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 Consultantirene@nnoha.org

Candace Owen, RDH, MS, MPHNNOHA Education Directorcandace@nnoha.org

National Network for Oral Health Access181 E 56th Avenue, Suite 401Denver, CO 80216Phone: (303) 957-0635Fax: (866) 316-4995info@nnoha.org