Tucked in a bill headed to the Governor’s desk in Delaware is a provision that details how to ease the pathway to hospital financial assistance for patients. The bill, supported by the Delaware Healthcare Association, is a monumental effort to protect patients from harm and help more patients access support. Presumptive eligibility for financial assistance (“PE”) is one approach to qualify eligible individuals for hospital financial assistance programs without lengthy applications.
At Undue Medical Debt, we understand this approach deeply because it is at the core of our work. We use predictive tools to qualify millions of people for debt relief nationwide. Many hospitals already deploy these tools, and the American Hospital Association has highlighted the practice through a series of case studies.
Simply put, hospitals can use data and predictive tools to estimate patient income, enabling them to enroll patients in financial assistance before the first bill drops. This is good news for patients and hospitals — it reduces the administrative work of both filling out and processing applications and reduces debt collection volume.
How Are States Standardizing PE for Financial Assistance?
States have supported use of presumptive screening to accelerate access to hospital financial assistance for many years. In Illinois, this took the form of providing hospitals with a list of categories eligible for streamlined access such as people enrolled in programs like SNAP (sometimes called food stamps), WIC or rental assistance. These patients are already verified as income-eligible for government public benefit programs at income levels aligned with most financial assistance thresholds.
This makes sense – no patient should have to be income-verified twice. Most recently, Oregon made significant progress by extending the presumptive screening requirement to include a practice of estimating income either through use of predictive tools and/or historical data the hospital already holds. Oregon law includes both practices: 1) leveraging programmatic information (people already income verified) and 2) estimating income to support people in financial assistance.
Delaware now joins these states (along with others, see table below) to provide a more efficient pathway to financial assistance for patients. The goal of this practice is to get patients the right financial outcome, lifting the weight and fear of debt so they can focus on getting healthy.
What Does Delaware’s New Law Include?
Delaware’s new law includes a requirement that patients earning below 300% federal poverty level (FPL) receive free care, and those up to 400% FPL receive discounts. It also includes a medical hardship discount for people earning up to 500% FPL. The bill clarifies that insured patients can access financial assistance for the portion of the medical bill that they owe out of pocket.
These mandatory levels and clarification reflect the reality families are facing right now — rising healthcare costs coupled with weak insurance plans alongside inflated housing, food and transportation costs. Together, these affordability drivers are squeezing budgets; people are delaying or forgoing needed healthcare to protect themselves financially.
The Delaware bill relies on their Diamond State Hospital Cost Review Board (“the Board”) to develop guardrails for hospital presumptive eligibility practice, acknowledging that the Board sets a floor and not a ceiling. The Board will develop a list of income-based public assistance programs and forms of verification that a hospital must accept and specifically lists homelessness as a PE category. Additionally, the state requires a PE determination to be valid for 180 days. If a patient is denied financial assistance via presumptive screening, they do not forgo their opportunity to apply and receive financial assistance through a paper application.
Importantly, the Delaware bill requires reporting on the number of completed presumptive eligibility screenings and the number of patients determined presumptively eligible. This will help inform their accountability work. The bill allows the Board to initiate reviews of hospitals that have unusually low presumptive eligibility usage.
State Tracking
While states are moving to adopt these presumptive screening practices (see table below) that come in a variety of forms, they originate from hospital practices that have used screening tools for many years as a part of their revenue cycle workflow.
Table 1. States With Presumptive Eligibility for Financial Assistance Laws
| State | Background | Bill Number |
|---|---|---|
| California | Passed in Oct 2025, implemented starting July 2027. Applies to all hospitals, allows patients to opt out. | AB 1312 |
| Delaware | To be fully implemented by July 2027. | SB 13 |
| Illinois | Passed in 2014, it is the oldest state-level PE law on the books. It applies to all hospitals, although at various tiers for urban vs. rural. | Fair Patient Billing Act |
| Maryland | Enacted in 2020, it applies to all hospitals. | HB 1420 |
| Minnesota | Passed in 2023. Tied to a broader Medicaid presumptive eligibility law. | Minn. Stat. § 144.587 (2025) |
| Oregon | Enacted in 2023 and effective in July 2024, updated in 2026 to raise billing threshold from $500 to $1500. Applies to all nonprofit hospitals. | HB 440 |
| North Carolina | In 2024, NC announced new actions leveraging the state’s Medicaid program to encourage hospitals to relieve existing medical debt and ease access to financial assistance. Approved by CMS through a state Medicaid directed payment arrangement. | SDP Preprint NC DHHS Blueprint |
Hospitals can and are reviewing these emerging practices as estimation technology improves. For a hospital, this means moving estimation tools up in the process so that patients are screened before they receive a bill rather than being screened prior to being sent to a debt collector. Through our work to relieve debt, we support hospitals in navigating key questions to ask their revenue cycle teams to evolve their billing practices by including early screening. Learn more about our best practices for financial assistance and read our primer on predictive tools.
States are taking steps to help patients access affordable care — Delaware and others are leaders to watch.