Immigration Status and Cancer Bills

Fear of a bill keeps people out of cancer care. So does fear of a record. Some of that fear is well founded. Some of it rests on rules that do not say what people think they say.

This page walks through four federal rules. They come up in almost every cancer billing talk. This is general information, not legal advice. Immigration law is complex and it changes. Have a nonprofit immigration lawyer, or an accredited representative, review your own facts.

One law covers the emergency room. It is the Emergency Medical Treatment and Labor Act, or EMTALA. It applies to any hospital that takes Medicare and offers emergency services. That is almost every hospital in the country.

Ask for care for an emergency condition, and the hospital must do three things. It must give you a medical screening exam. If it finds an emergency, it must treat you until you are stable. If it cannot make you stable with what it has, it must arrange a proper transfer. The same holds if you ask to be moved.

CMS states the obligation plainly: emergency services must be provided regardless of ability to pay.

EMTALA does not create a right to ongoing cancer care. It covers the emergency itself. Still, it means one thing clearly. A hospital cannot turn you away in an emergency over a bill or an insurance question.

A federal rule, 42 CFR 440.255, covers limited services for certain noncitizens. It has applied since January 1, 1987. It reaches people who are not lawfully admitted, and certain legalized noncitizens.

It pays for services needed to treat an emergency medical condition. The rule defines that term. There must be acute symptoms severe enough, including severe pain, that going without immediate care could reasonably be expected to do one of three things:

• Place your health in serious jeopardy.
• Seriously impair a bodily function.
• Cause serious dysfunction of an organ or body part.

Two practical points follow.

First, your state runs Emergency Medicaid. States differ in how they apply that test to cancer care. So whether a given treatment counts is a state call, not one fixed national answer. Ask the hospital's Medicaid eligibility worker to screen you. Ask for the answer in writing.

Second, apply even if you expect a no. A denial letter is useful on its own. Hospital charity care programs often ask to see one.

This is the fear that stops the most people, and the regulation is narrower than the rumor.

The rule is 8 CFR 212.22. Homeland Security looks at current or past receipt of just two things. One is public cash aid for income support. The other is long-term institutional care paid for by the government.

The same rule says what will not be counted. Its list includes:

• The Supplemental Nutrition Assistance Program, and other nutrition programs.
• The Children's Health Insurance Program.
• Medicaid, other than long-term use of institutional services.
• Housing benefits.
• Any benefits tied to shots or to testing for infectious disease.
• Other supplemental or special-purpose benefits.

Read that list again. Ordinary Medicaid is not counted. CHIP is not counted. SNAP is not counted. The one Medicaid exception is long-term institutional care. That means a long nursing home stay. It does not mean chemotherapy, surgery, or clinic visits.

Public charge rules also do not reach every immigration category. Refugees, asylees, and several other groups are exempt by law. Here, ask an immigration lawyer. Do not rely on a hospital employee for this answer.

Most cancer centers are nonprofit hospitals. They hold tax-exempt status under Section 501(c)(3). Since the Affordable Care Act, they must also meet four rules under Section 501(r). Each hospital site must meet them on its own:

• A community health needs assessment, under 501(r)(3).
• A financial assistance policy and an emergency medical care policy, under 501(r)(4).
• A limitation on charges for people who qualify under that policy, under 501(r)(5).
• Billing and collection rules, under 501(r)(6).

Final regulations were released on December 29, 2014.

Notice what is missing from that list. Nothing ties a financial assistance policy to immigration status. Hospitals do write their own rules for who qualifies. Some ask for proof of residence. But the duty to have a policy, and to publish it, applies to all of them. Ask for the policy in writing, by name. Then ask what papers can stand in for ones you do not have.

Section 501(r)(6) is the part that limits harsh collection. It restricts what are called extraordinary collection actions, or ECAs. Those include:

• Selling your debt to another party.
• Reporting adverse information to credit agencies.
• Deferring or denying medically necessary care because of unpaid prior bills.
• Actions that go through a court. That covers liens, foreclosure, seizing a bank account, a civil suit, or garnishing wages.

First, the hospital must make reasonable efforts to see if you qualify for help. Three numbers define that duty:

• No ECA may start for at least 120 days after the first bill you get post-discharge.
• The window to apply for help runs 240 days from that same first bill.
• Written notice must set a deadline. It can be no sooner than 30 days after the notice goes out.

In plain terms, if the first bill came last week, you have months. Not days. Apply for help in writing. Keep a copy with the date on it.

• Ask the hospital for its financial assistance policy and application, in your language.
• Ask to be screened for Emergency Medicaid, and request the result in writing.
• Write the date of the first billing statement on a calendar, and count 120 and 240 days forward.
• Ask whether the hospital has a patient navigator or financial counselor who works with immigrant families.
• Contact a nonprofit legal services provider or an accredited representative before signing anything that mentions status.
• Keep every letter, bill, and denial in one folder with dates.

https://www.cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-440/subpart-B/section-440.255

https://www.ecfr.gov/current/title-8/chapter-I/subchapter-B/part-212/subpart-A/section-212.22

https://www.irs.gov/charities-non-profits/charitable-organizations/requirements-for-501c3-hospitals-under-the-affordable-care-act-section-501r

https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6