REPORT: Hospital financial assistance and debt collection policies

What is financial assistance?

Most hospitals offer free or discounted care for patients who cannot afford to pay. This is known as “financial assistance” or “charity care.” Hospitals usually have a written policy that outlines eligibility standards based on income, family size, bill amount, insurance status, and other factors. Private nonprofit hospitals are required to make their financial assistance policy widely available.

FINDINGS

Most hospitals in our study (84%) have a financial assistance policy available online.
Private nonprofit hospitals (99%) are much more likely than public (57%) or for-profit hospitals (49%) to have their financial assistance policy available online.
The majority of private nonprofit (75%) and for-profit hospitals (74%) made their policies available in multiple languages, while only 43% of public hospitals had multiple languages available.

Who is eligible for financial assistance at U.S. hospitals?

Free care

There are no federal minimum requirements for financial assistance eligibility, which gives hospitals considerable leeway to craft their own policy. This flexibility leads to considerable variation in free care eligibility levels across hospitals.

FINDINGS

Among the hospitals in our study, 87% offer free care as part of their financial assistance policy.
The most common threshold for free care was 200% of federal guidelines (meaning that a family of three making about $50,900 would be eligible).* Fifty-two percent of hospitals offered free care for patients making 200-249% of federal guidelines.
Among outlier hospitals were 207 hospitals that restrict free care to those making under 150% of federal guidelines and 60 hospitals that offer free care to those making 400% and above.

*Some hospitals report their income eligibility based on the federal poverty guidelines (FPG) while others use federal poverty level (FPL). Alaska and Hawaii also have different FPG income levels than the contiguous US states. The differences between these thresholds are accounted for in our comparisons of median county income and income eligibility thresholds by family size. For simplicity, we use “federal guidelines” throughout this report to refer to either FPG or FPL-based income eligibility levels.

Discounted care

Hospitals generally provide discounted care for patients who do not qualify for free care. Discounted care means that a patient’s bill will be reduced, usually based on a flat discount or sliding scale.

FINDINGS

Among the hospitals in our study, 83% offer discounted care as part of their financial assistance policy.
The most common threshold for discounted care was 400% of federal guidelines (about $100,000 for a family of three). Fifty-two percent of hospitals offered discounted care for patients making 400-449% of federal guidelines.
Thresholds ranged from under 250% (124 hospitals) to 600% and above (70 hospitals).

Restrictions on financial assistance

Some hospitals put additional restrictions on financial assistance aside from income:

More than a third of hospitals (42%) limit financial assistance to those living in the state or local area, and 14% limit free care to uninsured patients.
Private nonprofit hospitals were more likely to have a residency requirement (46%) and public hospitals were more likely to restrict free care to uninsured patients (20%).
Some hospitals also exclude certain types of care from financial assistance, like birth control, infertility treatment, bariatric procedures, dental care, ambulance services, cardiac rehabilitation, transplant, vaccines, and physician services for emergency department, radiology, anesthesia, or pathology.

Do charity care thresholds match community need?

Hospitals are encouraged to offer free care at a rate that serves their community need, which differs based on local income levels, cost of living, and rate of uninsurance. However, our findings suggest that free care thresholds and local income are not always aligned.

For example, a hospital in Arlington County, Virginia and a hospital in Holmes County, Mississippi both offer free care at 200% FPG ($53,300 for a family of three). Most families in Arlington County, where the median income is over $200,000, would be unable to access free care, while most families in Holmes County, where the median income is $32,000, would easily qualify. Our findings indicate that hospitals in areas with a higher cost of living could further expand their eligibility criteria for free care to better serve their community need.

Same city, different free care policies

Even among hospitals in the same cities, there may be differences in who is eligible for free care. These thresholds may not always correspond to the amount of financial assistance spending, as hospitals differ in how well they advertise and implement their policy.*

*Some hospitals use the federal poverty guideline (FPG) for their financial assistance income thresholds, while others use federal poverty level (FPL). In this section we use the threshold specified in each hospital’s policy.

Boston, MA

In Boston, a family of three making $107k could be eligible for free care at Beth Israel Deaconess Medical Center, while the same family would have to make $40k or less to access free care at Brigham and Women’s Hospital.

Hospital	Free care income eligibility threshold for family of three
Brigham and Women’s Hospital	$40k (150% FPG)
Beth Israel Deaconess Medical Center	$107k (400% FPG)

Dallas, TX

In Dallas, TX, a family of three making $107k could be eligible for free care at William P. Clements Jr. University Hospital, while the same family would have to make $53k or less to access free care at Baylor University Medical Center.

Hospital	Free care income eligibility threshold for family of three
Baylor University Medical Center	$53k (200% FPG)
William P. Clements Jr. University Hospital	$107k (400% FPG)

Des Moines, IA

In Des Moines, a family of three making $80k could be eligible for free care at Broadlawns Medical Center, while the same family would have to make $50k or less to access free care at MercyOne Des Moines Medical Center.

Hospital	Free care income eligibility threshold for family of three
MercyOne Des Moines Medical Center	$50k (200% FPL)
Broadlawns Medical Center	$80k (300% FPG)

Grand Junction, CO

In Grand Junction, a family of three making $67k could be eligible for free care at St. Mary’s Regional Hospital, while the same family would have to make $10k or less to access free care at Montrose Regional Hospital.

Hospital	Free care income eligibility threshold for family of three
Montrose Regional Health	$10k (40.9% FPL)
St. Mary’s Regional Hospital	$67k (250% FPG)

Los Angeles, CA

In Los Angeles, a family of three making $101k could be eligible for free care at Cedars-Sinai Medical Center, while the same family would have to make $53k or less to access free care at Kaiser Permanente Los Angeles Medical Center.

Hospital	Free care income eligibility threshold for family of three
Kaiser Permanente Los Angeles Medical Center	$53k (200% FPG)
Cedars-Sinai Medical Center	$101k (400% FPL)

New York City, NY

In New York City, a family of three making $151k could be eligible for free care at Tisch Hospital, while the same family would have to make $53k or less to access free care at New York-Presbyterian Hospital.

Hospital	Free care income eligibility threshold for family of three
New York-Presbyterian Hospital	$53k (200% FPG)
Tisch Hospital	$151k (600% FPL)

Pittsburgh, PA

In Pittsburgh, a family of three making $80k could be eligible for free care at UPMC Passavant – McCandless, while the same family would have to make $53k or less to access free care at West Penn Hospital.

Hospital	Free care income eligibility threshold for family of three
West Penn Hospital	$53k (200% FPG)
UPMC Passavant – McCandless	$80k (300% FPG)

San Francisco, CA

In San Francisco, an uninsured family of three making $101k could be eligible for free care at UCSF Helen Diller Medical Center at Parnassus Heights, while the same family would have to make $50k or less to access free care at Kaiser Permanente San Francisco Medical Center.

Hospital	Free care income eligibility threshold for family of three
Kaiser Permanente San Francisco Medical Center	$50k (200% FPL)
UCSF Helen Diller Medical Center at Parnassus Heights	$101k (400% FPL)

Tucson, AZ

In Tucson, a family of three making $50k could be eligible for free care at Banner – University Medical Center Tucson, while the same family would have to make $25k or less to access free care at Tucson Medical Center.

Hospital	Free care income eligibility threshold for family of three
Tucson Medical Center	$25k (100% FPL)
Banner – University Medical Center Tucson	$50k (200% FPL)

Waco, TX

In the Waco, Texas area, a family of three making $67k could be eligible for free care at Ascension Providence, while the same family would have to make $6k or less to access free care at Goodall Witcher Hospital.

Hospital	Free care income eligibility threshold for family of three
Goodall Witcher Hospital	$6,000 (21% FPG)
Ascension Providence	$67k (250% FPG)

How many hospitals allow extraordinary collection actions?

In most states, nonprofit hospitals are allowed to engage in certain “extraordinary collections actions” (ECAs) to pursue outstanding medical debt, as long as they make reasonable efforts to determine whether patients are eligible for financial assistance. These ECAs include: selling debt to a third party, reporting medical debt to consumer credit reporting agencies or credit bureaus, denying non-emergency care for patients with outstanding debt, and taking legal actions to collect debt.*

FINDINGS

Most hospitals (59%) allow at least one ECA according to their policy.
Legal action to collect debt (51%) and reporting debt to credit agencies (42%) are the most commonly allowed ECAs.
Property liens were the most commonly allowed legal action (38%) followed by lawsuits (33%).
Many hospitals did not specify in their policy whether or not they allow certain collection actions. For example, 74% of hospitals do not state whether or not they will deny care for patients with outstanding debt.
Only 4% of hospitals disallow all extraordinary collection actions in their policy. That means they explicitly state they will not take legal actions or report debt to credit agencies.
At least 14% of hospital policies allow for the denial of non-emergency care to patients with outstanding debt

Extraordinary collection activities allowed in hospital policies

Private nonprofit hospitals were more likely to have information about allowed collection activities in their policies, compared to public and for-profit hospitals. Private nonprofit hospitals were more likely to disallow debt sales to third parties, denial of nonemergency care, and wage garnishments, compared to public and for-profit hospitals. For-profit hospitals were more likely to disallow reporting debt to credit bureaus, lawsuits, and property liens, compared to nonprofit hospitals.

Legal actions to collect debt allowed in hospital policies

	Lawsuits	Wage garnishment	Property lien
Policy allows	33%	30%	38%
Policy does not allow	14%	14%	15%
Policy does not mention	53%	56%	47%

*Just because a collection action is allowed in a hospital’s policy does not necessarily mean that the hospital conducts these activities in practice. In cases where a hospital representative clarified their collections practices, we have added a note in their hospital scorecard.

A look at U.S. News hospitals

Among U.S. News Honor Roll hospitals, free care thresholds range from 150% to 600% of federal guidelines, and discounted care thresholds range from 300% to 800% FPL of federal guidelines. While eight hospitals do not allow any extraordinary collection activities, all other hospitals allow at least one according to their collections policies or communication with representatives.

Hospital name	Free care threshold	Discounted care threshold	Financial assistance qualifiers	Extraordinary collection actions allowed
Brigham and Women’s Hospital	150% FPG	300% FPG, or medical expenses exceed 40% of family income.	Financial assistance only available to patients in MA, NH or receiving emergency care.	Denying care, lawsuits, and liens allowed
Cedars-Sinai Medical Center	400% FPL	600% FPL		Legal actions allowed with CFO approval
Cleveland Clinic Main Campus	250% FPG if uninsured	400% FPG if uninsured, or insured and medical expenses greater than 25% of annual family income	Financial assistance available to out-of-state patients only on case-by-case basis.	Reporting to credit agencies, denial of non-emergency care, and legal actions are allowed but not done in practice, according to hospital representative.
Duke University Hospital	200% FPG	300% FPG, or account balance greater than 15% of annual income		None allowed
Hospital of the University of Pennsylvania	300% FPG	Bill is greater than 10% of annual income	Financial assistance only available to patients in local area	None allowed
Houston Methodist Hospital	200% FPL	500% FPL, or above 500% FPL and account balance is 10% or greater than family income		None allowed
The Johns Hopkins Hospital	200% FPL	400% FPL or under 500% FPL and medical debt exceeds 25% of family income		None allowed
Massachusetts General Hospital	150% FPG	300% FPG, or medical expenses exceed 40% of family income.	Financial assistance only available to patients in MA, NH or receiving emergency care.	Denying care, lawsuits, and liens allowed
Mayo Clinic Hospital, Saint Marys Campus	200% FPG (includes both income and assets)	400% FPG (includes both income and assets)		Denying care and legal actions allowed
The Mount Sinai Hospital	200% FPL	400% FPL	Financial assistance only available to patients in local area (or state for emergency care)	Liens allowed (primary residence excluded)
North Shore University Hospital	200% FPG	500% FPG	Financial assistance only available to patients in state	Lawsuits and liens allowed (primary residence excluded)
Northwestern Memorial Hospital	250% FPG	600% FPG	Financial assistance only available to patients in state	Care denial and liens allowed (primary residence excluded)
NewYork-Presbyterian Hospital	200% FPG	600% FPG	Financial assistance only available to patients in local area (or state for emergency care)	Legal actions allowed (primary residence excluded)
RUSH University Medical Center	300% FPG	400% FPG for uninsured, 600% FPG for insured, or bill is 20% or greater than household income	Financial assistance only available to patients in state.	Credit reporting, care denial, lawsuits, and liens allowed
Stanford Hospital	400% FPG if uninsured or bill is 10% of family income for insured	All uninsured patients eligible for discounted care		None allowed
Tisch Hospital	600% FPL	800% FPL	Financial assistance only available to patient in state (unless emergency care)	Lawsuits and liens allowed (primary residence excluded)
UC San Diego Medical Center	400% FPG if uninsured or bill is 10% of family income	Discounts for uninsured patients who do not qualify for free care are available	Financial assistance only available to patients in state	None allowed
Ronald Reagan UCLA Medical Center	400% FPL if uninsured or medical cost or bill is 10% of family income	450% FPL if uninsured or medical cost or bill is 10% of family income	Financial assistance only available for patients within local area	None allowed
UCSF Helen Diller Medical Center at Parnassus Heights	400% FPL if uninsured or medical cost or bill is 10% of family income	Discounts for uninsured patients who do not qualify for free care are available		None allowed

Policy options to reduce medical debt

State policymakers are taking action to improve access to financial assistance, including the following reforms:

Creating standards for financial assistance income eligibility thresholds.

Example: Washington state requires most hospitals to make patients under 200% FPL eligible for free care, and patients at 200-300% FPL eligible for discounted care. The eligibility thresholds are higher for certain larger hospital systems.

Developing a uniform financial assistance application to simplify and streamline the application process.

Example: Maryland developed a common financial assistance application that must be accepted by all hospitals and provided to patients upon request.

Requiring hospitals to screen patients for financial assistance, to make sure all eligible patients receive discounts.

Example: Illinois requires hospitals to screen all uninsured patients for financial assistance or public health insurance program eligibility at the earliest reasonable moment, and insured patients upon request.

Clarifying or regulating other common restrictions on financial assistance

Example: In North Carolina, hospitals are required to offer financial assistance for both insured and uninsured patients if they meet the income criteria.

Setting minimum spending thresholds for financial assistance and other community benefits

Example: Oregon sets minimum thresholds for community benefit spending for each hospital, based on the hospital’s previous uncompensated care, patient revenue, and operating margin.

Limiting extraordinary collection actions hospitals are allowed to conduct to collect medical debt

Example: New York prohibits reporting medical debt to credit agencies, placing liens, or garnishing wages to collect medical debt. Legal actions may not be taken against patients making less than 400% FPL to collect medical debt.

Improving reporting requirements to increase transparency around the financial assistance hospitals provide and ECAs conducted.

Example: Colorado requires hospitals to report the number of patients who were screened for financial assistance, applications processed, and accounts sent to collections. Data must be reported by race, ethnicity, age, and primary language spoken.

Download our white paper

Stronger regulations around financial assistance and collections policies are an important step toward reducing medical debt, but they’re not the only necessary policy change. A companion report, Past due: How medical debt is harming Americans and the solutions we need now, written in collaboration with a dozen researchers and advocates, lays out additional changes we need to make healthcare accessible and affordable to all. These include protecting Medicaid coverage, expanding insurance coverage to all, limiting out-of-pocket costs, and bringing down prices for medical services.

Methodology

The Lown Institute Financial Assistance and Collections Policy Database contains information from a national sample of 2,500 hospitals.

This is a stratified random sample, where we randomly sampled from subgroups of all general hospitals (excluding specialty, federally-run, or hospitals outside the 50 U.S. states and Washington, D.C.). These subgroups took into account geographic location, hospital size, urban or rural location, state Medicaid expansion status, and state medical debt protections. A small number of hospitals were general hospitals at the start of our project in 2023, but have since been converted to other hospital types such as psychiatric facilities or rural emergency hospitals. We have also excluded hospitals that have closed since 2023.

The Lown Institute collected information on hospital financial assistance and billing practices by reviewing financial assistance and collection policies available publicly on hospital websites. We reached out via email to nearly all hospitals in the sample to ask for confirmation of the data. If we received a response, we recorded any additional information about hospital practices if provided by the contact and, in the case of debt collection practices, if they were willing to publish their name to that fact (e.g. if a hospital policy said they may take a certain action, but a spokesperson said they never do it in practice). We also included additional hospitals in our data, if a health system contact provided policy data for facilities which were not in our original sample.

Financial assistance policies were collected in two rounds. The first round of collection occurred between September 2023 and May 2024 and was reviewed for updates between November 2024 and April 2025. The second data collection round started in June 2024 and ended in April 2025. Hospitals were initially contacted starting December 2023 and the process is on-going. We considered a hospital to have not responded if they were contacted three times with no response.

Some hospitals reported their income eligibility based on the federal poverty level (FPL) while others use federal poverty guidelines (FPG), which correspond to slightly different income amounts. The 2024 FPL thresholds, the most recent available, for a family of three with one child under 18 is $25,249, and is the same across all states. The 2025 FPG for a family of three is $26,650. The FPGs for Alaska and Hawaii are slightly higher than in the contiguous U.S. states and D.C. (FPG for a family of three is $33,310 in Alaska and $30,650 in Hawaii). The differences between these thresholds are accounted for when referring to specific hospital policies. For simplicity, we use “federal guidelines” throughout this report to refer to income eligibility levels, and FPG and FPL levels are grouped together in charts that compare eligibility percentage thresholds reported in hospital policies.

This work builds upon existing research conducted by Noam Levey, senior correspondent, at KFF Health News.

This project is supported by Arnold Ventures.

Hospital financial assistance and debt collection policies

Key Takeaways

Explore the data

DOWNLOAD: Hospital Financial Assistance, Billing and Collections Data

What is financial assistance?

Who is eligible for financial assistance at U.S. hospitals?

Free care

Discounted care

Restrictions on financial assistance

Do charity care thresholds match community need?

Same city, different free care policies

Boston, MA

Dallas, TX

Des Moines, IA

Grand Junction, CO

Los Angeles, CA

New York City, NY

Pittsburgh, PA

San Francisco, CA

Tucson, AZ

Waco, TX

How many hospitals allow extraordinary collection actions?

A look at U.S. News hospitals

Policy options to reduce medical debt

Download our white paper

Methodology

Hospital financial assistance and debt collection policies

Key Takeaways

Explore the data

DOWNLOAD: Hospital Financial Assistance, Billing and Collections Data

What is financial assistance?

Who is eligible for financial assistance at U.S. hospitals?

Free care

Discounted care

Restrictions on financial assistance

Do charity care thresholds match community need?

Same city, different free care policies

Boston, MA

Dallas, TX

Des Moines, IA

Grand Junction, CO

Los Angeles, CA

New York City, NY

Pittsburgh, PA

San Francisco, CA

Tucson, AZ

Waco, TX

How many hospitals allow extraordinary collection actions?

A look at U.S. News hospitals

Policy options to reduce medical debt

Download our white paper

Methodology

A newsletter for socially responsible hospitals and the communities they serve.