How to find free or discounted health care at Minnesota hospitals

Concerns about medical debt persist in Minnesota, even as the state boasts a high share of residents with health insurance that should help prevent unpaid bills.

Part of the trouble is coverage rules can be confusing and health plans often include high out-of-pocket spending requirements when patients seek treatment. Plus, the cost of health care itself keeps going up, which makes the prospect of uninsured patients trying to pay cash chilling.

Enter “charity care” programs, also known as financial assistance at hospitals and health systems.

Tax-exempt medical centers offer free and discounted care to patients through these programs as part of their community mission, said Joe Schindler of the Minnesota Hospital Association.

The program at Hennepin Healthcare in Minneapolis started helping about two years ago when Jireh Mabamba’s father sought treatment for a suspected cancer.

“We don’t have to worry about the finances ... which is a huge relief,” said Mabamba, 30, of Mounds View.

For years, there have been questions about whether nonprofit health systems provide enough charity care to justify their tax exemptions. Drug companies rekindled this skepticism last year following a report tallying more than $600 million in extra revenue across hospitals in Minnesota that benefit from an opaque program for discount medications.

Lawmakers here and across the country have been pushing hospitals to better publicize financial assistance. Meanwhile, medical centers are launching “presumptive eligibility” programs to connect qualifying patients with charity care even when they don’t apply for help.

Here’s what you need to know about charity care and financial assistance at health systems in Minnesota.

The Lown Institute, a Boston-based group that evaluates hospitals on their community investments, said patients can learn about charity care programs simply by calling up an online search engine, entering the name of a medical center and typing the phrase “financial assistance policy.”

That’s usually faster than clicking through the hospital’s website, said Judith Garber, a senior policy analyst with Lown.

“It will indicate the thresholds for accessing free and discounted care, usually based on family size and income,” Garber said via email.

Lown recommended patients check the financial assistance policies at all nearby hospitals, since there can be significant differences on who qualifies for varying levels of aid. Another wrinkle, Garber said, is some health systems could exclude some services and/or certain physicians from the policy.

The Minnesota Association of Community Health Centers said 17 federally qualified centers provide discounted non-hospital services based on income and family size. The Minnesota Hospital Association said nonprofit health systems generally extend hospital charity care policies to outpatient and clinic care, as well.

Health care entities typically offer financial assistance based on a household’s income relative to the federal government’s definition of poverty. So figuring out eligibility requires a bit of math.

Last year, the U.S. Department of Health and Human Services set the poverty guideline for a single-person household at $15,060. For a family of four, the government defined poverty in most states at $31,200.

Charity care programs usually establish eligibility “cutoffs” as a percentage of the federal poverty guideline, or FPG.

At Regions Hospital in St. Paul, for example, free and discounted care is available to patients up to twice the federal poverty guideline (200% FPG). That works out to $31,020 for a single-person household or $62,400 for a family of four.

The cut-off for free care at Hennepin Healthcare is three times poverty (300% FPG). Mayo Clinic Rochester offers free care up to 200% FPG and discounted care between 201% and 400% FPG.

While the eligibility cutoffs vary, Regions, Hennepin Healthcare and the Mayo Clinic in Rochester were similar in 2019 for each granting more than $15 million in charity care — making them the three largest providers that year, according to the most recent report from the Minnesota Department of Health.

In Minnesota, patients in poverty qualify for health care coverage through the state’s Medical Assistance program (Medicaid), while those at slightly higher income levels can enroll in a related health insurance program called MinnesotaCare.

So, hospital financial counselors often will start by seeing if uninsured patients can qualify for these programs, which typically have very low or no requirements for out-of-pocket spending.

People using employer-based and individual market policies might still qualify for financial assistance depending on their income levels and the out-of-pocket spending requirements with their health plan. Check with hospitals for details.

“You can have our charity care program secondary to your commercial [insurance] plan, as long as you still met the basic guidelines,” said Pam Quast, director for hospital registration and financial securing at Hennepin Healthcare. “So, it can help you with your out-of-pocket expenses after your primary insurance pays.”

Gillette Children’s Specialty Healthcare in St. Paul has been making changes in the past several years to make patients more aware of its financial assistance program, said Ashley Karlen, the hospital’s vice president for revenue cycle.

Gillette starts talking with patients about whether they need help when they schedule their appointments, Karlen said. Outreach workers send applications for the Gillette Assistance Program (GAP), she said, or patients can apply online.

In 2022, Gillette added a “presumptive eligibility” component to the program. This is a “back-end” process, Karlen said, so the hospital doesn’t send unpaid bills to collections when patients qualify for charity care.

“If there’s any patient at Gillette that has a self-pay balance, we automatically screen them to see if they can qualify for the GAP program,” she said.

Third-party vendors help hospitals assess patient income by looking at things like housing status, demographic information and whether families use means-tested government programs, like supplemental nutrition assistance.

If the screening results show a patient qualifies, Gillette can “auto-apply a financial assistance discount for them, without them actually having to go through the application process,” Karlen said.

The change is a big reason why the number of patients qualifying for financial assistance at Gillette increased from about 400 in 2019 to more than 2,000 last year. Regulatory filings show Gillette’s annual financial assistance tally during the time period grew from about $377,000 to more than $1.4 million.

“The number of families that qualify now for financial assistance, with smaller balances, increased dramatically,” said Patrick Nolan, the chief financial officer at Gillette Children’s.

Mayo Clinic started implementing presumptive eligibility in 2023, a move that included writing off about $90 million in patient debts.

Hennepin Healthcare added presumptive eligibility to its charity care program last year. From September through December, the health system wrote off about $19.5 million in patient debts as presumptive charity.

“It’s not advantageous to the patient, and it’s not advantageous to the organization even to try and collect on those balances,” said Angela Woodard, manager of the financial securing department at Hennepin Healthcare. “It’s just better for everybody involved.”

Schindler of the Minnesota Hospital Association said charity care totals across the state likely will grow as more hospitals implement presumptive eligibility programs. He’s seen data suggesting 60% to 80% of “bad debt” write-offs across the health care industry are for patients who might have qualified for financial assistance but didn’t apply.

“There’s some paperwork in applying for financial assistance, and not everybody is willing or able to figure out and complete all that paperwork — or maybe [they’re] resistant to sending in some of their tax forms or some validations of their income," he said. “So, I think hospitals are looking for an easier way to identify folks.”

Minnesota lawmakers passed a law that took effect in November 2023, Schindler said, requiring hospitals to do more up-front to screen patients for charity care programs. For uninsured patients, hospitals must try to complete the screening process in-person or by telephone within 30 days after the patient receives hospital or emergency room care.

Other states are taking action as well, said Eva Stahl, vice president for public policy at Undue Medical, a New York-based nonprofit that helps arrange programs that forgive medical debts.

Stahl cited an Illinois law that requires hospitals to fast-track certain patients, such as unhoused people and those who qualify for supplemental nutrition assistance, into charity care without an application. Patients in Oregon with bills of more than $500 must undergo screening for financial assistance, without regard to insurance coverage.

In North Carolina, “hospitals will honor other income-verified programs as a pathway to financial assistance,” she said via email.