Chapter 9: Sliding Fee Discount Program

The following points describe areas where health centers have discretion with respect to decision-making or that may be useful for health centers to consider when implementing these requirements:

• The health center determines whether to establish a nominal charge for individuals and families at or below 100% of the FPG.
• The health center determines how to document income and family size in health center records.
• The health center determines whether to take into consideration the characteristics of its patient population when developing definitions for income and family size and procedures for assessing patient eligibility for SFDS. For example, the health center may consider the availability of income documentation for individuals experiencing homelessness, build in cost of living considerations when calculating income, permit self-declaration of income and family size.
• The health center determines how and with what frequency to re-assess patient eligibility for the SFDS.
• The health center determines whether to identify individuals who refuse to provide information on income and family size as ineligible for SFDS.
• The health center determines how to make patients aware of sliding fee discounts (for example, signage, registration process).
• The health center determines:
  • Whether to establish more than three discount pay classes above 100% of the FPG and up to and including 200% of the FPG;
  • What income range to establish for each discount pay class above 100% of the FPG and up to and including 200% of the FPG;
  • What method to use for discounting fees above 100% of the FPG and up to and including 200% of the FPG (for example, percentage of fee, fixed/flat fee per discount pay class); and
  • Whether to establish multiple SFDSs (for example, separate SFDSs for medical services and dental services) including, if appropriate, different nominal charges for each SFDS.

  Footnotes

  1. See Chapter 16: Billing and Collections for more information on waiving or reducing charges due to a patient’s inability to pay.

  2. A health center’s sliding fee discount program consists of the schedule of discounts that is applied to the fee schedule and adjusts fees based on the patient’s ability to pay. A health center’s sliding fee discount program also includes the related policies and procedures for determining sliding fee eligibility and applying sliding fee discounts.

  3. See Chapter 4: Required and Additional Health Services for more information on requirements for services within the scope of the project.

  4. A distinct fee is a fee for a specific service or set of services, which is typically billed for separately within the local health care market.

  5. Income is defined as earnings over a given period of time used to support an individual/household unit based on a set of criteria of inclusions and exclusions. Income is distinguished from assets, as assets are a fixed economic resource while income is comprised of earnings.

  6. Nominal charges are not “minimum fees,” “minimum charges,” or “co-pays.”

  7. For example, a SFDS with discount pay classes of 101% to 125% of the FPG, 126% to 150% of the FPG, 151% to 175% of the FPG, 176% to 200% of the FPG, and over 200% of the FPG would have four discount pay classes between 101% and 200% of the FPG.

  8. See Chapter 16: Billing and Collections, if the health center has access to other grants or subsidies that support patient care.

  9. For example, an insured patient receives a health center service for which the health center has established a fee of $80, per its fee schedule. Based on the patient’s insurance plan, the co-pay would be $60 for this service. The health center also has determined, through an assessment of income and family size, that the patient’s income is 150% of the FPG and thus qualifies for the health center’s SFDS. Under the SFDS, a patient with an income at 150% of the FPG would receive a 50% discount of the $80 fee, resulting in a charge of $40 for this service. Rather than the $60 co-pay, the health center would charge the patient no more than $40 out-of-pocket, consistent with its SFDS, as long as this is not precluded or prohibited by the applicable insurance contract.

  10. Such limitations may be specified by applicable Federal or state programs, or private payor contracts.

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