• Introduction
• What is "Charity Care"?
• Who qualifies for Charity Care?
• To which hospitals do the Charity Care laws apply?
• How do I apply for Charity Care?
• How does the hospital decide whether I am eligible for Charity Care?
• What if my application for Charity Care coverage is denied?
• What if the hospital failed to make an initial or final determination of my eligibility for Charity Care in a timely manner?
• What if I applied for Charity Care coverage but no determination was made by the hospital and the hospital has turned me over to a collection agency?
• What if I have not yet applied for Charity Care coverage, but I believe I am eligible and the hospital has turned me over to a collection agency?
• What if the hospital or a collection agency is suing me?
• What if the hospital incorrectly determined me to be ineligible for Charity Care coverage and is suing me?
• What if a judgment has been obtained against me for hospital services which should have been covered by Charity Care?
• Other Rights and Requirements

Introduction

This publication is intended to answer common questions about the medical coverage program called "Charity Care"; the legal authority for this program is set forth in R.C.W. Ch. 70.170 and WAC Ch. 246-453, which should be available in your local library or on the internet. For information on other programs of medical coverage that may be available to low-income persons in the state of Washington, see our publication How Can I Get Medical Coverage or Help with Medical Bills?

If you are being sued for medical services provided by a hospital which should have been covered by Charity Care, you may also want to read our related publication, How to Present a Charity Care Defense to a Lawsuit for Hospital Debt Collection.

Because the laws governing Charity Care may be complicated and may change, it is advisable to contact an attorney or, if you live outside King County, call NJP's CLEAR line at 1-888-201-1014 (TTY: 1-888-201-9737) ), or 1-888-387-7111 for persons age 60 and over, for legal advice or referral.

You may also want to contact Washington Citizen Action, which is a private non-profit organization that does not provide legal advice but is interested in monitoring Charity Care cases as part of an effort to make sure that hospitals are complying with the law. If you are interested in discussing your experience with them, please call Citizen Action at (206) 389-0050.

What is "Charity Care"?

"Charity Care" is a program established under state law which requires hospitals to provide medical care for free or at a reduced cost if the recipient of the care is not able to pay fully for the services received. Charity Care covers services you receive from a hospital, whether the service is provided on an inpatient or outpatient basis.

Charity Care may not cover services that are provided by medical personnel not considered part of the hospital's medical staff; for example, radiologists or anesthesiologists not employed by the hospital.

Charity Care does not cover "extras" you receive while in the hospital, such as telephone or cable television services, unless those services are provided to the public for free.

Who qualifies for Charity Care?

Your eligibility for Charity Care is based on your income and resources. Additionally, you must apply for and use any private health care coverage or government health care coverage (such as Medicare and Medicaid) available to you. Assuming your income and resources make you eligible for Charity Care, and you have exhausted any other available health care coverage, Charity Care coverage should be available to you. Thus, Charity Care should cover unpaid bills for Charity Care applicants who have health care coverage, including those bills resulting from deductibles and co-pays.

State rules divide eligibility for Charity Care into 3 categories based on income and resources (the rules of some hospitals are more generous):

1. Any person whose income is at or below 100% of the Federal Poverty Level, adjusted for family size (see attached chart), is entitled to free care. There are no resource limits. [246-453-040(1).]

2. Any person whose income is more than 100% but not more than 200% of the Federal Poverty Level, adjusted for family size (see attached chart), is entitled to reduced cost care based on a sliding scale established by the hospital. The hospital's sliding scale "Charity Care Policy" must be made available to you upon request. The hospital has the discretion to impose a resource limit. [246-453-040(2), 246-453-050(1).]

3. Any person whose income exceeds 200% of the Federal Poverty Level, adjusted for family size, may be eligible for reduced cost care if their income and resources are not sufficient to enable them to fully pay for the hospital-based services. [246-453-040(3).] It is up to the hospital to decide whether to reduce charges if your income at this level.

Official 2005 Federal Poverty Level (FPL) (All income** amounts rounded up)

**"Income" means total cash receipts before taxes received from wages and salaries, welfare payments, Social Security payments, unemployment or disability benefits, strike benefits, child support, maintenance (alimony), and net earnings from business and investments. Changes in the income levels are made each April.

To which hospitals do the Charity Care laws apply?

The charity care laws apply to all hospitals, including psychiatric hospitals, in the state of Washington. [R.C.W. 70.170.020((2); WAC 246-453-010(2).] All hospitals are required to post or prominently display, within public areas of the hospital, information concerning the availability of free and reduced -cost Charity Care. [WAC 246-453-010(16), 246-453-020(2)]. Because not all hospitals comply with this notice requirement, you should always request that you be allowed to apply for Charity Care if you think you will need coverage.

How do I apply for Charity Care?

At the time the hospital requests information from you about the availability of insurance, the hospital is required to provide you with information in writing and explain how you may obtain Charity Care. If you are not able to read or do not understand the explanation, the hospital must find someone to make the explanation understandable. This written information and explanation must be made available in any language spoken by more than 10% of the population in the hospital's service area. For those patients who can't communicate effectively in English but don't qualify to receive the written information, the hospital must provide a qualified interpreter to explain the availability of free or reduced-cost care. [WAC Sections 246-453-010(16), 246-453-020(2).]

You may ask hospital staff for a Charity Care application at any time. Even if you are not properly notified, you should ask hospital staff for a Charity Care application and for their "Charity Care Policy" when you are first admitted to the hospital, or as soon as possible thereafter. Hospital staff is required to provide you with an application at any time you request an application.

How Does The Hospital Decide Whether I Am Eligible For Charity Care?

The hospital is required to make two decisions called determinations: an initial determination and a final determination of your eligibility for Charity Care.
The hospital is required to make its initial determination based on any oral information you provide. It is permissible for the hospital to require that you sign a statement that confirms the accuracy of the oral information you have provided. [246-453-030(1).] The initial determination must be completed at the time of admission, or as soon as possible following the initiation of services to the patient. [246-453-020(1)(b).] If you cooperate with the hospital's efforts to make an initial determination, then no collection actions may be taken against you and no deposits collected from you for hospital services provided. If the initial determination indicates you are eligible, then collection actions and deposits continue to be prohibited. [246-453-020(1)(c),(6).]

Once you are initially determined to be eligible for Charity Care, you are given at least 14 calendar days to obtain documentation which supports the information you provided orally so that the hospital can make a final determination regarding your eligibility for Charity Care. [246-453-020(3).] In addition, the hospital is required to make every reasonable effort to determine whether a government agency or private insurance company will cover some or all of the hospital charges to you. [246-453-020(4).]

You may submit any of the following documents as evidence of your eligibility for Charity Care: pay stubs, income tax returns from the previous year, "W-2" statements, unemployment compensation forms approving or denying your claim, forms approving or denying Medicaid and/or state-funded medical assistance, and written statements from employers or welfare agencies. [246-453-030(2).] This list is not exclusive: if you have other documents that will support your eligibility, you may submit those documents as well.

Hospitals should not require so much information or documents from you that you and others get discouraged and fail to apply. [246-453-030(5).] Hospitals must take into account language barriers and any physical, mental, intellectual or sensory deficiencies which may make it hard for you to comply with its application requirements. [246-453-020(5).]

Once the hospital has received the requested documentation from you, it must make a final determination and notify you of its decision within 14 calendar days. The notice must include the amount of money you will be required to pay for your hospital services. [246-453-020(7).]

What If My Application For Charity Care Coverage Is Denied?

If your application for Charity Care is denied, the notice of denial must provide a reason for the denial. [246-453-020(8).]
If your family income is equal to or less than 200% of Federal Poverty Standards, you must also be provided with, and notified of, an appeals procedure. The hospital's appeal procedure must include an opportunity for you to correct any deficiencies in the documentation you provided, and to request a review of the decision by the hospital's chief financial officer or equivalent. [246-453-020(9).] It is also advisable to send a copy of your appeal to the Department of Health, Attention Larry Hettick, Hospital and Patient Data Systems, P.O. Box 47811, Olympia, WA 98504-7811.

You must also be notified that you have 30 days to appeal. If you appeal within the first 14 days, then no collection action may be started until your appeal has been heard and denied; if you appeal after 14 days but within 30 days, then any collection actions which have been started must be stopped. [246-453-020(9)(a),(b).]

If your appeal is denied, you must be notified in writing of the decision and the reason for it. The hospital must send a copy of its decision, along with copies of the documentation upon which the decision was based, to the Department of Health. [246-453-020(9)(c).]

The Department of Health is required to review denials of Charity Care. If the hospital has inappropriately denied Charity Care, the Department of Health may seek penalties against the hospital and individual staff members. [RCW 70.170.070; WAC243-456-020(9)(d).] If you are interested in having the Department of Health review your denied application, call (360) 236-4210. The Department of Health and its contractors are required to maintain the confidentiality of any information which may identify you or any other individual patients. [RCW 70.170.090.]

What If The Hospital Failed To Make An Initial or Final Determination of My Eligibility For Charity Care In A Timely Manner?

Hospitals are required to make every reasonable effort to reach initial and final determinations of Charity Care eligibility in a timely manner; however, hospitals are required to make those determinations at any time upon learning of facts or receiving documentation which would support a finding of Charity Care eligibility. Moreover, if you paid for part or all of the charges made for hospital services received which should have been covered by Charity Care, then you are entitled to a refund within thirty days of your being designated eligible for Charity Care. [WAC 246-453-020(10), (11).]

Thus, if a hospital failed to properly process your application for Charity Care, you should immediately contact the hospital and demand that they do so in the manner discussed in these materials. Download this publication to print a sample and blank form demand letter.

What if I applied for Charity Care Coverage but no determination was made by the Hospital and the Hospital has turned me over to a Collection Agency?

You should contact both the collection agency and the hospital to inform them that the hospital has failed to follow the law and that you are requesting that the hospital immediately process your application for Charity Care and that collection actions be stopped. A sample and blank form letter to a collection agency are available. Download this document to print the letters.  It is advisable to send a copy of the hospital letter to the collection agency, and a copy of the collection agency letter to the hospital.

What if I have not yet applied for Charity Coverage but believe I am eligible and the Hospital has turned me over to a Collection Agency?

You should contact both the collection agency and the hospital to inform them that the hospital has failed to follow the law and that you are requesting that the hospital immediately send you an application for Charity Care. You should also request that collection actions be stopped. Download this publication to print sample letters and blank form letters to the hospital and collection agency. It is advisable to send a copy of the hospital letter to the collection agency, and a copy of the collection agency letter to the hospital.

What If The Hospital Or A Collection Agency Is Suing Me?

You should immediately write the opposing attorney to inform him/her that the hospital failed to follow the law by not considering you for Charity Care eligibility, and that the lawsuit should be dismissed or suspended pending a determination of your eligibility for Charity Care. If you haven't done so already, you should also write the hospital a letter requesting an application for Charity Care Coverage, or demanding they properly process the application you have already submitted (see above). A copy of your letter to the attorney should be sent to the hospital, and a copy of your letter to the hospital should be sent to the attorney. You may download this publication to print a sample letter and a blank form letter to an attorney.

In addition, you should use NJP's packet on How To Present a Charity Care Defense to a Lawsuit for Hospital Debt Collection to complete an ANSWER to the COMPLAINT in order to make sure that a default judgment is not entered against you. You may also obtain this packet by calling NJP's CLEAR line at 1-888-201-1014 (TTY: 1-888-201-9737) or 1-888-387-7111 for persons age 60 and over if you live outside King County.

If you are not able to convince the attorney to stop your case until a Charity Care determination is made, you should be prepared to go to a hearing and present evidence of your income and resources.

What If The Hospital Incorrectly Determined Me To Be Ineligible for Charity Care Coverage And Is Suing Me?

Assuming you were not able to convince the Department of Health to overturn the hospital's decision (see above), you should be prepared to convince a judge that the hospital made an incorrect decision despite the fact that you cooperated appropriately with its application process.

The key to winning will be your gathering of documentation that shows that your income and resources make you eligible for Charity Care. Because the Hospital or collection agency's attorney may not have been given a complete picture of your case, it is worthwhile to call and write the attorney and provide documentation of your eligibility. Download a sample and blank form letter.

REMEMBER: You must also file an ANSWER to the lawsuit; see How To Present A Charity Care Defense to A Lawsuit For Hospital Debt Collection.

What If A Judgment Has Been Obtained Against Me For Hospital Services Which Should Have Been Covered By Charity Care?

If proper legal procedures were used in obtaining the judgment (for example, you were properly notified of the lawsuit and failed to answer, or you answered but did not raise the defense that you were not considered for Charity Care), then the judgment will remain in effect and you will be legally responsible for the debt. If, however, you can show that the judgment was not obtained properly, and you can demonstrate that you would have been eligible for Charity Care, then the judgment may be vacated. You should contact a private attorney for further assistance or, if you live outside King County, you may call NJP's CLEAR line at 1-888-201-1014, (TTY: 1-888-201-9737), or 1-888-387-7111 for persons age 60 and over, for information on how to vacate a judgment and for a copy of our publication Motion to Vacate Judgment/Order.

Other Rights and Requirements

All hospitals must provide emergency care to patients who are unable to pay all or part of the costs. A hospital may not transfer a patient with an emergency condition, or who is in active labor, unless the patient gives permission or the transfer is due to the limited medical resources of the transferring hospital. [ RCW 70.170.060(2).]

No hospital or its medical staff may refuse to admit patients who would be expected to require unusually costly or prolonged treatment unless the care available at the hospital would not be appropriate to the patient's needs. [RCW 70.170.060(1)(c).]

No hospital or its medical staff may adopt or maintain admission practices or policies that result in a significant reduction in the proportion of low-income patients admitted who are not able to pay all or part of anticipated charges. [RCW 70.170.060(1)(a),(b).]

It is possible that a hospital may refuse to provide services to an otherwise eligible patient who does not need emergency care services or whose treatment would not be unusually costly or prolonged. If you believe your right to care has been violated, you should contact the Department of Health at (360) 236-4210. If the Department of Health is not willing to assist you and you are not satisfied with its reasons, you may call Northwest Justice Project's CLEAR line at 1-888-201-1014, (TTY: 1-888-201-9737) or 1-888-387-7111 for persons age 60 and over, if you live outside King County.

It is against the law for a hospital or its staff to engage in unfair and discriminatory practices because of an individual's race, creed, color, national origin, sex, the presence of a disability, or the use of a trained dog guide or service animal by a person with a disability. If you believe that a hospital has unfairly discriminated against you, you should call the Washington State Human Rights Commission at 1-800-233-3247.