Charity care covers emergency and medically necessary hospital services, provided free or at a reduced cost to patients who can’t afford to pay. Every nonprofit hospital in the United States is federally required to maintain a financial assistance policy, and the baseline rule is straightforward: the policy must apply to all emergency care and all other care the hospital deems medically necessary. What qualifies, how much of your bill gets reduced, and which providers are included varies significantly by hospital and state.
Services Charity Care Must Cover
Federal tax law requires nonprofit hospitals to include two categories of care in their financial assistance policies: emergency medical care and other medically necessary care. Emergency care follows the same definition used by federal law for emergency rooms, covering any condition where the absence of immediate treatment could place your health in serious jeopardy. That includes everything from chest pain and traumatic injuries to complications during pregnancy.
Medically necessary care is broader but less precisely defined at the federal level. Hospitals can use their state’s Medicaid definition, generally accepted standards of medicine in their community, or a treating physician’s determination of what’s necessary. In practice, this typically includes inpatient hospital stays, surgeries, lab work, imaging, intensive care, and other services your doctors order as part of your treatment. Some hospitals extend their policies to cover outpatient services performed in the hospital, like same-day procedures or diagnostic tests.
Colorado, for example, requires that all medically necessary care received in a general acute hospital, critical access hospital, or freestanding emergency department be discounted for eligible patients, including services provided by healthcare professionals in those settings.
What Charity Care Typically Does Not Cover
The federal requirement sets a floor, not a ceiling. Hospitals are required to cover emergency and medically necessary care but are free to exclude services they consider elective or non-essential. Cosmetic procedures, fertility treatments, and other elective services generally fall outside charity care policies. Some hospitals also exclude outpatient pharmacy costs, ongoing prescriptions after discharge, dental care, and vision services unless those services are tied directly to a medically necessary hospital visit.
Each hospital’s policy spells out exactly what’s included and excluded. You can find this information on the hospital’s website, or request a paper copy at no charge from the admissions area or emergency department. Hospitals are legally required to make these documents available in both locations.
The Physician Billing Gap
One of the most common surprises with charity care is that it often doesn’t cover every bill from your hospital visit. About 55% of U.S. physicians work in private, physician-owned practices, and many doctors who treat you inside a hospital are not hospital employees. Emergency medicine groups, anesthesiologists, radiologists, and pathologists frequently operate as contracted private practices or corporate-owned staffing companies. They bill separately, set their own rates, and are not bound by the hospital’s charity care policy unless state law specifically requires it.
This means you could receive full charity care coverage on your hospital bill but still owe thousands to the anesthesiologist who assisted in your surgery or the radiologist who read your imaging. In some states, laws prohibit the “corporate practice of medicine,” which forces physician practices to remain separate from hospitals and makes hospital charity care inapplicable to their charges. Maryland’s charity care laws, for instance, cover hospital charges but do not extend to independent hospital-based providers. If you’re applying for charity care, ask the hospital which providers in the facility are covered by the policy and which are not. Hospitals are required to include this list in their financial assistance documents.
Income Thresholds for Eligibility
Charity care eligibility is almost always based on household income measured against the federal poverty level (FPL). The specific thresholds vary by hospital and state, but most programs offer free care to patients earning below 200% of the FPL and discounted care for those earning up to 300% or 400%.
For 2024, the federal poverty guidelines for the 48 contiguous states are:
- 1 person: $15,060
- 2 people: $20,440
- 3 people: $25,820
- 4 people: $31,200
- 5 people: $36,580
At 200% of the FPL, a family of four would qualify with income under $62,400. At 300%, that same family could earn up to $93,600 and still receive discounted care at many hospitals. At 400%, the threshold reaches $124,800 for a household of four. Where your hospital draws the line depends on its own policy and your state’s requirements.
State Laws That Set Higher Standards
Several states go beyond the federal baseline and mandate specific income thresholds. Washington State requires hospitals to provide free care to patients with family incomes below 100% of the FPL and discounted care for incomes up to 200%. New Jersey and Massachusetts set the free care threshold at 200% of the FPL, meaning a single person earning under roughly $30,120 qualifies for completely free hospital care in those states regardless of which nonprofit hospital they visit.
State requirements can also affect which services are covered, whether physician bills are included, and how discounts are calculated. If you live in a state with strong charity care protections, the hospital’s policy may be more generous than what federal law alone would require.
How to Apply
You can apply for charity care before, during, or after receiving treatment. Most hospitals give you at least 240 days from your first billing statement to submit an application, and the hospital cannot send your bill to collections or take other aggressive collection actions until it has made reasonable efforts to determine whether you qualify.
The application itself asks for basic financial information. You’ll typically need to provide one or two documents proving your income. Accepted proof includes:
- Wages: A recent pay stub, a letter from your employer, or your most recent tax return
- Government benefits: An award letter from Social Security, unemployment compensation statements, or disability payment documentation
- Other income: Court orders for alimony or child support, dividend statements, or a written description of cash income from odd jobs or rental properties
- No income: A signed statement that you have no household income
You don’t need to provide every document on the list. In New York, for example, if you have an eligibility determination from the state health insurance marketplace, that single document is enough and the hospital cannot ask for additional income proof. Some hospitals also use “presumptive eligibility,” meaning they can determine you qualify based on information they already have, such as enrollment in Medicaid, SNAP, or other assistance programs, without requiring a separate application.
Free Care vs. Discounted Care
Charity care isn’t always all or nothing. Most hospital policies have two tiers. Patients with the lowest incomes receive completely free care, meaning the entire bill is written off. Patients who earn more than the free-care threshold but still fall within the program’s upper limit receive a discount, which could range from 25% to 80% off the bill depending on the hospital’s sliding scale.
When you do owe a balance after the discount, the hospital is restricted in what it can charge you. Federal rules prohibit nonprofit hospitals from billing charity-care-eligible patients more than the amount generally billed to insured patients. This prevents hospitals from charging you the inflated “chargemaster” rate that almost no one actually pays. The reduced rate should reflect something closer to what insurance companies negotiate, which is often a fraction of the listed price.