Alabama law does not expressly require nonprofit hospitals to provide community benefits.

Alabama law does not expressly require nonprofit hospitals to provide community benefits.

Alabama does not require nonprofit hospitals to report community benefits.

Alabama does not require nonprofit hospitals to conduct community health needs assessments.

Alabama does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

Alabama does not require nonprofit hospitals to adopt or implement financial assistance policies.

Alabama requires hospitals that have financial assistance policies to make written information about these policies available.

Each bill or summary of charges issued by a nonprofit or for-profit hospital must include a prescribed statement that a patient meeting income criteria may qualify “for the financial assistance policy of the hospital.” In addition, signs must be posted in admission and registration areas indicating the availability of financial assistance to qualified patients. A description of the financial assistance application process and a copy of the financial assistance application must be prominently posted on the hospital’s website “if financial assistance is available at the hospital.” Ala Code 22-21-300.

Alabama does not limit nonprofit hospital charges, billing, or collection practices.

Alabama exempts nonprofit hospitals from state income tax.

Alabama exempts from state income tax organizations that are exempt from federal income tax under Internal Revenue Code §501(a). Ala. Code 40-18-32(a).

Alabama exempts from ad valorem taxes nonprofit hospitals’ real and personal property used exclusively for charitable purposes unless the property is “let for rent or hire or for use for business purposes.” Ala. Code 40-9-1(1).

Alabama law provides for a general ad valorem tax exemption of the real and personal property owned and operated by a nonprofit hospital. For-profit hospitals that use a portion of their property for charitable purposes may qualify for a partial ad valorem tax exemption (limited to $75,000 of assessed value) if the hospital certifies that in the previous year it “has done 15 percent of its treatment of patients as charity work.” Ala. Code 40-9-1(1) and (2); Alabama Const., Amendment 373(k); Mingledorff v. Vaughan Regional Medical, 682 So. 2d 415, 422 (1996).

Alabama law does not generally exempt nonprofit hospitals from sales and use taxes.

Alabama law provides nonprofit organizations “no special exemption” from the state’s sales and use taxes; only organizations that are specifically identified in the statute are exempt. Ala. Admin. Code R. 810-6-3-.07.05.

California requires nonprofit hospitals to provide community benefits.

California law expressly recognizes that nonprofit hospitals receive "favorable tax treatment by the government... [i]n exchange [for assuming] a social obligation to provide community benefits …” Cal. Health & Safety Code 127340(a). California defines “community benefit” as hospital activity “intended to address community needs and priorities primarily through disease prevention and improvement of health status.” The statute lists, as non-exclusive examples of community benefit, the unreimbursed costs of providing health care services to vulnerable populations (including both Medicaid and Medicare shortfall); medical research; health professions education; adult day care; child care; sponsoring food, shelter, and clothing for the homeless; support of public health programs; contributions to a community priority; health care cost containment; enhancing access to care; and education, transportation, and other goods or services that help maintain a person’s health. Cal. Health & Safety Code §127345(c).

In addition, California’s certificate of need (CON) law exempts from certain specified CON requirements a health care project proposed by a hospital that agrees to provide free health care services to indigents, over a five year period, equivalent in dollar value to that of the proposed health care project. Cal. Health & Safety Code §127190.

California does not require nonprofit hospitals to provide a specified minimum level of community benefits.

California requires nonprofit hospitals to annually submit community benefit plans specifying the economic value of the community benefits to be provided.

Nonprofit hospitals must annually submit their community benefit plans which, “to the extent practicable,” report the economic value of the community benefits provided, mechanisms for evaluating the plan’s effectiveness, and measurable objectives to be achieved within specified timeframes. The plans must be submitted to the Office of Statewide Health Planning and Development (OSHPD), which makes them available to the public. Cal. Health & Safety Code §127350(d).

In addition, every two years—or when a significant change to the policy is made—a nonprofit hospital must provide copies to OSHPD of its discount payment policy, charity care policy, procedures for determining eligibility under those policies, review process, and the application for charity care or discounted payment programs. Cal. Health & Safety Code §127435.

California requires nonprofit hospitals to conduct assessments to evaluate the health needs of the communities they serve.

A hospital may conduct—either alone, with other health care providers, or through other organizational arrangements—an assessment that evaluates the health needs of the community the hospital serves. At a minimum, the assessment must describe the process employed by the hospital to consult with community groups and local government officials in identifying and prioritizing community needs that can be addressed directly by the hospital, and those that the hospital can address in collaboration with other entities, or through other organizational arrangements. The assessment must be updated at least every three years. Cal. Health & Safety Code §127350(b).

California requires nonprofit hospitals to submit annual community benefit plans that include the activities undertaken by the hospital to address community needs that are within the hospital’s mission and financial capacity. Cal. Health & Safety Code 127350(d).

The plan must also include a statement as to the economic value of the community benefits provided, mechanisms for evaluating the plan’s effectiveness, and measurable objectives to be achieved within specific timeframes. Community benefits are to be categorized into the following framework: 1) medical care services, 2) other benefits for vulnerable populations, 3) other benefits for the broader community, 4) health research, education, and training programs, and 5) nonquantifiable benefits. Cal. Health & Safety Code §127355.

California requires all hospitals to adopt financial assistance policies.

California’s Hospital Fair Pricing Policies Act establishes, as a condition of licensure, minimum standards to be used in determining eligibility for free or discounted care under a hospital’s charity care and discounted care policies. Cal. Health & Safety Code §§127400 – 127466. Hospitals have discretion to extend eligibility for their discount payment and charity care policies to patients with incomes over 350 percent of the federal poverty level. Cal. Health & Safety Code §127400(a)-(g). Hospitals have discretion to extend eligibility for their discount payment and charity care policies to patients with incomes over 350 percent of the federal poverty level. Cal. Health & Safety Code §127405(a)(1)(A).

Among the additional elements that financial assistance policies must include is a requirement that emergency room physicians provide discounted emergency services to patients who are uninsured or have high medical costs and whose incomes do not exceed 350 percent of the federal poverty level. Cal. Health & Safety Code §§127400 – 127466.

California requires hospitals to provide patients written notice of their financial assistance plans and to post notices of the hospital’s financial assistance policies for financially qualified and self-pay patients in specified locations in the hospital.

Each hospital’s written notice must contain information about the availability of the hospital’s discount payment and charity care policies and contact information for an individual or office from which additional information may be accessed. The notice must also advise that emergency room physicians in the hospital must provide discounted emergency services to uninsured patients and patients with high medical costs. Cal. Health & Safety Code §127405(a)(1)(B). Notice of the hospital’s policy for financially qualified and self-pay patients must be conspicuously posted in locations that are visible to the public, including in the emergency department, billing office, admissions office, and other outpatient settings. Cal. Health & Safety Code §127410.

California law limits hospital billing and collection practices.

California limits the amounts hospitals may charge patients with income not exceeding 350 percent of the federal poverty level. Cal. Health & Safety Code §12705. Hospitals must have written policies specifying when and under whose authority patient debt is referred for collection. Cal. Health & Safety Code §127425(a). For uninsured patients and those with high medical costs, the hospital or assignees of hospital debt owed by a “financially qualified” patient may not, until 150 days after the initial billing, report adverse information concerning the patient to a consumer credit reporting agency and may not commence an action against the patient in civil court. Cal. Health & Safety Code §127425(d). Additional details concerning a patient’s property rights and limits on hospital payment practices are set forth in Cal. Health & Safety Code §§127425-127430.

California exempts federally tax-exempt nonprofit hospitals from state income tax.

exclusively for charitable purposes and recognized exempt from federal income tax under §501(c)(3) of the Income Tax Code. In addition, a charitable corporation may not attempt to influence legislation or campaign on behalf of any candidate for public office. Cal. Rev. & Tax. Code §23701d.

California exempts from taxation the property of qualifying nonprofit hospitals.

California law exempts property used exclusively for charitable hospital purposes where, during its immediately preceding fiscal year, the hospital’s operating revenues (exclusive of gifts, endowments, and grants-in-aid) did not exceed operating expenses by an amount equivalent to 10 percent of those operating expenses. Cal. Rev. & Tax Code §214(a)(1).

California law includes no express statutory exemption from sales tax for purchases by nonprofit hospitals. California State Board of Equalization, Sales and Use Taxes: Exemptions and Exclusions (2012).

Colorado law does not expressly require nonprofit hospitals to provide community benefits.

Colorado law does not expressly require nonprofit hospitals to provide community benefits.

Colorado does not require nonprofit hospitals to report community benefits.

Colorado does not require nonprofit hospitals to conduct community health needs assessments.

Colorado does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

Colorado law requires hospitals that do not participate in the Colorado Indigent Care Program to provide financial assistance to qualified patients.

Colorado’s Hospital Payment Assistance Program, adopted in 2012, requires both nonprofit and for-profit hospitals to make financial assistance available to “qualified” patients on a community-specific basis. “Qualified patients” are individuals who 1) are uninsured, 2) have annual family income not exceeding 250 percent of the federal poverty level, and 3) received a service at a hospital at which the Colorado Indigent Care Program was not available. Colo. Rev. Stat. §25-3-112(2) (2012), (SB 12-134).

Colorado requires that both nonprofit and for-profit hospitals make financial assistance information available to patients and post their written financial assistance, charity care, and payment plan policies.

Colorado requires that these policies be posted on each hospital’s website and in patient waiting areas. It also requires the information to be made available, when possible, before the patient’s discharge, and that it be included in each patient billing statement. Colo. Rev. Stat. §25-3-112(1) (2012), (SB 12-134).

Colorado law limits nonprofit and for-profit hospital charges and collection practices.

Colorado law limits billing and collection practices against persons eligible for assistance under the hospital’s financial assistance policy. Such persons may be charged no more than the lowest negotiated rate charged to a private health plan. In addition, before initiating collection proceedings, hospitals must: 1) offer qualified patients a reasonable payment plan and 2) allow for a 30-day period past the due date of the first scheduled payment that is not paid in full. Colo. Rev. Stat. §25-3-112(3), (4)(a) (2014); (SB 14-50). If a hospital discovers it has made an error, then the hospital should correct the error or omission, inform the patient, provide a financial correction, and inform the health department. The health department will make self-reported incidents, investigations, and complaints available to the public. Colo. Rev. Stat. §25-3-112(3.5) (2014), (SB 14-50).

If a hospital is notified by the health department that it is not in compliance with governing statutes or regulations, then it must file a corrective action plan that includes measures to inform the patient or patients, and provide a financial correction consistent with the statute and regulations. A hospital should not initiate collections proceedings if it is notified that it must submit a corrective action plan or when it is operating under a corrective action plan. Colo. Rev. Stat. §25-3-112(4)(b) (2014), (SB 14-50).

SB 14-50 also establishes compliance monitoring of hospitals and hospital penalties for “knowing or willfull noncompliance.”

Colorado law exempts non-profit hospitals from state income tax.

Colorado law exempts from state income tax persons and organizations that are exempt from federal income tax. Colo. Rev. Stat. §39-22-112(1) (1987).

Colorado exempts from taxation property owned and used by nonprofit hospitals for a strictly charitable purpose.

Colorado exempts from state property tax real and personal property that is “owned and used solely and exclusively for strictly charitable purposes” by a nonprofit hospital that is licensed by the state as a health care facility. Colo. Rev. Stat 39-3-108(1)(b) (2013).

Colorado law exempts nonprofit hospitals from state sales and use taxes.

All sales made to charitable organizations in the conduct of their regular activities are exempt from taxation. The proceeds of occasional sales of tangible personal property (such as concessions) by charitable organizations for fund-raising purposes are also exempt, up to a maximum of $25,000 per year, if proceeds are “used in the course of the organization’s charitable service.” Colo. Rev. Stat. §39-26-718(1) (2008).

Florida law requires nonprofit hospitals to provide community benefits.

Florida law requires that nonprofit hospitals provide charity care and participate in the state’s Medicaid program. Fla. Stat. §617.2002(2).

Florida does not require nonprofit hospitals to provide a specified minimum level of community benefits.

Florida does not require nonprofit hospitals to report community benefits.

However, Florida’s Agency for Health Care Administration takes into account a Certificate of Need (CON) applicant’s previous and proposed provision of services to Medicaid patients and the medically indigent when reviewing CON applications. Fla. Stat. §408.035(1)(i).

Florida does not require nonprofit hospitals to conduct community health needs assessments.

Florida does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

Florida does not require nonprofit hospitals to adopt or implement financial assistance policies.

Florida law requires each licensed facility that has a financial assistance policy to make it available to the public.

Each licensed facility shall make available to the public on its website information to prospective patients on the facility’s financial assistance policy, including the application process, payment plans, and discounts, and the facility’s charity care policy and collection procedures. Fla. Stat. §395.301(1)(a)(1).

Florida law limits hospital billing practices.

Florida law requires hospitals to provide in writing a good faith estimate of reasonable anticipated charges for the patient’s treatment upon request and before providing any nonemergency medical services. Fla. Stat. §395.301(1)(b)(1). The estimate should include information regarding the hospital’s financial assistance policy (Fla. Stat. §395.301(1)(b)(2)), as well as a notification that the patient may be billed separately by other health care providers for services performed in the hospital (Fla. Stat. §395.301(1)(b)(5)). Hospitals must inform the public that estimates are available upon request. Fla. Stat. §395.301(1)(b)(5).

Upon request and after the patient’s discharge, the hospital must provide an itemized statement or bill detailing in plain language the specific nature of the expenses incurred by the patient. The initial bill should be provided within seven days after the patient’s discharge or request, whichever is later. The bill must identify each item as paid, pending payment by a third party, or pending payment by the patient, and must include the amount due if applicable. Fla. Stat. §395.301(1)(d)(1).

Florida law exempts nonprofit hospitals from state income tax.

Florida law exempts from state income tax nonprofit organizations that are exempt from federal income tax. Fla. Stat. §220.13 (2)(h).

Florida exempts nonprofit hospital property from taxation.

Florida law exempts from taxation the property of nonprofit hospitals that are exempt from federal income tax under Internal Revenue Code §501(c)(3). Fla. Stat. §196.197.

Florida law exempts nonprofit hospitals from state sales and use taxes.

Florida law exempts from state sales and use tax sales and leases to organizations that are exempt from federal income tax under Internal Revenue Code §501(c)(3) “when such leases or purchases are used in carrying on their customary nonprofit activities.” Fla. Stat. §212.08(7)(p).

Illinois requires nonprofit hospitals to provide charity care or other “health services to low-income or underserved individuals” as a condition of property and sales tax exemption.

Illinois specifies a minimum level of charity care or other “health services to low-income or underserved individuals” that a nonprofit hospital must provide to qualify for property and sales tax exemption.

Effective in 2012, an Illinois statute requires that nonprofit hospitals seeking property tax exemption provide charity care or other specified services or activities at levels at least equivalent to what the hospital otherwise would be required to pay in property taxes. S.B. 2194, codified at 35 ILCS 200/15-86(c) (2012). For-profit hospitals are eligible to receive an income tax credit in an amount that is the lesser of 1) real property taxes paid during the tax year on property used for hospital purposes during the previous tax year and 2) the cost of free or discounted services provided pursuant to the hospital’s financial assistance policy. S.B. 2194, codified at 35 ILCS 5/223(a) (2012).

The Illinois Community Benefits Act requires that each nonprofit hospital to which it applies develop a community benefit plan and file an annual report of the plan with the Office of the Attorney General. 210 ILCS 76/20 (2003).

The Act does not apply to 1) government hospitals, 2) hospitals located outside of a metropolitan statistical area, or 3) hospitals with 100 or fewer beds. 210 ILCS 76/5 (2003).

Illinois requires that a nonprofit hospital to which the Illinois Community Benefits Act applies develop a community benefit plan that identifies the populations and communities the hospital serves and outlines the hospital’s goals and objectives for providing community benefits, including charity care and government-sponsored indigent health care. 210 ILCS 76/15 (2003).

A nonprofit hospital to which the Act applies must develop and submit to the Attorney General an annual report of its community benefits plan disclosing the amount and types of “community benefits actually provided, including charity care.” The hospital must include with its report an audited annual financial report for the preceding fiscal year. 210 ILCS 76/20 (2003). The hospital must include a financial assistance report disclosing, among other things, the number of financial assistance applications received, approved, and denied as well as the total amount of financial assistance provided. Ill. Admin. Code tit. 77 §4500.60 (2013).

Hospitals to which the Illinois Community Benefits Act applies must include in annual reports of their community benefits plans “a disclosure of the health care needs of the community that were considered in developing the hospital’s community benefits plan.” 210 ILCS 76/20(a)(2) (2003).

The Act does not apply to 1) government hospitals, 2) hospitals located outside of a metropolitan statistical area, or 3) hospitals with 100 or fewer beds. 210 ILCS 76/5 (2003).

A nonprofit hospital to which the Illinois Community Benefits Act applies is required to develop a community benefit plan.

The community benefit plan must identify the populations and communities served by the hospital and set out goals and objectives for providing community benefits that include charity care and government-sponsored indigent health care. 210 ILCS 76/15 (2003).

The Act does not apply to 1) government hospitals, 2) hospitals located outside of a metropolitan statistical area, or 3) hospitals with 100 or fewer beds. 210 ILCS 76/5 (2003).

Illinois requires both nonprofit and for-profit hospitals to provide discounts to uninsured patients.

The 2012 amendments to the Illinois Hospital Uninsured Patient Discount Act mandate that hospitals provide patient discounts that take into account hospital type and family income once an application for a discount is made. 210 ILCS 89/10. The law requires that hospitals provide:

Charitable discount of 100 percent of charges for medically necessary health care services exceeding $300 for uninsured patients with family incomes of not more than 125 percent of the federal poverty level. Note: This applies to rural and critical access hospitals. 210 ILCS 89/10, (a)(4).

Charitable discount of 100 percent of charges for medically necessary health care services exceeding $300 for uninsured patients with family incomes of not more than 200 percent of the federal poverty level. Note: This applies to hospitals other than rural and critical access hospitals. 210 ILCS 89/10, (a)(2).

Discount from charges for medically necessary health care services exceeding $300 to any uninsured patient with a family income of not more than 300 percent of the federal poverty level. Note: This applies to rural and critical access hospitals. 210 ILCS 89/10, (a)(3)(2012).

Discount from charges for medically necessary health care services exceeding $300 to any uninsured patient with a family income of not more than 600 percent of the federal poverty level. Note: This applies to hospitals other than rural and critical access hospitals. 210 ILCS 89/10, (a)(1) (2012).

The 2012 amendment to the Fair Patient Billing Act (S.B. 3261, codified as 210 ILCS 88/27) also directed the Office of the Attorney General to develop rules requiring hospitals to include specifically prescribed language in financial assistance applications. The final rules require, among other things, that financial assistance applications include an opening statement advising applicants that they may be eligible for free or discounted care and that they are not required to provide a Social Security number. A required certification at the end of financial assistance applications must include the text that the rule prescribes, and none other. 77 Ill. Admin. Code §4500.30(a), (h) (2013); (38 Ill. Reg. 12673) (June 20, 2014).

The statute also required the Attorney General to promulgate rules setting forth appropriate methodologies for determining “presumptive eligibility” under which patients would be deemed “eligible for hospital financial assistance without further scrutiny.” S.B. 3261, codified as 210 ILCS 88/27 (2012). Ill. Admin. Code tit. 77 §4500.40(a) (2013). Under those rules, patients in rural or critical access hospitals will be deemed presumptively eligible if they are homeless, deceased with no estate, mentally incapacitated, or Medicaid eligible—but not on the date of service or for a non-covered service. Ill. Admin. Code tit. 77 §4500.40(b);(d) (2013). In addition to the above criteria, patients in hospitals that are not rural or critical access hospitals will also be presumptively eligible if enrolled in a public assistance program for individuals below 200 percent of the federal poverty level such as the Women, Infants and Children Nutrition Program, and the Supplemental Nutrition Program. Ill. Admin. Code tit. 77 §4500.40(b) (2013). A hospital may include additional presumptive eligibility criteria, provided it expands a patient’s presumptive eligibility. Ill. Admin. Code tit. 77 §4500.40(c);(e)(2013).

Illinois requires both nonprofit and for-profit hospitals to post and otherwise disseminate their financial assistance plans.

Each hospital must post a sign containing specified language conspicuously in the admission and registration areas. 210 ILCS 88/15 (2007). Each hospital that has a website must also post notice there and make a brochure, an application for financial assistance, or other written material available in the hospital admission or registration area. 210 ILCS 88/15(d) (2007). In addition, each patient bill or other summary of charges to an uninsured patient must include a prominent statement that an uninsured patient meeting specified income requirements may qualify for an uninsured patient discount, and information about how to apply for the discount. S.B. 3261, codified as 210 ILCS 89/10(d) (2012).

Illinois law limits nonprofit and for-profit hospital collection practices.

Generally, Illinois hospitals may collect as payment for health care services no more than 25 percent of the family income of a patient eligible for an uninsured patient discount. S.B. 3261, codified as 210 ILCS 89/10(c) (2012).

Before pursuing a collection action against an uninsured patient, a hospital must afford the patient an opportunity to assess the accuracy of the bill, apply for financial assistance, and agree to a reasonable payment plan offered by the hospital. In addition, for an uninsured patient who has indicated the inability to pay the full amount of the bill in a single payment, the hospital must give the patient at least 60 days after discharge to submit an application for financial assistance/charity care. 210 ILCS 88/30(a)(1)-(3) (2007). A hospital may not refer a bill to a collection agency without first offering the patient an opportunity to request a reasonable payment plan within 30 days of the date of the initial bill, and giving the patient another 30 days from the request to agree to a reasonable payment plan offered by the hospital. 210 ILCS 88/30(b) (2007).

Additionally, a hospital may not pursue legal action for non-payment against an uninsured patient who has clearly demonstrated a lack of sufficient income or assets to pay the bill and who has acted reasonably and cooperated with the hospital in good faith. 210 ILCS 88/35 (2007).

Illinois law exempts the income of nonprofit hospitals from state income tax.

Illinois law exempts from state income tax the income of charitable or similar organizations that are exempt from federal income tax. 35 ILCS 5/205(a) (2011).

For-profit hospitals are eligible to receive an income tax credit in an amount that is the lesser of a) real property taxes paid during the tax year on property used for hospital purposes during the previous tax year and b) the cost of free or discounted services provided pursuant to the hospital’s financial assistance policy. 35 ILCS 5/223(a) (2012).

Illinois law requires nonprofit hospitals to provide charity care/community benefits as a condition of property tax exemption.

Illinois’ statute, adopted in 2012, requires that nonprofit hospitals seeking property tax exemption (real property and tangible personal property) provide specified services and activities (charity care, health services to low-income and underserved individuals, etc.) at levels at least equivalent to what the hospital otherwise would be required to pay in property taxes. S.B. 2194, codified as 35 ILCS 200/ 15-86(c); 2012 Ill. Pub. L. No 97-0688 (2012).

For-profit hospitals are eligible to receive an income tax credit in an amount that is the lesser of a) real property taxes paid during the tax year on property used for hospital purposes during the previous tax year and b) the cost of free or discounted services provided pursuant to the hospital’s financial assistance policy. S.B. 2194 codified as 35 ILCS 5/223(a) (2012).

Illinois law requires nonprofit hospitals to provide charity care/community benefits as a condition of sales and use tax exemption.

Illinois’ statute, adopted in 2012, requires that nonprofit hospitals seeking sales tax and use tax exemptions provide specified services and activities (charity care, health services to low-income and underserved individuals, etc.) at levels at least equivalent to what the hospital otherwise would be required to pay in property taxes. 35 ILCS 120/2-9; 35 ILCS 105/ 3-8 (2012).

Indiana requires nonprofit hospitals to provide community benefits.

Indiana law requires nonprofit hospitals to develop a community benefit plan that sets out goals and objectives for providing community benefits that include charity care and government-sponsored indigent health care. Ind. Code §16-21-9-4.

Indiana does not require nonprofit hospitals to provide a specified minimum level of community benefits.

Indiana requires nonprofit hospitals to file with the Indiana Department of Health an annual report of their community benefit plans.

A nonprofit hospital’s annual report to the Indiana Department of Health must include a copy of the hospital’s community benefit plan and the hospital’s mission statement. It must disclose the community health needs considered in developing the hospital’s community benefit plan and the amount and types of community benefits provided, including charity care. Ind. Code §16-21-9-7.

Indiana requires nonprofit hospitals to perform community health needs assessments.

In developing its community benefit plan, a nonprofit hospital must consider its community’s health care needs, as determined by a community-wide needs assessment. Ind. Code §16-21-9-5.

Indiana requires nonprofit hospitals to develop a community benefit plan/implementation strategy.

A nonprofit hospital must develop a community benefit plan that sets out goals and objectives for providing community benefits, including charity care and government-sponsored indigent health care, and identifies the populations and communities the hospital serves. Ind. Code §16-21-9-4. The plan must also include a budget, measurable objectives with a specified time frame, an evaluation mechanism for assessing the plan’s effectiveness, and a method for soliciting input from the community the hospital serves. Ind. Code §16-21-9-6.

Indiana hospitals set their own eligibility guidelines for charity care and financial assistance.

Indiana requires nonprofit hospitals that operate charity care programs to develop written notices about such programs and how to apply for them. Ind. Code §16-21-9-7(d).

Indiana requires nonprofit hospitals that operate charity care programs to conspicuously post written notice of any charity care program they offer and how to apply.

The notice must be conspicuously posted in the hospital’s general and emergency room waiting areas, in the business office, and in other areas the hospital considers appropriate. Ind. Code §16-21-9-7(d).

Indiana law does not expressly limit nonprofit hospital charges, billing, or collection practices.

However, persons eligible for services under the state’s Hospital Care for the Indigent Program are not obligated to pay for covered services provided under the program and identified in a claim filed by the provider. Ind. Code §12-16-7.5-1.2.

Indiana law exempts non-profit hospitals from state income tax.

Indiana law exempts from state income tax the income of any organization that is exempt under Internal Revenue Code §501(a). Ind. Code §6-3-2-2.8(1).

Indiana law exempts nonprofit hospitals from state property tax.

Indiana exempts from taxation the buildings, land, and personal property of a nonprofit hospital when owned, occupied, and used for charitable purposes. Ind. Code §6-1.1-10-16.

Indiana law exempts nonprofit hospitals from state sales taxes.

Indiana law exempts from taxation sales made to nonprofit corporations if the property or service is primarily used to carry on—or to raise money to carry on—its nonprofit purpose. Ind. Code §6-2.5-5-25; Indiana Department of Revenue, Information Bulletin #10, Sales Tax, April 2012.

Maine requires both nonprofit and for-profit hospitals to provide free care to Maine residents with income up to 150 percent of the federal poverty level.

The Maine Department of Health and Human Services (MHHS) requires that each hospital adopt and implement a free care policy ensuring that free medically necessary services are provided to Maine residents with income up to 150 percent of the federal poverty level. 10-144-150 Me. Code R. §§1.01-1.02; Me. Rev. Stat. Ann. tit. 22, §401-1716.

Maine does not require nonprofit hospitals to provide a specified minimum level of community benefits.

Maine requires nonprofit and for-profit hospitals to report free care provided.

Maine hospitals must file with MHHS annual reports quantifying free care provided to individuals with income of less than 150 percent of the federal poverty level, free care provided beyond that required by state regulations, and patients who received free care. 10-144-150 Me. Code R. §1.08. Each hospital must also file and maintain with MHHS a current copy of its free care policy and a current copy of its posted notice of free care. 10-144-15-Me. Code R. §1.09.

Maine does not require nonprofit hospitals to perform community health needs assessments.

Maine does not require nonprofit hospitals to submit community benefit plans or implementation strategies.

Maine requires nonprofit and for-profit hospitals to adopt and implement a free care policy ensuring that free medically necessary services are provided to Maine residents with income up to 150 percent of the federal poverty level. 10-144-150 Me. Code R. §§1.01-1.02(c) (2007); Me. Rev. Stat. Ann. tit. 22, §401-1716.

Maine requires nonprofit and for-profit hospitals to post and provide to patients information about the availability of free care.

Maine requires that hospitals post notices that include specified information about the availability of free care in admitting areas, waiting rooms, business offices, and outpatient reception areas. 10-144-150 Code Me. R. §1.04. Hospitals must also provide patients with individual written notice of the availability of free care upon admission, before discharge, or accompanying the patient’s bill. 10-144-150Code Me. R. §1.04. Effective 2014, a hospital is required to provide information regarding its charity care policy to any uninsured patient who requests an estimate of the cost of a medical service. Me. Rev. Stat. Ann. tit. 22, §401-1718-C.

Maine law limits nonprofit hospital billing and collection practices.

Maine law requires hospitals and other health care providers to notify consumers of the availability of any payment arrangements offered. In addition, a payment arrangement offered by a hospital must provide a consumer with the ability to “reasonably rehabilitate, cure, or remedy” the default status of a medical debt under terms established by the hospital. These must include (but are not limited to) the option to pay in full or make six consecutive and timely monthly payments. Me. Rev. Stat. tit. 9-A, §5-116-A.

Maine law exempts non-profit hospitals from state income tax.

Maine law exempts from state income tax organizations that are exempt from federal income tax under Internal Revenue Code §501(c). Me. Rev. Stat. tit. 36, §801-5102(6),(8).

Maine law exempts the property of charitable institutions from state property tax.

Maine law generally exempts from state property tax the real and personal property “owned and occupied or used solely for their own purposes” by charitable institutions. Me. Rev. Stat. tit. 36, §105-652(1)(A). Maine also exempts from state property tax personal and real property “leased by and occupied or used solely for its own purposes” by an organization that is exempt from taxation under Internal Revenue Code §501 and is licensed as a charitable hospital, health maintenance organization, or blood bank. However, for tax years beginning on or after April 1, 2012, this exemption will no longer apply to real property. Me. Rev. Stat. tit. 36, §105-652(1)(K).

Maine law exempts nonprofit hospitals from state sales and use tax.

Maine law exempts from state sales and use tax sales of property or services to incorporated hospitals for use in connection with their charitable purposes. Me. Rev. Stat. tit. 36, §211-1760(16)(a); Me. Rev. Stat. tit. 36, §211-1760-C.

Maryland requires nonprofit hospitals to provide free or discounted care based on need to specified populations. Md. Code Ann. Health-Gen. §19-214-1(b); COMAR 10.37.10.26.

Maryland does not specify a minimum level of community benefits that a nonprofit hospital must provide.

Maryland requires that each nonprofit hospital submit an annual community benefit report to the Maryland Health Services Cost Review Commission (HSCRC).

Maryland requires that each nonprofit hospital’s annual community benefit report include the hospital’s mission statement and a list of each community benefit initiative undertaken by the hospital, a specification of its cost and objectives, and a description of the hospital’s efforts to evaluate the initiative’s effectiveness. Each hospital’s community benefit report must also include descriptions of gaps in the availability of specialist providers to serve the uninsured and of the hospital’s efforts to track and reduce health disparities in the community that the hospital serves. Md. Code Ann. Health-Gen., §19-303(c).

The HSCRC compiles all of the individual hospital community benefit reports into a consolidated Nonprofit Hospital Community Benefit Report for posting on its website. The report also includes a list of the unmet community needs identified in the most recent community needs assessment conducted by the state health department and by the local health department in each jurisdiction. Md. Code Ann. Health-Gen., §; 19-303(d).

Maryland requires nonprofit hospitals to conduct community health needs assessments.

Maryland law requires that each nonprofit hospital identify the health care needs of its community and, as part of the needs assessment process, consider the most recent community needs assessments developed by the state health department or by the local health department for the jurisdiction in which the hospital is located. Maryland law also provides that a hospital’s needs assessment process “may” include consultation with community leaders, local health care providers, and “any appropriate person who can assist the hospital in identifying community health needs.” Md. Code Ann. Health-Gen., §19-303(b).

Maryland requires nonprofit hospitals to submit annual community benefit reports.

Maryland law requires that each hospital’s individual community benefit report describes how the hospital plans to address the health needs of the community that have been identified and prioritized through the community health needs assessment process. Md. Code Ann. Health-Gen., §19-303(c).

Maryland requires nonprofit hospitals to submit annual community benefit reports.

Maryland law requires that each hospital’s individual community benefit report describes how the hospital plans to address the health needs of the community that have been identified and prioritized through the community health needs assessment process. Md. Code Ann. Health-Gen., §19-303(c).

Maryland law requires hospitals to develop and implement a financial assistance policy for “providing free and reduced-cost care to patients who lack health care coverage or whose health care coverage does not pay the full cost of the hospital bill.”

Maryland law and regulation require each acute care and chronic care hospital to develop and implement a financial assistance policy that provides, at a minimum, free medically necessary care to patients with family income at or below 200 percent of the federal poverty level; reduced cost medically necessary care to patients with family incomes between 200 and 300 percent of the federal poverty level “in accordance with the mission and service area of the hospital;” and reduced cost medical care to patients with family income below 500 percent of the federal poverty level who have a financial hardship. In addition, upon request, a hospital must offer a payment plan to uninsured patients with family income between 200 and 500 percent of the federal poverty level. Md. Code Ann. Health-Gen. §19-214.1(b); COMAR 10.37.10.26(A-2)(2)(a).

Maryland law limits hospital charges and billing and collection practices.

Maryland statutes and regulations establish detailed requirements and prohibitions concerning hospital charges, billing, and debt collection practices, including agency review of each hospital’s debt collection policy. A description of these policies must be submitted periodically for review by the HSCRC. The policy must provide a detailed description of its debt collection procedures; indicate the circumstances in which the hospital will seek a judgment against a patient; and include prohibitions on the charging interest on self-pay patients’ bills before obtaining a court judgment, forcing the sale or foreclosure of a patient’s primary residence, and selling patient debt. Md. Code Health-Gen., § § 19-214.1; 19-214.2; COMAR 10.37.10.26 A, A-1.

Maryland law exempts nonprofit hospitals from state income tax.

Maryland law exempts from state income tax organizations that are exempt from federal income tax under Internal Revenue Code §501. Md. Code Ann., Tax-Gen. §10-104(2).

Maryland law may exempt property owned or leased by nonprofit hospitals from state property tax.

Nonprofit hospital property is generally eligible for tax exemption if it is “necessary for and actually used for a charitable … purpose.” Md. Code Ann., Tax-Prop. §7-202(b).

Maryland exempts nonprofit hospitals from state sales and use tax.

Maryland law generally exempts charitable organizations, including nonprofit hospitals, from state sales and use tax. Md. Code Ann. Tax-Gen. §11-204(a) (3).

Massachusetts requires nonprofit and for-profit hospitals to provide charity care as a condition of original licensure. In addition, Voluntary Guidelines issued by the Attorney General recommend that all nonprofit hospitals develop a community benefit plan.

Massachusetts will not issue an original license to “establish or maintain” an acute care hospital unless the applicant agrees to either maintain or increase the percentage of gross patient revenues allocated to free care. Mass. Gen. Laws ch. 111, §51G(3).

Voluntary Attorney General’s Community Benefits Guidelines for Non Profit Hospitals (2009) (Voluntary Guidelines) emphasize the importance of community benefits to population health and recommend that the Board of each nonprofit acute care hospital affirm and make public a community benefit mission statement and develop and publicize a community benefit plan. Voluntary Guidelines, pp. 6-7.

Massachusetts does not specify a minimum level of community benefits that nonprofit hospitals must provide.

Although Massachusetts law does not require community benefit reporting, the Voluntary Guidelines recommend that each hospital annually report on its community benefit programs.

TTo comply with the Voluntary Guidelines, nonprofit hospitals complete a standard Community Benefit Report Form that is posted on the Attorney General’s website. Voluntary Guidelines, pp. 23–26. The form accommodates hospital reporting of: 1) organizational leadership, 2) community needs assessment and community involvement, 3) community benefit plans, 4) community benefit programs, and 5) community benefit expenditures, including charity care. Voluntary Guidelines, p. 5. The form also includes an optional section for reporting expenditures for community service programs and charitable activities that cannot be reported as community benefit programs; these “community service” expenditures do not count toward a hospital’s community benefit expenditure total. Voluntary Guidelines, pp. 23-26.

Although Massachusetts law does not require nonprofit hospitals to conduct community health needs assessments, the Voluntary Guidelines recommend that nonprofit hospitals conduct community needs assessments at least every three years.

The Voluntary Guidelines recommend that hospitals conduct community needs assessments before developing their mission statements and community benefit plans, and that an assessment be conducted at least every three years. Voluntary Guidelines, pp. 11.

Although Massachusetts law does not require nonprofit hospitals to develop community benefits plans or implementation strategies, the Voluntary Guidelines recommend that they do so.

The Voluntary Guidelines recommend that hospitals develop community benefits plans that specify the target population whose needs are to be addressed, describe specific activities directed toward the needs identified by the community health needs assessment, identify measurable short- and long-term goals, and include a budget. Voluntary Guidelines, pp. 13-19.

As a condition of original licensure, Massachusetts requires nonprofit and for-profit hospitals to provide charity or discounted care on an income-based sliding scale. Mass. Gen. Laws ch. 111, §51G(3). In addition, the Voluntary Guidelines recommend that all nonprofit hospitals develop written charity care policies.

The Voluntary Guidelines recommend that all nonprofit hospitals develop written “Credit and Collection” policies that describe any program through which a hospital offers discounts for the uninsured or medically indigent, including the hospital’s charity care policies. Voluntary Guidelines, p. 28.

Massachusetts requires that nonprofit and for-profit hospitals disseminate information about their financial assistance policies as a condition of reimbursement from the Health Safety Net Trust Fund.

In 2007, Massachusetts established a Health Safety Net Trust Fund as part of the state’s health care reform framework. The Trust Fund reimburses nonprofit and for-profit hospitals and other health care providers for medically necessary services provided to eligible uninsured and underinsured Massachusetts residents with family income below 400 percent of the federal poverty level or who qualify for medical hardship status. Mass. Gen. Law 118E § 69; 101 Code Mass. Reg. §§613.04 and 613.05. To be eligible for reimbursement from the Health Safety Net Trust Fund, hospitals must post large, legible signs notifying patients of the availability of financial assistance “and other programs of public assistance.” The signs must be posted in the inpatient, clinic, and emergency admissions/registration areas, as well as in the business office. 101 Code Mass. Reg. 613.08(e).

In addition, hospitals must supply individual notice of the availability of financial assistance programs to patients who are expected to incur charges, specifying that the hospital offers a payment plan to low-income and medical hardship patients. 101 Code Mass. Reg. 613.08(d).

In addition, the Voluntary Guidelines recommend that all nonprofit hospitals describe and make available to the public “any program through which the hospital offers discounts from charges for the uninsured or medically indigent.” This should occur during the patient intake and registration process, or as soon thereafter as possible, and notice should be included on hospital bills. Voluntary Guidelines, pp. 28-29.

Massachusetts law limits nonprofit and for-profit hospital collection practices as a condition of reimbursement from the Health Safety Net Trust Fund; Voluntary Guidelines recommend additional restrictions on nonprofit hospital billing and collection policies and practices.

As a condition of reimbursement from the Health Safety Net Trust Fund, hospitals may not seek legal execution against a low-income patient’s personal residence or motor vehicle without the express approval of the hospital’s Board of Trustees.

The Voluntary Guidelines recommend that all nonprofit hospitals develop written “Credit and Collection” policies that describe any program through which a hospital offers discounts for the uninsured or medically indigent, including the hospital’s charity care policies. The Voluntary Guidelines, (pp. 28-30) also recommend that all nonprofit hospitals refrain from:

Beginning collection activities before providing the patient a written statement of the availability of financial counseling services, and offering a patient facing financial hardship a reasonable payment plan;

Referring a patient’s account to a third-party collection agency before 120 days has passed after sending the first bill to the patient;

Executing a lien against a patient’s residence or automobile unless specifically approved by the hospital’s Board; and

Charging interest on patient debt.

Massachusetts generally exempts from the state’s corporate excise tax corporations that are federally recognized as tax-exempt under Internal Revenue Code §501(c)(3). Mass. Gen. Laws, ch.63, §30, ¶4; Massachusetts Department of Revenue, Corporate Excise Tax, Exemptions.

Massachusetts law exempts the personal property of charitable organizations from property tax and exempts charitable organizations’ real property “occupied … for the purposes for which it is organized.”

Personal property owned by a charitable organization is exempt from state property tax, regardless of the property’s use. Also exempt is real property owned and occupied by a charitable organization or its officers for its charitable purposes, or occupied by another charitable organization or its officer for its charitable purposes. Mass. Gen. Laws, ch. 59, § 5, Clause 3.

Massachusetts law exempts nonprofit hospitals from state sales tax.

Massachusetts law exempts from state sales tax organizations that are exempt from federal income tax under Internal Revenue Code §501(c)(3) if the subject of the sale is used “in the conduct of such … charitable … enterprise,” if the nonprofit corporation has a sales tax exemption certificate from the Commissioner of Revenue, and if the vendor keeps records of each tax-exempt transaction. Mass. Gen. Laws. ch. 64H, §6(e).

Although Minnesota law does not expressly require nonprofit hospitals to provide community benefits, the state’s nonprofit hospitals have voluntarily entered into legal agreements with the Attorney General that set forth legally binding requirements for financial assistance policies and charges, billing, and debt collection practices.

In 2012, Minnesota’s Attorney General executed voluntary agreements (2012 Agreement) with each of Minnesota’s nonprofit hospitals. (Virtually all Minnesota hospitals are nonprofit corporations.) Under the 2012 Agreement (the third in a series of five-year agreements between the Attorney General and Minnesota hospitals), a nonprofit hospital’s Board of Directors must adopt a charity care policy that takes into consideration a patient’s financial ability to pay a medical bill. 2012 Agreement, ¶36e. Before pursuing or authorizing a third party to pursue garnishment of a patient’s wages or accounts, a hospital must first 1) offer a reasonable payment plan to a patient who has indicated (subject to hospital verification) an inability to pay the entire bill at once and 2) if the circumstances suggest that a patient may be eligible, afford the patient a reasonable opportunity to apply for charity care. 2012 Agreement, ¶9d.

Hospitals are required by regulation to file publicly available financial reports annually; as a condition of claiming a “charity care adjustment,” a hospital must 1) provide charity care; 2) have a charity care policy that is communicated or made available to patients; 3) make reasonable efforts to identify third-party payers; 4) as appropriate, assist patients to apply for public programs; and 5) ensure that a patient to whom charity care is provided meets the hospital’s eligibility criteria for charity care. Minn. R. 4650.0115.

Neither Minnesota law nor the terms of the 2012 Agreement specify a minimum level of community benefits that hospitals must provide.

Minnesota law requires hospitals to annually report community benefits provided.

Minnesota hospitals must annually submit a publicly available financial report that details: 1) services provided at no cost or for a reduced fee to patients unable to pay; 2) teaching and research activities; and 3) other community or charitable activities Minn. Stat. §144.698.1(5), along with a copy of the hospital’s charity care policies. Minn. R. §4650.0112.3 (K); Minn. R. 4650.0115. The financial report may be filed with the commissioner of health or with a voluntary, nonprofit, reporting organization. Minn. Stat. §144.698.1; Minn. Stat. §144.702.1. The Minnesota Hospital Association is the designated voluntary, nonprofit reporting organization. Minnesota Hospital Association.

When reporting charity care, the hospital must report the total dollar amount and the number of service contacts between a patient and a provider, in three categories: 1) patients with family income at or below 275 percent of the federal poverty level (FPL); 2) patients with family income above 275 percent of the FPL; and 3) patients for which the facility, with reasonable effort, has been unable to determine family income. Minn. R. 4650.0115.3.

Minnesota’s Commissioner for Public Health is required to compile financial information reported by each hospital into a combined annual report reflecting the costs of each hospital’s community benefit activities. Minn. Stat. §144.699.5.

Minnesota does not require nonprofit hospitals to conduct community health needs assessments.

Minnesota does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

Although Minnesota law does not require hospitals to adopt and implement financial assistance policies, they are required to do so pursuant to a voluntary agreement with the Attorney General.

Under the 2012 Agreement, essentially an extension of two earlier agreements, each hospital’s Board of Directors must adopt a financial assistance policy that considers a patient’s financial ability to pay a medical bill. 2012 Agreement, ¶36e. That policy must also include specific eligibility criteria. Minn. R. 4650.0115. If a patient cannot pay his or her entire bill at once, then the hospital must attempt to negotiate a reasonable payment plan. 2012 Agreement, ¶9d.

Minnesota hospitals must communicate their financial assistance policies to patients or otherwise make them available.

A hospital may claim a “charity care adjustment” on the mandatory, publicly available financial report it submits each year only if (among other requirements) the hospital has a charity care policy that is communicated or otherwise made available to patients. Minn. R. 4650.0115.

Although Minnesota law does not limit nonprofit hospital charges, billing, or collection practices, a voluntary agreement with the Attorney General imposes such limitations.

The 2012 Agreement includes the following requirements:

For any uninsured service provided, a patient with annual income of less than $125,000 per year may not be charged more than the amount the hospital would be reimbursed for the service from its largest nongovernment insurer during the previous year. 2012 Agreement, ¶ 32.

Before taking legal action or garnishing a patient’s wages, the hospital must: 1) verify that the patient owes the debt; 2) confirm that all appropriate insurance companies have been billed; 3) offer the patient a payment plan if he/she cannot pay the bill all at once; and 4) if the circumstances suggest that the patient may be eligible, afford the patient a reasonable opportunity to apply for charity care. 2012 Agreement, ¶1b-d; ¶9b-d.

The Hospital Board will adopt and maintain policies to: 1) establish a “zero tolerance” policy for abusive or harassing debt collection practices; 2) monitor hospitals’ relationships with outside debt collectors and attorneys to ensure that their actions conform to the law and to the hospital’s mission; and 3) ensure that no default judgment is obtained against a patient until that patient has been given a fair opportunity to respond. 2012 Agreement, ¶36.

Minnesota exempts nonprofit hospitals from state corporate income tax.

Article X of the Minnesota Constitution exempts from taxation all “institutions of purely public charity” Minn. Const. art. X. In addition, Minnesota law exempts federally tax-exempt organizations from state income tax. Minn. Stat. §290.05(2).

Minnesota law exempts from taxation the property of “institutions of public charity” under specified circumstances.

Minnesota law exempts from state property tax the property of “institutions of public charity” that are exempt from federal income tax under Internal Revenue Code §501(c)(3), but only if these institutions also satisfy additional factors identified for consideration by Minnesota law. Minn. Stat. §272.02.7; Rainbow Child Care Ctr., Inc. v. County of Goodhue, 741 N.W.2d 880 (Minn. 2007).

Minnesota law exempts nonprofit hospitals from state sales tax.

Minnesota law exempts from state sales tax sales to nonprofit hospitals organized for “charitable purposes” within the meaning of Internal Revenue Code §501(c)(3) if the purchased items are used in providing hospital services. Minn. Stat. §297A.70(7)(a).

Nevada requires charity care to be provided by nonprofit and for-profit hospitals that have at least 100 beds and are located in a county that has at least 2 licensed hospitals. Nev. Rev. Stat. §439B.300(2); Nev. Rev. Stat. §439B.320.

Nevada requires that a specified minimum level of charity care be provided by nonprofit and for-profit hospitals that have at least 100 beds and are located in a county that has at least 2 licensed hospitals.

Nevada requires that nonprofit and for-profit hospitals that have at least 100 beds and are located in a county that has at least 2 licensed hospitals annually provide care for indigent inpatients in an amount that represents at least 0.6 percent of the hospital’s net revenue for the preceding fiscal year. Nev. Rev. Stat. §439B.320. If the amount of treatment a hospital provides to indigent patients is less than 0.6 percent of its net revenues for the previous year, the county will deduct the shortfall from payments otherwise owed to the hospital. Nev. Rev. Stat. §439B.340(2)(c).

Nevada requires community benefit reporting by nonprofit and for-profit hospitals that have at least 100 beds and are located in a county with at least 2 licensed hospitals.

Nevada requires each nonprofit and for-profit hospital that has at least 100 beds and is located in a county that has at least 2 licensed hospitals to file an annual report with the state Department of Health and Human Services that details the expenses associated with providing community benefits and in-kind services to the community in which it is located. Nev. Rev. Stat. §449.490(3)(a).

Nevada does not require hospitals to conduct community health needs assessments.

Nevada does not require hospitals to develop community benefit plans or implementation strategies.

Nevada does not require hospitals to adopt or implement financial assistance policies, but it requires nonprofit and for-profit hospitals that have at least 100 beds and are located in a county with at least 1 other hospital to provide indigent care equivalent to at least 0.6 percent of the hospital’s net revenues.

Nevada requires nonprofit and for-profit hospitals with 200 or more beds to include with a patient’s first statement after discharge a notice of any reduction or discount of charges available, along with the criteria a patient must meet in order to qualify for the reduction or discount. Nev. Rev. Stat. §§439B.260 (2).

Nevada law limits hospital charges and billing and collection practices.

Nevada requires nonprofit and for-profit hospitals with 200 or more beds to reduce by at least 30 percent the total charges billed for inpatient medical services to patients who are uninsured, ineligible for publicly funded health coverage, and make reasonable arrangements within 30 days after the hospital sends a bill that notifies them of available discounts and eligibility criteria. Nev. Rev. Stat. §§439B.260 (1) –(2).

Before undertaking collection efforts against patients who are insured or who may be eligible for public insurance, a hospital must have submitted its claim for hospital services to the third-party payer and received a determination as to payment. Nev. Rev. Stat. §449.757.

Nevada does not have a state income tax.

Nevada law exempts from taxation the property of nonprofit hospitals.

Nevada law exempts from taxation the property and buildings owned by a nonprofit corporation and used by “a hospital … for the care or relief of … sick, infirm, or indigent persons.” Nev. Rev. Stat. §361.083.

Also exempt is the property of any corporation “prohibited by its articles of incorporation from declaring or paying dividends” where its income is “devoted to the general purposes of charity” without private inurement and “where indigent persons without regard to race or color may receive medical care and attention without charge or cost.” Nev. Rev. Stat. §361.140(b).

Nevada law exempts nonprofit hospitals from state sales and use taxes.

Nevada law exempts from taxation personal property sold by or to nonprofit organizations created for charitable purposes. Nev. Rev. Stat. §§372.326; 372.3261.

New Hampshire requires nonprofit hospitals to provide community benefits if the total value of their fund balances exceeds $100,000.

New Hampshire’s community benefit law applies to “health care charitable trusts” (a term that includes nonprofit hospitals) that have total fund balances of over $100,000. N.H. Rev. Stat. Ann. Tit. I, §§ 7:32-d—l. A hospital may seek a waiver of community benefit requirements when “compliance would be a financial or administrative burden,” based on criteria established and administered by the Director of Charitable Trusts. N.H. Rev. Stat. Ann. Tit. I, §§ 7:32-j; Office of the Attorney General, Community Benefits Plan -Criteria for Exemption Pursuant to RSA 7:32-j.

In addition to the general community benefit requirements of N.H. Rev. Stat. Ann. Tit. I, §§ 7:32-d—l (2000), additional community benefit requirements are included in the standards for review of the Certificate of Need (CON) applications of nonprofit hospitals and other health care charitable trusts that propose new institutional health services. These include the provision of free care to uninsured patients with household income at or below 150 percent of the federal poverty level (FPL), subject to a “reasonable and nominal” (not over $100) copayment by the patient. In cases of patient hardship, a hospital must waive any required copayment. N.H. Rev. Stat. Ann. Titl. XI, §151-C; N.H. Code Admin. R. He-Hea 303.04(d). A CON application must indicate the degree to which the proposed project will be accessible to persons who are “medically underserviced,” including persons with disabilities and those with low income. N.H. Rev. Stat. Ann. Tit. XI §151-C:7(III); N.H. Code Admin. R. He-Hea 304.05(v). Effective June 30, 2016, the CON statutes will be repealed. N.H. Rev. Stat. Ann. Titl. XI, §151-C (2013).

New Hampshire does not specify a minimum level of community benefits that nonprofit hospitals must provide.

New Hampshire requires that nonprofit hospitals and other health care charitable trusts report community benefits provided during the previous year as part of community benefit plans filed with the Director of Charitable Trusts.

The plan must include: 1) information about community benefit activities the hospital undertook during the preceding fiscal year; 2) the results, outcomes, and unreimbursed costs of these activities; 3) a description of how the hospital solicited community input; 4) identification of the community groups, members of the public, and local government officials that were consulted in connection with the plan’s development; and 5) an evaluation of the plan’s effectiveness. N.H. Rev. Stat. Ann. Tit. I, §§7:32-e(2000). The state uses a “data-driven” Community Benefits Reporting Form that contains a three-page “List of potential Community Needs.” Included in the list are the following social and economic factors: poverty, unemployment, homelessness, economic development, educational attainment, high school completion, housing adequacy, vandalism/crime, air quality, and water quality (New Hampshire Office of the Attorney General, 2009).

New Hampshire requires nonprofit hospitals and other health care charitable trusts to conduct community needs assessments and to update them at least every five years. N.H. Rev. Stat. Ann. Tit. I, §7:32-f.

To assist in determining the activities to be included in its community benefit plan, each nonprofit hospital and other health care charitable trusts must conduct a community needs assessment. A hospital’s needs assessment may be conducted individually or with other health care charitable trusts in its community. The needs assessment process must include “consultation with members of the public, community organizations, service providers, and local government officials.” N.H. Rev. Stat., Tit. I, §7:32-f (2004).

New Hampshire requires nonprofit hospitals to develop and annually submit community benefit plans.

Nonprofit hospitals and other health care charitable trusts must annually submit to the Director of Charitable Trusts a community benefit plan developed on forms supplied by the Attorney General. The plan must take into consideration public input and identify the health care needs considered in developing the plan; identify community benefit activities the hospital will undertake along with an estimate of its cost; and specify which needs identified by the community needs assessment process these activities are intended to address. N.H. Rev. Stat. Ann., Tit. I § 7:32-e (2000).

New Hampshire requires nonprofit hospitals and other health care charitable trusts to submit their written financial assistance plans with CON applications.

New Hampshire requires nonprofit hospitals and other health care charitable trusts applying for CONs to provide with their applications a copy of their written financial assistance plans.

State regulations require hospital financial assistance plans to specify that 100 percent of uninsured individuals with household income less than or equal to 150 percent of the FPL are eligible to receive free care, subject to a reasonable and nominal payment by the patient of up to $100, which will be waived in cases of financial hardship. N.H. Code Admin. R. He-Hea 303.04(d).

An applicant’s written financial assistance plan must also include: application forms and instructions provided to any person who indicates his or her inability to pay for the facility’s services; eligibility determination procedures; appeal procedures for those denied eligibility for financial assistance; and a description of communication procedures to be used to inform the public of the hospital’s financial assistance policy. N.H. Code Admin. R. He-Hea 303.04(e)(1-4).

Effective June 30, 2016, the CON statutes will be repealed. N.H. Rev. Stat. Ann. Titl. XI, §151-C (2013).

New Hampshire requires nonprofit hospitals and other health care charitable trusts to describe, in their CON applications, the communications procedures to be used to inform the public of the hospital’s financial assistance policy.

A health care charitable trust must inform the public of its financial assistance policies by: posting the hospital’s financial assistance policy, referencing it in all public notices of service availability, and informing the public of the availability of staff to assist patients in all aspects of eligibility. N.H. Code Admin. R. He-Hea 303.04(e)(4).

Effective June 30, 2016, the CON statutes will be repealed. N.H. Rev. Stat. Ann. Titl. XI, §151-C (2013).

New Hampshire law does not limit nonprofit hospital charges, billing, or collection practices.

New Hampshire law exempts nonprofit hospitals and other charitable organizations from state income tax.

New Hampshire exempts from taxation income received by a charitable organization incorporated or organized in the state and used “for the purposes for which it is established.” N.H. Rev. Stat., Tit. V, §77:8.

New Hampshire exempts from taxation the property of nonprofit hospitals and other charitable organizations, subject to certain conditions.

The buildings, land, and personal property of a charitable organization are exempt from New Hampshire property tax if the property is owned, used, and occupied by the organization for the charitable purposes for which it was established. New Hampshire law requires that each charitable organization file an annual statement reflecting its financial condition and other information needed to establish its eligibility for the tax exemption. N.H. Rev. Stat., Tit. V, §72:23(V) and (VI).

New Hampshire does not have a sales tax. New Hampshire Department of Revenue Administration.

New Mexico requires nonprofit and for-profit hospitals to provide community benefits as a condition for licensure.

The New Mexico Department of Health issues licenses to acute-care, general, and limited service hospitals that agree, among other things, to participate in Medicaid, Medicare, and county indigent care programs, and to serve nonpaying and low-income reimbursed patients. N.M. Stat. §24-1-5.8 (C)(2) & (C)(5).

New Mexico does not require nonprofit hospitals to provide a specified level of community benefits.

New Mexico requires hospitals to report costs associated with the charity care they provide.

The New Mexico Department of Health requires all acute care hospitals—and all limited services hospitals licensed after January 1, 2003—to report annually the cost of care to nonpaying and low-income reimbursed patients. N.M. Code R. §7.7.2.8 (M).

All licensed non-federal hospitals are also required to report data on charity care charges and bad debt to the New Mexico Health Policy Commission on an annual basis. N.M. Code R. §7.1.24.8-.12.

New Mexico does not require nonprofit hospitals to conduct community health needs assessments.

New Mexico does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

New Mexico does not expressly require nonprofit hospitals to adopt or implement financial assistance policies.

Although New Mexico does not expressly require hospitals to adopt or implement financial assistance policies, Department of Health regulations provide that every patient is entitled to examine and receive an explanation of his or her hospital bill and may receive, upon request, information relating to financial assistance available through the hospital. N.M. Code R. §7.7.2.19(A)(1)(m).

Each licensed non-federal hospital is required to submit its charity care policy, including the qualifying income levels, to the Health Policy Commission on an annual basis. N.M. Code R. §7.1.24.8(C).

New Mexico requires nonprofit and for-profit hospitals to provide to patients upon request information relating to financial assistance available through the hospital. N.M. Code R. §7.7.2.19(A)(1)(m).

New Mexico law does not limit nonprofit hospital charges or billing and collection practices, other than recognizing that patients have the right to receive and examine an explanation of their bills. N.M. Code R. §7.7.2.19(A)(1)(m).

New Mexico law exempts nonprofit hospitals from state income tax.

New Mexico law exempts from state income tax nonprofit organizations that are exempt from federal tax under the Internal Revenue Code. N.M. Stat. §7-2A-4(C).

New Mexico exempts property used for charitable purposes from state property tax. N.M. Const., art. VIII §3.

Although New Mexico has no sales tax, it exempts from gross receipts tax organizations that are exempt from federal income tax under Internal Revenue Code §501(c)(3). N.M. Stat. Ann. §7-9-29 (A).

New York requires for-profit and nonprofit hospitals to provide discounted care as a condition of reimbursement from a state Pool.

As a condition of participation in New York’s General Hospital Indigent Care Pool, nonprofit and for-profit general hospitals must provide discounted care to qualifying patients with low income. The Pool provides reimbursement for a portion of hospital losses associated with unreimbursed care, including both charity care and bad debt expenses. To be eligible for disbursements from the Pool, a hospital must provide discounted care to eligible low-income patients in accordance with a proportional sliding fee schedule. N.Y. Pub. Health Law §§ 2807-k(9-a).

New York does not require nonprofit hospitals to provide a specified minimum level of charity care or other community benefits.

New York requires hospitals to report their costs of providing unreimbursed care and requires nonprofit hospitals to demonstrate their commitment to meeting community health needs.

New York law requires that nonprofit and for-profit hospitals file financial reports detailing, among other things, their costs of providing free or reduced cost services. N.Y. Pub. Health Law §§2805-a(2)(a); 2803-l(2)(iv). In addition, at least every three years the governing body of a nonprofit hospital must demonstrate the hospital’s commitment to meeting community health care needs, providing charity care, and improving underserved individuals’ access to health care services. The governing body must also make available to the public a summary statement of the hospital’s financial resources and allocation to hospital purposes, including its provision of free and discounted care. At least annually, the governing body must make available to the public an implementation report as to the hospital’s efforts to meet community health care needs, provide charity care, and improve access to care. At least every three years, a nonprofit hospital must file with the Commissioner of Health a report detailing changes to its mission statement and its operational and financial commitment to meeting community health care needs, to its provision of charity care, and to improving underserved individuals’ access to care. N.Y. Pub. Health Law §2803-l.

New York requires nonprofit hospitals to conduct community needs assessments in connection with developing a community service plan.

Every three years, as part of each nonprofit general hospital’s community service plan, its governing body must 1) solicit the views of the communities served by the hospital on such issues as the hospital’s performance and service priorities and 2) demonstrate the hospital’s commitment to meeting community health care needs, to providing charity care services, and to improving health care accessibility for the underserved. N.Y. Pub. Health Law §2803-l.

New York requires nonprofit hospitals to develop community benefit plans or implementation strategies.

These publicly available annual reports describe each hospital’s performance in meeting the health care needs of the community, providing charity care services, and improving access to health care services by the underserved. N.Y. Pub. Health Law §2803-l (3).

New York also incentivizes and promotes hospital community benefit initiatives that target community health improvement by expressly linking its State Health Improvement Plan (SHIP), titled Prevention Agenda 2013-2017, to required hospital community benefit plans (termed “community service plans”).

Each tax-exempt hospital’s community service plan must include two state Prevention Agenda priorities (selected jointly with the local health department) and describe strategies to address the priorities in a three-year action plan.

New York requires hospitals that participate in the state’s General Hospital Indigent Care Pool to adopt financial assistance policies.

New York require hospitals to adopt and implement financial assistance policies as a condition of participating in the state’s General Hospital Indigent Care Pool, which provides reimbursement for a portion of hospital losses associated with unreimbursed care, including both charity care and bad debt expenses. To be eligible for disbursements from the Pool, a hospital must provide discounted care to eligible low-income patients based on a sliding fee schedule. N.Y. Pub. Health Law §2807-k(9-a)(a).

New York requires dissemination of hospitals’ financial assistance policies as a condition of participating in the state’s General Hospital Indigent Care Pool.

In order to participate in the state’s General Hospital Indigent Care Pool, hospitals must develop a clear and understandable written financial assistance policy and make patients aware of the policy. Summaries of these policies must be available to patients and to the public. Hospitals that operate 24-hour emergency rooms must also conspicuously post notice of their financial assistance policies in appropriate languages and notify patients of the policies during the intake and registration process. In addition, notice that financial assistance may be available and instructions on how to obtain additional information must be included in bills and statements sent to patients. N.Y. Pub. Health Law § 2807-k(9-a)(c).

New York limits hospital charges and collections as a condition of participating in the state’s General Hospital Indigent Care Pool.

New York requires nonprofit and for-profit hospitals participating in the Pool to reduce charges to uninsured patients with family income below 300 percent of the federal poverty level. N.Y. Pub. Health Law §2807-k(9-a) (a),(f). Hospitals must provide the option of monthly installment plans for payment of outstanding balances, and payments under such plans may not exceed 10 percent of a patient’s gross monthly income. N.Y. Pub. Health Law §2807-k(9-a) (d). In addition, hospitals’ policies may not permit the forced sale or foreclosure of a patient’s primary residence in order to collect an outstanding medical bill. N.Y. Pub. Health Law §2807-k(9-a)(h).

New York law exempts nonprofit hospitals from state income tax.

New York exempts from taxation the net income of a non-stock corporation that is organized and operated on a nonprofit basis if no part of its net earnings inure to the benefit of any officer, director, or member. A nonprofit corporation that is exempt from federal income tax pursuant to Internal Revenue Code §501(a) is presumed to be exempt from state income tax. 20 N.Y. Comp. Codes R. & Regs. §1-3.4(b)(6).

New York law exempts from taxation the property of nonprofit hospitals.

New York exempts from taxation real property owned by nonprofit corporations organized or conducted exclusively for charitable or hospital purposes and used for carrying out that charitable or hospital purpose and not for private inurement. N.Y Real Property Tax Law §§420-a (1)(a)-(b).

New York law exempts nonprofit hospitals from sales and use taxes.

New York law exempts from sales and use tax sales to or by nonprofit corporations operated exclusively for charitable purposes. N.Y. Sales Tax Law § 1116(a)(4).

North Carolina law does not expressly require nonprofit hospitals to provide community benefits.

However, the state requires nonprofit hospitals to report community benefits as a condition of receiving authorization to issue tax-exempt financing. N.C. Gen. Stat.§§131A-21; 131A-7; North Carolina Medical Care Commission, Community Benefits Report (Hospitals).

North Carolina law does not expressly require nonprofit hospitals to provide community benefits.

North Carolina requires nonprofit hospitals to report community benefits.

Tax-exempt hospitals must submit annually to the state health department the information contained on IRS Form 990, which the department then posts on its website. The same information must be conspicuously displayed in the hospital’s original place of business. HB 97/SL 2015-241 (2015). North Carolina also requires nonprofit hospitals to report community benefits as a condition of receiving authorization from the state’s Medical Care Commission to issue tax-exempt financing. N.C. Gen. Stat.§§131A-21; 131A-7; North Carolina Medical Care Commission, Community Benefits Report (Hospitals).

North Carolina does not require nonprofit hospitals to conduct community health needs assessments.

North Carolina does not require nonprofit hospitals to submit community benefits plans or implementation strategies.

Although North Carolina does not require nonprofit hospitals to submit community benefit plans/implementation strategies, it requires an individual applying for a certificate of need (required prior to offering a new “institutional health service”) to include in the application a “commitment and plan for serving indigent and medically underserved populations.” N.C. Gen. Stat. §131E-178(a)(4). The application must indicate how the new service will meet the needs of the “medically underserved,” including low-income and medically indigent individuals. N.C. Gen. Stat. §131E-183(13).

North Carolina does not require nonprofit hospitals to adopt or implement financial assistance policies.

North Carolina requires nonprofit hospitals to provide the public access to their financial assistance policies.

Hospitals required to file IRC Form 990, Schedule H are also required to submit their financial assistance policies and financial assistance costs on an annual basis to the Department of Health and Human Services for display in one location on its website and in a manner that is searchable. Hospitals must also display this information “in a conspicuous place.” N.C. Gen. Stat. §131E-214.14 (2013).

North Carolina requires hospitals to provide to discharged patients an itemized list of charges upon request, as well as abide by reasonable collection practices.

Hospitals must provide an itemized list of charges to a patient upon request. A patient may request an itemized list at any time within three years after the date of discharge. N.C. Gen. Stat. §131E-91(a) (2013). Hospitals are also required to establish a method for patients to inquire about or dispute a bill. N.C. Gen. Stat. §131E-91(a) (2013). A hospital may not bill insured patients for charges that would have been covered by their insurance if the hospital had submitted the claim within the allotted time requirements. N.C. Gen. Stat. §131E-91(c) (2013).

Hospitals must also follow reasonable collection practices. Hospitals may not send a patient’s unpaid bill to collections while a decision on the patient’s charity care application is pending or attach a lien to a patient’s principal residence. N.C. Gen. Stat. §131E-91(d). Patients must be given written notice that their bill will be subject to collections activity at least 30 days prior to the referral for collection being made. N.C. Gen. Stat. §131E-91(d) (2013).

North Carolina law exempts nonprofit hospitals from state income tax.

North Carolina law exempts from state income tax corporations organized for charitable purposes and any other organizations that are exempt from federal income tax. N.C. Gen. Stat. § 105-130.11(a)(3).

North Carolina law exempts from taxation the real and personal property of nonprofit hospitals “actually and exclusively used for charitable hospital purposes.”

A “charitable hospital purpose” is defined as “a hospital purpose that has humane and philanthropic objectives [and] … benefits humanity or a significant rather than limited segment of the community without expectation of pecuniary profit or reward.” N.C. Gen. Stat. § 105.278.8.

North Carolina law does not exempt nonprofit hospitals from sales and use tax.

North Carolina law specifies that nonprofit hospitals are subject to state sales and use tax at the time tangible personal property is purchased. North Carolina Department of Revenue, State Taxation and Nonprofit Organizations, p. 4. However, subject to certain limitations, nonprofit hospitals are eligible to receive a semi-annual refund of sales and use taxes paid on purchases used to carry out their work. N.C. Gen. Stat.§105-164.14 (b)(1). All

Ohio requires hospitals that participate in the Hospital Care Assurance Program to provide community benefits.

Although Ohio law does not otherwise expressly require nonprofit hospitals to provide community benefits, a hospital that elects to participate in Ohio’s disproportionate share hospital program (called the Hospital Care Assurance Program) must provide “basic, medically necessary hospital level services” to Ohio residents whose income is below the federal poverty level and who are not eligible for Medicaid. Ohio Admin. Code 5160-2-07.17.

Ohio does not require nonprofit hospitals to provide a specified level of community benefits.

Hospitals participating in the Hospital Care Assurance Program are required to collect and report to the Department of Medicaid information on the identity and number of people who receive free care. Ohio Rev. Code, Ch. 5168.14(c); Ohio Admin. Code 5160-2-07.17(F).

Ohio does not require nonprofit hospitals to conduct community health needs assessments.

Ohio does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

Ohio does not require nonprofit hospitals to adopt and implement financial assistance policies.

Ohio requires nonprofit hospitals to disseminate financial assistance information as a condition of participation in the Hospital Care Assurance Program.

Hospitals that elect to participate in the Hospital Care Assurance Program must post notices in the admissions area, the business office, and the emergency room that specify the rights of persons with income at or below the federal poverty level to receive, without charge to the individual, basic, medically necessary hospital-level services at the hospital. Ohio Admin. Code 5160-2-07.17(D).

Ohio limits hospital collection practices.

Ohio law exempts a person’s residence from execution, garnishment, attachment, or sale to satisfy a judgment for money owed for health care services or supplies provided to the person or his/her dependant. The law does not preclude or invalidate the creation of a judgment lien under these circumstances but delays its enforcement until the property is sold or otherwise transferred by the owner. Ohio Rev. Code §2329.66(A)(1)(a). Additionally, hospitals that participate in Ohio’s disproportionate share hospital program (Hospital Care Assurance Program) may not bill individuals for services without meeting specified requirements, including the hospital’s provision of an explanation that low-income individuals may be eligible for services without charge. Ohio Admin. Code 5160-2-07.17(C).

Ohio exempts nonprofit organizations from its commercial activity tax. Ohio Rev. Code §5751.01(E)(8).

Ohio law exempts property used exclusively for charitable purposes from property tax.

Ohio law exempts real and tangible personal property belonging to institutions that is used exclusively for charitable purposes. Ohio Rev. Code §5709.12(B); Ohio Rev .Code §5709.121.

Ohio law exempts nonprofit organizations from sales tax.

Ohio law exempts sales of tangible personal property or services to “organizations exempt from taxation under Section 501(c)(3) [of the Internal Revenue Code].” Ohio Rev. Code. §5739.02(B)(12).

Pennsylvania requires “institutions of purely public charity” to provide community benefits as a condition of tax exemption.

In 2012, the Supreme Court of Pennsylvania ruled that to qualify for a property tax exemption an organization must first meet the definition of an institution of purely public charity under Pa. Const. art. VIII, § 2(a)(v). An organization will qualify as a purely public charity under the Pennsylvania Constitution if it: (1) advances a charitable purpose, (2) donates or renders gratuitously a substantial portion of its services, (3) benefits a substantial and indefinite class of persons who are legitimate subjects of charity, (4) relieves the government of some of its burden, and (5) operates entirely free from private profit motive. Hospital Utilization Project v. Commonwealth, 507 Pa. 1, 487 A.2d 1306, 1317 (Pa. 1985).

If an organization satisfies the constitutional standards, only then does a court look to the Institutions of Purely Public Charity Act to determine eligibility for property tax exemption under the statutory requirements. Mesivtah Eitz Chaim of Bobov, Inc. v. Pike County Board of Assessment Appeals, 615 Pa. 463, 44 A.3d 3 (Pa. 2012).

Pennsylvania’s Institutions of Purely Public Charity Act establishes specific criteria that a nonprofit corporation must satisfy in order to qualify as an “institution of purely public charity” that is exempt from Pennsylvania property and sales tax. These criteria include a requirement that the organization “donate or render gratuitously a substantial portion of its services” to benefit the community. 10 Pa. Stat. §375(d). In addition, the Hospital & Healthsystem Association of Pennsylvania has developed voluntary guidelines for hospital charity care and financial assistance policies: Charity Care and Financial Aid Guidelines for Pennsylvania Hospitals (2004).

Pennsylvania law permits most nonprofit hospitals to choose from among seven alternative community benefit standards in order to qualify as a tax-exempt “institution of purely public charity.” Six of these standards specify a minimum level of community benefits.

Pennsylvania’s Institutions of Purely Public Charity Act requires that in order to be deemed an “institution of purely public charity,” a hospital must do all of the following: advance a charitable purpose, operate free from any private profit motive, donate a substantial portion of its services to benefit the community, “benefit a substantial and indefinite class of persons who are legitimate subjects of charity,” and relieve government of some of its burden. 10 Pa. Stat. §375 (a)-(f).

To fulfill the requirement of §375(d)(1) that a hospital “donate or render gratuitously a substantial portion of its services to benefit the community,” a hospital must satisfy one of seven standards. Six of these seven standards specify a minimum level of community benefits.

1. Providing goods or services to all who seek them without regard of their ability to pay if the institution a) has a written policy to this effect, b) has published this in a reasonable manner, and c) provides these uncompensated goods or services equal to at least 75% of net operating income, but not less than 3% of total operating expenses. 10 Pa. Stat. §375(d)(1)(i)(C).
2. Providing goods or services that are based upon the recipient’s ability to pay if a) the institution can demonstration implementation of a written policy and fee schedule based on individual or family income, b) at least 20% of the individuals receiving these goods or services pay no fee or a fee which is lower than the cost of the goods or services, c) at least 10% of the individuals receiving the goods or services receive a reduction in fees of at least 10% of the cost of the goods or services provided to them, and d) no individual pays a fee which is greater than or equal to the cost of the goods or services. 10 Pa. Stat. §375(d)(1)(ii)(B)-(D).
3. Providing wholly gratuitous goods or services to at least 5% of those receiving similar goods or services from the institution. 10 Pa. Stat. §375(d)(1)(iii).
4. Providing financial assistance or uncompensated goods or services to at least 20% of those receiving similar goods or services if at least 10% either paid no fees or paid fees accounting for 90% or less than the cost of the goods or services. 10 Pa. Stat. §375(d)(1)(iv).
5. Providing uncompensated goods or services which in the aggregate equal at least 5% of the institution’s cost of providing the goods or services. 10 Pa. Stat. §375(d)(1)(v).
6. Providing goods or services at no fee or reduced fees to government agencies or goods or services to individuals eligible for government programs if any one of the following applies:
1. The institution receives 75% or more of its gross operating revenue from grants or fee-for-service payments by government agencies and if the aggregate amount of government agency fee-for-service payments does not exceed 95% of the institution’s costs for providing goods or services to the individuals for whom the fee for services payments are made. 10 Pa. Stat. §375(d)(1)(vi).
2. This alternative (which does not specify a minimum level of community benefits) does not apply to nonprofit general hospitals.
7. Providing fundraising on behalf of (or grants to) an institution of purely public charity. 10 Pa. Stat. §375(d)(1)(vii). (This standard does not specify a minimum level of community benefit.)

Pennsylvania requires nonprofit hospitals to report community benefits annually.

Except for religious institutions, a nonprofit hospital or other institution of purely public charity that receives contributions of $25,000 or more per year or collects service revenues of $5 million or more per year must submit an annual report, including a copy of its federal tax return, to the state Bureau of Charitable Organizations. 10 Pa. Stat. §379.

Pennsylvania does not require nonprofit hospitals to perform community health needs assessments.

Pennsylvania does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

Pennsylvania requires hospitals, including nonprofit hospitals, to adopt and implement financial assistance policies.

As a condition of receiving reimbursement from the state’s Uncompensated Care Program, hospitals must verify that they have a financial assistance policy in place under which the hospital: 1) accepts all individuals regardless of ability to pay for emergent medically necessary services; 2) seeks to collect claims only from the person(s) responsible for payment; 3) seeks to obtain health care coverage for patients, including assisting patients to apply for available public medical coverage; 4: ensures that emergency admission or treatment is not delayed or denied for monetary reasons; and 5) posts adequate notice of the availability of medical services and the obligations of hospitals to provide free services. Pa. Stat. §5701.1104(b). The Hospital & Healthsystem Association of Pennsylvania has also developed voluntary guidance on hospital financial assistance policies. Charity Care and Financial Aid Guidelines for Pennsylvania Hospitals (2004).

Pennsylvania requires all hospitals to post notices of the hospital’s obligation to provide charity care.

As a condition of receiving reimbursement from the state’s Uncompensated Care Program, hospitals must post adequate notice of the hospital’s obligation to provide free services. 35 Pa. Stat. §5701.1104(b)(5).

The voluntary guidance developed by the Hospital & Healthsystem Association of Pennsylvania also addresses the dissemination financial assistance policies. Charity Care and Financial Aid Guidelines for Pennsylvania Hospitals (2004).

Pennsylvania state law does not limit nonprofit hospital charges, billing, or collection practices.

However, the voluntary guidelines developed by the Hospital & Healthsystem Association of Pennsylvania offer a number of recommendations regarding hospital billing and collection policies including, among other things, offering reasonable patient payment plans and instituting legal action only when there is evidence that the patient has income or assets to meet his or her financial obligation. Charity Care and Financial Aid Guidelines for Pennsylvania Hospitals, p. 10 (2004).

Pennsylvania exempts from state income tax organizations that are exempt from federal income tax.

A corporation, trust or other entity that is an exempt organization under §501 of the Internal Revenue Code is exempt from Pennsylvania’s corporate net income tax. 72 Pa. Stat. § 7401(1)(iii)(3).

Pennsylvania Department of Revenue, Frequently Asked Questions.

Pennsylvania exempts institutions of purely public charity from state property tax.

All hospitals that are institutions of charity under the Pennsylvania Constitution and the Institutions of Purely Public Charity Act are exempt from state property tax. Mesivtah Eitz Chaim of Bobov, Inc. v. Pike County Board of Assessment Appeals, 615 Pa. 463, 44 A.3d 3 (Pa. 2012).

Pennsylvania exempts institutions of purely public charity from sales tax.

The sale [of personal property or services] at retail to or use by any charitable organization that has been granted exemption by the Internal Revenue Service is exempt from Pennsylvania sales tax. 72 Pa. Stat. § 7204(10). Pa. Rev-72–Application for Sales Tax Exemption.

Rhode Island requires hospitals to provide charity care, uncompensated care, and other community benefits as a condition of licensure.

Rhode Island has established statewide standards for the provision of charity care, uncompensated care, and community benefits as conditions of initial and continued hospital licensure and for hospital conversions. R.I. Gen. Laws §23-17-43; 23-17 R.I. Code R. §8.7; 23-17.14 R.I. Code R. §§11.0 – 11.6.

Rhode Island’s hospital licensing regulations expressly require that hospital charity and uncompensated care and community benefit standards be consistent with the rules and regulations applicable to hospital conversions. 23-17 R.I. Code R. §8.7. These define “community benefit” broadly to include the provision of hospital services that meet the community’s needs, charity care, uncompensated care, programs to meet the needs of medically indigent individuals, non-revenue-producing programs available in the community (e.g., health screenings or transportation services), scientific or medical research, education activities, forming linkages with community partners focused on improving community health, and engaging in community health advocacy. 23-17.14 R.I. Code R. §1.9.

Rhode Island does not specify a minimum level of community benefits that hospitals must provide.

Rhode Island law requires hospitals to submit annual community benefit reports to the Director of the Department of Health (Director).

The reports must include detailed descriptions, with supporting documentation, of the costs of charity care, bad debt, and contracted Medicaid shortfalls. R.I. Gen. Laws Ann. § 23-17.14-15(d). If the Department of Health receives “sufficient information” indicating that a licensed hospital is not in compliance with state community benefit standards, then the Director is required to hold a hearing, issue written findings, and impose appropriate penalties. R.I. Gen. Laws Ann. § 23-17.14-15(e).

Rhode Island requires each hospital to develop a formal Board-approved community benefit plan that includes a comprehensive assessment of the health care needs of its community.

The assessment must include needs related to the goals articulated in A Healthier Rhode Island by 2010: A Plan for Action, and a statement of priorities consistent with the hospital’s resources. 23-17.14 R.I. Code R. §11.5 (b).

Rhode Island requires hospitals to develop a formal Board-approved community benefit plan that considers the health care needs of the community or communities served.

A hospital’s community benefit plan, to be updated every three years, must specify the communities (including racial or ethnic minority populations) that will be the focus of the plan. Representatives of the designated community or communities must be involved in the planning and implementation process. The plan must reflect a comprehensive assessment of the health care needs of these designated communities. It must also specify the actual or planned dates when the activities and proposals included in the plan will be implemented. 23-17.14 R.I. Code R. §11.5(b).

Rhode Island law establishes a statewide community standard for the provision of free and discounted care.

Rhode Island hospitals must make full or partial charity care available to uninsured low-income state residents who are ineligible for government or employer-sponsored health coverage. 23-17.14 R.I. Code R. §11.3(b). Hospitals may expand their financial assistance policies beyond what the state requires but may not reduce the amount of assistance or make their financial assistance eligibility standards more restrictive than the state prescribes.

Hospitals must provide free care for patients with annual income at or below 200 percent of the federal poverty level (FPL) and must provide discounted care for patients with annual income between 200 and 300 percent of the FPL. Each hospital’s discounted care policy must be based on a sliding fee scale that the hospital determines based on its evaluation of the needs of its service area and the hospital’s financial resources. 23-17.14 R.I. Code R. §11.3(f).

In determining a patient’s eligibility for free or discounted care, a hospital has discretion to consider, in addition to income, a patient’s assets pursuant to a criterion establishing an assets protection threshold. If assets are considered in determining whether a patient qualifies for free care, additional restrictions on permissible hospital billing and collections against the patient apply. 23-17.14 R.I. Code R. §11.3(d)-(f).

Rhode Island requires hospitals to develop a public “Notice of Hospital Financial-Aid” and post it prominently in emergency departments, admissions areas, outpatient care areas, and on the hospital’s website.

Each hospital is required to develop a “Notice of Hospital Financial-Aid” on a specified template for approval by the Director, as well as include the notice on each patient bill. Each hospital’s financial-aid criteria for financial assistance eligibility, including the sliding fee schedule for discounted care, are also subject to the Director’s approval. Hospitals must also make their financial aid criteria available to all persons upon request. 23-17.14 R.I. Code R. §11.3(h)-(j).

Rhode Island law limits nonprofit hospital billing and collection practices.

Regulations promulgated under Rhode Island’s Hospital Conversions Act, which applies to both hospital licensing and conversions, require each hospital to formally adopt a written collections policy and make it available to all persons upon request. 23-17.14 R.I. Code R. §11.3(n). Although a hospital may attach a patient or guarantor’s primary residence due to non-payment of medical debt, it may not force a foreclosure of the primary residence. 23-17.14 R.I. Code R. §11.4.

Rhode Island exempts non-profit hospitals from state Business Corporation tax. Rhode Island Department of Revenue, R.I. Gen. Laws §44-11-1(1)(c)(4)(iv).

Rhode Island law exempts from taxation the property of a hospital “for the sick or disabled.”

Real and personal property held by or for a hospital for the sick and disabled and used exclusively for that purpose is exempt. R.I. Gen. Laws §44-3-3(12); Lifespan Corporation v. City of Providence, 776 A.2d 1061 (R.I. 2001). State law also exempts intangible personal property owned by, or held in trust for, a charitable organization if the principal or income is used or appropriated for charitable purposes. R.I. Gen. Laws §44-3-3(7).

Rhode Island sales and use tax does not apply to sales of personal property to nonprofit hospitals. R.I. Gen. Laws §44-18-30(5); Rhode Island Sales Regulation SU 07-48.

Tennessee law does not expressly require nonprofit hospitals to provide community benefits.

Tennessee law does not expressly require nonprofit hospitals to provide community benefits.

Tennessee requires nonprofit hospitals to report charity care.

All hospitals licensed by the Department of Health must file a joint annual report “of the statistical particulars relative to their patients for the fiscal year,” including financial data relating to charity care and bad debt. Tenn. Code 68-11-310(a)(1); Tenn. Code §68-1-109; Tennessee Department of Health, Joint Annual Report of Hospitals form, p. 18.

Tennessee does not require nonprofit hospitals to conduct community health needs assessments.

Tennessee does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

Tennessee does not require hospitals to adopt or implement financial assistance policies but requires hospitals that have charity care policies to develop a “concise statement” of these policies.

Tennessee requires each hospital that has a charity care policy to develop a “concise statement” of its policy “for use by members of the public.” Tenn. Code §68-11-268 (2007).

Tennessee requires hospitals to post their financial assistance policies.

Tennessee law requires all hospitals to post a statement of their charity care policies in a place accessible to the public. Tenn. Code §68-11-268.

Tennessee law limits nonprofit hospital charges, billing, and collection practices.

Tennessee law prohibits all hospitals from requiring an uninsured patient to pay an amount that exceeds 175 percent of the cost for the services provided (calculated using the cost-to-charge ratio in the most recent joint annual report to the state’s Department of Health). The Department of Health is required to maintain the confidentiality of information regarding the amounts a hospital bills for services obtained pursuant to §68-11-262. Tenn. Code §68-11-262.

Tennessee has no income tax except on interest and dividend income, from which nonprofit hospitals are not exempt. USA Today, April 26, 2014.

Tennessee exempts from state property tax charitable institutions’ property used for carrying out its exempt purposes.

Tennessee law exempts from state property tax the real and personal property owned by any charitable institution that is used for carrying out its exempt purposes. Tenn. Code §67-5-212(a)(1).

Tennessee law exempts nonprofit hospitals from its sales and business taxes.

Tennessee law governing sales and use tax provides for the exemption of sales to organizations that are exempt from federal tax pursuant to Internal Revenue Code §501(c)(3). Tenn. Code Ann. §67-6-322(b).

Texas requires nonprofit hospitals to provide community benefits as a condition of state tax exemption.

Texas law requires that, in order to qualify as tax-exempt “charitable organizations,” nonprofit hospitals and hospital systems must provide “charity care and government-sponsored indigent health care” or “charity care and community benefits” in at least the amount specified in accordance with one of four alternative standards. Nonprofit disproportionate share hospitals, nonprofit hospitals in counties with a population of less than 58,000, and hospitals that exclusively provide free care are exempt from this requirement. Texas Tax Code Ann. §11.1801; Tex. Health and Safety Code Ann. §§311.043 & 311.045.

Texas law directs nonprofit hospitals, as a condition of tax exemption, to provide community benefits in accordance with one of three alternative community benefit standards. Two of these alternative standards specify a minimum level of community benefits that a hospital must provide.

A nonprofit hospital may qualify as a tax-exempt charitable organization by providing community benefits in an amount that satisfies one of the following standards:

(1) Charity care and government-sponsored indigent health care (shortfall) at a level that is “reasonable in relation to the community needs, as determined through the community needs assessment, the available resources of the hospital or hospital system, and the tax-exempt benefits received by the hospital or hospital system;”

(2) Charity care and government-sponsored indigent health care (shortfall) provided in an amount equal to at least 100 percent of the hospital’s or hospital system’s tax-exempt benefits, excluding federal income tax;

(3) Charity care and community benefits provided in a combined amount equal to at least 5 percent of the hospital’s or hospital system’s net patient revenue, provided that charity care and government-sponsored indigent health care are provided in an amount equal to at least 4 percent of net patient revenue. Texas Tax Code Ann.§§11.1801(a); Tex. Health and Safety Code Ann. §§ 311.031(2) & (8); 311.045.

Texas requires nonprofit hospitals to submit annual community benefit reports.

The Texas Department of Health requires that each nonprofit hospital submit an “annual report of its community benefit plan” that includes a specification of: the hospital’s mission statement; the health needs of the community considered in developing the hospital’s community benefit plan; the amount and types of community benefits actually provided; total operating expenses; and the hospital’s cost to charge ratio. Tex. Health and Safety Code Ann. § 311.046(a).

Texas requires nonprofit hospitals to perform community-wide health needs assessments.

Nonprofit hospitals are directed to seek input from representatives in the community, including the local health department, consumers, private business, insurance companies, and health science centers. Tex. Health and Safety Code Ann. §311.044(a)-(d).

Texas requires nonprofit hospitals to develop community benefit plans.

A nonprofit hospital’s community benefit plan must be an operational plan for serving the community’s health care needs as determined by a community-wide health needs assessment. The plan must include mechanisms to evaluate the plan’s effectiveness, measureable objectives to be achieved within a specified time frame, and a budget for implementing the plan. Tex. Health and Safety Code Ann.§311.044.

Texas requires nonprofit hospitals to have a financial assistance policy that incorporates specified eligibility criteria.

Each Texas nonprofit hospital must “develop, implement, and enforce” a written financial assistance policy. The policy must provide that patients who satisfy the statutory definitions of “financially indigent” or “medically indigent” are eligible for financial assistance. A “financially indigent” patient is one with income at or below 200 percent of the federal poverty level; a “medically indigent” patient is one who is unable to pay the remaining balance on hospital bills that, after payment by third-party payers, exceeds a percentage of the patient’s annual gross income (as specified in the hospital’s financial assistance policy). Tex. Health and Safety Code Ann. §§324.101, 311.031(11),(13).

Texas requires a nonprofit hospital to make information available to the public about its community benefit plan and its charity care program.

Texas law requires that a nonprofit hospital provide to each person seeking any health care service at the hospital a notice (in appropriate languages and in language readily understandable to the average reader) about the hospital’s charity care program, including its eligibility policies and how to apply for the program. The notice must be posted in prominent hospital locations, including the general waiting area, the emergency department waiting area, and the business office. A nonprofit hospital must also publish notice of its charity care policies annually in a local newspaper. Tex. Health and Safety Code Ann. §311.046(d).

Texas law requires hospitals to submit patient bills in a timely manner.

Texas law requires that medical providers submit their bills for medical services to patients and health plans in a timely manner. The law specifies the number of days within which billing must occur under various circumstances. Tex. Health and Safety Code Ann. §146.002. Claims billed in violation of these timeliness standards may be unenforceable against a patient who, had the billing been timely, would not have been obligated to pay. Tex. Health and Safety Code Ann. §146.003.

Texas does not levy a corporate income tax.

Texas exempts nonprofit hospitals from property tax if they provide medical care without regard to ability to pay, “which means they provide charity care and community benefits in accordance with Texas law.” Texas Tax Code Ann. §11.18(d)(1).

Texas exempts charitable organizations from state sales tax.

Texas law exempts from state sales tax organizations that are exempt from federal income tax under Internal Revenue Code §501(c)(3). Texas Tax Code Ann. §151.310(a)(2). Nonprofit hospitals that qualify for an exemption under that provision must provide community benefits that include charity care and government-sponsored indigent health care. Texas Tax Code Ann. §151.310(e).

Utah requires that nonprofit hospitals provide community benefits as a condition for property tax exemption.

Utah’s Property Tax Exemption Standards of Practice (Standards of Practice) require charitable institutions to contribute “something of value ... to the common good” as a “gift to the community … identified either by a substantial imbalance in the exchange between the charity and the recipient of its services or in the lessening of a government burden through the charity’s operation.” Utah County v. Intermountain Health Care, Inc., 709 P.2d 265, 269 (Utah 1985). These gifts may include: unreimbursed indigent care, medical discounts, community education and service, donations of time, donations of money, operation of critical services or programs that might not otherwise be available in the community, or the continued operation of hospitals at a loss. Each nonprofit hospital must establish a charity care plan and have an open access policy that permits indigent persons to receive needed services for no charge or for a reduced charge in accordance with their ability to pay. Standards of Practice, Appendix 2D, Standards III-V, (2014) pp. 32-34.

As a condition of property tax exemption, Utah requires a nonprofit hospital to contribute annual “gifts to the community” (community benefits) in an amount exceeding the value of its annual property tax liability in the absence of the exemption. Standards of Practice, Appendix 2D, Standard V, (2014) p. 33.

Utah requires community benefit reporting as a condition of property tax exemption.

Utah does not require nonprofit hospitals to conduct community health needs assessments.

A rebuttable presumption of compliance with the requirements for property tax exemption arises if the hospital: is governed by a Board composed of a broad-based membership from the community served by the hospital; confers at least annually with the county board of equalization about the community’s clinical needs that the hospital might appropriately address; and maintains a charity plan to ensure compliance with the Standards of Practice. Standards of Practice, Appendix 2D, Standard IV, (2014) p. 33.

Utah does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

Utah requires nonprofit hospitals to adopt and implement financial assistance policies as a condition of tax exemption.

As a condition of property tax exemption, Utah requires nonprofit hospitals to develop an “open access policy” that provides for indigent persons receiving needed medical services for no charge or for a reduced charge in accordance with their ability to pay. Standards of Practice, Appendix 2D, Standard III (2014) p. 32.

Utah requires nonprofit hospitals to adopt and implement financial assistance policies.

As a condition of property tax exemption, a nonprofit hospital must “provide evidence of its efforts to affirmatively inform the public of its open access policy and the availability of services for the indigent.” Standards of Practice, Appendix 2D, Standard III, (2014) p. 32.

As a condition of property tax exemption, Utah limits what nonprofit hospitals may charge indigents who are unable to pay the charges ordinarily billed.

To qualify for property tax exemption, a nonprofit hospital must ensure that “indigent persons who, in the judgment of the admitting physician, require the service generally available at the hospital … receive those services for no charge or for a reduced charge, in accordance with their ability to pay.” Standards of Practice, Appendix 2D, Standard III, p. 32.

Utah law exempts nonprofit hospitals from state income tax.

Utah law exempts from state income tax organizations that are exempt from federal income tax under Internal Revenue Code §501. Utah. Code. §59-7-102.

Utah law exempts from taxation property owned by a nonprofit hospital that complies with the Standards of Practice.

Utah law exempts from state property tax nonprofit hospitals that satisfy the requirements of the Standards, including: adoption of an open access policy, informing the public of their charity plans and charity and discounted care policies, adoption of policies reflecting the public interest, and making annual “gifts to the community” in amounts that exceed their property tax liabilities in the absence of exemption. Standards of Practice, Appendix 2D, Standard III-V, (2014) pp. 32 – 34.

Utah exempts charitable institutions from sales and use tax.

Utah law exempts from state sales and use tax sales made to or by charitable institutions “in the conduct of their regular charitable … functions and activities.” Utah Code §59-12-104(8), Utah Code §59-12-104.1.

Virginia may require a nonprofit hospital to provide community benefits as a condition of certificate of public need approval.

The Commissioner of the State Board of Health is authorized to condition approval of applications for certificates of public need on an applicant’s agreement to provide an acceptable level of reduced-rate care to indigents, provide care to persons with special needs, or facilitate primary care services in designated medically underserved areas within its service area. Va. Code §32.1-102.2(C); 12 Va. Admin. Code §§5-220-270(A) and 5-220-420(A). In 2013, an amendment was passed that allows the Commissioner to approve amendments to existing certificates related to the provision of reduced-rate care to indigents, care to patients requiring specialized care, or the facilitation of primary care services in designated medically underserved areas. Va. Code §32.1-102.4(G).

Virginia may require a nonprofit hospital to provide community benefits as a condition of certificate of public need approval; agreed conditions of approval may include quantifiable amounts of community benefit expenditure.

The Commissioner of the State Board of Health is authorized to condition approval of applications for certificates of public need on an applicant’s agreement to provide an acceptable level of reduced-rate care to indigents, provide care to persons with special needs, or facilitate primary care services in designated medically underserved areas within its service area. The terms of such agreements (which may specify quantifiable amounts of care that the applicant must provide) must be specified in writing before the Commissioner makes a decision to approve the application. The Commissioner is authorized to impose a civil penalty of $100 per day for failure to honor the terms of the agreement. Va. Code §32.1-102.2(C); 12 Va. Admin. Code §§5-220-270(A) and 5-220-420(A).

Virginia requires community benefit reporting by nonprofit hospitals that agree to provide community benefits as a condition of certificate of public need approval.

Nonprofit hospitals whose certificates of public need are conditioned on an agreement to provide reduced rates to indigents must file annual reports detailing their compliance with that condition. Guidance Document, Virginia Department of Health (2004).

Virginia does not require nonprofit hospitals to conduct community health needs assessments.

Virginia does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

Virginia may require hospitals to adopt or implement financial assistance policies as a condition of certificate of public need approval.

Although Virginia law does not generally require hospitals to adopt or implement financial assistance policies, a hospital that has agreed, as a condition of certificate of public need approval, to provide reduced services to indigents at reduced rates must comply with the terms of the agreement, subject to a civil penalty of $100 per violation per day of noncompliance. 12 Va. Admin. Code §§5-220-270(A), 5-220-420(A).

Virginia requires all hospitals to disseminate their financial assistance policies.

Although Virginia does not generally require hospitals to adopt and implement financial assistance policies, all hospitals are required to provide written information about their free and discounted care policies. This information must be posted conspicuously in public areas of the hospital, including admissions/registration areas, emergency departments, and waiting rooms associated with these areas. In addition, information regarding eligibility and how to apply for free and discounted care must be provided to patients at admission, discharge, or when services are provided; must be included with billing statements to uninsured patients; and must be posted on the hospital’s website. Va. Code §32.1-137.01.

Virginia does not limit hospital charges, billing, or collection practices.

Virginia exempts from state income tax nonprofit corporations that are exempt from federal income tax.

Virginia exempts from state income tax “benevolent or other corporations not organized for pecuniary profit” that are exempt from federal income tax. Va. Code §58.1-401(5).

Virginia law exempts nonprofit hospitals from state property tax.

Virginia law exempts from state property tax property belonging to and “actually and exclusively occupied and used” by nonprofit hospitals. Va. Code §58.1-3606(A)(5).

Virginia law exempts nonprofit hospitals from state sales and use taxes.

Virginia law exempts from state sales and use taxes purchases of tangible personal property for use or consumption by a nonprofit entity that is federally tax-exempt under Internal Revenue Code §501(c)(3) and satisfies several additional conditions. Va. Code §58.1-609.11(C).

Washington requires both nonprofit and for-profit hospitals to provide free and discounted care to indigent patients. Wash. Rev. Code §70.170.060(5).

Washington law does not specify a minimum level of community benefits that nonprofit hospitals must provide.

Washington requires nonprofit and for-profit hospitals to report charity care provided.

Washington law requires hospitals to compile and report to the Washington Department of Health the amount of free and discounted care provided. Wash. Admin. Code §246-453-080.

Washington requires nonprofit hospitals that have been federally recognized under §501(c)(3) of the Internal Revenue Code to make their federally required community health needs assessment widely available to the public within 15 days of its submission to the IRS. Wash. Rev. Code §70.41.470(1).

Washington requires nonprofit hospitals to make community benefit plans and implementation strategies publically available.

Washington requires each federally recognized 501(c)(3) tax-exempt hospital to make widely available to the public, within one year of completing its community health needs assessment, its federally required implementation strategy. Either as part of the implementation strategy or separately, the hospital must explain why any recommendations for community benefit proposals identified in the hospital’s community health needs assessment through stakeholder consultation were not accepted. If data are available, the implementation strategy must be evidence-based; innovative programs and practices should be supported by evaluation measures. Wash. Rev. Code §70.41.470 (2012).

Washington requires nonprofit and for-profit hospitals to adopt and implement financial assistance policies. Wash. Rev. Code §70.170.060(5).

Washington requires hospitals to provide free and discounted care to patients whose responsible parties are identified as indigent, based on specified criteria: responsible parties with family income not exceeding 100 percent of the federal poverty level are indigent and qualify for “charity sponsorship” for the full amount of hospital charges not otherwise covered by public or private sources. Wash. Admin. Code §246-453-040(1). Responsible parties with family income of 101 to 200 percent of the federal poverty level are indigent and qualify for discounted charges in accordance with the hospital’s sliding fee schedule and policies regarding individual financial circumstances. Wash. Admin. Code §246-453-040(2). Hospitals also have discretion to identify responsible parties with higher income as indigent and eligible for discounted charges based on individual financial circumstances. Wash. Admin. Code §246-453-040(3). Hospitals must implement a sliding fee schedule for patients identified as indigent for discounted charges following mandated guidelines. Wash. Admin. Code §246-453-050(1).

Washington requires hospitals to make publicly available notice that hospital charges incurred by indigent responsible parties may be waived or reduced. Wash. Admin. Code 246-453-020(2).

Washington limits nonprofit hospital billing and collection practices.

A nonprofit or for-profit hospital may not begin collection activities until it has made an initial determination of whether the patient has public or private insurance and whether the responsible party is indigent and eligible for free or discounted care. Wash. Admin. Code 246-453-020(1); Wash. Rev. Code §70.170.060(6). If a hospital’s initial determination finds that the patient may be an indigent person, collection efforts must cease until a final determination is made. Wash. Admin. Code 246-453-020(1)(c).

Washington does not have a state income tax.

Washington law exempts nonprofit hospitals from state property tax.

Washington law exempts from taxation the real and personal property used by nonprofit hospitals. Wash. Rev. Code §84.36.040(1)(e).

Washington law exempts nonprofit hospitals from state property tax.

In general, Washington nonprofit organizations must pay sales tax on goods and services they purchase. Wash. Rev. Code §82.08.020(1); Washington State Department of Revenue. However, Washington law exempts sales to hospitals that do not charge patients for health care. Wash. Rev. Code §82.08.02795.

West Virginia nonprofit hospitals must demonstrate that their property is used for charitable purposes in order to qualify for property tax exemption.

West Virginia exempts from taxation “property used for charitable purposes and not held or leased out for profit” and “property belonging to … any hospital not held or leased out for profit.” W. Va. Code §11-3-9(a)(12) and (a)(17). Regulations establish that the primary factor in determining the charitable purpose of a hospital is the provision of charity care. W. Va. Code R. §110-3-24. Additional factors include “[t]he provision of activities which promote the health of the community served by the hospital and/or decrease the burdens of state, county and municipal governments …” W. Va. Code R. §§ 110-3-24.2. Charity care is uncompensated care provided to “indigent and medically indigent people” as part of a written mission or charity care policy. West Virginia Health Care Authority, 2013 Annual Report.

West Virginia law does not specify a minimum level of community benefits that nonprofit hospitals must provide.

As a condition of property tax exemption, nonprofit hospital property must be used for a charitable purpose. A hospital may demonstrate charitable use of its property by providing charity care “in a volume and frequency determined by the hospital board of trustees, as articulated in the charity care plan …” W. Va. Code R. §§ 110-3-24.2.1.

West Virginia nonprofit hospitals must report charity care discharge data to the state Health Care Authority.

West Virginia requires hospitals to report data extracted from billing systems with respect to all hospital inpatient stays, regardless of the expected source of payment, expressly including “charity discharges.” West Virginia HealthCare Authority, Data Collection Policies and Procedures, p.1.

West Virginia does not require nonprofit hospitals to conduct community health needs assessments.

West Virginia does not require nonprofit hospitals to develop community benefit plans or implementation strategies.

West Virginia nonprofit hospitals that rely on the provision of charity care to establish their property’s “charitable use” and qualification for property tax exemption must develop a charity care plan.

A hospital’s charity care plan must be reviewed by its Boards of Trustees at least every two years. W. Va. Code R. §§110-3-24.9.3 - 110-3-24.9 .8.5.

West Virginia nonprofit hospitals that rely on the provision of charity care to establish their property’s “charitable use” and qualification for property tax exemption must disseminate their financial assistance policies.

West Virginia requires that such hospitals post in the emergency and admitting areas a notice containing a statement of the existence of their obligation to provide free and below-cost care and of the criteria and mechanism for receiving such care. Written notices must also be provided to each person admitted or treated who does not demonstrate payment coverage under governmental programs or private insurance. W. Va. Code R. §110-3-24.9.4.5.

West Virginia does not limit nonprofit hospital charges, billing, or collection practices.

West Virginia law exempts nonprofit hospitals from state income tax.

West Virginia law exempts from state income tax corporations that are exempt from federal income tax. W. Va. Code §11-24-5(a).

West Virginia law exempts from state property tax real and personal property that is used for a “charitable purpose.”

West Virginia exempts from taxation “property used for charitable purposes and not held or leased out for profit” and “property belonging to … any hospital not held or leased out for profit.” W. Va. Code §11-3-9(a)(12) and (a)(17). Regulations establish that the requisite charitable uses include charity care and “[t]he provision of activities which promote the health of the community served by the hospital and/or decrease the burdens of state, county and municipal governments ….” W. Va. Code R. §§ 110-3-24.2. Charity care is uncompensated care provided to “indigent and medically indigent people” as part of a written mission or charity care policy. West Virginia Health Care Authority, 2013 Annual Report.

West Virginia law does not generally exempt nonprofit organizations from sales tax. W. Va. Code §11-15-9(a)(6).

Wisconsin law does not expressly require nonprofit hospitals to provide community benefits.

Wisconsin law does not expressly require nonprofit hospitals to provide community benefits.

Wisconsin requires nonprofit and for-profit hospitals to report charity care.

Each Wisconsin hospital must annually submit a fiscal survey reporting the number of patients to whom it provided “uncompensated health care services” during the prior year and the total accrued charges for those services. The report must include a breakdown of charity care and bad debt expenses. Wis. Admin. Code [DHS] §120.12(2)(b)(2).

Wisconsin does not require nonprofit hospitals to conduct community health needs assessments.

Wisconsin does not require hospitals to develop community benefit plans or implementation strategies.

However, each Wisconsin hospital must submit an annual uncompensated health care service plan that projects the number of patients to whom the hospital expects to provide uncompensated health care services in the upcoming year and the expected charges for those services. Wis. Stat. §153.20(2).

Wisconsin requires nonprofit and for-profit hospitals to submit their financial assistance policies to the state Department of Health and Family Services.

Wisconsin requires that each hospital’s annual uncompensated health care service plan indicate how the hospital notifies the public about the availability of charity care and must describe the procedure for obtaining such care. Wis. Admin. Code [DHS] §120.12(1)(a)(3). In 2007, The Wisconsin Hospital Association issued the voluntary, nonbinding, Billing and Collection Guidelines for Wisconsin Hospitals, which also addresses financial assistance.

Wisconsin law implicitly requires nonprofit and for-profit hospitals to inform the public about their financial assistance policies.

Wisconsin hospitals must annually submit an uncompensated health care service plan that includes an indication of how it informs the public “about charity care available at that hospital and a description of the procedure for obtaining the care.” Wis. Admin. Code [DHS] §120.12(1)(a)(3).

Wisconsin law does not limit nonprofit hospital charges, billing, or collection practices.

In 2007, The Wisconsin Hospital Association issued the voluntary, nonbinding, Billing and Collection Guidelines for Wisconsin Hospitals.

Wisconsin law exempts nonprofit corporations from state income tax.

Wisconsin law exempts from taxation “income … of all religious, scientific, educational, benevolent, or other corporations or associations of individuals not organized or conducted for pecuniary profit.” Wis. Stat. §71.26(1)(a).

Wisconsin law exempts nonprofit hospitals from property tax.

Wisconsin exempts from property tax real property owned and used, and personal property used exclusively for, the charitable purposes of any [nonprofit] hospital of 10 beds or more. Wis. Stat. §70.11(4m).

Wisconsin exempts nonprofit charitable organizations from state sales and use tax.

Wisconsin law exempts from state sales and use tax corporations organized and operated exclusively for religious, charitable, scientific, or educational purposes. Wis. Stat. §77.54(9a)(f).