1. A. Financial Assistance Policy.

   1. (1) Requirements.

      1. (a) Each hospital and each chronic care hospital under the jurisdiction of the Commission shall develop a written financial assistance policy for providing free and reduced-cost medically necessary care to low-income patients who lack health care coverage or to patients whose health insurance does not pay the full cost of the hospital bill.

      2. (b) A hospital shall provide written notice of the hospital's financial assistance policy to the patient, the patient's family, or the patient's authorized representative before discharging the patient and in each communication to the patient regarding collection of the hospital bill.

         1. (i) The required notice shall state that the patient has up to 240 days after the day the patient receives the initial hospital bill to apply for financial assistance from the hospital.
         2. (ii) The hospital shall obtain documentation ensuring that the patient or the patient’s authorized representative acknowledges the patient’s receipt of the notice before discharging the patient.
         3. (iii) If a patient chooses not to apply for financial assistance, the patient’s documented acknowledgement shall indicate that the patient is not applying for financial assistance on the day of the acknowledgment but may apply within 240 days immediately following the patient’s receipt of the initial hospital bill.

      3. (c) The financial assistance policy shall provide at a minimum:

         1. (i) Free medically necessary care to patients with family income at or below 200 percent of the federal poverty level, consistent with the provisions of §A(2) of this regulation;
         2. (ii) Reduced-cost medically necessary care to patients with family income between 200 and 300 percent of the federal poverty level, consistent with the provisions of §A(2) of this regulation;
         3. (iii) A description of the payment plan required under Health-General Article, §19-214.2(d), Annotated Code of Maryland and Regulation .05 of this chapter; and
         4. (iv) A mechanism for a patient, irrespective of that patient’s insurance status, to request the hospital to reconsider the denial of free or reduced-cost medically necessary care, including the address, phone number, facsimile number, email address, mailing address, and website of the Health Education and Advocacy Unit, which can assist the patient or patient’s authorized representative in filing and mediating a reconsideration request.

      4. (d) If a patient is eligible for reduced-cost medically necessary care under §A(1)(c)(ii) of this regulation, the hospital shall, at a minimum, reduce the patient’s out-of-pocket expenses for the hospital services:

         1. (i) For a patient with family income of at least 201 percent but not more than 250 percent of the federal poverty level, by 75 percent; and
         2. (ii) For a patient with family income of more than 250 percent but not more than 300 percent of the federal poverty level, by 60 percent.
      5. (e) The hospital shall provide free and reduced-cost medically necessary care to all qualified Maryland residents, regardless of their citizenship or immigration status.
      6. (f) The hospital shall provide free and reduced-cost medically necessary care under §A(1)(c) of this regulation to all qualified Maryland residents, regardless of whether the patient resides in the hospital’s service area.
      7. (g) The financial assistance policy applies to all medically necessary hospital services provided to qualified Maryland residents. Hospitals may not exclude non-urgent or elective, but medically necessary, care from their financial assistance policy.
   2. (2) The financial assistance policy shall calculate a patient’s eligibility for free medically necessary care under §A(1)(c)(i) of this regulation and Health-General Article, §19-214.1(b)(2)(i), Annotated Code of Maryland, or reduced-cost medically necessary care under §A(1)(c)(ii) of this regulation and Health-General Article, §19-214.1(b)(2)(ii), Annotated Code of Maryland, at the date of service or updated, as appropriate, to account for any change in the financial circumstances of the patient that occurs within 240 days after the initial bill is provided.
   3. (3) The hospital shall consider any change in the patient’s financial circumstance in accordance with Health-General Article, §19-214.1(b)(11), Annotated Code of Maryland.

   4. (4) Income Documentation.

      1. (a) Hospitals shall accept generally acceptable forms of documentation that verify income, such as tax returns, pay stubs, and W2s to evaluate if the patient is eligible for financial assistance, including free and reduced-cost medically necessary care, including reduced-cost medically necessary care due to financial hardship, in accordance with this regulation .
      2. (b) Hospitals shall use available information, including information provided by the patient, to approximate the patient’s income if the patient has not provided their tax returns, pay stubs, W2s, or another form of documentation.

      3. (c) Income Attestations.

         1. (i) Hospitals may accept patient attestation of the patient’s monthly or annual income and the number of filers and dependents on their tax return without documentation.
         2. (ii) Such an attestation shall include the patient’s income and the number of filers and dependents on their tax return.
         3. (iii) If the patient provides an attestation of income the hospital is not required to conduct any additional income verification.
      4. (d) A hospital’s inability to obtain complete income information does not preclude the hospital's ability to reasonably predict a patient’s income for the purposes of providing financial assistance. For example, a hospital may multiply income reported at the monthly level by 12 to determine income at the annual level, allowing for reasonably predictable changes in income throughout the year.

   5. (5) Presumptive Eligibility for Free Medically Necessary Care. Unless otherwise eligible for Medicaid or CHIP, patients who are beneficiaries/recipients of the following means-tested social services programs are deemed eligible for free medically necessary care:

      1. (a) Households with a child in the free or reduced lunch program and is eligible for the program based on the household’s income;
      2. (b) Supplemental Nutritional Assistance Program (SNAP);
      3. (c) Low-income-household energy assistance program;
      4. (d) Primary Adult Care Program (PAC), until such time as inpatient benefits are added to the PAC benefit package;
      5. (e) Women, Infants and Children (WIC); or
      6. (f) Other means-tested social services programs deemed eligible for hospital free medically necessary care policies by the Maryland Department of Health and the Commission, consistent with this regulation.

2. B. Hospital Reports. Each hospital shall submit to the Commission within 120 days after the end of each hospital’s fiscal year:

   1. (1) The hospital’s financial assistance policy developed in accordance with this regulation; and

   2. (2) An annual report on the hospital's financial assistance policy that includes:

      1. (a) The total number of patients who completed or partially completed an application for financial assistance during the prior year;
      2. (b) The total number of inpatients and outpatients who received free medically necessary care during the immediately preceding year and reduced-cost medically necessary care for the prior year;
      3. (c) The total number of patients who received financial assistance during the immediately preceding year, by race or ethnicity and gender;
      4. (d) The total number of patients who were denied financial assistance during the immediately preceding year, by race or ethnicity and gender;
      5. (e) The total cost of hospital services provided to patients who received free medically necessary care; and
      6. (f) The total cost of hospital services provided to patients who received reduced-cost medically necessary care that was covered by the hospital as financial assistance or that the hospital charged to the patient.

3. C. Financial Hardship Policy.

   1. (1) Subject to Regulation .05D of this chapter, the financial assistance policy required under §A of this regulation and Health-General Article, §19-214.1, Annotated Code of Maryland, shall provide reduced-cost medically necessary care to patients with family income below 500 percent of the federal poverty level who have a financial hardship.

   2. (2) If a patient has received reduced-cost medically necessary care due to a financial hardship, the patient or any immediate family member of the patient living in the same household:

      1. (a) Shall remain eligible for reduced-cost medically necessary care when seeking subsequent care at the same hospital during the 12-month period beginning on the date on which the reduced-cost medically necessary care was initially received; and
      2. (b) To avoid an unnecessary duplication of the hospital’s determination of eligibility for free and reduced-cost medically necessary care, shall inform the hospital of the patient’s or family member’s eligibility for the reduced-cost medically necessary care.

   3. (3) If a patient is eligible for reduced-cost medically necessary care under a hospital’s financial hardship policy, the hospital shall, at a minimum, reduce the patient’s out-of-pocket expenses for hospital services:

      1. (a) For a patient with family income of at least 201 percent but not more than 250 percent of the federal poverty level, by 75 percent;
      2. (b) For a patient with family income of more than 250 percent but not more than 300 percent of the federal poverty level, by 60 percent;
      3. (c) For a patient with family income of more than 300 percent but not more than 350 percent of the federal poverty level, by 50 percent;
      4. (d) For a patient with family income of more than 350 percent but not more than 400 percent of the federal poverty level, by 45 percent;
      5. (e) For a patient with family income of more than 400 percent but not more than 450 percent of the federal poverty level, by 40 percent; and
      6. (f) For a patient with family income of more than 450 percent but not more than 500 percent of the federal poverty level, by 35.

4. D. The Commission may, by regulation, establish income thresholds higher than those in this regulation:

   1. (a) Patient mix;
   2. (b) Financial condition;
   3. (c) Level of bad debt experienced;
   4. (d) Amount of financial assistance provided; and
   5. (e) Other relevant factors.

5. E. Notice Requirements.

   1. (1) A notice shall be posted in conspicuous places throughout the hospital including the billing office informing patients of their right to apply for financial assistance and who to contact at the hospital for additional information.
   2. (2) If the hospital uses a vendor to assist with financial assistance eligibility, billing, or debt collection, such as a debt collector or eligibility vendor, that vendor shall post a notice in a conspicuous place on their website or online payment portal, informing patients of their right to apply for financial assistance, providing a link to the financial assistance application, and providing information on how to submit the application. Placement on the website or online payment portal should be based on the best interest of the patient.

6. F. The notice required under §E of this regulation shall be in:

   1. (1) Simplified language;
   2. (2) At least 10-point type; and
   3. (3) The patient’s preferred language or, if no preferred language is specified, each language spoken by a limited English proficient population that constitutes at least 5 percent of the overall population within the city or county in which the hospital is located as measured by the most recent census.

7. G. Financial Assistance Application. Each hospital shall:

   1. (1) Use a Financial Assistance Application in the manner prescribed by the Commission in order to determine eligibility for free and reduced-cost medically necessary care;
   2. (2) Use a Financial Assistance Application that meets the requirements of this regulation and is consistent with the Uniform Financial Assistance Application; and
   3. (3) Establish a mechanism to provide a Financial Assistance Application to patients regardless of their insurance status. A hospital may require from patients or their guardians only those documents required to validate the information provided on the application.
8. H. Asset Test Requirements. A hospital may utilize a monetary asset test when determining eligibility for financial assistance, using the definition of monetary assets as defined in Regulation 01B of this chapter.

Authority: Health-General Article, §§19-214.2, 19-214.3, 19-207, and 19-219, Annotated Code of Maryland

Effective date: December 11, 2025 (52:24 Md. R. 1198)