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).

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

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

Connecticut requires hospitals that voluntarily develop community benefit programs to satisfy specific reporting requirements.

Connecticut law requires both nonprofit and for-profit hospitals to file annually with the state Office of the Healthcare Advocate (Advocate) their policies on charity care and reduced cost services to the indigent and their debt collection practices. A hospital shall file its audited financial statements no later than February 28th of each year; a health system may file one such statement that includes the audited financial statements for each hospital within the health system (2015). The reports must include, among other things, the total number of applicants and the number of approved applicants for uncompensated care, and the total and average charges and costs of the uncompensated care provided. Conn. Gen. Stat. §19a-649 (a), (b).

Connecticut also requires each hospital to report biennially to the Advocate whether or not it has a community benefit program in place. A hospital that has elected to develop a community benefit program must include in its annual report 1) a community benefit policy statement; 2) a mechanism for securing community input and its incorporation into the program; 3) a description of the community health needs that the hospital considered in developing and implementing its community benefit program; 4) a narrative describing the community benefits, community services, and preventive health education provided or proposed; (5) evaluation measures and proposed program revisions; 6) to the extent feasible, a community benefit budget and a good-faith measurement of expenditures and administrative costs; and 7) a summary reporting the extent to which the hospital has developed and met community benefit guidelines “intended to promote preventive care and to improve the health status for working families and populations at risk” focusing on principles the statute specifies. A hospital’s community benefit report must be provided to members of the public upon request. Conn. Gen. Stat. §19a-127k(c)-(d).

Each nonprofit hospital that is exempt from federal taxation under Internal Revenue Code §501(c)(3) shall also submit a complete copy of the hospital’s most recently completed Form 990, including all parts and schedules. Conn. Gen. Stat. §19a-649(c).

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

However, a hospital that voluntarily develops a community benefit program must report how it secured community input and incorporated it into the program. Conn. Gen. Stat. §19a-127k(d). Nonprofit hospitals that are exempt from federal corporate income tax pursuant to Internal Revenue Code §501(c)(3) must submit data compiled to prepare the hospital’s community health needs assessment. Conn. Gen. Stat. §19a-649(c).

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

However, a hospital that voluntarily develops a community benefit program must describe in its annual report to the Advocate specified community benefit planning and implementation activities, including: a description of the community health needs that the hospital considered in developing its community benefit program; a narrative describing the community benefits, community services, and preventive health education proposed; a program budget; and report of expenditures and administrative costs. Conn. Gen. Stat. §19a-127k(d).

Connecticut does not require nonprofit hospitals to develop or implement financial assistance policies.

Hospitals are required to annually file their policies on charity care and reduced cost services to the indigent with the Office of Health Care Access division of the Department of Public Health. Conn. Gen. Stat. §19a-649(a).

Connecticut law does not generally require nonprofit hospitals to adopt, implement, or disseminate financial assistance policies.

A hospital that administers a “hospital bed fund” (a “gift … made by any donor for the purpose of establishing a fund to provide medical care to patients”) must post information regarding the availability of those funds in conspicuous places. In addition, a one-page summary describing the fund and its application process, as well as other hospital charity and reduced-cost care policies for the indigent, must be made available in the admissions office, emergency room, social services department, and patient billing office. Collection agencies must include a copy of the summary when sending all bills and collection notices. A copy of the summary must also be provided to any patient who appears to have limited ability to pay during admission or during review of his or her financial resources. Conn. Gen. Stat. §19a-509b.

Connecticut law limits the billing and collection practices of both nonprofit and for-profit hospitals.

Connecticut law requires hospitals to include in their bills to patients an explanation of any items identified by a code or initials, and must provide an itemized bill to a self-pay patient upon request. Conn. Gen. Stat. §19a-509(b). Connecticut prohibits hospitals from initiating an action to collect fees for hospital care unless the hospital has determined whether the individual 1) has an income at or below 250 percent of the federal poverty level, 2) has applied for and been denied eligibility for the state-administered general assistance program (Medicaid), and 3) is not eligible for coverage under Medicare or any other health insurance program, including any hospital bed fund(s). Conn. Gen. Stat. §§19a-673; 673b. No hospital that has provided health care services to an uninsured patient may collect from that patient more than the cost of providing the services. Conn. Gen. Stat. §§19a-673(b).

Hospitals may initiate an action to collect coinsurance and deductibles where these amounts may be eligible for reimbursement through a judicial award or where they have been paid or reimbursed, or are likely to be paid or reimbursed, directly to the patient. Conn. Gen. Stat. §19a-673b(b).

If, at any point during the debt collection process, a hospital or collection agency becomes aware that a patient is eligible for hospital bed funds, free or reduced price hospital services, or any other program, then collection efforts must be stopped until an eligibility determination is made. Conn. Gen. Stat. §19a-673d.

Connecticut law exempts from its corporation business tax nonprofit hospitals that are exempt from federal corporate income tax. Conn. Gen. Stat. §12-214(a)(2)(B); Conn. Dept. Revenue, 2011 Form CT-1120 Instructions, p. 7.

Connecticut law exempts from taxation real and personal property owned by a corporation organized and used exclusively for charitable purposes, provided no officer, member, or employee receives any pecuniary profit from its operation, except as reasonable compensation for services or as a proper beneficiary of its strictly charitable purposes. Conn. Gen. Stat. §12-81(7).

Connecticut also exempts all property of any Connecticut hospital corporation, provided no officer, member, or employee receives any pecuniary profit from the operation thereof, except as reasonable compensation for services. Conn. Gen. Stat. §12-81(16).

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

Connecticut law exempts from state sales and use taxes sales of tangible personal property and services to or by nonprofit charitable hospitals. Conn. Gen. Stat. §12-412(5)(A). Also exempt are sales of tangible personal property by any organization that is exempt from federal income tax under Internal Revenue Code §501(a) when those sales are made on hospital premises. Conn. Gen. Stat. §12-412(5)(B).

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).

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

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

Kansas does not require nonprofit hospitals to report community benefits.

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

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

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

Kansas does not require nonprofit hospitals to adopt, implement, or disseminate financial assistance policies.

Kansas limits nonprofit hospital collection practices.

If a person’s or a family member’s illness prevented the person from working for over two weeks, a court may not order the garnishment of that person’s wages to repay a medical debt until two months after his or her recovery from the illness. Kan. Stat. Ann. §60-2310(c). (2012). Other restrictions limit the percentage of an individual’s wages that may be subjected to garnishment, and generally preclude a creditor from issuing more than one garnishment against the earnings of the same judgment debtor during any 30-day period. Kan. Stat. Ann. §60-2310(b) (2012).

Kansas exempts nonprofit hospitals from state income tax.

Kansas law exempts from state income tax the income of organizations that are exempt from federal income tax. Kan. Stat. Ann. §79-32,113(a).

Kansas law exempts from taxation property owned by nonprofit hospitals under specified circumstances.

Kansas exempts from state property tax all real property and all tangible personal property “actually and regularly used exclusively for hospital purposes by a hospital.” Kan. Stat. Ann. §79-201(b).

Kansas law exempts nonprofit hospitals from state sales tax.

The sales of tangible personal property and services purchased by a public or private nonprofit hospital for its exclusive use are exempt from Kansas sales tax. Kan. Stat. Ann. §79-3606(b).

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

The ten state-supported charity hospitals of the Louisiana State University (LSU) Health Care Services Division are responsible for providing nonemergency care to medically indigent and uninsured patients. La. Rev. Stat. Ann.§ §46:6; 17:1519.4(a), (B)(1).

Louisiana does not expressly require private nonprofit hospitals to provide community benefits.

Louisiana does not require nonprofit hospitals to report community benefits.

Louisiana does not require private nonprofit hospitals to conduct community needs assessments.

The Community Advisory Committees of the ten state-supported charity hospitals of the LSU Health Care Services Division are required to assess their communities’ unmet health needs through their Community Advisory Committees, which make recommendations on how the identified needs may be met. La. Rev. Stat. Ann. §17:1519.7(E).

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

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

The ten state-supported charity hospitals of the LSU Health Care Services Division are solely responsible for providing nonemergency care to medically indigent and uninsured patients. La. Rev. Stat. Ann.§ §46:6; 17:1519.4(a), (B)(1).

Louisiana does not require nonprofit hospitals to adopt, implement, or disseminate financial assistance policies.

Louisiana limits specified collection practices of both nonprofit and for-profit hospitals.

Louisiana prohibits the seizure and sale of a person’s homestead to satisfy debts arising from “catastrophic or terminal illness or injury.” La. Rev. Stat.§ Ann. 20:1(A)(2).

Louisiana law exempts nonprofit hospitals from state income tax.

Louisiana exempts from state income tax the income of any organization that is exempt from federal income tax under Internal Revenue Code §501. La. Rev. Stat. Ann. §47:287.501(A).

The Louisiana Constitution exempts from taxation the property of nonprofit corporations.

The Louisiana Constitution exempts from state taxation property owned by a nonprofit corporation organized and operated exclusively for charitable purposes. La. Const. art 7, §21(B)(1)(a)(i). Medical equipment leased for a term exceeding five years to a nonprofit corporation that operates a small rural hospital may also be exempt from property tax if additional statutory requirements are met. La. Const. art 7, §21(B)(1)(a)(ii).

Louisiana does not exempt nonprofit hospitals (except “free hospitals”) from state sales tax.

Louisiana exempts free hospitals from sales tax. (A “free hospital” is one that “does not charge any patients for health care provided by the hospital.”) The exclusion applies to sales of supplies, equipment, and services that are “reasonably necessary for the operation of free hospitals.” La. Rev. Stat. Ann. 47:301(7)(3), (10)(p), (18)(c), (21).

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).

Mississippi requires nonprofit hospitals to provide community benefits as a condition of property tax exemption and a component of Certificate of Need (CON) applications.

Under current law, Mississippi requires nonprofit hospitals to maintain “one or more charity wards that are for charity patients” as a condition of property tax exemption. Miss. Code Ann. §27-31-1(f).

In addition, the Mississippi Department of Health will disapprove a CON unless the applicant provides (or confirms that it will provide) a reasonable amount of indigent care and has admission policies that do not deny indigent patients access to care. CON Review Manual, Ch. 1, §100.01. A “reasonable amount” of indigent care is comparable to the amount of such care offered by other providers of the requested service within the same, or proximate, geographic area. CON Review Manual, Ch. 1, §100.01.

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

However, as a condition of property tax exemption, a nonprofit hospital must maintain a “charity ward.” In addition, a CON applicant must provide or confirm that it will provide a “reasonable amount” of indigent care. Miss. Code Ann. §27-31-1(f); CON Review Manual, Ch. 1, §100.01.

Mississippi requires community benefit reporting as a condition of CON approval.

A CON application must contain a commitment to record and maintain information about charity care and care to the medically indigent and Medicaid populations, such as patient utilization, costs and charges, and geodemographic data. CON Review Manual, Ch. 8, §100.01, pp. 65-66.

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

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

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

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

Mississippi law limits the amounts nonprofit and for-profit hospitals may charge patients, and limits hospital billing and collection practices.

Mississippi generally prohibits both nonprofit and for-profit hospitals from “charging, accepting, or retaining any additional payment” for hospital services from an indigent patient unless it appears that the patient’s qualification or admission as “indigent” was erroneous. Miss. Code Ann. §41-7-35.

Mississippi law exempts charitable institutions from state income tax. Miss. Code Ann. §27-7-29(a)(3).

Mississippi law exempts from taxation the property of nonprofit hospitals that maintain “one or more charity wards.” Miss. Code Ann. §27-31-1(f).

Mississippi law exempts nonprofit hospitals from state sales tax.

Mississippi law exempts from state sales tax the sales of tangible personal property to nonprofit hospitals. Miss. Code Ann. §27-65-111(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 Jersey does not expressly require nonprofit hospitals to provide community benefits.

New Jersey does not expressly require nonprofit hospitals to provide community benefits.

New Jersey requires hospitals to report on people who receive charity care.

All acute care hospitals are required to submit demographic information regarding people who qualify for charity care or receive uncompensated care. N.J. Stat. §26:2H-18.59c(a)(1996); N.J. Admin. Code §8:31B-4.40 (2006).

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

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

New Jersey does not require nonprofit hospitals to adopt or implement their own financial assistance policies.

New Jersey does not require nonprofit hospitals to adopt, implement, or disseminate their own financial assistance policies.

Although New Jersey does not require hospitals to adopt or implement their own financial assistance policies, the state requires nonprofit and for-profit hospitals to post signs advising the public of the New Jersey Hospital Care Payment Assistance Program, a state-funded program that provides free and discounted care to eligible New Jersey residents. Read the New Jersey Hospital Care Payment Assistance Fact Sheet (2011). New Jersey further requires that all hospitals provide patients with written notice of the availability of charity care, Medicaid, or NJ Family Care at either the time of service or no later than at the time the hospital issues the first bill to the patient. N.J. Admin. Code §10:52-11.5(a).

New Jersey limits nonprofit hospital charges and billing and collection practices.

New Jersey limits the amounts that nonprofit and for-profit hospitals may charge uninsured state residents with family gross income of less than 500 percent of the federal poverty level. Patients meeting these criteria may not be charged more than 15 percent above the applicable federal Medicare payment rate. N.J. Stat. §26:2H-12.52.

Hospitals may not bill for services or initiate collection procedures against persons determined to be eligible for charity care. Persons determined to be eligible for reduced charge charity care may not be billed or subjected to collections procedures for the portion of the bill that is reduced charge charity care. N.J. Admin. Code §10:52-11.14.

New Jersey law exempts nonprofit corporations from state income tax. N.J. Stat. §54:10A-3(e).

New Jersey law exempts the property of nonprofit organizations from taxation.

The New Jersey Constitution exempts from state property tax real and personal property owned by nonprofit corporations and used exclusively for charitable purposes. N.J. Const. art. VIII, §1, ¶2.

In addition, New Jersey law specifically exempts from property tax “all buildings actually used in the work of … corporations organized exclusively for hospital purposes.” N.J. Stat. §54: 4-3.6.

New Jersey law exempts from state sales and use tax sales to corporations organized exclusively for charitable purposes. N.J. Stat. § 54:32B-9(b).

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

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

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

North Dakota does not require nonprofit hospitals to report community benefits.

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

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

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

North Dakota does not require nonprofit hospitals to adopt, implement, or disseminate financial assistance policies.

North Dakota law limits late payment charges by both nonprofit and for-profit hospitals.

North Dakota law prohibits medical service providers from charging, receiving, or collecting a late payment charge on medical expenses incurred until 90 days after the services are rendered. N.D. Cent. Code §13-01-14.1(2). Hospitals may not assess a finance charge or rate of interest that exceeds 1 percent per month, or 25 dollars per month. N.D. Cent. Code §13-01-14.1(5).

North Dakota law exempts nonprofit hospitals from state income tax.

North Dakota exempts from state income tax organizations that are exempt from federal income tax. N.D. Cent. Code §57-38-09.

North Dakota law exempts from taxation the real property of nonprofit hospitals used for charitable purposes.

North Dakota law exempts from taxation the land and buildings belonging to “institutions of public charity” and used “wholly or in part for public charity.” N.D. Cent. Code §57-02-08(8).

North Dakota generally exempts sales to hospitals from state sales and use taxes.

The gross receipts of sales made to hospitals for the use or benefit of patients are exempt from North Dakota sales and use tax. N.D. Cent. Code §57-39.2-04(24). The state also exempts from use tax medical equipment purchased as tangible personal property by a hospital when that property is subsequently installed by a contractor into the hospital facility. N.D. Cent. Code 57-40.2-03.3(3).

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).

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

Oklahoma does not expressly require nonprofit hospitals to provide community benefits.

Oklahoma does not require nonprofit hospitals to report community benefits.

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

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

Oklahoma law requires all hospitals to establish a discounted care program that provides medically necessary services at a reduced rate to qualified self-pay patients.

Discounted medically necessary care must be made available to individuals with household incomes below 300 percent of the federal poverty level who are ineligible for and not enrolled in a public or private insurance plan that provides hospital coverage. The minimum required hospital discount must be such that the hospital charge after discount is not more than the greater of the Medicare rate for the service or the hospital’s cost of providing the service. Okla. Stat. tit. 63 §1-723.2.

Oklahoma does not require hospitals to disseminate financial assistance policies.

Oklahoma limits nonprofit hospital charges.

Hospitals may charge patients who qualify for financial assistance no more than the greater of the amount Medicare would pay for the same services or the hospital’s cost of providing the services. A hospital’s disregard of this limitation may be raised as a defense to a collection action initiated by the hospital against a patient for medical debt. Okla. Stat. tit. 63 §1-723.2.

Oklahoma law exempts nonprofit hospitals from state income tax.

Oklahoma law exempts from state income tax organizations that are exempt from federal income tax. Okla. Stat. tit. 68 §2359.

Oklahoma law exempts nonprofit hospitals from state property tax.

Oklahoma law exempts from taxation property of nonprofit and charitable hospitals that are used “directly, solely, and exclusively” within Oklahoma for charitable purposes, with no part of its income inuring to private benefit. In addition, the hospital’s facilities must be open to the public without discrimination as to race, color, or creed and regardless of ability to pay. Okla. Stat. tit. 68 §2887(10).

Oklahoma does not exempt nonprofit hospitals from sales tax.

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.

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

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

Vermont requires all community hospitals to report certain community benefit expenses in annual “Hospital Community Reports.”

Vermont community hospitals are required to submit Hospital Community Reports to the Commissioner of the Department of Financial regulation. The reports must include as a mandatory reporting category “a summary of the hospital’s budget, including revenue by source and quantification of cost shifting to private payers.” “Cost shifting to private payers” encompasses a hospital’s costs associated with Medicare and Medicaid reimbursement shortfalls and uncompensated care costs. Vt. Stat. Ann. tit. 18 §9405b(a)(5).

Vermont requires hospitals to conduct community health needs assessments.

Vermont law requires each hospital to have a protocol for “meaningful public participation” in its process for “identifying and addressing health care needs that the hospital provides or could provide in its service area.” These needs must be summarized in the hospital’s community report and integrated with the hospital’s long-term planning. Vt. Stat. Ann. tit. 18 §9405a; 9405b(a)(10).

Vermont requires hospitals to develop strategic initiatives to address identified community health care needs.

Vermont requires hospitals to include in their hospital community reports a description of strategic initiatives “discussed with or derived from the identification of health care needs” along with short- and long-term capital expenditure plans and facility depreciation schedules. A summary of identified community needs must be “integrated with the hospital’s long-term planning.” Vt. Stat. Ann. tit. 18 §9405a; 9405b(a)(10).

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

Although not legally required, the Department of Banking, Insurance, Securities, and Health Care Administration (BISHCA) found in 2007 that every Vermont hospital had its own written uncompensated care policies for providing free care to patients with income not exceeding 100 percent of the federal poverty level. BISHCA, Report on Vermont Community Hospitals Uncompensated Care Policies (Jan., 2007), at 5.

Vermont does not require nonprofit hospitals to adopt, implement, or disseminate financial assistance policies.

Vermont law requires hospitals to provide patients with an “itemized, detailed, and understandable” explanation of charges, regardless of the source of payment. Vt. Stat. Ann. tit. 18 §1852 (12).

Vermont exempts nonprofit hospitals from state income tax.

Vermont law expressly adopts federal income tax law for purposes of computing state income tax liability so that a federally tax-exempt corporation is also exempt from Vermont income tax. Vt. Stat. Ann. tit. 32 § 5824.

Vermont exempts nonprofit hospitals from state property tax.

Vermont exempts from state property tax any real and personal property that is “used for … charitable uses.” Vt. Stat. Ann. tit. 32 §3802(4).

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

Vermont law exempts from state sales and use taxes organizations exempt from federal income tax. Vt. Stat. Ann. tit. 32 §9743(3).

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.