About this series: The Cost of Living will explore how Austin became so expensive, who is being squeezed by the city’s economic boom and what local leaders are — or aren’t — doing to address it
Last October, Caitlin Musignac experienced chest pain. The Austin mom of two who has health insurance through the federal Affordable Care Act Marketplace went to the emergency room. At St. David’s South Austin Medical Center, she received an X-ray. Everything looked normal. She was given ibuprofen for the pain.
Then the bills started coming in. More than $2,000 between the $1,214 hospital bill and bills for the radiologist and emergency room doctor. “I didn’t think it would be over $2,000,” Musignac said. “I thought maybe my insurance would cover it.”
Musignac, 32, who works in sales, makes $28,000 a year. “How am I going to pay this?” she said when the bills started arriving.
Even people with health insurance can face thousands of dollars in unexpected medical bills after emergency room visits. Before draining savings, taking out loans or putting medical bills on credit cards, patients might have options including charity care, government assistance programs, billing corrections, discounts and payment plans
“One of the most complex and often confusing parts of the healthcare journey is the billing process,” said Christy Millweard, Baylor Scott & White’s director of public relations, in a statement. “Our goal is to simplify what can be a complex process and to make sure patients have access to the support and information they need.”
Hospital systems provide patients with information on financial assistance and hospital billing policies in the many documents patients receive at the time of treatment as well as through links in the actual bills they receive.
“Our trained financial counselors are available to assist patients in understanding bills, insurance coverage and potential assistance programs,” Gabriel Martinez, senior director of external communications for Ascension Texas, said in a statement. “Patients can call Patient Financial Services, visit the hospital in person or request information online.”
Another patient faces mounting bills
Regina Pineda came back from a trip to Puerto Rico in October 2024 so sick she needed a wheelchair to get through the airport. She went to a St. David’s emergency room directly from the airport, but nothing was found
In February 2025, she was having extreme dizziness and difficulty walking and talking. This time she went to Dell Seton Medical Center. She was given fluids and a CT scan, but doctors again did not identify the cause
A month after her Dell Seton visit, Pineda had a scheduled colonoscopy that was delayed. The preparation left her extremely dehydrated. She went to Ascension Seton Medical Center, where she was given fluids to sustain her until she could have the colonoscopy the next day.
Pineda had three different hospital emergency department experiences in less than six months. The bills began to stack up. Pineda has insurance through her job as an academic advisor at Austin Community College. She began to worry that the medical bills would wipe out her savings.
Then Pineda, 32, who is single with no children and makes $58,000 a year, began trying to figure out how she could deal with the thousands of dollars in medical bills while also handling her regular financial obligations, including student loans
Both Pineda and Musignac navigated the process of seeking help with their bills, a process they say was complicated and was not explained proactively by the hospitals
How much medical debt are people carrying?
In Texas, at any one time, 10.6% of adults have unpaid medical bills, higher than the national average of 8.6%, according to KFF and the Peterson Center for Healthcare’s analysis of the U.S. Census Bureau’s 2019 to 2021 Survey of Income and Program Participation
The KFF Health Care Debt Survey from 2022 found that 41% of adults in the U.S. have current debt related to health care bills.This survey included not just unpaid medical bills, but bills that a person had paid by taking out a loan, using a credit card or asking family members for assistance. Of those with medical or dental debt, 21% are directly paying the health care provider; 17% owe a lender or a collection agency; 17% owe a credit card company; and 10% owe a family member. Some people had a combination of these debts.
About 27% of medical debt develops over time because of a chronic illness, but most medical debt, 72%, results from a short-term eventsuch as an unexpected hospital stay or treatment
KFF’s survey also found that 3 in 10 people who don’t have medical debt said they would not be able to cover a $500 unexpected health care bill without borrowing money. Of the people who do have debt, 18% said they would never be able to pay it off
Is the medical bill correct?
Providers like to get their money up front at the time of service, but you do not have to pay until after your bill is processed through your insurance or until after you’ve received services if you don’t have insurance.
Medical bills often have errors.You should look at three different things to make sure the bill is correct:
The actual bill:
Ask for an itemized bill that lists everything you received. Did you actually receive that care? Are the dates correct? Is the insurance information correct?
The Explanation of Benefits:Often people assume that the explanation of benefits they receive is the actual bill. It is not. It shows what hospitals or providers think your insurance company will pay based on the services provided.
Your insurance company’s statement:Your insurance company will send you a statement showing what it will pay and what you will owe. Make sure this statement accurately reflects your policy coverage.
If all three agree and you did receive the services, then you can move to the next step. If there are discrepancies, call the entity with the discrepancy or ask for a three-way conversation between your insurance carrier and the provider’s billing office to sort out the bill
If your care was planned in advance, such as a scheduled procedure, your provider also should have provided you with a bill estimate. You can also compare that with the bill, the Explanation of Benefits and your insurance company’s statement
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Do you qualify for government assistance?
You might qualify forMedicaid, Medicare, the Children’s Health Insurance Program or the Medical Assistance Program through Central Health. Medicaid covers adults making less than 200% of the federal poverty level who are pregnant or within 12 months after giving birth. Severely low-income adults who have dependents also might qualify for Medicaid, as well as some adults and children with disabilities. Pregnant people who make more than 200% of the federal poverty level also might qualify for CHIP.
The federal poverty level is $15,960 for a single person, $21,640 for a family of two, $27,320 for a family of three and $33,000 for a family of four. Medicaid also covers people with certain disabilities
Medicare covers many people who are 65 or older. There are certain qualifications, such as citizenship and having worked or had a spouse who worked and paid into the Medicare program
Austin-Travis County’s hospital district, Central Health, covers people making up to 200% of the federal poverty level through its MAP and MAP Basic programs
Texas’ Health Insurance Premium Payment Program also helps parents whose children qualify for Medicaid pay for their employee-sponsored insurance plan premiums.
Often, health systems will require patients to determine whether they qualify for government programs before approving charity care
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Do you qualify for charity care?
Each hospital system, whether nonprofit or for-profit, has a financial assistance program. It is not something that hospitals routinely tell patients about, but you can find the program application and qualifications, as well as the billing policies, on a hospital’s website. The hospitals consider income and sometimes assets to determine eligibility
Martinez explained that Ascension Texas looks at liquid assets that can be converted to cash within a year, including bank accounts and investments; real estate that is not the primary home; and recreational vehicles, motorcycles, boats or non-essential cars. Retirement accounts that cannot be drawn down without a penalty, such as a 401(k) are not considered.
Both Pineda and Musignac did not realize they qualified for assistance until they foundDollar For, a nonprofit that helps patients fill out hospital financial assistance applications and guides them through the process of talking to hospitals about their need for assistance.
We looked at Central Texas’ three largest hospital systems: St. David’s HealthCare, Ascension Texas and Baylor Scott & White. Sometimes the hospitals within these systems can have different policies, but most of the time they are the same
Charity care often does not apply to the doctors or medical services such as radiation that are provided by vendors that have hospital privileges but do not directly work for the hospital. Each health system has a list of which doctors and companies are covered by its charity care program.
- People making less than or equal to 250% of the federal poverty level could qualify for 100% coverage.
- People making between 250% and 400% of the federal poverty level could qualify for a sliding scale ranging from 95% to 85% assistance.
- People making more than 400% of the federal poverty level could qualify if they have excessive medical debt.
- People making less than or equal to 200% of the federal poverty level could qualify for 100% coverage.
- People making between 200% and 500% of the federal poverty level could qualify for bill reductions if medical bills after insurance coverage exceed 5% of their yearly household income.
- People making less than or equal to 200% of the federal poverty level for could qualify for 100% coverage.
- People making between 200% and 500% of the federal poverty level could qualify for a discount between 40% and 90% if all medical bills after insurance coverage exceed 10% of their yearly household income.
- People who have an abnormally large catastrophic account balance could receive a discount to reduce bills to between 10% and 40% of their annual income.
Are there discounts available?
If you are uninsured, health care providers often will apply an uninsured discount that is closer to the negotiated rates they give to insurance companies or a percentage of the amount generally billed for that service
You also might be able to negotiate a discount if you can pay a bill in full. Sometimes those discounts can be as much as 20% to 30%.
What if I cannot pay the bill all at once?
Ask for a payment plan. These plans are interest-free. “Our financial counselors work directly with patients to review their individual circumstances and help identify solutions that make payments more manageable,” Millweard said.
Do whatever you can to avoid taking out a loan or putting the bill on a credit card to avoid paying interest. Most providers would rather you pay something in installments rather than sell your debt for pennies on the dollar to a collection agency
When can I be sent to collections?
According to Texas law, health care providers cannot send patients to collections unless they have sent the patient an itemized bill written in plain language first. Patients must request that bill in writing for this law to apply
Healthcare providers in Texas also have to send a bill by the first day of the 11th month after the services were provided or within the terms laid out by your insurance plan. If they do not, they cannot collect from you, but they can bill your insurance and try to collect that way.
Nonprofit hospitals, which include Baylor Scott & White and Ascension Texas hospitals, cannot take any “extraordinary collection actions,” such as sending the bill to a collection agency, until 120 days after you received the first bill after discharge. The hospital also has to send you a final written notice, make you aware of financial assistance programs and wait 30 days after that final written notice before sending you to collections
Ascension Texas said it waits 150 days before sending a bill to a collection agency. “We do not pursue extraordinary collections actions,” Martinez said.
Baylor Scott & White said: “We do not report patient payment activity to credit agencies, file liens against personal property, or garnish wages for non-payment.”
For-profit hospitals can set their own policies, but most wait at least 90 days before sending you to collections. St. David’s HealthCare did not respond to questions about its billing, financial assistance and collections practices
Will medical debt affect my credit rating?
The three credit reporting bureaus came to an agreement in 2022 to not put medical debt on a credit report until a year has passed from the time a bill collector receives it. They also agreed in 2023 to not put medical bills of less than $500 on your credit report
These policies are being done on a voluntary basis after an attempt to make them federal law was overturned in 2025.
Medical debt does not weigh as heavily as other debts on your credit report. This is why you want to pay credit cards, car payments, mortgage or rent payments before you pay medical bills.
If you put your medical bill on a credit card, take out a loan or put it on a medical credit card like CareCredit, it is no longer seen as medical debt and can be reported to the credit bureaus immediately and can impact your credit rating like any other bill
Finding help with medical bills
Both Musignac and Pineda say they did not know about the ree programs. Musignac called 211 to search for any assistance programs and was referred to Dollar For. Pineda found Dollar For on Instagram.
Pineda didn’t qualify for financial assistance through St. David’s, but she was able to have St. David’s contact her insurance company to reduce her bill by almost half, to $579, by correcting a mistake. She also was able to negotiate a $75-per-month payment plan and has fully paid the bill
With both Ascension Seton and Dell Seton, Pineda qualified for a 90% discount on her $1,164 Dell Seton bill and paid $116, and an 85% discount on the $454 Ascension Seton bill and paid $68. She was refunded her original co-pay.
“Thank God for Dollar For,” Pineda said. “I did not have to go through my entire savings.”
Musignac qualified for assistance through St. David’s South Austin and had her bill covered in full by St. David’s assistance program
When she found out that her application had been approved, “I was jumping for joy,” she said. “I yelled out loud. I was so happy and grateful and blessed. I have a little bit of tears. I feel overjoyed and undeserving. It was really kind and glad I sought that help.”
