Availability of Hospital Financial Assistance Documents in Non-English Languages

ABSTRACT

Objectives: Millions of people struggle to afford hospital care in the US, and individuals who speak languages other than English (LOTE) are particularly vulnerable due to language barriers in understanding and accessing hospital financial assistance policies (FAPs). Nonprofit hospitals are required under Internal Revenue Service (IRS) rules to provide translated financial documents in any language spoken by at least 1000 individuals or 5% of the population in their service area. However, adherence to these requirements is unknown, and to our knowledge, no study has evaluated whether for-profit or government hospitals voluntarily offer translations of FAP documents to aid individuals who speak LOTE.

Study Design: Cross-sectional study.

Methods: We reviewed the websites of all 426 nonfederal hospitals in the 10 most linguistically diverse US core-based statistical areas (CBSAs), focusing on the availability of 4 financial documents in multiple languages: financial assistance policies, plain language summaries, financial assistance applications, and billing/collections policies. We assessed the association between the number of languages served and hospitals’ system and ownership status (nonprofit, for-profit, government) using multivariate regression, adjusting for CBSA.

Results: The study findings demonstrate that system-affiliated and nonprofit hospitals provide more translated documents than their for-profit, governmental, and unaffiliated counterparts. Nonprofit hospitals provided significantly more language options across all document types, suggesting compliance with IRS requirements. System-affiliated hospitals also performed better, possibly due to greater administrative resources.

Conclusions: The study highlights a gap in multilingual access among for-profit, governmental, and unaffiliated hospitals, raising concerns that individuals who speak LOTE may face greater challenges navigating financial assistance and medical billing at these hospitals.

Am J Manag Care. 2026;32(6):334-337. https://doi.org/10.37765/ajmc.2026.89953

Takeaway Points

We audited the availability of financial assistance documents in different languages on hospital websites within the 10 most linguistically diverse core-based statistical areas in the US. Nonprofit hospitals face language access requirements to maintain tax exemptions. Adherence to these requirements and potential voluntary adoption among for-profit and government hospitals were unknown.

• In regression analyses, nonprofit and system-affiliated hospitals demonstrate superior language access for financial assistance policies, plain language summaries, and applications as well as for billing/collections policies.
• For-profit and government-owned hospitals are not typically adopting the standards of their nonprofit peers.
• Large systems may have more resources to dedicate to document translation.

Millions of Americans struggle with medical debt,¹ and the 25 million people in the US who speak languages other than English (LOTE) may particularly struggle to navigate insurance, medical billing, and financial assistance programs.^2,3 Further complicating this issue, noncitizens in the US have substantially higher rates of uninsurance. According to a 2024 Urban Institute report, 39.2% of noncitizens are uninsured compared with 9.8% of the US population.⁴ This disparity increases further for noncitizens with limited English proficiency (LEP), as they have an uninsured rate of 49.1% compared with 26.6% for noncitizen families proficient in English.⁴ Providing diverse language access to financial assistance documents may enable individuals who speak LOTE to understand their eligibility and apply for financial assistance.

Nonprofit hospitals have special requirements to provide financial assistance and meet the needs of individuals who speak LOTE to maintain tax-exempt status under the Internal Revenue Service (IRS).⁵ Under the requirements of IRS section 501(r), nonprofit hospitals must “widely publicize” their financial assistance policies (FAPs) by, among other requirements, providing a paper copy of a plain language summary of the policy upon request; displaying the policy in public spaces; and making the FAP, the application, and the plain language summary available on the hospital’s website.⁶ Additionally, the IRS requires that if a language is spoken by at least 1000 individuals or 5% of the population in the hospital’s service area, the hospital must translate all FAP documents into that language.⁵ In contrast, there is no similar federal requirement for government-owned and for-profit hospitals. Although IRS standards requiring nonprofit hospitals to translate financial assistance documents to meet the needs of linguistically diverse communities can ease administrative burdens for patients and bolster health equity, this aspect of tax-exemption requirements generally goes unscrutinized.⁷

In this study, we audited the availability of financial assistance and billing documentation in different languages on hospital websites in selected linguistically diverse areas in the US. We also assessed whether hospital ownership type and system affiliation are associated with increased language access. To assess the accessibility of financial aid documents for individuals who speak LOTE, we looked at hospitals in the top 10 linguistically diverse core-based statistical areas (CBSAs) from the American Community Survey (ACS) and the US census. These CBSAs were chosen to focus on areas where multilingual access to FAPs is most critical. In such regions, higher proportions of individuals who speak LOTE necessitate translations of financial aid materials to improve patient experience and prevent medical debt.

METHODS

To select hospitals for our sample, we used the language spoken at home from the 2023 ACS 1-year estimates.⁸ These data do not include every language spoken in a CBSA but do include 5 language categories: English, Spanish, other Indo-European languages, Asian and Pacific Island languages, and other languages. Then we calculated language diversity using Greenberg’s Language Diversity Index (LDI),⁹ which ranges from 0 to 1 and represents the likelihood that 2 random individuals in an area will speak the same language. This formula is A = 1 – Σ_i(i²), where A is the measure and i successively takes on the values of the proportion of the speakers of each language to the total population. An LDI of 1 means that all individuals in an area speak the same language, because there is absolute certainty that the 2 random individuals would speak the same language.

Hospitals within the 10 CBSAs with the highest language diversity were identified using 2021 American Hospital Association Annual Survey data, and these data enabled us to observe the ownership and system affiliation of each hospital.¹⁰ All non–federally owned hospitals were included in our analytic sample, including general and surgical hospitals, children’s hospitals, and other specialty hospitals. We manually reviewed each hospital’s website to assess the availability of 4 key financial documents: FAPs, plain language summaries, applications for financial assistance, and billing/collections policies. We counted the number of languages for which these documents were available on each hospital’s website. The data were collected from September 1, 2024, through February 27, 2025.

Regression analysis was used to assess the association between the number of languages for which these documents are available and hospital ownership and system affiliation status. Four separate models were fit, one for each type of financial document: FAPs, plain language summaries, applications, and billing/collections policies. These regression analyses controlled for the CBSA each hospital is located within to account for regional variations in the number of languages commonly spoken.

RESULTS

The top 10 linguistically diverse CBSAs were Gallup, New Mexico; Salinas, California; Fresno, California; Merced, California; New York–Newark–Jersey City, New York–New Jersey–Pennsylvania; Stockton, California; San Francisco–Oakland–Berkeley, California; Miami–Fort Lauderdale–Pompano Beach, Florida; Los Angeles–Long Beach–Anaheim, California; and San Jose–Sunnyvale–Santa Clara, California. Our analytic sample included 426 hospitals across nonprofit (n = 241; 56.6%), for-profit (n = 109; 25.6%), and government (n = 76; 17.8%) ownership types. There were 311 (73.0%) system-affiliated hospitals and 115 (27.0%) unaffiliated hospitals in the analytic sample. A description of hospitals within each CBSA is provided in the online supplement in eAppendix Table 1 (eAppendix available at ajmc.com).

Of the 426 hospitals in our sample, 349 (81.9%) posted a FAP document in at least 1 language on their website, 226 (53.1%) had at least 1 plain language policy, 337 (79.1%) had a financial assistance application, and 201 (47.2%) had a billing and collections policy. Of the hospitals with posted FAPs, 136 (39.0%) offered this policy only in English, and 213 (61.0%) offered it in LOTE (Table 1). There were 226 hospitals with posted plain language documents, of which 39 (17.3%) offered this policy only in English and 187 (82.7%) offered it in LOTE. Of the 337 hospitals with posted financial assistance applications, 69 (20.5%) offered the application only in English, and 268 (79.5%) offered it in LOTE. Among the 201 hospitals with a posted billing and collection policy, 72 (35.8%) offered it only in English, and 129 (64.2%) offered it in LOTE. Hospitals with policies in LOTE offered a mean (SD) of 10.31 (9.07) languages for the FAP, 10.44 (8.29) for the plain language policy, 9.78 (9.15) for the financial assistance application, and 11.58 (8.50) for the billing and collections policy.

System Affiliation

Hospitals affiliated with a large system had significantly higher language access, offering all 4 document types in more languages than unaffiliated hospitals (Table 2). After controlling for CBSA and hospital ownership type, system-affiliated hospitals averaged 4.35 more languages in FAP documents (P < .001) and 5.06 more in plain language policies (P < .001) than non–system-affiliated hospitals. Similarly, affiliated hospitals offered a mean of 5.22 more language options (P < .001) for financial assistance applications and 3.52 more language options (P < .001) for billing and collections policies in adjusted models.

Ownership Type

Nonprofit hospitals also offered significantly more languages across all document types than for-profit hospitals, whereas government hospitals largely had no statistically significant difference in the number of languages offered compared with for-profit hospitals (Table 2). Controlling for CBSA and system affiliation, nonprofit hospitals had a mean of 6.57 more languages for FAPs (P < .001), 6.15 more languages for plain language documents (P < .001), 7.84 more languages for financial assistance applications (P < .001), and 4.16 more languages for billing and collections policies (P < .001) relative to for-profit hospitals. Government hospitals offered significantly more languages than for-profit hospitals for plain language policies, with a mean of 2.64 more languages (P = .014). Additionally, a description of the prevalence of document availability in LOTE disaggregated by hospital ownership type is presented in eAppendix Table 2.

DISCUSSION

In this cross-sectional study of language access for online financial documents among hospitals in linguistically diverse CBSAs, we observed that nonprofit and system-affiliated hospitals have superior language access. Presumably, larger health systems have more administrative resources to promote multilingual access to financial assistance for individuals who speak LOTE. Language access among nonprofit hospitals aligns with their IRS tax-exempt status requirements and their commitment to community benefits and services. It is notable that for-profit hospitals and government hospitals are not typically voluntarily achieving the same level of language access for financial documentation as their nonprofit peers within the same CBSA. States have the opportunity to extend translation regulations beyond the nonprofit sector, as some already do for a range of FAP requirements.¹¹

Some states have stepped in to fill this need for translation services. For example, in 2024, the California Department of Health Care Access and Information launched the Hospital Fair Billing Program.¹² As part of the program, patients can submit billing and other financial documents from hospitals to this state office for translation into other languages to meet the needs of state residents. Such state-based approaches could be evaluated and shared to support individuals who speak LOTE.

Patients may also seek translation from an eclectic landscape of service providers. Some of this third-party aid comes from nonprofit organizations offering free translation services, such as Translators without Borders, or from local community organizations.¹³ Other vendors offer translation services for a fee to individuals or organizations.^14,15 There is also a recent emergence of vendors offering artificial intelligence–based services, targeting individuals, organizations, and companies. As technology evolves rapidly, policy makers and patient advocates will need to stay abreast of new tools and the potential need for regulatory changes.

Limitations

There are limitations to this study. Our findings may not be generalizable to other CBSAs with different needs. Online documents were limited, and hospitals may provide more comprehensive interpretation services. Additionally, the data were captured at a single point in time and may not reflect future or past availability. Finally, the study does not assess the quality or accuracy of the documents reviewed.

CONCLUSIONS

This cross-sectional study identified heterogeneity in multilingual access to financial assistance information and application forms, whereby nonprofit and system-affiliated hospitals offer greater access than for-profit, governmental, and unaffiliated hospitals. The lower adoption of language access practices in these settings suggests that individuals who speak languages other than English may face greater barriers when navigating financial assistance policies and medical billing and, in turn, financial barriers to care. Addressing these disparities may require support for underresourced hospitals and expansion of policies to apply standards to all hospitals, not just the nonprofit sector. 

Author Affiliations: University of Southern California (USC) Leonard D. Schaeffer Center for Health Policy & Economics (NLN, SR, EC, ET, ELD), Los Angeles, CA; USC Alfred E. Mann School of Pharmacy (ET), Los Angeles, CA; USC Sol Price School of Public Policy (ELD), Los Angeles, CA.

Source of Funding: This study was funded by a Student Empowerment Award from the USC Office of Research and Innovation.

Author Disclosures: Ms Nguyen is employed by KPMG and has received a Student Empowerment Award from the USC Office of Research and Innovation. Dr Trish is a member of the editorial board of The American Journal of Managed Care, is funded by a Student Empowerment Award from the USC Office of Research and Innovation, and has served as a consultant and litigation expert on matters in the hospital, health insurance, health information technology, public health, and life sciences sectors. Dr Duffy reports providing expert testimony on matters in the health care industry and receiving grants from Arnold Ventures, California Health Care Foundation, and Gates Ventures. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (NLN, SR, ELD); acquisition of data (NLN, SR, EC); analysis and interpretation of data (NLN, EC, ET, ELD); drafting of the manuscript (NLN); critical revision of the manuscript for important intellectual content (NLN, EC, ET, ELD); statistical analysis (NLN, SR); provision of patients or study materials (NLN); obtaining funding (NLN); administrative, technical, or logistic support (SR); and supervision (ET, ELD).

Address Correspondence to: Erin L. Duffy, PhD, MPH, USC Schaeffer Center for Health Policy & Economics, 635 Downey Way, VPD 414F, Los Angeles, CA 90089-3333. Email: eld_805@usc.edu.

REFERENCES

1. Lopes L, Kearney A, Montero A, Hamel L, Brodie M. Health care debt in the U.S.: the broad consequences of medical and dental bills. KFF. June 16, 2022. Accessed June 19, 2025. https://www.kff.org/health-costs/report/kff-health-care-debt-survey/

2. Chin KK. HHS must improve language access to make meaningful access a reality. Health Affairs Forefront. July 22, 2016. Accessed June 19, 2025. https://www.healthaffairs.org/content/forefront/hhs-must-improve-language-access-make-meaningful-access-reality

3. Haldar S, Pillai D, Artiga S. Overview of health coverage and care for individuals with limited English proficiency (LEP). KFF. July 7, 2023. Accessed June 19, 2025. https://www.kff.org/racial-equity-and-health-policy/issue-brief/overview-of-health-coverage-and-care-for-individuals-with-limited-english-proficiency/

4. Buettgens M, Ramchandani U. The health coverage of noncitizens in the United States, 2024. Urban Institute. May 2023. Accessed June 16, 2025. https://www.urban.org/sites/default/files/2023-05/The%20Health%20Coverage%20of%20Noncitizens%20in%20the%20United%20States%202024.pdf

5. Charitable hospitals — general requirements for tax‑exemption under section 501(c)(3). Internal Revenue Service. Updated August 20, 2024. Accessed June 16, 2025. https://www.irs.gov/charities-non-profits/charitable-hospitals-general-requirements-for-tax-exemption-under-section-501c3

6. Financial assistance policies (FAPs). Internal Revenue Service. Updated May 27, 2025. Accessed June 16, 2025. https://www.irs.gov/charities-non-profits/financial-assistance-policies-faps

7. United States Government Accountability Office. Testimony before the Subcommittee on Oversight, Committee on Ways and Means, House of Representatives: tax administration: IRS oversight of hospitals’ tax-exempt status, statement of Jessica Lucas-Judy, director, strategic issues. GAO-23-106777. April 26, 2023. Accessed June 19, 2025. https://www.gao.gov/assets/gao-23-106777.pdf

8. American Community Survey S1601: language spoken at home: 1-year estimates subject tables: table S1601. US Census Bureau. 2023. Accessed September 10, 2025. https://data.census.gov/table/ACSST1Y2023.S1601?q=Language+Spoken+at+Home

9. Greenberg JH. The measurement of linguistic diversity. Language. 1956;32(1):109-115. doi:10.2307/410659

10. AHA Annual Survey Database. American Hospital Association Data and Insights. Accessed September 1, 2023. https://www.ahadata.com/aha-annual-survey-database

11. Kona M, Raimugia V. State protections against medical debt: a look at policies across the U.S. in 2025. The Commonwealth Fund. September 2023. Updated July 16, 2025. Accessed September 3, 2025.
https://www.commonwealthfund.org/publications/fund-reports/2025/jul/state-protections-against-medical-debt-look-policies-across-us

12. Language Access Plan. California Department of Health Care Access and Information. Updated January 31, 2025. Accessed June 19, 2025. https://hcai.ca.gov/home/language-access-plan/

13. Translators without Borders. Accessed June 19, 2025. https://translatorswithoutborders.org/

14. Rapid Translate. Accessed June 19, 2025. https://www.rapidtranslate.org/

15. LanguageLine Solutions. Accessed June 19, 2025. https://www.languageline.com/industries/non-profit