Sliding Fee Discount Program

• Sliding fee discount program (SFDP) policies.
• SFDP procedures.
• Sliding fee discount schedule (SFDS), including any SFDSs that differ by service or service delivery method.
• Any related policies, procedures, forms and materials that support the SFDP (for example, registration and scheduling, financial eligibility, screening, enrollment, patient notifications, billing and collections).
• For health centers that choose to have a nominal charge for patients with incomes at or below 100 percent of the FPG:
  • Documentation that the nominal charge was set at a level that would be nominal from the perspective of patients with incomes at or below 100 percent of the FPG. For example, based on input from patient board members, patient surveys, advisory committees, or a review of co-pay amounts associated with Medicare and Medicaid for patients with comparable incomes.
  • Documentation that shows each nominal charge does not reflect the actual cost of the service being provided.
  • If the board-approved SFDP policy does not state a specific amount for each nominal charge or how each nominal charge is determined: Other documentation of board involvement in setting the amount of each nominal charge (for example, board minutes, reports).
    
     

• Sample of 5–10 records, files, or other forms of documentation of patient income and family size. Ensure the sample includes records for: 

  • Uninsured and insured patients; and
  • Initial assessments for income and family size as well as re-assessments. 
• For any service delivered via Column II (whether or not the service is also delivered via Column I and/or Column III): At least one but no more than three written contracts/agreements for EACH Required and EACH Additional Service. Provide any other supporting documentation showing how the health center ensures sliding fee discounts for those selected services.
  
  Note: Use the same sample of contracts/agreements for the review of Required and Additional Health Services, Clinical Staffing, and Sliding Fee Discount Program. The sampling methodologies for Sliding Fee Discount Program are different from Contracts and Subawards and Conflict of Interest, even though they may result in some overlap in the contracts/agreements reviewed.

• For any service delivered via Column III (whether or not the service is also delivered via Column I and/or Column II): At least one but no more than three written referral arrangements for EACH Required and EACH Additional Service. Provide any other supporting documentation showing how the health center ensures sliding fee discounts for those selected services.
  
  Note: Use the same sample of referral arrangements for the review of Required and Additional Health Services, Clinical Staffing, and Sliding Fee Discount Program.
• If the health center is subject to legal or contractual restrictions applicable to sliding fee discounts for patients with third-party coverage: Documentation of such restrictions.
• Data, reports, or any other relevant materials used to evaluate the SFDP. 

The health center has a sliding fee discount program (SFDP)¹ that applies to all required and additional health services² within the HRSA-approved scope of project for which there are distinct fees.³

Site Visit Team Methodology

• Interview health center staff involved in implementing SFDP policies (for example, key management staff, eligibility and outreach staff, front desk staff, billing staff, office manager, case managers) including a walk-through of the SFDS screening and enrollment process.
• Review the health center’s SFDP policies, procedures, and all sliding fee discount schedules. 
• Review any related policies, procedures, forms, and materials that support the SFDP.
• Review the health center’s Form 5A. 
• For services provided via Column II or Column III, review the same documentation (policies, procedures, forms, and materials) in elements “i” and “j” to assess sliding fee eligibility.

Site Visit Findings

1. Are ALL services within the approved scope of project:
   • Offered on a sliding fee discount schedule (SFDS) (for Columns I and II); or
   • Offered under any other type of discount (for Column III)?

   Notes:

   • Include any findings about the specific STRUCTURE of the SFDS for services in Columns I, II, and III within elements “c,” “i,” and “j.” 
   • “Services” refers to all Required and Additional services across all service delivery methods on the health center’s Form 5A for which there are distinct fees.
   • Services (for example, transportation, translation, other non-clinical services) on Form 5A that are not billed for in the local health care market may be excluded from the health center’s fee schedules and, therefore, from any health center SFDS.
   • Do not review discounts for supplies and equipment that are related to but NOT included in the service itself as part of prevailing standards of care (for example, eyeglasses, prescription drugs, dentures). These supplies and equipment are not considered services and are not subject to Health Center Program SFDP requirements.

   Response is either: Yes or No

   If No, an explanation is required, including specifying which in-scope services are excluded from sliding fee discounts or any other type of discount.

2. FOR ANY REQUIRED OR ADDITIONAL SERVICE (COLUMN I, II, OR III) WITHIN THE HRSA-APPROVED SCOPE OF PROJECT: Are there any patients with incomes at or below 200 percent of the Federal Poverty Guidelines (FPG) who are not eligible for the sliding fee discount program?

   Response is either: Yes or No

   If Yes, an explanation is required, including specifying why those patients are not eligible.

The health center has board-approved policy(ies) for its SFDP that apply uniformly to all patients and address the following areas:

• Definitions of income⁴ and family;
• Assessment of all patients for sliding fee discount eligibility based only on income and family size, including methods for making such assessments;
• The manner in which the health center’s SFDS(s) will be structured in order to ensure that patient charges are adjusted based on ability to pay; and
• Only applicable to health centers that choose to have a nominal charge for patients at or below 100 percent of the FPG: The setting of a flat nominal charge(s) at a level that would be nominal from the perspective of the patient (for example, based on input from patient board members, patient surveys, advisory committees, or a review of co-pay amount(s) associated with Medicare and Medicaid for patients with comparable incomes) and would not reflect the actual cost of the service being provided.⁵

Site Visit Team Methodology

• Interview board members and key management staff about the health center’s SFDP policies.
  
  Note: Interviews may be conducted in collaboration with the governance/administrative expert.

•  Review the health center’s SFDP policies. Review any other related policies, procedures, and materials that support the SFDP.
  
  Note: This may be combined with the policy review conducted for element “a.”

• For health centers that choose to have a nominal charge for patients with incomes at or below 100 percent of the FPG: 

  • Review the documentation that the nominal charge was set at a level that would be nominal from the perspective of patients with incomes at or below 100 percent of the FPG. For example, based on input from patient board members, patient surveys, advisory committees, or a review of co-pay amounts associated with Medicare and Medicaid for patients with comparable incomes.
  • Review the documentation that shows each nominal charge does not reflect the actual cost of the service being provided.
  • If the SFDP policy does not state the specific amount of each nominal charge or how each nominal charge is determined, review other documentation of board involvement in setting the amount of each nominal charge (for example, board minutes, reports).

Site Visit Findings

3. Does the health center’s SFDP policy include language or provisions that address all of the following:
   • 3.1 The policy applies uniformly to all patients?

     Response is either: Yes or No

   • 3.2 The definitions of income and family (or “household”)? For example, what the health center includes or does not include in the definitions.

     Response is either: Yes or No

   • 3.3 The methods for assessing patient eligibility based only on income and family size?

     Response is either: Yes or No

   • 3.4 The way each SFDS is structured to ensure charges are adjusted based on ability to pay? For example, the policy addresses that flat fee amounts differ across discount pay classes or that there is a graduated percent of charges for patients with incomes above 100 percent and at or below 200 percent of the FPG.

     Response is either: Yes or No

   • 3.5 The setting of any nominal charges for patients with incomes at or below 100 percent of the FPG?

     Note: Select “Not Applicable” if the health center does not charge patients with incomes at or below 100 percent of the FPG.

     Response is: Yes, No, or Not Applicable

   If No was selected for any of the above, an explanation is required.

4. Does the health center’s SFDP policy ensure that any charges for patients with incomes at or below 100 percent of the FPG are: 
   • 4.1 A flat fee?

     Response is: Yes, No, or Not Applicable

   • 4.2 Nominal from the perspective of patients with incomes at or below 100 percent of the FPG? For example, based on input from patient board members, patient surveys, advisory committees, or a review of Medicare and Medicaid co-pay amounts for patients with comparable incomes.

     Response is: Yes, No, or Not Applicable

   • 4.3 Not based on the actual cost of the service?

     Response is: Yes, No, or Not Applicable

   If No was selected for any of the above, an explanation is required.

For services provided directly by the health center (Form 5A: Services Provided, Column I), the health center’s SFDS(s) is structured consistent with its policy and provides discounts as follows:

• A full discount is provided for individuals and families with annual incomes at or below 100 percent of the current FPG, unless a health center elects to have a nominal charge, which would be less than the fee paid by a patient in the first sliding fee discount pay class above 100 percent of the FPG.
• Partial discounts are provided for individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the current FPG, and those discounts adjust based on gradations in income levels and include at least three discount pay classes.⁶
• No discounts are provided to individuals and families with annual incomes above 200 percent of the current FPG.⁷

Site Visit Team Methodology

• Review the structure of the health center’s SFDSs for Column I services. 
  
  Note: For health centers that use multiple SFDSs, review the structure of each SFDS including any nominal charges.
• Interview key management staff about the health center’s SFDSs for Column I services. 

Site Visit Findings

When responding to the question(s) below, please note:

The questions relate to services provided directly by the health center (Form 5A, COLUMN I).

5. For patients with incomes at or below 100 percent of the FPG, does the health center’s SFDS: 
   
   Notes: For a health center with more than one SFDS:
   • If some SFDSs provide a full discount and other SFDSs have a nominal charge, then answer “Yes” to both sub-bulleted questions.
   • If ANY of the SFDSs fail to provide a full discount OR a nominal charge, select “No” to both sub-bulleted questions.
   • 5.1 Provide a full discount (no nominal charge)?

     Response is either: Yes or No

   • 5.2 Require only a nominal charge (“fee”)?

     Response is either: Yes or No

   If No was selected for BOTH of the above, an explanation is required.

6. If the health center has nominal charges, are the nominal charges less than the fees paid by patients in the first sliding fee discount pay class above 100 percent of the FPG?

   Response is: Yes, No, or Not Applicable

   If No, an explanation is required.

7. For patients with incomes above 100 percent and at or below 200 percent of the FPG, do the SFDSs:
   • Provide partial discounts adjusted in accordance with gradations in income levels (i.e., as patient income increases, the discounts decrease accordingly); and
   • Consist of at least three discount pay classes?

   Response is either: Yes or No

   If No, an explanation is required.

8. For patients with incomes above 200 percent of the FPG, are the SFDSs structured so that these patients are not eligible for a sliding fee discount under the Health Center Program?

   Note: Health centers that provide discounts to patients with incomes above 200 percent of the FPG may do so, as long as these discounts are supported through other funding sources (for example, Ryan White Part C award).

   Response is either: Yes or No

   If No, an explanation is required.

For health centers that choose to have more than one SFDS, these SFDSs would be based on services (for example, having separate SFDSs for broad service types, such as medical and dental, or distinct subcategories of service types, such as preventive dental and additional dental services) and/or on service delivery methods (for example, having separate SFDSs for services provided directly by the health center and for in-scope services provided via formal written contract) and no other factors.

Site Visit Team Methodology

• If the health center has more than one SFDS:
  • Review each SFDS and the basis for the separate discount schedules.
  • Interview key management staff about the multiple SFDSs. 

Site Visit Findings

9. Does the health center have more than one SFDS?

   Response is either: Yes or No

10. IF YES: Is each SFDS based either on service or service delivery method and no other factors? For example, no SFDS is based on patient insurance status, location of site, patient characteristics, or other patient demographics. 

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required.

The health center’s SFDS(s) has incorporated the most recent FPG.

Site Visit Team Methodology

• Review the SFDSs for income ranges and family size.
• Review the current FPG and related resources.

Site Visit Findings

11. Based on the review of the health center’s current SFDSs, does the health center incorporate the current FPG in the calculations for all of the discount pay classes?

    Response is either: Yes or No

    If No, an explanation is required.

The health center has operating procedures for assessing/re-assessing all patients for income and family size consistent with board-approved SFDP policies.

Site Visit Team Methodology

• Interview health center staff involved in implementing SFDP policies (for example, key management staff, eligibility and outreach staff, front desk staff, billing staff, office manager, case managers) including a walk-through of the SFDS screening and enrollment process.
• Review the health center’s SFDP policies, procedures, and all sliding fee discount schedules. Review any related policies, procedures, forms, and materials that support the SFDP.
  
  Note: This may be combined with the policy review conducted for element “a.”

Site Visit Findings

12. Does the health center have operating procedures for assessing and re-assessing all patients, regardless of their insurance status, for income and family size?

    Response is either: Yes or No

    If No, an explanation is required.

13. Are these procedures consistent with the board-approved policy for the SFDP?

    Response is either: Yes or No

    If No, an explanation is required.

The health center has records of assessing/re-assessing patient income and family size except in situations where a patient has declined or refused to provide such information.

Site Visit Team Methodology

• Review the sample of records, files, or other forms of documentation of patient income and family size. The health center will specifically provide a sample that includes records for:
  • Uninsured and insured patients; and
  • Initial assessments for income and family size as well as re-assessments.
• Interview key management staff about the health center’s assessment, re-assessment, and documentation of patient income and family size. 

Site Visit Findings

14. Did the review of the sample indicate that the health center is consistently assessing and re-assessing patient income and family size?

    Response is either: Yes or No

    If No, an explanation is required.

The health center has mechanisms for informing patients of the availability of sliding fee discounts (for example, distributing materials in language(s) and literacy levels appropriate for the patient population, including information in the intake process, publishing information on the health center’s website).

Site Visit Team Methodology

• Participate in site tours.
• Interview key management staff about the health center’s mechanisms for informing patients of sliding fee discounts. Interview health center staff involved in informing patients of sliding fee discounts (for example, eligibility and outreach staff, front desk staff, billing staff, office manager, case managers).
• Review the mechanisms (for example, health center signage, health center website or social media, patient brochures) for informing patients.

Site Visit Findings

15. Based on site tours, interviews, and review of related materials, does the health center have mechanisms for informing patients of the availability of sliding fee discounts and how to apply for these discounts?

    Response is either: Yes or No

    If No, an explanation is required.

For in-scope services provided via contracts (Form 5A: Services Provided, Column II, Formal Written Contract/Agreement), the health center ensures that fees for such services are discounted as follows:

• A full discount is provided for individuals and families with annual incomes at or below 100 percent of the current FPG, unless a health center elects to have a nominal charge, which would be less than the fee paid by a patient in the first sliding fee discount pay class above 100 percent of the FPG.
• Partial discounts are provided for individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the current FPG, and those discounts adjust based on gradations in income levels and include at least three discount pay classes.
• No discounts are provided to individuals and families with annual incomes above 200 percent of the current FPG.

Site Visit Team Methodology

• Interview health center staff involved in administering contracts for services.
• For any service delivered via Column II (whether or not the service is also delivered via Column I and/or Column III), review at least one but no more than three written contracts/agreements for EACH Required and EACH Additional Service.

  Notes:

  • Use the same sample of contracts/agreements for the review of  Required and Additional Health Services, Clinical Staffing, and Sliding Fee Discount Program. The sampling methodologies for Sliding Fee Discount Program are different from Contracts and Subawards and Conflict of Interest, even though they may result in some overlap in the contracts/agreements reviewed.
  • The fiscal expert may wish to collaborate with the clinical expert on this review because the same sample is used in Required and Additional Health Services and Clinical Staffing.
  • If the health center does not ensure sliding fee discounts through provisions in the contracts/agreements, review any other documentation (for example, documentation that patients are billed under the health center’s compliant SFDP) provided by the health center showing how the health center ensures such discounts.  

Site Visit Findings

When responding to the question(s) below, please note:

• The questions relate to services provided via contracts (Form 5A, Column II).
• Services (for example, transportation, translation, other non-clinical services) on Form 5A that are not billed for in the local health care market may be excluded from the health center’s fee schedules and, therefore, from any health center SFDS.

16. Does the health center provide services via contracts/agreements (Form 5A, Column II)?

    Response is either: Yes or No

17. For patients receiving services through these contracts/agreements, does the health center ensure sliding fee discounts are provided in a manner that meets all Health Center Program requirements? For example, the health center applies its own SFDS to eligible patients’ fees; a contract contains specific sliding fee provisions; contracted services are provided by another health center which uses an SFDS that meets all Health Center Program requirements. 

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required.

18. For patients with incomes at or below 100 percent of the FPG, the health center ensures that such patients are:
    
    Notes:
    • If some SFDSs provide a full discount and other SFDSs have a nominal charge, then answer “Yes” to both sub-bulleted questions.
    • If ANY of the SFDSs fail to provide a full discount OR a nominal charge, select “No” to both sub-bulleted questions.
    • 18.1 Provided a full discount (no nominal charge)?

      Response is: Yes, No, or Not Applicable

    • 18.2 Assessed a nominal charge (“fee”)?

      Response is: Yes, No, or Not Applicable

    If No was selected for BOTH of the above, an explanation is required.

19. If there are nominal charges, are the nominal charges less than the fees paid by patients in the first sliding fee discount pay class above 100 percent of the FPG?

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required.

20. For patients with incomes above 100 percent and at or below 200 percent of the FPG, do the SFDSs:
    • Provide partial discounts adjusted in accordance with gradations in income levels (i.e., as patient income increases, the discounts decrease accordingly); and
    • Consist of at least three discount pay classes?

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required.

21. For patients with incomes above 200 percent of the FPG, are the SFDSs structured so that these patients are not eligible for a sliding fee discount under the Health Center Program?

    Note: Health centers that provide discounts to patients with incomes above 200 percent of the FPG may do so, as long as these discounts are supported through other funding sources (for example, Ryan White Part C award).

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required.

For services provided via formal referral arrangements (Form 5A: Services Provided, Column III), the health center ensures that fees for such services are either discounted as described in element “c” above or discounted in a manner such that:

• Individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the FPG receive an equal or greater discount for these services than if the health center’s SFDS were applied to the referral provider’s fee schedule; and
• Individuals and families at or below 100 percent of the FPG receive a full discount or a nominal charge for these services.

Site Visit Team Methodology

• Interview health center staff involved in administering referral arrangements for services.
• For any service delivered via Column III (whether or not the service is also delivered via Column I and/or Column II), review at least one but no more than three written referral arrangements for EACH Required and EACH Additional Service.

  Notes:

  • Use the same sample of referral arrangements for the review of Required and Additional Health Services, Clinical Staffing, and Sliding Fee Discount Program.
  • The fiscal expert may wish to collaborate with the clinical expert on this review because the same sample is used in Required and Additional Health Services and Clinical Staffing.
  • If the health center does not ensure sliding fee discounts through provisions in the referral arrangements, review other documentation (for example, a compliant charity care policy) showing how the health center ensures such discounts.

Site Visit Findings

When responding to the question(s) below, please note:

• The questions relate to services provided via formal referral arrangements (Form 5A, Column III).
• Services (for example, transportation, translation, other non-clinical services) on Form 5A that are not billed for in the local health care market may be excluded from the health center’s fee schedules and, therefore, from any health center SFDS.

22. Does the health center provide services via formal referral arrangements (Form 5A, Column III)?

    Response is either: Yes or No

23. For patients receiving services through these referral arrangements, does the health center ensure sliding fee discounts are provided in a manner that meets the structural requirements noted in element “c”?

    Response is: Yes, No or Not Applicable

24. IF NO: For patients receiving services through these referral arrangements, does the health center ensure sliding fee discounts are provided in a manner such that:
    • Individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the current FPG receive an equal or greater discount (“good deal”) for these services than if the health center’s SFDS were applied to the referral provider’s fee schedule (for example, health center has a referral arrangement with organizations that charge no fee at all for patients with incomes at or below 200 percent of the FPG); and
    • Individuals and families with incomes at or below 100 percent of the current FPG receive a full discount or a nominal charge for these services?

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required, including describing the format and type of any discounts provided.

Health center patients who are eligible for sliding fee discounts and have third-party coverage are charged no more for any out-of-pocket costs than they would have paid under the applicable SFDS discount pay class.⁸ Such discounts are subject to potential legal and contractual restrictions.⁹

Site Visit Team Methodology

• Interview health center staff involved in implementing SFDP policies (for example, key management staff, eligibility and outreach staff, front desk staff, billing staff, office manager, case managers) including a walk-through of the SFDS screening and enrollment process.
• Review the health center’s SFDP policies, procedures, all sliding fee discount schedules.
• Review any related policies, procedures, forms, and materials that support the SFDP.
  
  Note: This may be combined with the policy review conducted for element “a.”
• Interview relevant health center staff to determine whether the health center is subject to legal or contractual restrictions applicable to sliding fee discounts for patients with third-party coverage. If so, review the specific documentation of the restrictions.

Site Visit Findings

25. Based on interviews and a review of related documents, does the health center ensure that patients who are eligible for sliding fee discounts and who have third-party coverage are charged no more for any out-of-pocket costs (for example, deductibles, co-pays, and services not covered by the plan) than they would have paid under the applicable SFDS discount pay class?

    Response is either: Yes or No

    If No, an explanation is required, including describing any legal or contractual restrictions that the health center has documented.

The health center evaluates, at least once every 3 years, its SFDP. At a minimum, the health center:

• Collects utilization data that allows it to assess the rate at which patients within each of its discount pay classes, as well as those at or below 100 percent of the FPG, are accessing health center services;
• Utilizes this and, if applicable, other data (for example, results of patient satisfaction surveys or focus groups, surveys of patients at various income levels) to evaluate the effectiveness of its SFDP in reducing financial barriers to care; and
• Identifies and implements changes as needed.

Site Visit Team Methodology

• Interview health center staff involved in evaluating the SFDP.
• Interview board members and key management staff about the health center’s evaluation of its SFDP. 
  
  Note: Interviews may be conducted in collaboration with the governance/administrative expert.
• Review the data, reports or any other relevant materials used to evaluate the SFDP.

Site Visit Findings

26. Does the health center evaluate the effectiveness of the SFDP in reducing financial barriers to care?

    Response is either: Yes or No

    If No, an explanation is required.

27. IF YES: Is this evaluation conducted at least once every 3 years?

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required.

28. Does the health center collect utilization data to assess whether patients within each of its discount pay classes are accessing health center services?

    Response is either: Yes or No

    If No, an explanation is required.

29. IF YES: Does the health center use these data or other data, such as collections or patient survey data, to evaluate the effectiveness of its SFDP? 

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required.

30. Has the health center implemented any follow-up actions based on evaluation results? For example, improved sliding fee eligibility screening, enhanced notification methods for sliding fee discounts, or board changes to SFDP policy. 

    Response is either: Yes or No

    If No, an explanation is required.