Can’t Pay a Hospital Bill? The 240-Day Rule Most People Miss

Can’t pay a hospital bill? Learn the federal 240-day charity-care rule, the 120-day collection pause, what nonprofit hospitals must do, and what to file.

If you cannot pay a hospital bill, ask for the hospital’s Financial Assistance Policy and application in writing and submit it inside the federal window. Nonprofit hospitals must accept financial assistance applications for at least 240 days after your first post-discharge bill, and while a complete application is under review they must stop selling your debt, reporting you to credit bureaus, suing you, and garnishing your pay.

Apply for Medicaid in the same week. Do not sign a medical credit card agreement while you wait.

Key takeaways

  • The 240 days is a floor, not a cutoff. The hospital may have to accept your application later, and many do. Check your first bill date rather than assuming you are late.
  • Both clocks start on the hospital’s own first post-discharge billing statement, not the date of your visit. Bills from independent doctors, radiology groups, and ambulance companies sit on a different clock.
  • An incomplete application also suspends collections. The hospital must tell you what is missing and give you a reasonable chance to fix it.
  • A letter from a collection agency can arrive before day 120. Referring your account to an outside agency for billing is not itself an extraordinary collection action. Selling the debt is.
  • Insured patients can qualify. No federal law sets an income cutoff, so each hospital writes its own.
  • A denial removes the protection. Treat a denial as a paperwork problem with a deadline, not a verdict.

Denise is a composite built from patterns documented in federal guidance, published research, and patient accounts. She is not a real person, and nothing here is her story or anyone else’s.

Does your hospital even have to offer this?

Yes, if the hospital is a nonprofit. Federal tax law requires tax-exempt hospitals to publish a written Financial Assistance Policy, or FAP, and to apply it to all emergency and medically necessary care (IRS).

Most community hospitals are nonprofits, but the number of beds behind that word is small. Of 5,121 community hospitals, 2,984 (58%) are nongovernment not-for-profit, 1,224 (24%) are investor-owned for-profit, and 913 (18%) are state or local government facilities (American Hospital Association, 2026). About 42% of community hospitals carry no federal charity-care duty at all.

The hospital count also understates nonprofit reach. Nonprofit community hospitals take nearly three-quarters of all community hospital admissions, while for-profits take a much smaller share (AHA, 2025). If you were admitted to a nonprofit hospital, the rules below probably apply to you.

The rule lives in Section 501(r) of the Internal Revenue Code, added by the Affordable Care Act in 2010. It does not say “forgive bills.” It says the hospital must have a policy, publicize it, tell you the policy exists on your billing statement, and follow it.

What the law does not do. It sets no income limit. Each hospital writes its own eligibility rules (IRS). A KFF review found that 62% of nonprofit hospitals limit discounted care to patients at or below 400% of the federal poverty guidelines and 38% use a higher cap (KFF, 2025). A 2024 Health Affairs study of nearly 3,000 nonprofit hospitals found free-care income limits ranging from 41% to 600% of the poverty guideline, and that 3.2% of hospitals excluded insured patients from free care entirely (Health Affairs, 2024).

Where it breaks down in practice. Having the law on your side is not the same as getting help. A 2026 review of 166 Texas nonprofit hospital policies found that 44% of them bill patients before screening for financial assistance, 41% screen only after handing the account to collectors or threatening garnishment, and about 8% require screening before a bill goes out at all (KFF Health News and Tradeoffs, 2026). Dollar For, an advocacy group that files applications for patients, reports that only 29% of patients with unaffordable hospital bills manage to learn about, apply for, and receive charity care, and that 65% of likely-eligible patients who did not apply said they simply did not know it existed (Dollar For, 2024; Dollar For, 2025). Those figures come from advocacy research, not peer-reviewed studies, and they describe people who reached out to that group.

Do you qualify? Three checks before you call anyone

Three checks decide most cases: who owns the hospital, how your income compares with that hospital’s own published cap, and how many days have passed since your first bill. Do these before you call.

Check 1: Who owns the hospital? Look up the hospital’s legal name in the IRS Tax Exempt Organization Search, or read its “About” page. If it is for-profit or government-owned, the federal charity-care rules do not apply. State law, Medicaid, and your insurer may still help. This check changes what you can ask for, so do not skip it.

Check 2: What is the income cap? Download the hospital’s FAP. It is usually a PDF under “billing” or “patient financial services.” Find two numbers: the income level for free care and the income level for discounted care. Some policies count insured patients. Some exclude them.

For scale, the 2026 federal poverty guideline is $15,960 for one person, $33,000 for a household of four, and $5,680 for each additional person in the 48 contiguous states and D.C. Alaska and Hawaii use higher figures (HHS, 2026). A household of three earning $47,000 sits at about 172% of the guideline. At a hospital with a 200% free-care ceiling, that is inside the range.

Check 3: How many days have passed? Find the date on your hospital’s first post-discharge billing statement. That is day zero for both federal clocks. Bills from a radiologist, an independent physician group, or an ambulance company are not the hospital’s bill and do not start the hospital’s clock.

A note on the tables you will find elsewhere. Many articles publish national charity-care income charts. No national chart exists. Some states do set floors.

Washington requires free care at or below 200% of the poverty guidelines at all hospitals and at or below 300% at large hospitals, with discounts down to 400% (RCW 70.170.060). New Jersey’s Charity Care program gives free care at or below 200% and a sliding scale from 201% to 300%, where the patient’s share runs from 20% to 80% of the bill (New Jersey Department of Health). Elsewhere, your hospital’s own policy is the only rule that counts.

The three federal deadlines, mapped

Two federal clocks run from your hospital’s first post-discharge bill, and a third notice runs alongside them (IRS).

DeadlineWhat starts itWhat it protects
120 daysYour hospital’s first post-discharge billing statementNo sale of your debt, credit reporting, lawsuit, lien, or garnishment before this
240 daysSame dateYour window to submit a financial assistance application, which is a minimum, not an expiry
30 daysWritten notice of intended collection actionA final warning naming the specific actions the hospital plans to take

The 120-day rule is a floor, not a shield. The hospital must also notify you in writing at least 30 days before any extraordinary collection action, and must make a reasonable effort to tell you by phone. The rules define those actions precisely: selling your debt, reporting adverse information to credit bureaus, requiring payment before providing medically necessary care because of an old bill, or using the courts (IRS).

One exception trips people up. Denying or delaying medically necessary care over an unpaid bill counts as an extraordinary collection action, but it sits outside the 120-day wait when the hospital hands you the application and a deadline at least 30 days out (CRS, 2024). So a hospital that hands you the application can, in practice, stop non-emergency care sooner than a hospital that never told you the program existed.

Collections can start before day 120. The rules do not prohibit a hospital from referring your account to an outside collection agency for billing, as long as it does not sell the debt during the notification period (Federal Register, 2012). A collection letter before day 120 is not proof of a violation. Selling the debt, reporting you, or suing you before day 120 is.

The window is long, but the protection ends at a decision. Once the hospital decides on a complete application, the suspension lifts and collection actions can proceed.

The clock is not the only one running. A No Surprises Act dispute must be filed within 120 days of the bill, and a Medicaid application filed now may still reach back to the month of care. The Medicaid section and the insurance section cover both.

The phone call that changes the outcome

Ask for the Financial Assistance Policy and its application by name. The word “help” gets you a payment plan. The words “financial assistance application” get you a process with deadlines attached.

Use this sequence:

  1. Confirm the account: “I’m calling about account [number] for services on [date].”
  2. Name the request: “I’m requesting your Financial Assistance Policy and the application under IRC 501(r).”
  3. Ask for it in writing: “Please email or mail the policy and the application today.”
  4. Ask about the clock: “What is the date on my first post-discharge statement, and is my application period still open?”
  5. Ask what “complete” means: “What documents do you require for a complete application, and what is the deadline if I am missing one?”
  6. Set the terms: “Please note on my account that I am applying and that I am requesting a hold on collection activity.”
  7. Get a name and a reference number before you hang up.

Do not accept a payment plan during this call. Say: “I’d like the assistance decision first. I’ll pay whatever balance results.” Asking for a written hold is stronger than a verbal promise, because the federal refund rules protect you only if the hospital did not make an upfront payment a condition of your care (26 CFR 1.501(r)-5).

If you get a no on the phone. Billing staff are not the policy. Ask for patient financial services, a financial counselor, or a hospital social worker. Then submit the request in writing anyway, so the date is recorded.

What to send, and what to do if you can’t

Send exactly what the policy lists, dated, once. An incomplete application is a separate category in the rules: the hospital must tell you what is missing, give you a reasonable opportunity to fix it, and keep collections suspended while you do (IRS). If you blow the deadline the hospital gives you for missing documents, the hold can end.

Typical requirements include two to three months of pay stubs, last year’s tax return, bank statements, proof of household size, and sometimes a list of monthly expenses. Some hospitals ask for far more. Stanford University health economist Neale Mahoney described the process as “like going through a tax audit” (KFF Health News, 2026).

Before you send, do this. Write down every item the policy requires and check them off as you attach them. Keep a full copy. Send by portal, fax, or certified mail, and keep the receipt.

If you cannot produce a document. Say so in writing, in the application, and offer a substitute. A documented explanation is stronger than a missing page.

Say what you have. If you have no bank account, say that. If you are paid in cash, provide a signed statement and any deposit records.

If you are supporting an adult relative, provide evidence of the shared household.

The completeness receipt. After submitting, send one short message: “Please confirm in writing the date my application was received and the date it was deemed complete.” That single request turns a silent process into a dated record you can use later.

Can they sue me or send me to collections while I’m applying?

Not while an application is under review. Once the hospital receives a complete application inside the window, it must suspend extraordinary collection actions, decide, and notify you in writing of the decision and the basis for it (IRS).

Bills and phone calls can continue. Lawsuits, liens, garnishment, debt sales, credit reporting, and refusals of medically necessary care cannot.

If collections proceed anyway. Send a one-page notice, by certified mail, to the hospital and to any collector: your name, the account number, the date you submitted your application, and a request that collection activity stop while it is reviewed. Attach proof of submission. Then tell the collector, in writing, that you dispute the debt and want validation. A collector must give you written validation information and a 30-day window to dispute (CFPB).

If a lawsuit arrives. Do not ignore it. A default judgment can lead to wage garnishment or a lien on your home. Contact legal aid in your county the same day. A 2022 KFF Health News review of 528 hospitals found that more than two-thirds had policies permitting lawsuits, wage garnishment, or property liens, while only 19 of the 528 had posted policies barring extraordinary collection actions (KFF Health News, 2022).

If you have insurance, run this track in parallel

Your balance may exist because the claim was processed wrongly. Read the Explanation of Benefits before you accept the number as your debt.

Insurers deny a lot of claims. ACA marketplace plans denied 19% of in-network claims in 2024, and consumers appealed fewer than 1% of those denials. Of the appeals that were filed, insurers upheld their original decision 66% of the time (KFF, 2026).

Those odds sound bad. They are also the reason to check whether your denial is the kind that gets reversed. Prior authorization denials are rarely appealed, but when they are, 43% were overturned in the marketplace, 47% in Medicaid managed care, and 67% in Medicare Advantage (KFF, 2026).

Your sequence. Get the denial reason code from the Explanation of Benefits, call the insurer and ask what would make the claim payable, file the internal appeal in writing before the deadline, then file for external review if the internal appeal fails. External review is a separate process with its own deadline, and it is free.

Check the No Surprises Act. If the bill came from emergency care, from an out-of-network provider at an in-network facility, or from an air ambulance, federal law may cap what you owe at in-network cost sharing (CMS). If you were uninsured or chose not to use insurance, you may be entitled to a Good Faith Estimate, and you can dispute a bill that came in at least $400 above it within 120 days, using a federal dispute process with a $25 fee (CMS). Good Faith Estimates are not issued for emergency care.

Apply for Medicaid now, because the lookback is shrinking

Medicaid can pay for care you received before you applied, up to three months back in most states today, if you would have qualified in that month. That window narrows on January 1, 2027.

Under the 2025 federal budget law, retroactive coverage for adults in the Medicaid expansion group drops from three months to one month for applications filed on or after that date. Other groups, including children, pregnant enrollees, and people with disabilities, drop to two months (KFF, 2026). The trigger is the date you file, not the date of your care.

Coverage changes financial outcomes at scale. Medicaid expansion cut the incidence of newly accrued medical debt by 30% to 40%, worth roughly $920 per newly insured person in its first two years (Brevoort, Grodzicki and Hackmann, NBER 2017).

Other research found newly covered adults owed about $1,140 less in third-party collections (Hu et al., NBER 2016). In Michigan, Medicaid expansion enrollees carried $983 less medical debt in collections seven years after enrollment, and the share with a subprime credit score had fallen by 23 percentage points (Becker et al., JAMA Network Open, 2026).

What to do. Apply through your state Medicaid agency or HealthCare.gov this week, and state the month of service explicitly on the application. If the hospital’s assistance office asks whether you want to apply for Medicaid, say yes. Hospitals commonly sequence their decision after Medicaid resolves, so ask for the expected timeline in writing rather than waiting in silence.

If you qualify, what the hospital must do

If you are approved, two federal rules kick in.

You cannot be charged more than the amounts generally billed. For emergency and medically necessary care, the hospital must limit what it charges a qualifying patient to what it generally bills insured patients, and it may not use its gross “chargemaster” price (26 CFR 1.501(r)-5). That cap applies to what you personally owe after insurance, not to the total bill.

You get refunded what you paid above your responsibility. The regulation requires a refund of amounts paid beyond your responsibility as an eligible patient, unless the excess is under $5, and requires the hospital to reverse collection actions it already took, including removing adverse credit information and taking reasonable steps to vacate judgments (IRS).

In practice, hospitals rarely volunteer this. About 40% of Texas nonprofit hospitals said they would not inform patients when a balance was cleared, and roughly two-thirds of their policies said patients would not receive full refunds (KFF Health News, 2026).

Write this request: “I was determined eligible under your Financial Assistance Policy for services on [date]. Under 26 CFR 1.501(r)-6, please refund the $[amount] I paid above my responsibility as a financial-assistance-eligible patient and confirm the refund in writing.”

Do not put a hospital bill on a medical credit card while an application is pending. Medical credit cards carried interest rates of about 26.99% against roughly 16% for conventional cards, and consumers paid about $1 billion in deferred interest between 2018 and 2020 (CFPB, 2023). Paying by card can also convert a no-interest hospital balance into a debt a creditor has more incentive to sue over.

If they say no

Ask for the written basis, correct whatever the denial rested on, re-apply, and escalate. A denial without a stated reason is a compliance problem you can raise.

Reason on the denialWhat it usually meansYour next move
Application incompleteA document was missing or a form unsignedSupply the missing item and ask for the date it became complete
Income too highWrong income basis, wrong household size, or a policy excluding insured patientsRequest the calculation in writing; supply household size and expense evidence
Insured patients not eligibleA hospital policy choice, not a federal oneAsk for hardship review; run the insurer appeal and Medicaid tracks
No reason givenPossible 501(r) violationDemand the basis in writing; escalate to hospital compliance and the state attorney general

The escalation ladder, in order. The hospital’s patient financial services manager, then the hospital’s compliance officer, then your state attorney general’s consumer protection division, then the IRS on Form 13909. Know the limit before you start: Section 501(r) gives you no private right of action, so you cannot sue the hospital in federal court over a charity-care violation. Enforcement runs through the IRS and state attorneys general, which means referral, not remedy. None of these are fast.

Get help if the process stalls. Legal aid offices handle medical debt at no cost. Hospital social workers know the internal funds. Dollar For files applications for patients. Navigation helps most when you have the capacity to follow up.

The evidence on navigation is mixed. A financial navigation program at one North Carolina cancer center helped 96% of 50 participants receive some form of assistance (JNCCN, 2024), though that was a small, single-site study with no control group. A 2026 randomized trial of navigation in advanced cancer found no average benefit across 329 participants, though a subgroup with more financial and social resources did better (ASCO Post, 2026).

What changed recently

  • Oregon loosened its own rule. The state required hospitals to screen before billing starting July 2024. One large health system said 64% of its patients then qualified for help, up from 12% (KFF Health News, 2026). In 2026 lawmakers raised the threshold for screening from $500 to $1,500 for a single visit. No published study yet shows whether Oregon’s law reduced medical debt.
  • Six states will require automatic screening. By July 2027, California, Delaware, Illinois, Maryland, North Carolina, and Oregon will require hospitals to screen certain patients for presumptive eligibility, meaning no application. California’s rule begins July 1, 2027 under AB 1312, which took effect January 1, 2026 (California Department of Health Care Access and Information).
  • The federal medical-debt credit ban is gone. The CFPB finalized a rule in January 2025 that would have removed medical bills from most credit reports. On July 11, 2025, the U.S. District Court for the Eastern District of Texas vacated it at the Bureau’s own request, finding it exceeded CFPB authority and conflicted with the Fair Credit Reporting Act (CFPB; CRS, 2025). What remains are voluntary bureau policies: paid medical collections are removed, unpaid medical collections under $500 are excluded, and a waiting period runs before a medical collection can be reported (NCLC, 2026). Larger, older, unpaid medical bills can still appear.
  • State credit-reporting bans are unsettled. The same Texas decision said in dicta that the Fair Credit Reporting Act preempts state bans on medical-debt reporting, and the CFPB issued a separate interpretive rule in October 2025 making the same claim. No court has ruled on that question, and it conflicts with the First Circuit’s 2022 decision in Consumer Data Industry Association v. Frey. If your state bans medical debt from credit reports, treat its status as uncertain.
  • Congress is weighing hospital charity-care disclosure. The House Ways and Means Committee advanced the Tax Exempt Hospital Transparency Act, H.R. 9504, on July 1, 2026. It would require tax-exempt hospitals to report the number of financial assistance applications received, granted, and denied, plus the value of assistance provided (Congress.gov). It is not law.

What this article cannot tell you

  • Whether your hospital’s policy will approve you. Only the hospital decides eligibility, and only the hospital can say what “complete” means.
  • Whether your specific bill qualifies. The FAP can exclude certain services, and a pre-service review or retroactive application can land differently.
  • How fast you will hear back. No national figure exists for charity care decision times, and the federal rules set no deadline for deciding an application.
  • Whether a state rule helps you. State charity-care floors differ, and this article names only Washington and New Jersey. Check your own state attorney general’s medical debt resources.
  • Whether collection activity was lawful. Only a lawyer can assess a specific account, a specific judgment, or a specific garnishment.

FAQ

Can a nonprofit hospital refuse to help me?
It can deny you under its own policy, but it must tell you in writing and state the basis for the decision. A denial with no explanation is a compliance issue you can escalate to the hospital’s compliance officer and your state attorney general. Denials can be re-applied for once you correct what the hospital says was wrong. One caveat: Section 501(r) gives you no private right of action, so escalation is a referral to an agency, not a lawsuit.

Do I qualify if I have insurance?
Often, yes. Eligibility depends on the hospital’s own written policy, not your coverage status. Some hospitals exclude insured patients from free care entirely, about 3.2% in a 2024 study of nearly 3,000 nonprofit hospitals, though most do not. Federal rules also bar hospitals from charging eligible patients more than the amounts generally billed to insured patients, which is one reason insured balances are worth challenging.

My bill is already in collections. Can I still apply?
Yes. The 240-day application window does not close because a collector called, and a hospital that sells your debt must bind the buyer to the same suspension. Ask the hospital to recall the account from the collector, submit a complete application, and tell the collector in writing that you dispute the debt and are seeking financial assistance. If you qualify, the hospital must take reasonable available steps to reverse what was already done, including removing adverse credit information.

Will this hurt my credit?
Not while an application is pending, because credit reporting is one of the collection actions hospitals must suspend during review. A denial lifts that suspension. Check your reports at all three national bureaus and dispute anything that appears while your application was under review. Applying for financial assistance is not itself a credit inquiry, and a patient who qualifies is entitled to have adverse information removed.

Is medical debt off credit reports now?
No. The 2025 federal rule that would have removed it was vacated on July 11, 2025. What remains are voluntary bureau policies: paid medical collections are removed, unpaid collections under $500 are excluded, and a waiting period runs before reporting. Larger, older, unpaid medical debts can still show up. State bans exist in several states, but their status is contested.

How long does charity care take?
There is no national figure, and federal rules set no deadline for a decision. Ask the hospital in writing for its stated decision timeline, then follow up at day 30 if nothing arrives. You have at least 240 days to apply, but protection against collection actions applies once an application is on file, so filing early is safer than filing perfectly. Many hospitals wait for a Medicaid determination before deciding.

Can I apply after I already paid?
Yes. If you were eligible, the hospital must refund what you paid above your responsibility, unless the excess is under $5. Send a written refund request that cites 26 CFR 1.501(r)-6 and the hospital’s policy, and keep a copy. Hospitals rarely offer this on their own. In Texas, about 40% of nonprofit hospitals had policies saying they would not tell patients their balance had been cleared.

What if the hospital is for-profit?
The federal charity-care rules do not apply, because they are a condition of federal tax exemption. Check whether your state has its own charity-care law, apply for Medicaid if you might qualify in the month of care, appeal any insurance denial, and negotiate a written settlement you can actually pay. Legal aid can help you evaluate the offer before you sign anything, and a hospital that is 42% of community hospitals is exactly the case where this check matters.

What if I can’t gather the documents the policy lists?
Submit anyway, and in writing explain what you could not produce and offer a substitute. A documented explanation is stronger than a missing page, and an incomplete application filed inside the window still suspends collections while the hospital tells you what is missing and gives you a reasonable chance to fix it. If you have no bank account, are paid in cash, or are supporting an adult relative, say so and attach what you have.

Will the hospital let me pay nothing while I wait?
Usually, but not always in writing, and the protections you care about come from the written application, not from silence. Ask for the account to be held and get the request logged. Refuse to sign a medical credit card agreement or a payment plan while the application is pending. Know that the federal safe harbor for charges above the amounts generally billed does not protect you if the hospital required an upfront payment as a condition of your care.

The short version

Read the bill as an unanswered eligibility question with a deadline attached.

What matters most: a complete application on file and a written decision in hand, before any payment and before any collection action.

What to do first: confirm who owns the hospital, download its policy, and find the date on your hospital’s first bill.

What to watch: whether the hospital confirms your application is complete, whether the letters keep coming, and whether anything appears on your credit reports.

What to change if it fails: move to the written escalation ladder, then to legal aid or a navigator. Do not repeat the same call with the same words.

What to stop expecting: a guaranteed write-off, a fast answer, and a system that volunteers what you are entitled to.

When to escalate: the day a court paper arrives, a paycheck is garnished, a lien is filed, care is refused, or a denial arrives with no reason.

Sources

Federal rules and guidance: IRS, Billing and collections, Section 501(r)(6); IRS, Financial assistance policies; IRS, Section 501(r)(4); 26 CFR 1.501(r)-5, Limitation on charges; 26 CFR 1.501(r)-6, Billing and collection; Federal Register, Additional Requirements for Charitable Hospitals (2012); HHS, Annual Update of the HHS Poverty Guidelines (2026); CMS, No Surprises Act; CMS, Know your medical bill rights when not using insurance; CFPB, What information does a debt collector have to give me?; CFPB, Report on costly credit cards and loans pushed on patients (2023); CFPB, Final rule to remove medical bills from credit reports (2025); CRS, Overview of Medical Debt (2025); CRS, Legal Requirements for Section 501(c)(3) Hospitals (2024); Congress.gov, H.R. 9504 Tax Exempt Hospital Transparency Act.

State law: RCW 70.170.060 (Washington); New Jersey Department of Health, Charity Care; California HCAI, Hospital Fair Billing Program Laws and Regulations.

Data and research: AHA, Fast Facts on U.S. Hospitals 2026; AHA, Nonprofit Hospital Community Benefits; KFF, Hospital Charity Care (2025); KFF, Health Provisions in the 2025 Federal Budget Reconciliation Law; KFF, Claims Denials and Appeals in ACA Marketplace Plans in 2024; KFF, Prior Authorization Metrics (2026); Health Affairs, US Nonprofit Hospitals Have Widely Varying Charity Care Criteria (2024); KFF Health News and Tradeoffs, What Texas Reveals (2026); KFF Health News, Hundreds of Hospitals Sue Patients (2022); KFF Health News, Oregon (2026); Dollar For, Bridging the Chasm (2024); Dollar For, Fixing Hospital Financial Assistance Programs (2025); NCLC, Keeping Medical Debt Out of Credit Reports (2026); Brevoort, Grodzicki and Hackmann, Medicaid and Financial Health (NBER 2017); Hu et al., The Credit Consequences of Unpaid Medical Bills (NBER 2016); Becker et al., Financial Outcomes Among Medicaid Expansion Enrollees, JAMA Network Open (2026); Adams et al., American Economic Review: Insights (2022); Kluender et al., Quarterly Journal of Economics (2025); JNCCN, Financial Navigation Intervention (2024); The ASCO Post, CREDIT trial (2026).


  1. Internal Revenue Service. “Billing and collections – Section 501(r)(6).” 2025 (page dated July 2, 2026). https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6
  2. Internal Revenue Service. “Financial assistance policies (FAPs).” 2025 (page dated Dec. 28, 2025). https://www.irs.gov/charities-non-profits/financial-assistance-policies-faps
  3. Internal Revenue Service. “Financial assistance policy and emergency medical care policy – Section 501(r)(4).” 2025. https://www.irs.gov/charities-non-profits/financial-assistance-policy-and-emergency-medical-care-policy-section-501r4
  4. eCFR. “26 CFR 1.501(r)-6 – Billing and collection.” Current. https://www.ecfr.gov/current/title-26/chapter-I/subchapter-A/part-1/subject-group-ECFR062882ac6495890/section-1.501(r)-6
  5. eCFR. “26 CFR 1.501(r)-5 – Limitation on charges.” Current. https://www.ecfr.gov/current/title-26/chapter-I/subchapter-A/part-1/subject-group-ECFR062882ac6495890/section-1.501(r)-5
  6. Federal Register. “Additional Requirements for Charitable Hospitals; Community Health Needs Assessments…” 2012. https://www.federalregister.gov/documents/2012/06/26/2012-15537/additional-requirements-for-charitable-hospitals
  7. Congressional Research Service. “Legal Requirements for Section 501(c)(3) Hospitals.” R48027, April 15, 2024. https://www.congress.gov/crs-product/R48027
  8. Congressional Research Service. “An Overview of Medical Debt: Collection, Credit Reporting, and Related Policy Issues.” IF12169, Aug. 29, 2025. https://www.congress.gov/crs-product/IF12169
  9. U.S. Department of Health and Human Services. “Annual Update of the HHS Poverty Guidelines.” 91 FR 1797, Jan. 15, 2026 (effective Jan. 13, 2026). https://www.federalregister.gov/documents/2026/01/15/2026-00755/annual-update-of-the-hhs-poverty-guidelines
  10. American Hospital Association. “Fast Facts on U.S. Hospitals, 2026.” Feb. 5, 2026. https://www.aha.org/statistics/fast-facts-us-hospitals
  11. American Hospital Association. “Nonprofit Hospital Community Benefits: Addressing Each Community’s Unique Needs.” April 10, 2025. https://www.aha.org/nonprofit-hospital-community-benefits-addressing-each-communitys-unique-needs
  12. KFF. “Hospital Charity Care: How It Works and Why It Matters.” Aug. 9, 2025. https://www.kff.org/health-costs/hospital-charity-care-how-it-works-and-why-it-matters/
  13. KFF. “Health Provisions in the 2025 Federal Budget Reconciliation Law.” July 23, 2026. https://www.kff.org/medicaid/health-provisions-in-the-2025-federal-budget-reconciliation-law/
  14. KFF. “Claims Denials and Appeals in ACA Marketplace Plans in 2024.” March 24, 2026. https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/
  15. KFF. “Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain.” Sept. 29, 2026. https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/
  16. Health Affairs. “US Nonprofit Hospitals Have Widely Varying Criteria To Decide Who Qualifies For Free And Discounted Charity Care.” Nov. 4, 2024. https://www.healthaffairs.org/doi/10.1377/hlthaff.2023.01615
  17. Evans, Melanie / Tradeoffs. “What Texas Reveals About the Obstacles to Getting Hospital Financial Aid.” KFF Health News, Oct. 15, 2026. https://kffhealthnews.org/health-industry/hospital-financial-aid-obstacles-presumptive-eligibility-texas-oregon/
  18. KFF Health News. “Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds.” Dec. 21, 2022. https://kffhealthnews.org/health-care-costs/medical-debt-hospitals-sue-patients-threaten-credit-khn-investigation/
  19. KFF Health News / Tradeoffs. “States Are Forcing Hospitals To Offer More People Financial Aid. In Oregon, It’s Working.” Oct. 22, 2026. https://kffhealthnews.org/health-care-costs/oregon-hospitals-presumptive-eligibility-screening-law-medical-debt-tradeoffs/
  20. Tradeoffs. “Experts Weigh In on Emerging Tool To Prevent Medical Debt.” Oct. 26, 2026. https://tradeoffs.org/2026/10/26/experts-weigh-in-on-emerging-tool-to-prevent-medical-debt/
  21. Dollar For. “Bridging the Chasm: Closing the $14 Billion Access Gap in Charity Care.” April 2024. https://dollarfor.org/wp-content/uploads/2024/04/Dollar_For.Bridging_the_Chasm.pdf
  22. Dollar For. “Fixing Hospital Financial Assistance Programs.” May 2025. https://dollarfor.org/wp-content/uploads/2025/05/fixing_hfa.pdf
  23. National Consumer Law Center. “The Latest on Keeping Medical Debt Out of Credit Reports.” 2026. https://library.nclc.org/article/latest-keeping-medical-debt-out-credit-reports
  24. Consumer Financial Protection Bureau. “CFPB Report Highlights Costly Credit Cards and Loans Pushed on Patients.” May 4, 2023. https://www.consumerfinance.gov/archive/newsroom/cfpb-report-highlights-costly-credit-cards-and-loans-pushed-on-patients/
  25. Consumer Financial Protection Bureau. “CFPB Finalizes Rule to Remove Medical Bills from Credit Reports.” Jan. 7, 2025 (with July 11, 2025 vacatur notice). https://www.consumerfinance.gov/archive/newsroom/cfpb-finalizes-rule-to-remove-medical-bills-from-credit-reports/
  26. Consumer Financial Protection Bureau. “What information does a debt collector have to give me about the debt?” https://www.consumerfinance.gov/ask-cfpb/what-information-does-a-debt-collector-have-to-give-me-about-the-debt-en-331/
  27. Centers for Medicare & Medicaid Services. “No Surprises: Understand your rights against surprise medical bills.” March 3, 2026. https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills
  28. Centers for Medicare & Medicaid Services. “Know your medical bill rights when not using insurance.” Aug. 17, 2026. https://www.cms.gov/medical-bill-rights/know-your-rights/no-insurance
  29. Washington State Legislature. “RCW 70.170.060: Charity care – Prohibited and required hospital practices and policies.” https://app.leg.wa.gov/rcw/default.aspx?cite=70.170.060
  30. New Jersey Department of Health. “Charity Care.” https://www.nj.gov/health/hcf/charity-care/overview/
  31. California Department of Health Care Access and Information. “Hospital Fair Billing Program – Laws and Regulations.” Aug. 21, 2026. https://hcai.ca.gov/affordability/hospital-fair-billing-program/laws-and-regulations/
  32. Congress.gov. “H.R.9504 – Tax Exempt Hospital Transparency Act, 119th Congress (2025-2026).” Introduced June 29, 2026; ordered reported July 1, 2026. https://www.congress.gov/bill/119th-congress/house-bill/9504
  33. Brevoort, K., Grodzicki, D., and Hackmann, M. “Medicaid and Financial Health.” NBER Working Paper 24002, Nov. 2017. https://www.nber.org/system/files/working_papers/w24002/w24002.pdf
  34. Hu, X., et al. “The Credit Consequences of Unpaid Medical Bills.” NBER Working Paper 22170, 2016. https://www.nber.org/system/files/working_papers/w22170/w22170.pdf
  35. Becker, N.V., Levy, H., Hirth, R.A., Clark, S.J., Tipirneni, R., and Ayanian, J.Z. “Financial Outcomes Among Medicaid Expansion Enrollees.” JAMA Network Open 9(4):e269328, April 27, 2026. https://doi.org/10.1001/jamanetworkopen.2026.9328
  36. Adams, A., Kluender, R., Mahoney, N., Wang, J., Wong, F., and Yin, W. “The Impact of Financial Assistance Programs on Health Care Utilization: Evidence from Kaiser Permanente.” American Economic Review: Insights 4(3):389-407, Sept. 2022. https://www.nber.org/papers/w29227
  37. Kluender, R., Mahoney, N., Wong, F., and Yin, W. “The Effects of Medical Debt Relief: Evidence from Two Randomized Experiments.” Quarterly Journal of Economics 140(2):1187-1241, 2025. https://academic.oup.com/qje/article/140/2/1187/7933321
  38. Wheeler, S.B., et al. “Impact of a Comprehensive Financial Navigation Intervention to Reduce Cancer-Related Financial Toxicity.” JNCCN 22(8):557-562, Oct. 1, 2024. https://jnccn.org/view/journals/jnccn/22/8/article-p557.xml
  39. “Financial Navigation Support May Help Reduce Financial Toxicity for Some People With Advanced Cancer.” The ASCO Post, Oct. 13, 2026 (CREDIT trial, abstract 634). https://ascopost.com/news/october-2026/financial-navigation-support-may-help-reduce-financial-toxicity-for-some-people-with-advanced-cancer/
  40. American Society of Clinical Oncology. Press release, “Financial Navigation Support May Help Reduce Financial Toxicity in Advanced Cancer.” Oct. 12, 2026. https://www.asco.org/about-asco/press-center/financial-navigation-support-may-reduce-financial-toxicity-advanced-cancer

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