Charity care? They found it on ... TikTok
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.”
Do you qualify for charity care? Good luck finding it and applying for it.
While nonprofit hospitals are required to offer free or discounted care, also known as “charity care” or “financial assistance,” many patients are unaware that such life-changing assistance exists.
Anna Odegaard, director of Minnesota Asset Building Coalition, a statewide nonprofit coalition committed to offering asset building opportunities to low-income Minnesotans, said most patients haven’t heard of charity care, and when they have, many struggle due to burdensome application processes, or they avoid applying, reluctant to solicit for “charity.”
Financial assistance is available for individuals and families based on their incomes. Each hospital sets its own terms for eligibility. For example, Mayo Clinic offers assistance to patients with incomes at or below 400% of the federal poverty guideline. That's $54,360 for a single person or $111,000 for a family of four. Olmsted Medical Center has set its threshold at 300% of the poverty guideline.
While those assistance programs are not widely known by those who might benefit, there are solutions Odegaard recommends to make the programs more accessible, such as advertising the policies more widely, expanding eligibility and streamlining the application process.
”If everyone who was eligible for charity care, according to the hospital’s own policies, was knowledgeable and had assistance with the application and actually had their bills covered, it could make an enormous difference,” Odegaard said.
The Internal Revenue Service requires nonprofit hospitals to “widely publicize” their financial assistance policies and has set guidelines for hospitals to follow, such as including “conspicuous” written notices in billing statements, in public displays and on the website.
Ge Bai, an accounting and health policy professor who researches charity care at Johns Hopkins University, said most nonprofit hospitals meet the IRS's legal requirements.
Mayo Clinic, for example, said in an email that it promotes its financial assistance policy on its website, authorization forms, monthly statements and letters.
“Mayo Clinic has extensive financial assistance programs in place for patients who do not have the ability to pay for care,” said Justin Furst, a Mayo Clinic spokesman, “and we reach out to patients to provide information and support before and after they receive care at Mayo.”
Megan Bass, a Mayo Clinic patient who lives in New Prague, Minnesota, qualified for charity care assistance to cover her $3,110 medical bill, but Bass said Mayo Clinic staff didn’t mention the possibility of charity care to her in conversations. She didn’t even know charity care existed until she discovered it through TikTok.
Bai was not surprised. Although most hospitals follow the letter of the law, Bai said nonprofit hospitals should be more proactive in how they advertise the policy to ensure eligible patients like Bass don’t slip through the cracks.
For example, nonprofit hospitals could give every arriving patient a flier with the charity care application, so patients don’t need to go to the website to search for it, Bai said. Hospitals could also screen patients presumptively to see if they qualify for financial assistance before receiving care.
Furst said Mayo Clinic has not used third-party tools or vendors to assess presumptive eligibility and instead uses Medicaid eligibility as a criterion to consider patients for financial assistance. Furst said Mayo Clinic is currently researching to determine if third-party vendors could help.
The Minnesota Hospital Association said in an email that its members advertise charity care policies through the website and financial counselors, but its “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.”
Bai noted that while some hospitals are well-intentioned in advertising their policies, others “conceal their charity care policies from patients or use vague and confusing language to discourage applications.”
Erica Dowden, who has helped more than 200 patients fill out charity care applications as an advocate at Dollar For, has seen this in practice. She said if a patient knows to ask the hospital about its charity care policy, some hospital staff are trained to first recommend other payment options, such as a loan or payment plan, even if the patient qualifies for free care.
“Most of the people who reach out to us for help only heard about charity care because of TikTok, or from a friend or referral,” said Dowden, whose organization works to alleviate medical debt. “They didn’t hear about it from the hospital.”
Patients who learn about financial assistance and want to apply for free or discounted care often face a complicated process.
Mayo Clinic, for example, requires applicants to submit recent tax returns, pay stubs, bank statements and W-2s or unemployment statements in addition to the application, a description of financial need and evidence of all other sources of income — from retirement accounts to child support — and personal assets. It also reviews any care previously provided and available coverage and other sources of payment.
“It was really challenging to dig through the paperwork to find all my pay stubs and my tax information, and I was scared of messing things up,” said Bass, who applied for financial assistance at Mayo Clinic with support from Dollar For.
After submitting her application, Bass received partial reimbursement of her bill. However, she and Dollar For believe she qualifies for complete forgiveness based on her income. She is in the appeals process awaiting Mayo Clinic’s decision. Furst said he could not comment on the status of her appeal.
Odegaard said the paperwork isn’t the only hurdle applicants face. For example, most hospitals require uninsured individuals to apply for Medicaid before applying for financial assistance.
This is true at Mayo Clinic. “Mayo Clinic asks that patients apply for Medicaid, as Medicaid can cover both existing services and future services at any health care facility, so that financial assistance is not required,” Furst said.
While this may seem reasonable, Odegaard said that this sort of requirement can elongate an already complicated process and deter potential applicants, especially members of the immigrant community.
Defunct legislation under the Trump administration made it harder for immigrants who used public benefits, like Medicaid, to obtain U.S. citizenship or a green card. While the legislation is no longer in place, Odegaard said many Minnesota immigrants that she works with still worry that applying for Medicaid could put their immigration status in jeopardy.
Dowden said many of the patients she works with don’t complete the process because of these application complications and that it's even harder for patients going through a health crisis or for folks who don’t speak English as their first language.
Dowden, Odegaard and other experts recommended that hospitals hire support staff and interpreters who can help patients through the application process. Mayo Clinic already does this. Furst said that financial counselors and interpreters are available in person and by phone to assist with applications.
Odegaard suggested that Minnesota hospitals without support staff partner with local resources, like the Minnesota Navigator Network, to ensure patients have assistance in filling out the application.
“Without support, It can be a mess,” Dowden said. “The process is confusing and a lot of people get fatigued and give up.”
Delays and deadlines
Brittany Leary, a patient at the Wisconsin-based Aspirus Riverview Hospital, echoed what Bass said about how difficult it was to wrangle the paperwork and decipher the application. She also noted that stilted communications from her hospital delayed the process.
After she submitted her application, with help from Dollar For, Leary said she had trouble communicating with the hospital and would only hear from Aspirus Riverview Hospital through the mail. At one point, the hospital refused to move forward with her application because she hadn’t turned in her mortgage documents. Leary didn’t have a mortgage, a fact that she had noted in her application.
“It was so confusing,” Leary said. “They want you to jump through hoops. I think they honestly want to make it so that you don’t get financial aid.”
Although Leary was eventually approved and had her $3,340 lab work and MRI bill completely forgiven, for some patients, delays like this can mean missing out on funding.
Last month, for example, one of Dowden’s Minnesota clients received a letter from her hospital after submitting her application requiring more documentation. The patient, who has a disability, was able to get the documentation in without support, despite not having access to a car or a printer, but by the time the hospital received it, she had missed the IRS-mandated 240-day deadline and could not qualify.
Mayo Clinic does not have a deadline for charity care applications, Furst said. Dowden hopes more hospitals will follow suit, so clients, like her own, won’t miss out on funding after they go to the trouble of applying.
Another wrinkle is that some hospitals send applicant bills to collections before the deadline is up. This can derail the process because some patients assume financial assistance is no longer an option.
“Once a patient starts getting calls from a collection agency, they think that's it,” Dowden said.
A final barrier experts noted is that, even when patients are eligible and aware of the financial assistance policy, they might not apply because of the stigma around public assistance and the term charity care, in particular.
“The word charity is off-putting to a lot of people,” said Ruth Lande, vice president of hospital relations at RIP Medical Debt, whose nonprofit works to end unaffordable medical debt. “They say, I have a job. I take care of my bills. I work and have insurance. I’m not a charity case.”
Lande said it’s important to destigmatize applying for financial assistance, especially as medical costs rise, and more and more patients are stuck with unaffordable high deductible health insurance plans.
“People have got to understand that the way health care is set up, often you can’t afford it,” Lande said. “There's nothing wrong with reaching out for help.”
The numbers show that Minnesotans struggling with medical debt are not struggling in isolation.
Nearly 750,000 Minnesotans, or 17% of the adult population, have medical bills in collection, according to the 2018 U.S. Financial Capability Study. In 2019, the Minnesota Department of Revenue found that more than two-thirds of medical claims sent to collections were for patients with household incomes below $40,000.
Kim Miller, a certified financial counselor with LSS Financial Counseling, a program of Lutheran Social Service of Minnesota, said there’s often a lot of shame involved with medical debt, shame that could be alleviated with more open conversation.
“It’s important to increase awareness so people know that it’s OK to use financial assistance and that a lot of us have used it,” Miller said. “These programs are here to help us, and we shouldn’t feel embarrassed to ask for help. We don’t have to do this all alone.”