If you have medical debt, there’s a good chance you owe money to a hospital.
One way patients can avoid medical debt is through hospital financial assistance, also known as charity care. Most of the nation’s hospitals offer free or discounted medical care to patients with very high medical debt or low incomes.
Getting financial assistance, however, can be challenging. Many patients don’t know that hospitals offer financial help, surveys show, and complex application forms leave others stymied.
Hospitals often demand that applicants turn over bank statements, pay stubs, tax returns, divorce filings, or other materials, and submit their applications in person, by mail, or by fax.
“They don’t make it easy,” said Neale Mahoney, a Stanford University economist who studies medical debt.
Such hurdles leave many patients with unpaid bills they should never have had to pay in the first place. In a single year, hospitals and health systems billed patients for at least $2 billion that they likely didn’t owe, one analysis found.
As healthcare costs climb and more people lose their coverage, states and hospitals are testing an emerging approach to fix this problem: automatically screening patients to see if they qualify for assistance and proactively wiping out debt when they do. This is known as “presumptive eligibility.”
Under this approach, patients may have the cost of their care wiped out before they see any bills — but not always. Hospitals differ on when, how, and for whom they use auto-enrollment, potentially impinging on patients’ finances.
Here’s what you need to know about how auto-enrollment works.
What is hospital financial assistance?
In many states, hospitals set their own criteria for whom they provide financial aid. Eligibility is typically based on income for the patient’s entire household. The closer patients are to poverty, the less they have to pay. Patients with middle incomes and insurance are sometimes eligible for discounts, especially if their bills would gobble up a big chunk of what they earn.
At least 11 states require hospitals to wipe out bills for low-income patients, though income cutoffs vary. Georgia, for example, mandates free care for anyone with income slightly above the federal threshold for poverty. In several states — including Oregon, North Carolina, and Maryland — patients can earn double that amount and still get free care.
But in most states, many patients must complete applications to receive assistance.
Several states in recent years have launched investigations and passed legislation designed to make it easier for people to get help. Research into medical debt, however, suggests gaps persist.
How many hospitals use auto-enrollment?
Nearly all nonprofit hospitals say they screen and automatically reduce bills for certain patients.
Under the Affordable Care Act, nonprofit hospitals must make reasonable efforts to find people who are eligible for help before they take patients to court, sell their debt to collection agencies, or ding their credit over bills. Presumptive eligibility is one way hospitals can comply with the regulation, which took effect in 2016.
In the first year under the new rules, about 70% of tax-exempt hospitals nationwide said they screened patients and proactively reduced bills, according to an analysis of federal data for Tradeoffs by the independent research institute RTI International. As of 2022, that figure was nearly 90%.
The federal law doesn’t apply to for-profit and public hospitals, which don’t have to report the actions they take before going after patients for unpaid bills.
In six states, policymakers require hospitals to use presumptive eligibility and skip applications for certain patients. Those states are California, Delaware, Illinois, Maryland, North Carolina, and Oregon.
Who is eligible to be automatically enrolled in financial assistance?
In most states, hospitals decide which patients can skip the application.
Common groups automatically screened include people who are homeless, deceased, or already enrolled in state or federal programs to help low-income households with housing, food, or prescriptions. Other hospitals have more unique criteria, like Christus Health, which will write off bills for anyone in a religious order who took a vow of poverty.
Eligibility criteria are often buried in official policies and hard to find or decipher. Some hospitals share little to no public information about whom they will proactively screen. Thirteen hospitals owned by Ascension, one of the nation’s largest Catholic health systems, state only that they may screen patients “with a sufficient unpaid balance.”
Across the half-dozen states with presumptive eligibility mandates, eligibility rules vary. Maryland, for example, requires hospitals to proactively wipe out bills only for patients who already get government help for food or utilities but are ineligible for Medicaid. In Illinois, lawmakers created less-stringent requirements for rural hospitals compared with urban facilities.
In Oregon, starting in 2024, hospitals had to screen anyone who owed more than $500 and every patient on Medicaid or who is uninsured. In 2025, roughly 80% of Oregon patients who got financial help with bills never filled out an application, based on data shared publicly by the first 26 hospitals to do so. The state’s legislature this year raised the screening threshold to include patients who owe at least $1,500 for a single visit.
Without an application, how do hospitals figure out who gets help?
Hospitals have several ways to find patients eligible for financial assistance.
Typically, hospitals turn to public records, any information patients have previously volunteered, or tools from consumer credit companies to estimate whether patients qualify to have bills reduced.
For example, if a hospital sees that a patient lives in a high-poverty ZIP code or has no address listed, that could be enough to deem them eligible. Many pay companies to run employment and credit checks on patients to determine whether they qualify for free care.
Hospitals may also consider how likely patients are to pay bills, regardless of how much they earn. This is called “propensity to pay.” California and Oregon prohibit its use, concerned that hospitals may try to collect more often from people who dutifully pay their bills even though their incomes qualify them for financial assistance.
When do hospitals screen patients for financial aid?
It depends.
Illinois, North Carolina, and Oregon require hospitals to screen certain patients before they send any bills. California hospitals will have to do the same starting in 2027.
Some hospitals voluntarily screen patients before sending bills; others try to collect money from patients first. As long as they screen patients before suing them for very overdue bills, hospitals can stay within the letter of the federal law that pushed many of them to embrace presumptive eligibility.
For example, the policy of Christus Health is to screen patients only “after all other eligibility and payment sources have been exhausted.”
Anna Stelter, vice president of policy for the Texas Hospital Association, said hospitals want to investigate other options for payment — like Medicaid or county safety net programs — before they give out financial assistance.
“We do want to make sure that whoever is financially responsible for that care is identified and pays,” Stelter said. “Charity care is the relief of last resort.”
Hospitals’ publicly posted policies may also be fuzzy about when they will screen for patients likely eligible for help. For example, Cook Children’s Health Care System in Fort Worth, Texas, says its goal is to determine a patient’s eligibility “as soon as sufficient information is available.”
Who pays the bills when patients get free care?
In one sense, we all do. Taxpayers cover some or all of the cost of financial assistance, though the amount varies by hospital.
About half the nation’s hospitals are nonprofit and legally get a pass on paying most taxes. KFF estimates that nonprofit hospitals pocketed $24 billion in 2020 that they would otherwise have paid as income, sales, or property taxes.
Government-owned and for-profit hospitals have their own sets of tax benefits to help offset costs for low-income patients. Government hospitals often get additional taxpayer support, and for-profit hospitals generally receive smaller government subsidies, like additional payments for caring for high numbers of uninsured and Medicaid patients.
Whether taxpayer dollars fully cover hospitals’ costs for financial assistance depends on the amount of government support they receive — information often not publicly available. It also hinges on how many patients need help, how many meet hospitals’ criteria for assistance, and how many get through an application. Research shows hospitals spend widely different amounts on financial assistance, from less than 1% of yearly expenses to more than 7%.
Philanthropy and hospitals’ income cover costs not absorbed by tax dollars.
This article is part of “Hidden Help,” an investigative series from Tradeoffs and KFF Health News about how hospitals can protect their patients from the life-altering harms of medical debt.
Melanie Evans is a reporter for Tradeoffs, a nonprofit newsroom reporting on healthcare’s toughest choices. Sign up for the weekly newsletter to get the latest stories every Thursday morning.
Tradeoffs’ reporting for this series was supported, in part, by the California Health Care Foundation, the National Institute for Health Care Management Foundation, and the Solutions Journalism Network.
