About the Community Benefit State Law Profiles

The Hilltop Institute’s Community Benefit State Law Profiles (Profiles) present a comprehensive analysis of each state’s community benefit landscape as defined by its laws, regulations, tax exemptions, and, in some cases, policies and activities of state executive agencies. The Profiles organize these state-level legal frameworks by the major categories of federal community benefit requirements found in §9007 of the Affordable Care Act (ACA), §501(r) of the Internal Revenue Code. As state policymakers and community stakeholders assess their state’s community benefit landscape in the wake of national health reform, the Profiles provide a needed contextual basis for consideration of these policies against those of other states and federal community benefit benchmarks.

Profiles Updates

The Profiles were originally published in March 2013. Because states typically update laws during their annual legislative sessions, Hilltop methodically reviewed the community benefit laws of all 50 states twice in 2015 and once in 2016 to ensure that all legislative changes were identified. The first update, published January 2015, identifies changes that occurred between March 2013 and December 31, 2014. The second update, published December 2015, identifies changes that occurred between January 1, 2015, and October 31, 2015. The third update, published June 2016, identifies changes that occurred between November 1, 2015, and May 31, 2016.

Read a brief summary of the notable changes.

The material on this page has been combined with all 50 state Profiles, a snapshot of the comparison table, and a brief summary of notable changes in a compilation document.

Read the June 2016 Compilation Document.

Read the December 2015 Compilation Document.

Read the January 2015 Compilation Document.

Read the original 2013 Compilation Document.

Methodology

2015-2016 Updates

Hilltop legal staff conducted independent analyses of state community benefit laws and regulations to identify changes that occurred between the initial publication of the Profiles in March 2013 and December 31, 2014; between January 1, 2015, and October 31, 2015; and then between November 1, 2015, and May 31, 2016. Where appropriate, text was revised to reflect the current state of the law. The updated Profiles retain the organizational structure of the original Profiles: they are organized by the major categories of federal community benefit requirements found in §9007 of the ACA, §501(r) of the Internal Revenue Code.

2013

The initial identification of community benefit laws in the 50 states was performed by law students using a data collection tool developed by Hilltop. The tool’s variables were designed to capture state law requirements similar to those of §9007 of the ACA (IRC §501(r)) and IRS “community benefit” reporting requirements, with three additional variables for capturing relevant state tax exemptions. Primarily for the purpose of confirming law students’ negative findings, Hilltop conducted an electronic survey of state hospital associations. Both the law student-collected data and results of the hospital association survey were used as part of an independent review and analysis of primary source materials-state community benefit laws and regulations-conducted by JD/MPH-credentialed Hilltop staff. The results of that review appear in the Profiles.

The Hilltop Institute’s Hospital Community Benefit Program thanks the Network for Public Health Law for providing essential collaborative research support for the project.

Classification Criteria

The Profiles classify each state’s statutes and regulations as either including or not including requirements applicable to non-government, nonprofit hospitals in 11 distinct topic areas. This binary classification approach led to interpretive issues, such as whether to consider something a community benefit requirement if the law requires hospitals to provide community benefits only if they are seeking a certificate of need. In order to ensure consistent interpretation of requirements in each topic area from state to state, Hilltop adopted classification criteria that would be applied uniformly.

There are other, equally valid approaches to distinguishing between states that do or do not have such requirements. In many cases, differences in interpretive approach may account for variation in reports of “how many states” require nonprofit hospitals, for example, to provide a minimum level of community benefits. In developing classification criteria for this study, Hilltop generally elected to construe the requirements broadly, flagging each statutory and regulatory provision that arguably has a requirement and explaining its limitations.

Specific classification rules were developed for seven of the eleven topic areas. Listed below are the topic areas for which those rules were developed, along with an explanation of each.

Community Benefit Requirement
The requirement need not expressly reference “community benefits;” for example, the requirement could be that nonprofit hospitals must provide “free and reduced cost care.” The requirement need not apply generally to all nonprofit hospitals; for example, a nonprofit hospital could be required to provide community benefits as a condition of certificate of need approval, or when tax exemption is conditioned on the provision of community benefits.

Minimum Community Benefit Requirement
A quantifiable amount of community benefits must be specified, rather than “a reasonable amount” or “free care to uninsured patients with family income at or below 150 percent of the federal poverty level.” Examples of minimum community benefit requirements include “in an amount equivalent to the hospital’s property tax liability in the absence of exemption” and “in an amount equivalent to 5 percent of the hospital’s operating expenses.” If a community benefit requirement includes more than one option by which a hospital can satisfy its community benefit responsibility, then it would qualify as a minimum community benefit requirement if any of the available options requires the provision of a quantifiable level of community benefits.

Community Benefit Reporting Requirement
The requirement need not expressly reference “community benefits;” for example, hospitals could be required to report “free care provided.”

Community Health Needs Assessment (CHNA)
The requirement need not include the term “community health needs assessment;” any provision requiring hospitals to determine the health needs or health priorities of the community served qualifies as a CHNA requirement.

Community Benefit Plan/Implementation Strategy  
The requirement need not include the terms “implementation strategy” or “community benefit plan.” If a hospital is required to undertake prospective planning of how it will address community needs, then that would be considered an implementation strategy or community benefit plan. 

Financial Assistance Policy 
The requirement need not include the term “financial assistance policy.” If hospitals are required to develop their own policies as to the circumstances under which discounted charges or free care will be provided, regardless of the presence or absence of state standards with which a hospital’s policies must comply, then that would qualify as a requirement for the purpose of the Profiles.

Financial Assistance Policy Dissemination
The requirement need not include the term “financial assistance policy.” If law or regulation requires the hospital to provide to patients, post, or otherwise publicize the conditions under which the hospital will provide free or reduced cost care, then that would be considered a requirement.

All material produced by Hilltop’s Hospital Community Benefit Program is for informational purposes only and is not legal advice.
The Hilltop Institute does not enter into attorney-client relationships.