OVERVIEW:  Florida law contains a general requirement that nonprofit hospitals must provide charity care and care to Medicaid patients.  The requirements are vague, however, and do not set standards for how much charity care a provider must give.  As discussed below, there are three separate ways by which a hospital may qualify for partial reimbursement for the charity care and/or uncompensated care it provides: through participation in the Health Care Responsibility for Indigents Program or the Shared County and State Health Care Program for Low-Income Persons Program, or through Florida’s Low-Income Pool.  Requirements for all three of these reimbursement programs vary. 

Corporation Not For Profit Organized Pursuant to s. 2, ch. 87-296; Requirements
Florida Statutes § 617.2002

Health Care Responsibility for Indigents
Florida Statutes §§ 154.301 to 154.331

Disproportionate Share Program (Low Income Pool)
Florida Statutes § 409.911

Shared County and State Health Care Program for Low-Income Persons
Florida Statutes §§ 409.2673; 409.2675

Charity care
Indigent person

The Agency for Health Care Administration (hereinafter “AHCA”) oversees licensure, inspection, and regulatory enforcement of health facilities.  Fla. Stat. § 20.42.  AHCA investigates consumer complaints related to health care facilities and managed care plans and oversees the implementation of Florida’s certificate of need program.  Id.  AHCA makes quarterly payments of Medicaid disproportionate share funds to hospitals that provide a disproportionate share of Medicaid and charity care, as that term is defined in Section 409.911(c) of the Florida Statutes (see Definitions section below).  Under the Health Care Responsibility for Indigents Act, AHCA sets statewide uniform eligibility rules and adopts rules for determining a patient’s county of residence.  Fla. Stat. §§ 154.308(1) and 154.309.

The Bureau of Certificate of Need/Financial Analysis certifies to the counties which hospitals are qualified to participate in the Shared County and State Health Care Program for Low-Income Persons by virtue of their having met their charity care obligations.  Fla. Admin. Code r. 59H-1.0055(1).

For county hospitals, the board of hospital trustees shall have power to determine whether patients are “subjects of charity” and to fix prices for all services, except for medical and surgical attendance, for those patients as the board deems “just and proper.”  Fla. Stat. § 155.20.

Definitions of “charity care” differ slightly throughout Florida’s statutory law and regulatory code.  For example, Florida’s licensing requirements for trauma centers define “charity care” or “uncompensated trauma care” as follows:

“[T]hat portion of hospital charges…for which there is no compensation, other than restricted or unrestricted revenues provided to a hospital by local governments or tax districts regardless of method of payment, for care provided to a patient whose family income for the 12 months preceding the determination is less than or equal to 200 percent of the federal poverty level, unless the amount of hospital charges due from the patient exceeds 25 percent of the annual family income.  However, in no case shall the hospital charges for a patient whose family income exceeds four times the federal poverty level for a family of four be considered charity.”  Fla. Stat. § 395.4001; see also Fla. Stat. § 409.911(c) (using this definition to determine whether a hospital is eligible for Medicaid or charity care disproportionate share funds/Low Income Pool funds); Fla. Admin. Code r. 59C-1.040(2)(d) (using this definition with regard to certificates of need for hospital inpatient general psychiatric services); see Fla. Admin. Code r. 59C-1.041 (using this definition with regard to certificates of need for hospital inpatient substance abuse services). 

For purposes of hospital reporting to the AHCA, however, “charity” is defined to mean “medical care provided by a health care entity to a person who has insufficient resources or assets to pay for needed medical care without utilizing his resources which are required to meet his basic need for shelter, food, or clothing.”  Fla. Admin. Code r. 59B-9.013(3) (regarding ambulatory patient care); see also Fla. Admin. Code r. 59E-7.011 (regarding hospital inpatient data reporting to AHCA).  Hospitals may claim services as charity care only for those individuals with family incomes up to 150 percent FPL, with an exception for cases in which the hospital’s charges exceed 25 percent of the family’s annual income.  Id.  Charity care, per the CON regulations, expressly excludes bad debt.  Fla. Admin. Code r. 59C-1.039. 

“Bad debt” is defined in CON regulations as “the portion of health care provider charges for which there is no compensation for care provided to a patient who fails to qualify for charity care.”  Fla. Admin. Code r. 59C-1.039.  Bad debt does not include “administrative or courtesy discounts, contractual allowances to third-party payors, or failure of the hospital to collect full charges due to partial payment by government programs.”  Fla. Admin. Code r. 59C-1.039.


The Health Care Responsibility for Indigents Act.  The Health Care Responsibility for Indigents Act is not a traditional “free care” program; that is, it does not create an obligation in hospitals to provide financial assistance of any type.  However, it splits responsibility for indigent care between the state and the counties, with ultimate financial responsibility resting with the counties.  It also sets eligibility criteria for patients that counties must certify – and hospitals observe – if the care in question is to be eligible for reimbursement.  See Fla. Stat. § 154.302.  Currently, those criteria dictate that patients must:

Counties may establish thresholds of financial eligibility which are less restrictive than 100 percent FPL.  Fla. Stat. § 154.308(5).  There is a spend down program for people who would otherwise qualify as indigent patients but whose average family income for the past twelve (12) months is between 100 and 150 percent FPL.  Fla. Stat. § 154.308(6). 

It is the responsibility of participating hospitals to initiate eligibility or certification determination procedures with the appropriate state or county agency, which then determine whether an individual meets the state or county financial and residency criteria.  Fla. Stat. § 154.316(b).  

Under the Health Care Responsibility for Indigents Act, hospitals must provide a minimum amount of uncompensated care to qualified indigent residents, patients unable to pay their medical bills, and patients who are ineligible for government-funded programs in order to be eligible for reimbursement.  Fla. Stat. § 154.304(4); see also Fla. Stat. § 154.302.  The current standard is that hospitals’ uncompensated care days must equal at least two (2) percent of their total inpatient days to be eligible for funds under the Health Care Responsibility for Indigents Act.  Fla. Stat. § 154.304(4).  Once a hospital can show that it has fulfilled its “charity care obligations,” the financial obligation to pay for the care of “qualified indigent patients” rests with the county where the patient resides.  Fla. Stat. §§ 154.302; 154.304(4); 154.306.

Hospital reimbursement under the Shared County and State Health Program for Low-Income Persons is conditioned, in part, on the requirement that hospital taxing districts participating in this program a) enter into a signed formal agreement with the county to deliver care to the indigent and b) deliver at least two and a half (2.5) percent of their net revenues in charity care.  Fla. Stat. § 409.2673(10)(c) and (e); see also Fla. Admin. Code r. 59H-1.0055(2) and 59H-2.005(5).

The Health Care Responsibility for Indigents Act does not require counties to reimburse an out-of-county hospital for any elective or non-emergency care that their residents could have received at the local county hospital.  Fla. Stat. § 154.306(2). 


Counties are responsible for determining whether one is indigent under the Health Care Responsibility for Indigents Act.  That determination may be made either prior to or following admission to the hospital so long as it is made within 60 days of the request.  Fla. Stat. § 154.308(2) and (3). 




Not-for-profit corporations: obligation to provide charity care.  Hospitals owned by corporations that are organized as not-for-profits under Florida law must provide both Medicaid and charity care.  Fla. Stat. § 617.2002(2).

CON requirements.  Florida’s Certificate of Need statutes require AHCA to take a CON applicant’s previous and proposed provision of services to Medicaid patients and the medically indigent into account when reviewing CON applications for health care facilities and health services.  Fla. Stat. § 408.035(9).  As of 2003, there is an exemption from the CON process for certain hospitals that are establishing adult open-heart surgery programs.  Fla. Stat. § 408.036.  To qualify for this exemption, hospitals must satisfy certain criteria, including one that the applicant hospital’s payor mix “reflects the community average for Medicaid, charity care, and self-pay patients or the applicant must certify that it will provide a minimum of 5 percent of Medicaid, charity care, and self-pay to open-heart surgery patients.”  Id.

Conversions.  Sale or lease of a county, district, or municipal hospital organized under Florida law to a for-profit or not-for-profit corporation must provide for the continued care of indigents pursuant to the Health Care Responsibility for Indigents Act.  Fla. Stat. § 155.40(2)(c).

Low Income Pool.  Effective July 1, 2006, Florida negotiated a waiver with CMS that allowed it to pilot a Medicaid managed care program.  One of the Special Terms and Conditions listed in the waiver was the requirement that Florida establish and maintain a Low Income Pool that would provide direct reimbursement to safety net providers for uncompensated care to three core populations: Medicaid participants, the uninsured, and the underinsured.  The Low Income Pool may be used to reimburse the State, hospitals, clinics, and other providers for the uncompensated costs of medical services to the uninsured; Medicaid shortfall; and premium assistance payments.  See CMS Waiver, Special Terms and Conditions # 94.  Local governments, including counties and hospital taxing districts, pay the non-federal portion of the Pool’s funding. 

Health Care Responsibility Act Handbook.  This guide was created and revised by the Agency For Healthcare Administration (AHA) in consultation with the Florida hospitals and counties to which it applies.  It provides detailed uniform policies and procedures to the hospitals, counties, and others in complying with the applicable statutes and administrative rules.  The AHA maintains an updated version of the Handbook on its website, along with other explanatory materials regarding the HCRA. 

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