Hospital charity care in Texas
Texas takes a different approach from California: instead of one statewide income cutoff for patients, state law sets minimum charity-care spending requirements for nonprofit hospitals, and runs a separate, very-low-income county safety net alongside it.
Health & Safety Code Ch. 311
Subchapter D (§§311.041–311.045) and the parallel Tax Code §11.1801 set nonprofit hospitals' community-benefit duties.
One of four spending paths
Hospitals must meet a "reasonable" community-needs standard, or a 4%, 5%, or 100%-of-tax-benefit spending test — see below.
Texas DSHS
The Department of State Health Services collects hospital financial and charity-care data under the Ch. 311 reporting system.
County Indigent Health Care
A separate, county-run program (Ch. 61) for residents at or below roughly 21% of FPL who aren't covered elsewhere.
How much charity care Texas nonprofit hospitals must provide
Rather than setting a single income percentage that every patient is entitled to apply under, Texas law requires each nonprofit hospital or hospital system to satisfy one of several spending-based standards every year in order to keep its status as a charitable organization for state tax-exemption purposes. In practice, this shapes how generous a hospital's own Financial Assistance Policy ends up being — but the federal 501(r) floor (a written FAP, the AGB pricing limit, and the collections pause) still applies to every Texas nonprofit hospital regardless of which path it uses.
| Compliance path | What it requires |
|---|---|
| Reasonable amount | Charity care + government-sponsored indigent care at a level "reasonable" relative to a community needs assessment, available resources, and tax-exempt benefit received. |
| 4% test | Charity care + government-sponsored indigent care ≥ 4% of net patient revenue. |
| 100% test | Charity care + indigent care ≥ 100% of the value of the hospital's tax-exempt benefits (excluding federal income tax). |
| 5% combined test | Total community benefits ≥ 5% of net patient revenue, provided charity care + indigent care alone is ≥ 4%. |
Hospitals already designated as Medicaid disproportionate-share hospitals — in the current fiscal year or either of the prior two — are automatically deemed compliant. So are small nonprofit hospitals in counties under 58,000 people that are designated health-professional-shortage areas, and certain hospitals (often run by religious orders) that provide care without billing any payer at all.
County Indigent Health Care Program (CIHCP)
Apart from any individual hospital's FAP, Texas counties are separately required, under the Indigent Health Care and Treatment Act (Health & Safety Code Chapter 61), to fund basic health services for very low-income residents who have no other source of coverage — as the "payer of last resort." This works through either a public hospital district or a county-run CIHCP, depending on where you live.
- The state's minimum income standard is 21% of the federal poverty level in net monthly income — counties may set a more generous standard, up to 50% of FPL, and still qualify for state matching funds.
- Applicants generally must have resources under roughly $2,000 and not already be eligible for Medicaid.
- Coverage is limited to basic primary, specialty, and inpatient/outpatient hospital services defined by the state — not the same comprehensive scope as a hospital's own charity care policy.
- There's no minimum residency duration — even someone newly arrived or experiencing homelessness in the county can qualify as a resident.
Because this program is administered locally, contact your county's CIHCP office or public hospital district directly to apply — eligibility rules and contact points are county-specific.
Practical takeaways for a Texas hospital bill
- Hospital-specific
No single statewide income cutoff
Unlike California, Texas doesn't guarantee you can apply at a specific % of FPL — check the individual hospital's posted FAP for its actual tiers.
- Always applies
Federal protections still apply everywhere
The 240-day application window, the AGB pricing ceiling, and the pre-collections screening requirement under IRS 501(r) apply to every Texas nonprofit hospital.
- Worth checking
Check your county program too
If your income is very low, your county's CIHCP may help with costs a hospital's own FAP doesn't fully cover.
For-profit hospitals
Texas's Chapter 311 spending mandate applies to nonprofit hospitals. For-profit hospitals aren't bound by it, though EMTALA still requires emergency screening and stabilization — ask any Texas hospital directly whether it offers financial assistance.
Where this page's claims come from
- 1.Texas Health & Safety Code §311.045, Community Benefits and Charity Care Requirements — statutes.capitol.texas.gov
- 2.Texas Tax Code §11.1801, Charity Care and Community Benefits Requirements for Charitable Hospital — law.justia.com
- 3.Texas Health & Safety Code Chapter 61, Indigent Health Care and Treatment Act — statutes.capitol.texas.gov
- 4.Texas Law Help, "County Indigent Health Care Program" — texaslawhelp.org
- 5.Texas Department of State Health Services, Chapter 311 hospital reporting requirements — dshs.texas.gov
General information, not legal advice
County indigent-care rules vary locally and statutes are updated over time. Confirm current details with your county's CIHCP office or the hospital's financial assistance office.