Charity care is federal. Write-off floors are not.

Federal overlay — every state

• 501(r)

  501(c)(3) hospital organizations must publish a Financial Assistance Policy, a plain-language summary, and generally may not take extraordinary collection actions (selling the debt, reporting it, liens, lawsuits) until they have made reasonable efforts to determine FAP eligibility.

• No Surprises Act

  Emergency services, air ambulance, and many out-of-network clinicians at in-network facilities cannot balance-bill beyond in-network cost-sharing. Independent dispute resolution is between the plan and the provider — not a reason to pay the sticker rate.

• FDCPA

  15 U.S.C. § 1692g. Within 30 days of first collector contact, demand validation. Until validated, collection and credit reporting should stop. Partial payment can restart a state’s statute of limitations.

• EMTALA

  Emergency departments must screen and stabilize regardless of ability to pay. An ER bill is not an agreement that chargemaster rates are the cash price.

• Medicare appeals

  Five levels: redetermination (MAC, 120 days), reconsideration (QIC), ALJ at OMHA, Medicare Appeals Council, then federal district court. A remaining patient balance is often a claim the provider still needs to work.

• Credit bureaus

  The CFPB’s 2025 medical-debt reporting rule was vacated in July 2025. Industry practice still generally omits paid medical collections and unpaid balances under $500. Unpaid medical debt over $500 can appear after a delay unless a state ban applies. FCRA-preemption fights over those state bans are ongoing.