By state law, anyone in Washington who goes to the hospital for medical services and voices concern about their ability to pay must be offered charity care. 

The state's Charity Care Act (RCW 70.170.060) puts the onus on hospitals to proactively offer charity care as soon as patients express financial concerns and it's determined that they don't have any insurance that might cover the cost of care.

Hospitals are not allowed to require deposits or put patients through financial screening before providing charity care information.

There is no set quota or required amount of charity care that a hospital must provide, though the Department of Health is supposed to monitor hospitals and ensure they are providing comparable amounts to the average paid by other hospitals in the region. Rather, the gauge of whether hospitals are providing adequate charity care is based on whether or not they offer charity care whenever appropriate.

For patients with annual incomes below 100 percent of the federal poverty level - which in 2017 is about $12,000 for individuals or $24,600 for a family of four - who are not eligible for Medicaid or Medicare or any other assistance, hospitals must write off the full cost of care as charity care.

Patients who make between 100 and 200 percent of the federal poverty level must be offered partial charity care, according to an income-based sliding fee scale.

State law also requires all hospitals to make information about charity care "publicly available," which means "posted or prominently displayed in public areas of the hospital," and provided to individuals in writing, and explained at the time hospital staff ask for insurance information. Charity care policies must be available in any language spoken by more than 10 percent of the local population, and interpreted for patients who can't read or understand the written version.

Federal regulations for nonprofit hospitals are even more strict, requiring that billing statements include notice of financial assistance programs, that the policy be "widely available" on hospitals' websites, and that the policy be available in any language spoken by 5 percent or more of the local population.

In recent years, Columbia Legal Services has sued several hospitals in the state on behalf of low-income patients who say they were forced to pay deposits or sent to collections over medical bills that, by law, should have been covered by charity care.

Astria Regional Medical Center, formerly Yakima Regional Medical and Cardiac Center, is one such hospital. A class action suit against Regional was first filed in 2013, and in 2015 and 2016 a judge in the case ruled the hospital had violated the Charity Care and state Consumer Protection acts.

Regional and its then-parent company, Community Health Systems, settled the case in December, agreeing to pay $4.5 million to affected patients.

After conducting a series of test calls from patient actors, Columbia Legal sent out letters this summer to a dozen hospitals statewide that still don't appear to be in compliance with charity care requirements. So far, they've received a few positive responses from facilities that are updating their policies.

But hospitals could still do better, says attorney Tony Gonzalez with the law firm's Wenatchee office.

At health fairs during back-to-school or holiday seasons, health care organizations provide all sorts of free or discounted care, including screenings and physicals.

But when it came to charity care information, he said, "Nothing was mentioned at these events."

Columbia Legal often has a booth at health fairs, and provides charity care informational brochures. Some hospital staff even came and picked up stacks of the brochures, Gonzalez said, but he's not sure if they in turn passed them out to patients.

"They are going out into the communities; they are engaging with the communities; the flyers and events were perfectly bilingual," and still no charity care information was provided, he said. In Columbia Legal's reports on the subject, patients are "shocked" to learn they have a right to charity care.

In various lawsuits, internal emails provide insight into hospital staff's thought process, Gonzalez said.

"They know their opportunity to get payment is up front, right when the patient is there; right when they're getting services. So they structure their system to get as much money as they can right up front," even asking uninsured patients for copays, he said.

Ideally, he said, that would instead be a perfect opportunity to inform patients that they have the option of charity care.