Health Center Program Compliance Frequently Asked Questions (FAQ)

This question relates to Element d. Multiple Sliding Fee Discount Schedules

Yes, a health center can have multiple SFDSs. However, if a health center has more than one SFDS, each SFDS would be based either on a service type or on a service delivery method.

• Examples of a SFDS based on service type: 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.

• Examples of a SFDS based on service delivery method: Having separate SFDSs for services provided directly by the health center and for services provided via formal written contract.

For each SFDS, eligibility for sliding fee discounts, including any nominal charges, would be applied uniformly to all patients and would be based solely on income and family size. In addition, the health center would evaluate the effectiveness of each SFDS, including any SFDSs based on current procedural terminology (CPT) codes, in reducing financial barriers to care.

In addition, each SFDS would be consistent with the SFDP requirements in the Health Center Program Compliance Manual Chapter 9: Sliding Fee Discount Program.

(Added: 3/8/2023)

This question relates to Element b. Sliding Fee Discount Program Policies and Element d. Multiple Sliding Fee Discount Schedules

A health center cannot establish different nominal charges within the same sliding fee discount schedule (SFDS).

However, if a health center has multiple SFDSs, a health center can establish a nominal charge for each SFDS.

Any nominal charge set up by the health center would be:

• A flat amount;
• Set at a level that is nominal from the perspective of the patient; and
• Not reflect the actual cost of the service being provided.

As a reminder, nominal charges are not "minimum fees," "minimum charges," or "co-pays."

Eligibility for sliding fee discounts, including any nominal charges, would be applied uniformly to all patients and would be based solely on income and family size.

(Added: 3/8/2023)

This question relates to Element d. Multiple Sliding Fee Discount Schedules

No, a health center cannot have different SFDSs that vary between in-scope health center sites.

However, health centers are permitted to take into account locally prevailing rates or charges, which may vary between sites (for example, at an urban site versus a rural site). Those rates or charges determine the fee schedules. The health center applies the SFDS to the fee schedules. Therefore, this may result in differences in the amounts charged to patients, depending on the site where they receive care.

For any SFDS, eligibility for sliding fee discounts, including any nominal charges, would be applied uniformly to all patients and would be based solely on income and family size.

For more information, refer to the Health Center Program Compliance Manual Chapter 16: Billing and Collections.

(Updated: 10/24/2023)

This question relates to Element d. Multiple Sliding Fee Discount Schedules

No, a health center cannot have different SFDSs that vary by special populations. Eligibility for sliding fee discounts, including any nominal charges, would be applied uniformly to all patients and would be based solely on income and family size. Eligibility for sliding fee discounts cannot be based on whether a patient is identified as being part of a "special population" or any other demographic category.

(Added: 3/8/2023)

This question relates to Element d. Multiple Sliding Fee Discount Schedules

No, a health center cannot have a different SFDS for telehealth services. However, if the locally prevailing charges or the actual costs for services delivered via telehealth differ from those delivered in-person, a health center may have different charges for those telehealth services on the center's fee schedule. The health center applies the SFDS to the fee schedule.

For example, when the cost of providing a primary health care visit through telehealth is less than an in-person visit, the health center may establish a lower charge for the telehealth primary care visit on the health center's fee schedule. If a health center has a percentage-based SFDS, the health center would apply that SFDS to the charge for the telehealth primary care visit, which would be the same SFDS percentage discount applied to an in-person primary care visit. This would result in a lower charge to the patient for the telehealth primary care visit.

As a reminder, nominal charges are set up to be a flat amount; nominal from the perspective of the patient; and not reflective of the actual cost of the service being provided. Therefore, nominal charges do not change based on the fee schedule.

For more information, refer to the Health Center Program Compliance Manual Chapter 16: Billing and Collections.

(Added: 3/8/2023)

This question relates to Element j. Sliding Fee for Column III Services

Whether the referral provider has to offer a discount that is equal to or greater than the health center's sliding fee discount depends on the discounts offered by the Column III referral provider. The referral provider does not have to use the same sliding fee discount schedule as the health center. Instead, a health center would demonstrate compliance with sliding fee discount program requirements for a Column III referral service through the following:

1. The health center ensures that the referral provider's sliding fee discount schedule (SFDS) meets all Health Center Program Compliance Manual Chapter 9: Sliding Fee Discount Program Element "c" requirements. In this case, the referral provider's discount does not have to be equal to or greater than the health center's sliding fee discount.

   For example: A health center provides a full discount to patients with incomes at or below 100 percent of the current Federal Poverty Guidelines (FPG) and, for patients with incomes above 100 percent but at or below 200 percent of the current FPG, the health center's SFDS includes four discount pay classes based on gradations in patient income levels.

   The health center has an arrangement with a referral provider who provides obstetrical services for health center patients. For patients with incomes at or below 100 percent of the current FPG, the referral provider applies a nominal charge. For patients with incomes above 100 percent but at or below 200 percent of the current FPG, the referral provider's SFDS includes three discount pay classes based on gradations in patient income levels.

   Although the referral provider's discounts may not be equal to or greater than the health center's sliding fee discounts, the referral provider's SFDS meets all Health Center Program SFDS requirements.

OR

2. When the referral provider does NOT offer a discount that meets all Health Center Program Compliance Manual Chapter 9: Sliding Fee Discount Program Element "c" requirements, the health center ensures both of the following:
   • The referral provider's discount offers individuals and families with incomes at or below 100 percent of the current FPG a full discount or a nominal charge for the referral provider's services. The referral provider's nominal charge does NOT have to be equal to or less than that of the health center, as long as the charge is nominal.
   • The referral provider's discount offers individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the current FPG an equal or greater discount for the referral provider's services than if the health center's SFDS were applied to the referral provider's fee schedule. The referral provider is NOT required to have a SFDS that includes at least three discount pay classes between 100 and 200 percent of the current FPG.

   For example: A health center applies a nominal charge for patients with incomes at or below 100 percent of the current FPG and for patients with incomes above 100 percent but at or below 200 percent of the current FPG, the health center's SFDS includes four discount pay classes based on gradations in patient income levels. The health center has an arrangement with a referral provider who provides free diagnostic laboratory services for health center patients with incomes at or below 200 percent of the current FPG. Because health center patients are not paying for the diagnostic laboratory services, the health center has ensured that individuals with incomes above 100 percent and at or below 200 percent of the current FPG receive greater discounts than if the health center's SFDS were applied to the referral provider's fee schedule.

(Added: 3/8/2023)