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The Sliding Fee Discount and Nominal Fees: Dental Program Financials Part II
Learning Objectives
Review the history of the sliding fee discount program in health centers
Describe what the nominal fee is Understand the tiered structure of the sliding scale Learn how costs such as dental laboratory fees can
be structured to comply with HRSA regulations
Health Center Program Compliance Manual
August 2017 https://bphc.hrsa.gov/
programrequirements/pdf/healthcentercompliancemanual.pdf
Chapter 9 Chapter 16 Supersedes PIN
2014-02
Requirements
The Health Center must operate in a manner that no patient will be denied service due to an individual's inability to pay.
The Health Center Program must prepare a schedule of fees or payments for the provision of its services consistent with locally prevailing rates or charges and designed to cover its reasonable costs of operation and….
Sliding Fee Discount Requirements
…and must prepare a corresponding schedule of discounts (sliding fee discount scale [SFDS]) to be applied to the payment of such fees or payments by which discounts are adjusted on the basis of the patients ability to pay.
The health center must establish systems for (sliding fee) eligibility determination.
Sliding Fee Discount Requirements
The schedule of discounts must provide for: • Full discount for individuals and families with annual
incomes at or below 100 percent of the Federal Poverty Guidelines (FPG0, except that nominal charges for service may be collected from such individuals and families
• No discount to individuals and families with annual incomes greater than 200 percent of the FPG. These individuals are expected to be charged the Usual and Customary Rate (UCR) for your community ie. the full fee
Authority Section 330 Grant Funding
Section 330(k)(3)(G) of the Public Health Service Act
HRSA health center grants are given to subsidize sliding scale for clients between 100-200% FPL
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Sliding Fee Discount Compliance
The health center SFDP applies to all required and additional health services within the HRSA-approved scope of project
Sliding Fee Discount Compliance
Health center has board-approved policies for the sliding fee discount program that apply uniformly to all patients in the following areas • Definition of income & family; • Assessment of all patients for SFDS based on income &
family size; methods for assessment;• Manner in which the SFDS will be structure (tiered) to
ensure that patient charges and adjusted based on ability to pay;
Nominal Charge
If health center chooses to have a nominal charge for patients at or below 100 of FPG • Must be less than the fee paid by a patient in the first
“sliding fee discount pay class” beginning above 100 percent of the FPG .
• Setting a flat nominal charge at a level that would be nominal from the patient perspective (surveys, comparable populations etc.)
Sliding Fee Discount Compliance
Partial discounts are provided to individuals and families with income above 100% of FPG and at or below 200% of FPG
Those discounts are based in income levels and include at least three discount pay classes
Example of 4 tiers:• 101-125%• 126-150%• 151-175%• 176-200%
Does the Dental SFDS need to be the same asMedical? No Health centers may elect to have multiple SFDS
based on services (broad services, such as medical or dental, or distinct subcategories of service types, such as preventive (required) dental and additional dental services)
The nominal fee may also be different
Patient Eligibility
Health centers must have operating procedures for assessing all patients for income and family size
Health center has mechanisms for informing patients of the availability of sliding fee discount
Health Center & Board Decides…
Nominal fee-yes/no How to document income & family size for SFDS Definitions of income & family size for SFDS How frequently to re-assess eligibility for SFDS How many tiers in the SFDS (minimum 3) Income ranges for tiers Method of discounting within tiers Whether to establish multiple SFDS (ie. Medical &
dental)
Requirements Billing & Collections
Health center must prepare a schedule of fees consistent with locally prevailing charges and designed to cover its reasonable costs of operation
Health center must establish eligibility system Health center must make every effort to collect
reimbursement from Medicaid, CHIP, Medicare, other 3rd
party insurers Health center must make every effort to collect payment
for services from patients
Setting Dental Program Full Fee Schedule
Researching, reviewing and determining charges used by other health care providers in the community for the same or similar services
This information may be available from a number of sources, such as Medicare, Medicaid, private providers, or commercial sources
Don’t sell the program short Monitor & update
Setting Dental Program SFDS Tiers Schedule
An art & a science Must know actual cost for providing required and
additional services. Understanding how the 330 grant fits
Eligibility & Billing Compliance
Educating patients on 3rd party coverage available to them
Systems & operating procedures for billing 3rd party payers
Systems & operating procedures for requesting payment from patients
Eligibility & Billing Compliance
Health centers may have additional billing options or payment methods
Payment plans, grace periods, prompt or cash payment incentives
Eligibility & Billing Compliance
Board-approved policies & operating procedures describing circumstances under which fees or payment may be reduced or waived
Board-approved policies for limiting or denying services based on refusal to pay and inability to pay, and when such patients may be permitted to rejoin the practice
Dental Lab Fees
If a health center provides supplies or equipment that are related to, but not included in, the service itself as part of the prevailing standard of care (eyeglasses, prescription drugs, dentures) and charges for these items, the health center informs patients of such charges (“out of pocket costs”) prior to the time of service
Dental Lab Fees
Lab cost for dentures, partials, crowns, bridges and other appliances may be charged before the SFDS is applied to determine what the final charge to the patient will be• For instance, your lab bill for a denture is $150.00 per
denture. Your Full Fee for the denture is $1000.00. You may charge $150.00 to your lowest SFDS and the full $1000. for the full fee SFDS
• At each level of your SFDS the difference between the lab charge and Full Fee is discounted based on your SFDS policy
Conclusion
Becoming knowledgeable about the financial aspects of your Health Center will help your program become more efficient, productive, and ultimately able to provide more care to the patients in the community.
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Contact Us!Irene V. Hilton, DDS, MPH, FACDNNOHA Dental [email protected]
Candace Owen, RDH, MS, MPHNNOHA Education [email protected]
National Network for Oral Health Access181 E 56th Avenue, Suite 401Denver, CO 80216Phone: (303) 957-0635Fax: (866) [email protected]