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Would you qualify for a discount on your next hospital stay in Southeast Minnesota?

Nonprofit hospitals are required to provide free or discounted care, also known as charity care; yet eligibility and application requirements vary across hospitals. Could you qualify? We found out.

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The Post Bulletin conducted an examination of every Minnesota nonprofit hospital’s website, more than 100 health systems, collecting charity care eligibility requirements, applications and interviewing hospitals that had not disclosed the information online.
Post Bulletin graphic / Molly Castle Work
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ROCHESTER — Charity care, free or discounted hospital care, is available, but few Minnesotans know they could be eligible.

Minnesota hospitals generally determine patient eligibility based on the patient’s household income in relation to the federal poverty guidelines. At Olmsted Medical Center, for example, patients are eligible to apply for aid if their family makes less than 300% of the federal poverty guidelines, meaning a single person could qualify if they make less than $43,740 or a family of four if they make less than $90,000.

“Hospital charity care, also known as financial assistance, is one tool we have to protect lower-income patients from being driven into bankruptcy or struggling for years to pay off high medical bills,” said Anna Odegaard, the director of the Minnesota Building Asset Coalition. “And it’s not just uninsured patients that can be burdened with unaffordable bills. People with high deductible health plans can end up with thousands of dollars of medical debt for a single hospital stay.”

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Providing charity care is a requirement of all nonprofit hospitals, as a condition of not paying taxes — a benefit that saves hospitals like Mayo Clinic hundreds of millions of dollars each year . Yet, eligibility varies across hospitals and, for many Minnesotans, it can be difficult to access charity care information , an issue that Odegaard and Minnesota lawmakers are hoping to alleviate through legislation .

The Post Bulletin conducted an examination of every Minnesota nonprofit hospital’s website, more than 100 health systems, collecting charity care eligibility requirements, applications and interviewing hospitals that had not disclosed the information online. The findings are included in the following database.

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No standard for eligibility

Nonprofit hospitals are mandated by the Affordable Care Act to provide financial assistance policies, but it’s up to the hospital what they decide to cover in their policy.

“There are no exact standards for these benefits,” said Maddie Renneke, Minnesota Hospital Association communication specialist. “However, Minnesota health systems have tended to be generous with their community benefits and financial assistance policies, contributing $3.3 billion to their communities in 2020 alone.”

Renneke also noted that hospitals offer payment plans, and that hospital emergency rooms are open 24/7 and provide service to all who enter regardless of ability to pay.

Nonprofit hospitals must offer free or discounted care to eligible patients. But the Post Bulletin discovered that some patients sued by Mayo for unpaid medical bills didn't know this option existed.

Because there are no exact standards as to how much charity care hospitals provide and to whom, aid eligibility and application requirements vary. Odegaard said this variability makes it difficult to educate communities about the availability of financial assistance, because a person may be eligible for assistance at one hospital but not at another.

For example, OMC requires that home equity assets fall below those specific income guidelines and declines care for certain medical services like surgical birth control. Other hospitals take health insurance status or other assets into consideration.

"Medical debt is seldom chosen, and most of us don’t believe a family should face a financial crisis for seeking necessary healthcare. Hospital financial assistance is one tool we have to protect low-income patients."
Anna Odegaard, Minnesota Building Asset Coalition

The common thread between the policies across the state is that household income is the starting point to determine eligibility.

Mayo Clinic, Winona Health Services, Gundersen St. Elizabeth's Hospital and 22 other Minnesota hospitals with available data, consider patients for financial assistance up to 400% of the federal poverty guideline.

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Meanwhile, aid at around the same amount of Minnesota hospitals, 21, is limited to patients with household annual incomes at or below 200% FPG or $29,160 for a single person.

Riverview Health in Crookston has the most restrictive income requirements, and is limited to patients who make less than 150% FPG or $21,870.

“Hospitals have broad discretion over charity care eligibility policy,” said Ge Bai, a Johns Hopkins University accounting and public health professor, who researches charity care. “Some have chosen to be more generous than others. Hospitals interested in advancing charitable missions should consider lifting their income test ceiling for charity care eligibility.”

In a 2022 charity care study that Bai co-authored, her team determined that three-quarters of nonprofit hospitals nationwide covered at least 200% FPG for discounted charity care and 38% of hospitals covered at least 400% FPG, according to 2018 data.

Compared to the national data, Minnesota nonprofit hospitals income requirements are more restrictive. Less than a quarter of Minnesota nonprofit hospitals cover up to 400%.

Many patients haven’t heard of "charity care," also known as financial assistance, although every nonprofit hospital, including Mayo Clinic, is required to provide it. And even when patients discover it, many struggle because the application process is too burdensome or they avoid it altogether, reluctant or hesitant to apply for “charity.”

Some states, such as Washington, have imposed higher standards for hospital financial assistance, and Odegaard said she hopes Minnesota will follow Washington's lead. She also wants the state to consider adding provisions to support smaller hospitals that are more financially precarious, so they don’t have to short shrift their charity care provisions in order to keep the hospital afloat.

“As a state, we should find another way of supporting these hospitals and not allow them to shift the financial burden to low-income families,” Odegaard said.

Shrouded information

The IRS requires that nonprofit hospitals “widely advertise” the financial assistance policy by including a plain language summary and the application on their websites and in public locations as well as notifying and informing members of the community who receive care of the program's existence. Many hospitals, including Mayo Clinic, include a link to financial assistance information in the billing statement.

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“There are a full spectrum of services in place to make patients aware of payment options — from websites to financial counselors in facilities,” Renneke said. “Hospitals and health systems are constantly looking for new ways to spread awareness about these options so that Minnesotans receive the right care at the right place and the right time.”

However, a Post Bulletin analysis found that the following systems, 8% of all Minnesota hospitals, do not share charity care eligibility information, or in some cases, the application or policy on their websites even though it is a federal requirement: CCM Health, Madison Health Care Services, Mahnomen Health Center, Welia Health, Hendricks Community Hospital, Big Fork Valley Hospital, Appleton Area Health, Cook Hospital & Care Center and Sleepy Eye Medical Center.

Sheila Peterson, Welia Health spokesperson, said the eligibility information is not yet posted online, but the hospital plans to post it online within the next quarter.

Sleepy Eye Medical Center’s spokesperson, Mikayla Bruggerman, also said that the information will be posted online in the near future. At the time of publication, neither hospital had added the information to their websites.

The other hospitals did not respond to multiple requests for comment. None of these hospitals are in Southeast Minnesota.

This issue occurs at a national level as well. According to a December investigation by Kaiser Health News, 1-in-5 hospitals researched by KHN, don’t post aid policies online.

Hospitals have broad discretion over charity care eligibility policy. Some have chosen to be more generous than others.
Ge Bai, a Johns Hopkins University

The majority of Minnesota hospitals do display the information online, but it can be tricky to find. Where information on bill pay is almost always prominently displayed on the homepage, most Minnesota hospitals require users to click through several pages to find any information about charity care.

For example, Olmsted Medical Center patients need to navigate through the “Patients & Visitors” page to find information on charity care. Northfield Hospital’s financial assistance policy was not easily accessible by clicking through the website. The Post Bulletin could only locate the policy by looking it up on Google. Other hospital policies were deep into multipage PDFs.

Mayo Clinic is one of only 12 Minnesota nonprofit hospital systems that advertise financial assistance on the homepage.

“Hospitals can make it easy or hard for patients to become aware of their option of applying to charity care,” Bai said. “Hospitals that want their eligible patients to receive charity care should minimize the information barrier faced by patients.”

Every nonprofit hospital, including Mayo, is required to provide free or discounted care, also known as "charity care," to maintain its nonprofit status with the IRS and reap the benefits of tax exemption. Experts say that financially strong nonprofit hospitals need to be doing more to make it a fair exchange.

One method Odegaard is pushing for is to require Minnesota hospitals to provide patients with information about the policy during the initial intake procedure, on a separate document, in nontechnical language and in large print, preferably in a language in which they are fluent. Further, patients should be asked to sign an acknowledgment that they received and understand the information, just as they are required to do for information about their HIPAA rights.

“If all patients who qualify for financial assistance knew it was available and were able to apply, we would see fewer families in crisis, struggling to pay down debt while coming up short for rent and groceries and foregoing necessary care,” Odegaard said.

Molly Castle Work is an award-winning investigative journalist. She has investigated a range of topics such as OSHA and worker safety during COVID-19, racially-disproportionate juries and white-owned newspapers' role in promoting lynchings. Readers can reach Molly at 507-285-7771 or mwork@postbulletin.com.
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