Most hospitals offer financial assistance to patients who struggle to afford their bills, often referred to as charity care. But many people are stymied by cumbersome aid applications. Others don’t even know help exists.
Hospitals have the ability to proactively screen patients to see if they’re eligible for aid and, if so, automatically wipe out or reduce their bills — a process known as presumptive eligibility.
A growing number of state policymakers and researchers believe requiring hospitals to use presumptive eligibility would protect low-income Americans from falling into medical debt, especially with federal funding cuts expected to increase the number of people without health insurance.
This story is part of Hidden Help, an investigative series from Tradeoffs and KFF Health News about how hospitals can protect their patients from the life-altering harms of medical debt. Explore the series →
Data shows that Texas has among the highest state rates of people in medical debt, and policymakers in Texas are considering legislation that would require nonprofit hospitals to use presumptive eligibility before sending patients a bill.
In a first-of-its-kind analysis, Tradeoffs examined the presumptive eligibility policies of 166 nonprofit general and children’s hospitals in Texas. The goal was to shed light on how easy or difficult hospitals make it for low-income people to get financial aid without an application.
Scroll to the bottom of the page to explore a searchable table with all 166 hospitals’ policies.
Here’s what we found:
Nearly half of nonprofit hospitals in Texas (44%) say they will bill patients before screening them for free or discounted care.
Some hospitals screen patients after sending a single bill. Others may send multiple bills and hire collection agencies to chase after debts before they check whether a patient is eligible for help.
The most common approach is for hospitals to say they will screen patients before taking “extraordinary collection actions,” which include garnishing their wages, selling the debt to a debt collector, or denying further care until outstanding bills are paid.
Anna Stelter, vice president of policy for the Texas Hospital Association, said hospitals want to investigate other options for payment — like Medicaid or county safety net programs — before they offer financial assistance.
“We do want to make sure that whoever is financially responsible for that care is identified and pays,” Stelter said. “Charity care is the relief of last resort.”
Just one nonprofit in Texas, Memorial Hermann Health System, has a written policy that requires its hospitals to check and proactively reduce or wipe out what patients owe before sending bills.
Research shows that when patients receive financial aid makes a difference.
A 2022 study found that patients who received hospital financial aid within weeks of care were much more likely to return to the doctor and get treatment for conditions like diabetes and depression. Conversely, a landmark study published in 2024 found that wiping out people’s medical debt years later had no effect on their mental and physical health, health care use, or financial situation.
Most hospitals say they do not reimburse patients who qualify for financial aid for money they have already paid.
Hospitals often put patients on payment plans to chip away at bills they can’t afford. But only 10 of 166 nonprofit hospitals in Texas guarantee a full refund to patients found to be eligible for financial aid. Most others say they won’t return money that patients paid before being screened.
Surveys show patients take out loans and rack up credit card debt to cover what they owe. In one recent survey, one-third of Americans without health insurance said they had borrowed money for medical care in the previous year.
“It is very frustrating,” said Aimee Carlock, who was required to pay $5,500 to Texas Health Resources to schedule uterus surgery. She later qualified for free care, and the hospital wiped out her remaining $16,000 bill. But the $5,500 was gone. “That’s a lot of money to me,” said Carlock, a self-employed house cleaner who was recently approved for food stamps.
Texas Health’s policy offers refunds only in the amount a patient has paid in excess of what the hospital typically charges someone with insurance. All hospitals must offer refunds to patients who qualify for financial aid in these situations to avoid federal penalties.
Texas Health didn’t respond to an interview request after Carlock agreed to grant the system permission to speak about her experience.
In some cases, patients must fill out extensive applications to recoup their money. The application for Abilene-based Hendrick Health instructs patients to “completely and precisely” fill in financial and personal details, describing their savings and listing Social Security numbers for family members they live with who might help with the bills. Patients must submit two current pay stubs, a tax return, two months of bank statements, and a justification of why they need help.
“Explain circumstances in which paying this hospital bill would create a hardship,” the application says.
Hendrick Health didn’t respond to questions about its policy.
Many hospitals never tell patients that their debt has been forgiven.
Some of the largest nonprofit hospital systems in Texas don’t notify patients when their bill has automatically been wiped out. That includes Christus Health, Texas Health Resources, and Texas hospitals owned by CommonSpirit Health, one of the nation’s largest Catholic health systems.
Research shows patients who don’t know their debt has been forgiven may skip needed care. A 2026 study found that people with medical debt were three to four times as likely to delay future physical and mental health care as people without medical debt.
“If the patient doesn’t get some sort of notice,” said Erin Fuse Brown, a health policy researcher at Brown University, the possibility that they could be billed “hangs like a sword over their neck.”
Stelter, with the Texas Hospital Association, said many hospitals have limited staff in their billing departments. “Notifying patients whose bill was completely forgiven that they were presumptively eligible is probably lower on the totem pole than helping somebody who’s trying to complete an application,” she said.
If hospitals offer someone less than the maximum discount available, federal law requires the hospital to notify the patient, in case they want to appeal for a full write-off.
Texas Health and Christus Health didn’t respond to interview requests about their policies. A CommonSpirit spokesperson declined an interview.
Some hospitals say their financial assistance policies don’t reflect how they actually operate. These discrepancies can work to patients’ advantage — or detriment.
AdventHealth says some of its Texas patients get screened for financial assistance before getting bills, a consumer-friendly practice. The system’s policy, however, has no requirement for when hospitals must screen patients.
“We want patients to understand and have access to available financial assistance before receiving a bill whenever possible,” said Tim Reiner, senior vice president for revenue cycle for the system, which owns and operates four hospitals in Texas.
Houston Methodist also screens patients for help before sending bills, if they are uninsured, a spokesperson said. There is no requirement for its eight hospitals to do so under the system’s policy.
According to its policy, Covenant Health, a five-hospital system based in Lubbock, must screen patients before sending bills to collection agencies and lists detailed criteria for who is eligible to have bills proactively wiped out.
But in 2019, the system decided not to use presumptive eligibility “due to the regulatory requirements and administrative complexities,” said spokesperson Ainsley Nelson. “Our focus continues to be ensuring compassionate access to care and helping patients navigate the financial assistance options available to them.”
Covenant is owned by Providence, a multistate Catholic health system based in Renton, Washington, which agreed to refund or erase more than $150 million in patient bills after investigations charged that the system failed to inform patients of charity care.
Providence said the system fixed the problem identified by investigators, refunded patients, and now coaches its employees to communicate “with compassion and respect.”
Who qualifies for presumptive eligibility varies significantly from one hospital to another.
Hospitals in Texas get to decide who is eligible to be automatically screened for and enrolled in financial assistance.
Presumptive eligibility policies often apply to people who are homeless, deceased, or already enrolled in state or federal programs to help low-income households with medical care, housing, food, or prescriptions. Some hospitals have additional criteria, including writing off bills for anyone in a religious order who took a vow of poverty.
Some hospitals share little to no public information about who they will proactively screen. Thirteen hospitals owned by Ascension, one of the nation’s largest Catholic health systems, says only that it may screen patients “with a sufficient unpaid balance.”
Ascension didn’t respond to questions about its eligibility criteria.
This variation means that a patient’s ability to access free care depends greatly on where they go.
Some hospitals provide less generous charity care to patients who receive it automatically instead of submitting an application.
At CommonSpirit’s hospitals across southeastern Texas, patients who are auto-enrolled get help with debt from the prior 12 months. Patients who submit an application get the same help with prior bills, plus free or discounted treatment for the next six months.
North Texas Medical Center limits financial assistance for auto-enrolled patients to individual visits. Applicants may be eligible going back 12 months before approval.
North Texas Medical Center didn’t respond to additional questions about its policy.
Policies that are supposed to be easily accessible to patients are often difficult to find.
Hospital financial assistance policies are intended to be transparent to patients and the public. For more than a decade, federal law has required nonprofit hospitals to widely publish their policies.
In practice, finding these policies and deciphering them is often hard.
To find the policies of all nonprofit hospitals in Texas, Tradeoffs started with a list of hospital financial assistance policy websites maintained by the nonprofit Dollar For. To verify websites were up to date and fill in missing policies, Tradeoffs scoured hospital websites, often clicking through multiple links to locate policies.
In cases in which hospitals did not publish full policies online, Tradeoffs requested copies from hospitals and filed a public records request with the state of Texas, which requires hospitals to submit charity policies annually.
“You would have to know what you’re looking for before you went looking for it, or you’re never going to find it,” said Ray Kluender, an associate professor at Harvard University, who has had to hunt for hospital policies as part of his research on medical debt.
Tradeoffs’ reporting for this series was supported, in part, by the California Health Care Foundation, the National Institute for Health Care Management Foundation, and the Solutions Journalism Network.