Policy AD-330 Sliding Fee Discount Program (SFDP)-Sliding Fee Scale (SFS) 2023-02-38

Purpose

The overriding purpose of this policy is to ensure that all Westside Family Healthcare (Westside) patients have access to all services in Westside’s scope of project, regardless of their ability to pay.  It serves to minimize all financial barriers to care for those living below, at, or close to the poverty level.

This policy meets the HRSA Bureau of Primary Care (BPHC) requirements in Chapter 9: Sliding Fee Discount Program (SFDS) of the Health Center Program Compliance Manual, as well as some of the requirements contained in Chapter 16: Billing and Collections.  It also meets the HHS Office of Population Affairs (OPA) requirements in Chapter 3: Title X Program Expectations (Financial Accountability section) of the Title X Program Handbook.

Policy

Westside Family Healthcare (Westside) does not deny care to patients based on their ability to pay.  

Westside has an established Sliding Fee Discount Program (SFDP) that applies to all required and additional health services within the HRSA-approved scope of project for which there are distinct fees, regardless of service type or mode of delivery.  As a component of its SFDP, Westside maintains a Sliding Fee Scale (SFS) that is structured to ensure that patient charges are adjusted based on ability to pay.  In the development and maintenance of its SFS, Westside complies with the HRSA Health Center Program and the OPA Title X Family Planning Program sliding fee discount requirements for patients with incomes at or below 200% of the Poverty Guidelines for HRSA-approved health center services and patients with incomes at or below 250% of the Poverty Guidelines for Title X family planning services, as summarized in Attachment A.

Westside informs all patients of the availability of the SFS through multiple approaches, as described in the procedures below.  The SFS is uniformly applicable to all patients, whether uninsured or insured.  Eligibility for a sliding fee discount is based exclusively on assessment of a patient’s family income and family size, as defined below.  Westside assesses and annually reassesses patients for sliding fee discount eligibility using clear definitions of income and family, appropriate patient-provided documentation, and standardized, consistent procedures for making such assessments, as defined in the procedures below and in the applicable operations manuals and forms listed in Attachment B.  

The SFS is evaluated and updated every calendar year, typically in the first quarter following the release of the updated Poverty Guidelines. Annual SFS review includes evaluation of the nominal fee based on patient survey.  The Westside Board of Directors (Board) reviews and approves the annually updated scale levels and discounts. The full SFDP is evaluated every three years, which includes review and updating of this policy AD-330 and an analysis of fee scale utilization data.  The Board makes recommendations as appropriate and approves all updates to this policy (triennial and otherwise).

It is Westside’s policy to attempt to collect fees for services delineated in the Sliding Fee Scale as a means for sustaining the financial viability of the organization.  In addition, fees demonstrate there is value in the services provided.  Patients who are unable to pay fees at the time of service may qualify for deferred or waived fees, as outlined in the procedures below.  

In the application of its SFPD and SFS, Westside complies with federal civil rights laws and prohibits discrimination on the basis of race, color, national origin, disability, age, religion, conscience, and sex (including gender identity, sexual orientation, and pregnancy).

All Westside staff maintain patient privacy and confidentiality throughout the sliding fee scale process.  

Scope

All Westside patients and all Westside health center locations and operations.  

Site Operations, Enrollment, Finance, Leadership, and Board of Directors (as outlined in the Roles and Responsibilities section).

Definitions

Scope of Project – Defines the service sites, services, providers, service area(s), and target population included in the HRSA-approved Health Center Program project.

Sliding Fee Discount Program (SFDP) – A health center’s SFDP 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 SFDP also includes the related policies and procedures for determining sliding fee eligibility and applying sliding fee discounts.

Sliding Fee Scale (SFS) – A schedule of discounts that is applied to the fee schedule and by which discounts are applied on the basis of the patient’s ability to pay.  (Note that HRSA calls this the Sliding Fee Discount Schedule (SFDS).  SFS is the Westside term for the SFDS.)

Fee Schedule – The schedule of fees or payments for the provision of a health center’s services consistent with locally prevailing rates or charges and designed to cover its reasonable costs of operation.  (Note that procedures for establishing the fee schedule are not discussed in this policy.)

Services – Services refers to all Required Services and Additional Services across all applicable service delivery methods for which there are distinct fees, all of which are listed on the health center’s Form 5A.

Required Services – Services that a health center must provide, as defined by HRSA and in Section 330(b)(1) of the Public Health Service Act.  

Additional Services – Optional services that are defined by HRSA but not required and that may be offered as appropriate to meet the health needs of the population served by the health center.  

Distinct Fee – A distinct fee is a fee for a specific service or set of services (listed on the fee schedule), which is typically billed for separately within the local health care market.

Service Type – Service types (e.g., medical, dental, laboratory, transportation, translation, etc.) are listed within the Required Services and Additional Services categories on HRSA Form 5A.  

Service Delivery Method – One or more of three service delivery methods – referred to as Columns I, II, and III by HRSA – that must be used by health centers to provide each required and additional service in the Scope of Project. Service delivery method(s) (Columns I, II, III) are documented on Form 5A for each Service Type.

Column I – Services provided directly by the health center and for which it pays and bills.

Column II – Services provided on behalf of the health center by another entity via a formal written contract/agreement and for which the health center pays and/or bills.

Column III – Services provided by another entity via a formal written referral arrangement for which the health center does not pay or bill.  Services are paid for or billed by the other entity (the referral provider).

Form 5A – Form 5A: Services Provided is the HRSA form in the HRSA Electronic Handbook (EBH) on which health centers must document all their services (Required and Additional) and service delivery methods (Columns I, II, and III).

Income – 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.  Proof of Income (POI) is determined by Westside using the criteria in the table below.

Poverty Guidelines – The Poverty Guidelines are a simplification of the Poverty Thresholds, which are updated each year by the Census Bureau, and are used for administrative purposes (for instance, determining financial eligibility for certain Federal programs).  The guidelines reflect annual income levels below which a person or family is considered to be living in poverty, and the amounts increase according to the size of the family. The Poverty Guidelines are updated annually by the Department of Health and Human Services (HHS) in the Federal Register and posted as the Office of the Assistant Secretary of Planning and Evaluation (ASPE) Poverty Guidelines.

The HRSA Health Center Program refers to the HHS ASPE Poverty Guidelines (which must be used to develop the schedule of fee discounts for health center services) as the Federal Poverty Guidelines (FPG).

The OPA Title X Program refers to the HHS ASPE Poverty Guidelines (which must be used to develop the schedule of fee discounts for family planning services) as the Federal Poverty Level (FPL).

Nominal Fee – A nominal fee is a flat nominal charge(s) set 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. Nominal charges are not “minimum fees,” “minimum charges,” or “co-pays.”

Procedures

1. Sliding Fee Discount Program (SFDP) Applicability to Health Center Program Services
   1. The Sliding Fee Discount Program (SFDP) is applied to all required and additional services within the HRSA-approved scope of project for which there are distinct fees, regardless of service type or service delivery method.  (See definitions above for terms used in this statement.)
      1. Westside’s in-scope required services and additional services are documented on HRSA Form 5A: Services Provided, which is organized by service type.
      2. The service delivery method(s) for each service type, referred to as Columns I, II, and III (defined above), are documented by Westside on Form 5A: Services Provided.
   2. Aside from the exceptions noted in c below, all in-scope services (i.e., services listed on Form 5A) are either:
      1. Offered on a sliding fee scale (for Columns I and II and option for Column III); or
      2. Offered under another type of discount (option for Column III only).
   3. The Sliding Fee Scale (SFS) is not applicable to:
      1. Services not listed on Westside’s Form 5A (i.e., not in the scope of project);
      2. Services listed on Form 5A that are not billed for in the local health care market, which includes all non-clinical enabling services (e.g., transportation and translation); and
      3. Supplies and equipment that are related to but not included in the underlying service, for example, eyeglasses, prescription drugs, and dentures.
         1. Although Westside lists pharmaceutical services provided through the HRSA 340B Drug Discount Program in Column II on Form 5A (as advised by HRSA), these services are not subject to the HRSA sliding fee scale requirement because pharmaceuticals are considered “supplies” in this context.    

Health Center Program Sliding Fee Scale (SFS)

• 1. Sliding Fee Scale (SFS) Structure
     1. The Westside SFS is maintained as a six-tier scale with five tiers for individuals and families with incomes at or below 200% of the current Poverty Guidelines, covering all family sizes from one to twelve members.
        1. HRSA refers to the Poverty Guidelines as the Federal Poverty Guidelines (FPG).
     2. The six SFS tiers are designated as Scale A to Scale F based on income % of FPG as follows:

• • 1. Fees are adjusted based on a patient’s ability to pay and designated SFS tier as follows:
       1. Scale A individuals and families (incomes at or below 100% of the current FPG) are charged a nominal fee.  
       2. Scale B to E individuals and families (incomes at 101% to 200% of the current FPG) are given partial discounts based on the gradations in income level, with discounts increasing as income % of FPG decreases.
       3. Scale F individuals and families (incomes at 201% and above of the current FPG) receive no discount and are billed the full charge of the service.  
       4. The table below depicts the application of discounts by SFS designation:

• • 1. The nominal fee for Scale A is always:
       1. A flat fee (never a percent of full charge);
       2. Less than the Scale B discounted fee;  
       3. At a level that would be considered nominal from the perspective of Scale A patients; and
       4. Not based on the actual cost of the service being provided.
  1. In development or updating of the Health Center Program SFS, multiple service categories are based on services (e.g., medical, prenatal, dental, preventive dental, etc.) and/or on service delivery methods (e.g., Column I or Column II) and no other factors.
  2. Health Center Program sliding fee discounts are provided on the Westside Sliding Fee Scale for the following service categories (at the time this policy was effective; may change as the SFS changes annually):
     1. Medical and Behavioral Health (including dispensed medications);
     2. Prenatal Care;
     3. Daily Lab Fee;
     4. PPD Placement;
     5. Diabetic Retinal Exam;
     6. Dental Visit (routine care); and
     7. Dental Endodontics and Labs.
        1. Services beyond routine dental care are discounted for both provider services and any dental equipment or supplies needed to complete care.
        2. Patients are provided a cost estimate prior to initiating these services based on the Dental Fees spreadsheet.

1. Title X Program Sliding Fee Scale
   1. Title X SFS Structure
      1. The Title X Sliding Fee Scale (SFS) is maintained as a seven-tier scale with six tiers for individuals and families with incomes at or below 250% of the current Poverty Guidelines, covering all family sizes from one to twelve members.
         1. The OPA refers to the Poverty Guidelines as the Federal Poverty Level (FPL).
      2. The seven SFS tiers are designated as Scale A to Scale G based on income % of FPL as follows:

• • 1. Fees are adjusted based on a patient’s ability to pay and designated SFS tier as follows:
       1. Scale A individuals and families (incomes at or below 100% of the current FPL) are charged no fee.  
       2. Scale B to F individuals and families (incomes at 101% to 250% of the current FPL) are charged set discounted fees based on the gradations in income level, with discounts increasing as income % of FPL decreases.
       3. Scale G individuals and families (incomes at 251% and above of the current FPL) receive no discount and are billed the full charge of the service.  
    2. The table below depicts the application of discounts by Scale designation:

• 1. Title X SFS discounts are provided on the Westside Sliding Fee Scale for the following service categories (at the time this policy was effective; may change as the SFS changes annually):
     1. Family planning visit (medications included);
     2. Depo-Provera contraceptive injection (DEPO); and
     3. Long-acting reversible contraceptive (LARC) placement.

1. Application of the Health Center Program SFS and Title X SFS
   1. When a sliding fee scale-approved patient’s visit is for HRSA-approved in-scope health center services only, the primary Health Center Program SFS is applied for fee determination and billing.
   2. When a sliding fee scale-approved patient’s visit is for Title X family planning services only, the Title X SFS is applied for fee determination and billing.
      1. As in fee structure above, patients receiving only Title X family planning services with family incomes at or below 100% of the FPL are not charged for services received.
      2. Clients receiving only Title X family planning services with family incomes that are between 101% FPL and 250% FPL must be charged in accordance with a specific Title X SFDS based on the client’s ability to pay.
         1. Unemancipated minors who receive confidential Title X family planning services are billed according to the income of the minor (not the parents).
   3. When a sliding fee scale-approved patient’s visit is for both health center services and Title X services, Westside utilizes its health center program discounting schedule (which ranges from 101% to 200% FPL), including collecting one nominal fee for health center services provided to clients with family incomes at or below 100% FPL.
2. Third Party Insurance
   1. Patients with third-party insurance that does not cover, or only partially covers, fees for health center services are eligible (as are all patients) for sliding fee discounts based on family income and family size.
      1. In such cases, subject to contractual limitations, the charge for each sliding fee discount pay class is the maximum amount an eligible patient in that pay class (scale designation) is required to pay for a certain service, regardless of insurance status.  
3. SFS Patient Eligibility and Scale Designation
   1. The sliding fee program is offered to all Westside patients, regardless of whether they have insurance or not.
      1. Patients with third party payor coverage – including private insurance, Medicare, and Medicaid – may apply for the SFS.
   2. Eligibility for a sliding fee discount is based exclusively on assessment of a patient’s family income and family size.
   3. Eligibility for the SFS is not based on insurance status; however, Westside patients who most often request or require the SFS tend to include (but are not limited to):
      1. the uninsured,
      2. the underinsured (e.g., high deductible insurance plan; high co-pays and/or co-insurance; and/or insurance limited to specific types of services), and
      3. those with limited or no dental insurance coverage.
   4. In order to apply for the SFS, patients complete Westside’s Financial Aid Application and provide all required information and documentation.
      1. Notification of Medical and Dental Fees is included with the application.
      2. The application is available in English, Spanish, and Haitian Creole.
   5. Once the Financial Aid Application is completed by the patient and the assessment of income and family size is completed by Westside, patients are designated as:
      1. Scale A, B, C, D, E or F for in-scope Health Center Program services and
      2. Scale A, B, C, D, E, F, or G for Title X Family Planning services, if applicable.  
      3. Scale A to E designations are typically the same for both categories, whereas, for Scales F and G, a patient could fall into Scale F for both categories or into Scale F for health center services and Scale G for family planning services.
   6. Sliding Fee Scale designations for all relevant patients are entered into the practice management (PM) system.
   7. Proof-of-income SFS designations are effective for one year, and all patients assigned a scale on the SFS are reassessed annually.
      1. Reassessment includes review of income annually.
      2. Scale A and B are effective for three months, if the patient qualifies or may qualify for Medicaid.  
   8. Self-declared SFS are effective for three months, with the exceptions discussed below.

Income and Family Composition Determination

• 1. Westside staff use consistent means of determining who is included in a family and what income is counted in order to assign them to a tier on the Sliding Fee Scale.    
  2. Patients must provide information and/or documentation to:
     1. Establish their income level and
     2. Support family member inclusion.  
  3. Patients who are unwilling to provide any level of information and/or documentation are not eligible to participate in the sliding fee discount program and will be required to pay 100% of their charges, until such time as they provide documentation.
  4. Family Composition
     1. Patients self-report their family members, based on guidance provided by Westside. Written documentation is not required.
     2. When confirming family members and determining family size, Westside staff use the following definitions:
        1. Family: An individual, their spouse or partner, and their children under age 19.
           1. Children aged 19 and over are considered separate families.

There may be unusual family circumstances in which an exception is made to the above rule regarding children of age 19 and over.  Such situations are reviewed and approved by the Manager of Enrollment Services.

• • • • 1. Grandparents living with their adult children are also considered separate families.
        2. It is possible to have more than one family living at the same location, but each person can only be on one scale.
        3. If a family is split between locations, each family member can only be on one scale.
      1. Family Size: The total number of individuals in a family, as defined above.
  1. Individual or Family Income
     1. When determining and confirming individual or family income, Westside staff use appropriate sources and acceptable proof of income (POI), as listed in the table below:

Self-Declared Income

• 1. In the absence of acceptable proof of income (POI), patients may self-declare family income for the calculation and designation of a tier on the Sliding Fee Scale.
     1. Exceptions
        1. Prenatal patients are an exception.  Their SFS designation must always be based on POI (to meet requirements of external health care partners providing obstetric services).
           1. If they choose not to provide POI, the prenatal patient is put on Scale F (full charge).
        2. Within the Title X program:
           1. Uninsured patients receiving Title X services only are an exception. They are not required to provide POI and may self-declare their income.
           2. Unaccompanied minors receiving Title X services only are an exception. They are not required to provide POI and their self-declared income is documented as $0.
  2. Westside staff employ a consistent means of collecting self-declared income from patients.
  3. Patients who do not provide acceptable POI for the creation of a new or the renewal of an expired Sliding Fee Scale may submit a Self-Declared Income Form which can then be used to calculate the family Sliding Fee Scale.  
     1. The Self-Declared Income Form provides definitions for income and family members.
        1. Self-declared income is the patient’s honest and reasonable estimate of total family earnings.
     2. The Self-Declared Income Form is completed by a member of the family and signed by the Guarantor and/or patient.
        1. The Guarantor is the individual(s) who is/are responsible for payment of services for any person listed on the account of that Guarantor.
  4. Sliding Fee Scale assignments based on self-declared income must be converted to a proof of income (POI) scale within three (3) months.  If acceptable proof of income is not supplied within three months, the discount will be eliminated.
     1. At all patient / family visits following establishment of a self-declared SFS, a request for POI is made in order to facilitate establishment of a POI-based SFS as soon as possible.
  5. A scale based on self-declared income may not immediately follow another self-declared scale within a 36-month period (i.e., a patient may not renew a self-declared sliding fee scale based on self-declared income).  A proof of income (POI)-based scale must be established after a self-declared income-based scale for discounts to continue.  Patients who have not received discounted services within a 36-month period may re-establish as new patients and receive discounts based on a self-declared income.
     1. Uninsured patients receiving Title X services only are an exception. They are not required to provide POI and will always complete the Self-Declared Income Form.  They are permitted to have back-to-back self-declared SFS.
     2. With the approval of the Manager of Enrollment Services, exceptions are permitted under circumstances in which formal proof of income is not attainable due to the form of payment (cash or unavailable paycheck) or lack of cooperation by the employer.
        1. The Manager of Enrollment Services reports exception data to the Director of Site Operations and the Director of Revenue Cycle.

SFS Evaluation

• 1. Westside evaluates the sliding fee scale annually to ensure that financial barriers to care are minimized.  
  2. During each calendar year, a survey is distributed to Sliding Fee Scale A patients to determine if the nominal fee is affordable from their perspective.  
     1. Additionally, Board member patients may be surveyed for their input.  
     2. If less than 65% of Scale A survey patients agree that the nominal fee is affordable, leadership and the Board will discuss the result and potentially recommend changing the nominal fee.
     3. Using these practices, and others as the Board sees fit, the Board decides whether the nominal fee is nominal (affordable) from the patient’s perspective.
  3. The sliding fee scale is reviewed and revised as necessary annually when the new Poverty Guidelines are released, typically in the first quarter.

Informing Patients of SFS Availability

• 1. All patients are informed about the Sliding Fee Scale (SFS) through multiple mechanisms, including:
     1. upon enrollment as a new patient;
     2. through signage located at waiting areas adjacent to the reception desk;
     3. through patient brochures (including new patient materials);
     4. through information on Westside’s website; and
     5. through trained staff in relevant roles.
  2. Documentation is prepared in Westside’s primary patient languages of English and Spanish.  
     1. For patients speaking other languages, interpretation services are available to review documents over the phone.
     2. Video interpretation is provided for patients communicating in sign language.  

1. Training on the SFS
   1. During New Hire Orientation, all new employees are given an overview of the Sliding Fee Discount Program and Sliding Fee Scale.
   2. Relevant staff – primarily Enrollment Specialists, Patient Service Representatives (PSRs), Office Managers, and Schedulers – are trained on the availability of sliding fee scales and how to apply them.  
      1. As appropriate for their role, these staff are trained to uniformly implement the SFS process and systems.
      2. As appropriate for their role, these staff are trained upon hire and each time procedures are updated.
   3. Relevant operations manuals and forms are summarized in Attachment B: Westside Sliding Fee Scale Operations Manuals and Forms.  
2. Maintenance of Records
   1. Westside retains records of assessing and reassessing patient income and family size and designating in the practice management system, except in situations in which a patient declined or refused to provide such information.
   2. Retained records include, when applicable, the following:
      1. Completed Sliding Fee Scale application / Financial Application
      2. Proof of Income (PIO) documentation
         1. Acceptable documents
         2. Letters of support
      3. Self-Declared Income Form
      4. Fee Waiver Request Form
3. Sliding Fee for Contracted Services (Column II Services)
   1. For in-scope health center services provided via contracts (Form 5A, Column II, Formal Written Contract/Agreement), Westside ensures that fees for such services are discounted for its patients in accordance with the Westside Sliding Fee Scale (SFS) and that eligibility for the SFS is based solely on income and family size.
   2. In its contracting for Column II services, Westside ensures that:
      1. Provisions within the contract ensure application of the SFS and/or
      2. Supporting documentation (such as internal procedures) demonstrate how Westside ensures that appropriate discounts for contracted services are applied.  
4. Sliding Fee or Discount for Referral Services (Column III Services)
   1. For services provided via formal referral arrangements (Form 5A, Column III, Referral Agreement), Westside ensures that fees for such services are either discounted in accordance with the Westside SFS or discounted in a manner such that:
      1. 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 Westside’s SFS were applied to the referral provider’s fee schedule; and
      2. Individuals and families at or below 100 percent of the FPG receive a full discount or a nominal charge for services that is equal to or less than the Westside nominal fee.
   2. In its agreements for Column III referral services, Westside ensures that:
      1. Provisions within the agreement ensure application of the SFS or an equivalent or greater discount arrangement that complies with all eligibility criteria and/or
      2. Supporting documentation (such as internal procedures) demonstrate how Westside ensures that appropriate discounts for referral services are applied.  
5. Policy Review and Update & SFS Utilization Analysis
   1. This policy – AD-330 Sliding Fee Discount Program (SFDP) / Sliding Fee Scale (SFS) – and the procedures contained herein are reviewed and updated, as needed, at least every three years.
   2. With the triennial review of the policy, a SFS utilization analysis is conducted, which includes:
      1. Collecting utilization data that allows Westside to assess the rate at which patients within each of the discounted SFS tiers (Scales B to F), as well as those at or below 100 percent of the FPG (Scale A), are accessing health center services;
      2. Using this utilization data 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 the SFDP in reducing financial barriers to care; and
      3. Identifying and implementing follow-up actions and changes, as needed, based on the evaluation results.
         1. For example, changes to the SFDP/SFS policy or implementation of improved eligibility screening processes or notification methods for sliding fee discounts.
   3. The Board of Directors reviews and approves all updates to this AD-330 SFDP/SFS policy, with the Board Chair as signatory.

 Roles and Responsibilities

• 1. Site Operations
     1. The Director of Site Operations and/or Associate Director of Site Operations distribute the annually updated SFS, ensure that education of Office Managers and Patient Services Representatives (PSRs) is provided, and provide SFDP operations oversight.
     2. The PSR Trainer educates the PSRs on the SFDP program specifications and SFS workflows.
     3. Office Managers (oversight) and Medical and Dental Patient Service Representatives (PSRs) inform patients of the SFS option and provide and complete the SFS application with patients.
     4. Medical and Dental Patient Service Representatives (PSRs) refer patients to enrollment, when appropriate, to determine eligibility for various forms of insurance coverage and/or other assistance programs.
  2. Enrollment
     1. The Manager of Enrollment Services (oversight) and Enrollment Specialists review patient eligibility for various forms of insurance coverage and/or other assistance programs.
     2. Enrollment Specialists perform quality review of a sample of SFSs.  
     3. Enrollment Specialists review prenatal patient eligibility for the Health Center Program and Title X SFSs.
  3. Finance
     1. CFO and Director of Revenue Cycle Management in conjunction with the Director of Site Operations update the SFS annually.
     2. The Director of Revenue Cycle Management ensures that the annual SFS and SFS tier level data are entered into the practice management system.
     3. The Director of Revenue Cycle Management and billing and collections staff bill SFS-qualifying patients based on their assigned SFSs for Health Center Program and the Title X program services.
  4. Board of Directors (Board)
     • 1. The Board reviews SFS and policy AD-330 updates with leadership,  
       2. The Board provides final approval of the annual (or other) update(s) to the SFS.
       3. The Board provides final approval of the triennial (or other) update(s) of policy AD-330.

References

1. HRSA Health Center Program
   1. Sliding Fee Discount Program
      1. Chapter 9: Sliding Fee Discount Program, HRSA Health Center Program Compliance Manual, August 2018.
      2. Sliding Fee Discount Program chapter, HRSA Health Center Program Site Visit Protocol, May 26, 2022.
      3. Federal Regulatory Authority – Section 330(k)(3)(G) of the PHS Act; 42 CFR 51c.303(f), 42 CFR 51c.303(g), 42 CFR 51c.303(u), 42 CFR 56.303(f), 42 CFR 56.303(g), and 42 CFR 56.303(u)
   2. Billing and Collections
      1. Chapter 16: Billing and Collections, HRSA Health Center Program Compliance Manual, August 2018.
      2. Billing and Collections chapter, HRSA Health Center Program Site Visit Protocol, May 26, 2022.
      3. Federal Regulatory Authority – Section 330(k)(3)(E), (F), and (G) of the PHS Act; and 42 CFR 51c.303(e), (f), and (g) and 42 CFR 56.303(e), (f), and (g)
   3. Feldesman Tucker Leifer Fidell (FTLF) document Sliding Fee Discount Program and Related Billing and Collections Checklist

HHS Office of Population Affairs (OPA) Title X Program

• 1. Title X Statutes, Regulations, and Legislative Mandates (https://www.opa.hhs.gov/grant-programs/title-x-service-grants/title-x-statutes-regulations-and-legislative-mandates)
  2. Title X Program Handbook, Chapter 3: Title X Program Expectations, Financial Accountability (https://opa.hhs.gov/sites/default/files/2022-08/title-x-program-handbook-july-2022-508-updated.pdf)
  3. Title X Program Policy Notice, Integrating with Primary Care Providers. OPA Program Policy Notice: 2016-11 - Integrating with Primary Care Providers. November 22, 2016 (https://opa.hhs.gov/grant-programs/title-x-service-grants/about-title-x-service-grants/program-policy-notices/opa-program-policy-notice-2016-11-integrating-with-primary-care-providers)

Integrating Title X with Primary Care: Developing and Implementing Compliant Sliding Fee Discount Schedules Job Aid, Reproductive Health National Training Center (RHNTC) (https://rhntc.org/resources/integrating-title-x-primary-care-developing-and-implementing-compliant-sliding-fee)

HHS, Office of the Assistant Secretary of Planning and Evaluation (ASPE), Poverty Guidelines   (https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines)

ATTACHMENT A:

HEALTH CENTER PROGRAM AND TITLE X PROGRAM

DISCOUNTED FEE REQUIREMENTS¹

HRSA Health Center Program Requirements

The Sliding Fee Discount Program (SFDP) chapter of the HRSA Health Center Program Compliance Manual requires that clients not be denied services due to an inability to pay.  

The SFDP chapter requires implementation of a Sliding Fee Discount Schedule (SFDS) that is applied to individuals and families with annual incomes at or between 101% and 200% of the Federal Poverty Guidelines (FPG).  Note: Westside calls its SFDS the Sliding Fee Scale (SFS).

Individuals and families with annual incomes at or below 100% of the FPG must not be charged unless a health center elects to have a nominal fee, which must be less than the fee in the first SFDS pay class above 100% of the FPG.

OPA Title X Program Requirements

HHS Office of Population Affairs (OPA) requires in the Financial Accountability section of the Title X Program Handbook that individuals and families with annual incomes at or between 101% and 250% of the Federal Poverty Level (FPL) must be charged in accordance with a schedule of discounts based on ability to pay.

Individuals and families with annual incomes at or below 100% of the Federal Poverty Level (FPL) must not be charged.

Title X grantees are responsible for implementing policies and procedures to charge, bill, and collect funds for Title X family planning services provided by sub-recipients and service sites in their networks.  Note: Westside is a Title X sub-grantee of the Delaware DHSS Division of Health.

Health Center Program vs. Title X Requirements

The two notable differences between the programs’ sliding fee scale requirements relate to:

(1) the upper poverty threshold addressed by the fee scale and

(2) charges for individuals and families with incomes at or below 100% of the FPG/FPL.

Note: The Health Center Program requirements reference the Federal Poverty Guidelines (FPG), and the Title X Program requirements reference the Federal Poverty Level (FPL). Both are terms for the HHS ASPE Poverty Guidelines.

Multiple Sliding Fee Scales

The Health Center Program Compliance Manual allows for a health center to have multiple SFDSs for different programmatic services, though it does not mention Title X family planning services specifically.

The Title X Program Policy Notice, Integrating with Primary Care Providers explains that a Title X-funded health center is permitted to utilize its health center SFDS for all services rendered to the client during a non-Title X service or an integrated visit (both family planning services and non-Title X services such as primary care).

The Health Center Program Compliance Manual, Chapter 16: Billing and Collections, Related Considerations states: “If a health center has a funding source that subsidizes or covers all or part of the fees for certain services for specific patients (in accordance with the terms and conditions of such funding sources), the health center may use such funding sources to support discounts greater than those available through the health center’s sliding fee discount program.”  Therefore, current health center program requirements allow for the higher discount threshold required by Title X when only providing Title X family planning services in a health center.

¹Information on Attachment A has been adapted primarily from Integrating Title X with Primary Care: Developing and Implementing Compliant Sliding Fee Discount Schedules Job Aid, Reproductive Health National Training Center (RHNTC)

ATTACHMENT B:  

WESTSIDE SLIDING FEE SCALE (SFS) OPERATIONS MANUALS AND FORMS*

* This list was current on this AD-330 policy’s most recent effective date.  If changes are made to Westside operations/standard operating procedures, the manuals and/or forms utilized may change before the next time this policy is reviewed and updated.