any collection attempts.
Table of Contents
- What Federal Law Requires
- How States Are Adding Stricter Requirements
- Income Thresholds Vary Dramatically
- Timeline Rules Before Debt Collection
- What You Should Do Now
- Frequently Asked Questions
What Federal Law Requires
The Affordable Care Act's Section 501(r) requires all nonprofit hospitals to maintain written financial assistance policies. This is the baseline for every nonprofit hospital in the country, regardless of state rules. But the federal requirement does not specify how or when hospitals must screen patients—a hospital could theoretically wait for a patient to apply rather than offering screening proactively. This gap is where state rules come in.
How States Are Adding Stricter Requirements
Several states have enacted rules that go beyond the federal baseline by requiring hospitals to actively inform patients about assistance and screen them before attempting to collect any payment. Washington State requires hospitals to inform patients about financial assistance options both verbally and in writing, and must screen patients for eligibility before attempting to collect any payments. Oregon enacted similar legislation in 2023, requiring nonprofit hospitals to screen patients for presumptive eligibility if they are uninsured or owe more than $500 for medical services.
New York took a different approach with a uniform form requirement: all hospitals must use a uniform financial assistance form for screening and cannot use immigration status as an eligibility criterion, with requirements taking effect October 20, 2024. Maryland created a shortcut—since 2020, hospitals must treat patients already enrolled in other need-based assistance programs as "presumptively eligible" for free care without requiring a separate financial assistance application.
Income Thresholds Vary Dramatically
No federal law specifies which income-screening criteria states must use for hospital financial assistance, creating a patchwork where some states mandate screening while others do not, and thresholds differ by up to 4 times. This means the same income level may qualify you for free care in one state but not another.
Maine requires free care at less than 150% of federal poverty level, Washington State at 200% FPL, and California at up to 400% FPL depending on family size. California's threshold is nearly 3 times higher than Maine's, so someone might qualify for free or discounted care in California but not in Maine.
Timeline Rules Before Debt Collection
Some states impose waiting periods or require hospitals to make reasonable efforts to determine assistance eligibility before pursuing debt collection. New York hospitals may not commence debt collection actions against patients for at least 180 days after the first bill and must demonstrate reasonable efforts to determine financial assistance eligibility before pursuing legal action. This gives you a six-month window to apply for assistance before a hospital can sue for the debt.
Without such state rules, a hospital could theoretically begin collection within weeks. State screening requirements are designed to ensure hospitals determine assistance eligibility before pursuing collection efforts.
What You Should Do Now
If you receive a hospital bill you cannot pay, take three steps. First, ask the hospital's financial assistance office for screening and a copy of their assistance policy—federal law requires all nonprofit hospitals to have one and make it available to patients. Second, if your state has specific screening requirements (like New York, Washington, Oregon, or Maryland), mention that when you call—hospitals may not actively offer screening, but they are legally required to provide it when you ask.
Third, do not wait for the hospital to pursue collection; hospitals have 240 days from the first bill to consider assistance, and states like New York impose additional waiting periods before legal action, so you have time. If a hospital refuses to screen you or denies assistance without explaining why, request the written policy they must maintain under federal law and review whether they followed it correctly. Your state's Department of Health can field complaints if a hospital is not complying.
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Frequently Asked Questions
Do for-profit hospitals have to screen me for assistance?
No. The federal requirement applies only to nonprofit hospitals. For-profit hospitals are not required to maintain financial assistance policies under the ACA, though some do.
What if my hospital says I don't qualify for assistance?
Ask them to explain in writing how they calculated your income and eligibility. If their explanation doesn't match the written policy they must have, file a complaint with your state's Department of Health. —