Tuition fees have sparked a mental health crisis. Then the heavy hospital bill came
Despite a lifelong struggle with panic attacks, Divya Singh took a brave trip around the world last fall from her home in Mumbai, India. She enrolled at Hofstra University in Hempstead, NY, to study physics and explore an interest in stand-up comedy in Manhattan.
Arriving in the middle of the pandemic and isolated in her dorm, Singh’s anxiety exploded when her family struggled to find the money for a $16,000 tuition installment. Hofstra warned her that she would have to leave the dorm after the term ended if she was not paid. At one point, she ran into obstacles transferring money to her campus meal card.
“I was a literally broke student who had no money for food,” she recalls. “At this moment of panic, I didn’t want to do anything or leave my bed.”
In late October, she called the campus counseling center hotline and saw a psychologist. “All I wanted was for someone to listen to me and validate that I wasn’t going crazy,” Singh said.
Instead, when she mentioned suicidal thoughts, the psychologist insisted on a psychiatric evaluation. Singh was taken by ambulance to Long Island Jewish Medical Center in New Hyde Park, NY, and kept for a week in a psychiatric ward at nearby Zucker Hillside Hospital. Both institutions are part of the Northwell Health system.
The experience — lots of alone time and a few therapy sessions — was of minimal psychological benefit, Singh says. She emerged facing the same tuition debt as before.
And then another bill came.
The patient: Divya Singh, a 20-year-old student at Hofstra University.
Medical service: Seven-day inpatient psychiatric stay at Zucker Hillside Hospital in Glen Oaks, NY
Service provider: Northwell Health, a large nonprofit hospital system in New York and Long Island.
Total bill: Northwell billed $50,282, which Singh’s insurer, Aetna, reduced to $17,066 under its contract with Northwell. The plan required Singh to pay $3,413.20 for it.
Which give: Singh had purchased his Aetna insurance plan through Hofstra, paying $1,107 for the fall term. Etna markets the plan specifically for students. Under its terms, students can be responsible for up to $7,350 in medical care costs for a year, according to planning documents. Singh’s Northwell bill of around $3,413 reflects the plan’s requirement that she pay 20% of the costs of her hospital stay.
While such co-insurance requirements are common in US health plans, they can be financially overwhelming for students with no income and families whose finances are already under extreme stress from high tuition fees. Singh’s Hofstra bill for the academic year, including room and incidentals, was $68,275.
As a result, Singh has found herself plagued with a double whammy of bills from two of America’s most expensive types of institutions – colleges and hospitals – with prices rising inexorably faster than inflation.
For hospitals, there is supposed to be a relief valve. The Internal Revenue Service requires all nonprofit hospitals to have a financial aid policy that reduces or eliminates the bills of people who do not have the financial resources to pay them. Such financial assistance – commonly referred to as charitable care – is a requirement for any hospital wishing to retain its tax-exempt status; this status saves the institution from having to pay property taxes on its often large campus.
by Northwell the financial aid policy prevents the hospital from charging more than $150 for people earning $12,880 per year or less. It offers rebates on a sliding scale for people earning up to $64,400 a year, though people with savings or other “disposable assets” above $10,000 may get less or not be eligible. eligible.
The IRS requires hospitals to “publicize widely” the availability of financial assistance, tell all patients how they can get it, and include “a prominent written notice” on billing statements .
Although the bill sent by Northwell to Singh includes a reference to “financial hardship” and a phone number to call, it does not explicitly state that the hospital could reduce or waive the bill. Instead, the letter obliquely said “we can help you make budget payment arrangements” – a phrase that suggests installment payments rather than debt relief.
Resolution: In a written statement, Northwell said that while “all eligible patients are offered generous financial payment options…providers need not list options on the bill.” Northwell said: “If a patient calls the number provided and expresses financial hardship, the patient is assisted with a financial need application.” However, Northwell lamented, “unfortunately a lot of patients don’t call.”
In effect, a KHN survey in 2019 found that nationally, 45% of nonprofit hospital organizations routinely sent medical bills to patients whose income was low enough to qualify for charitable care. These bills, which totaled $2.7 billion, were most likely understated since they only included debt that the hospitals had waived to collect.
Singh says the worker who took her insurance information while she was in hospital never explained that Northwell could reduce her share of the costs. The student adds that she didn’t realize it was a possibility because of the wording of the invoice they sent.
Northwell said in a statement that after KHN contacted her about Singh’s case, Northwell sent a social worker to contact her. Singh says the social worker helped Singh enroll in Medicaid, the federal health insurance program for low-income people. Foreign students are generally not eligible for Medicaid, but in New York they can get coverage for emergency services. With the addition of Medicaid coverage, Singh should end up paying nothing if the stay is retroactively approved, Northwell said.
At the same time the social worker was helping him, Singh received a “final reminder” letter from Northwell regarding his bill. This letter also mentioned financial assistance from Northwell, but only in the context of people completely without health insurance.
“Send payment or contact us within 21 days to avoid further collection activity,” the letter read.
The takeaway: Despite stricter requirements from the Affordable Care Act and the IRS to require nonprofit hospitals to proactively educate patients about the various forms of financial assistance they offer, the onus still lies with the patients. If you are having trouble paying a bill, call the hospital and ask for a copy of their financial assistance policy and request to reduce or waive your bill.
Be aware that hospitals usually require proof of your financial situation, such as pay stubs or unemployment checks. Even if you have health insurance that covers a large portion of your medical bill, you may still qualify for a bill reduction or a government insurance program like Medicaid.
You can also find documentation online: All nonprofit hospitals are required to post financial assistance policies on their websites. They should provide summaries written in plain language and translated versions in foreign languages spoken by significant parts of their communities. Be aware that financial assistance is separate from paying off your debt in full in installments, which hospitals sometimes offer first.
Although IRS rules do not govern for-profit hospitals, many of them also offer concessions to people with proven financial difficulties. The criteria patients must meet for charity care — and the likely generosity of the hospital — vary by institution, but many are giving breaks to families with middle-class incomes. Northwell’s policy, for example, extends to families of four earning up to $132,500 a year.
Singh’s family has paid for his fall tuition and half of his spring tuition so far. She still owes $16,565.
Singh says the back and forth on his hospital bill continues to cause anxiety.
“The treatment I received in the hospital, after I was discharged, didn’t help,” she says. “I have nightmares about this place.” The biggest benefit of her week there, she says, was bonding with the other patients “because they were also miserable with the way they were being treated.”
Dan Weissmann, host of the “An Arm and a Leg” podcast, contributed an audio profile that aired on NPR’s “Morning Edition.”