Page: 1

Policy #: 8.11
Issued: October 2009
Reviewed/Revised: May 2013, December 2013, March 2015, March 2017,
March 2018, May 2018, March 2019, April 2020, March 2021, December 2021,
March 2022, March 2023, March 2024, July 2024
Section: Finance
SLIDING SCALE DISCOUNT PROGRAM POLICY AND PROCEDURE

Purpose:This purpose of the policy is to provide our patients with the opportunity to apply forfurther financial assistance through the Health Resources and Services Administration(HRSA) Sliding Fee Discount Schedule (SFDS) Policy for all in-scope services that
DotHouse Health (DHH) provides. DHH participates in all programs available to support
the care of patients and to assure maximization of revenue in accordance with Federal
guidelines and requirements.
Policy Statement:
It is the policy of DotHouse Health (DHH) to ensure that all patients seeking care, receive
services regardless of ability to pay. In addition to quality health care, patients are entitled
to financial counseling by someone who can offer potential solutions for those patients
who can’t pay in full. The Financial Counselor at DHH works with the patient andguarantor to find reasonable payment alternatives. On an annual basis, DHH will evaluate
the effectiveness of the SFDP in reducing financial barriers to care by communicating withpatients and DHH staff members most responsible for the policy and procedure
implementation, collecting utilization data by discount pay classes to study theeffectiveness of the SFDP.
DHH will offer s l i d i n g f e e discounts on all services that are within our federal scopeof project. For services within our federal scope but that we do not provide directly(Column III of Form 5A), we will ensure that those eligible patients are offeredcomparable discounts and are not balanced billed. A sliding fee schedule is used to
calculate the basic discount and is updated each year using the most recently approved
Federal Poverty Guidelines. These guidelines are structured using the total annual income
and total number of family or household members residing within a home. DHH will baseprogram eligibility on a person’s ability to pay and will not discriminate based on age,gender identity, race, sexual orientation, creed, religion, disability or national origin.
Notice of the availability of sliding scale discounts will be displayed in a variety oflocations and methods throughout the health center.
A schedule of discounts is available to all eligible individuals and families with annual
incomes at or below 200% of the Federal Poverty Level (FPL), with a full discountavailable to individuals and families with annual incomes 100% and below the FPL.
Patients who

Page: 2

qualify for the sliding fee discount will receive said discount after all third-party
adjudications have been exhausted. Patients at or below 200% of FPL with third party
insurance may be eligible for this discount for services that are not covered through theirinsurance, annual deductibles and co-payments.
The Federal sliding fee scale does not provide for discounts to individuals over 200% of
the Federal Poverty Level. Other state or local programs (e.g. Massachusetts Health
Safety Net Program, a state-funded public program) may provide for other levels of
discounts (e.g. tiered discounts to individuals up to 400% of the Federal poverty level.).
Supplies and Equipment
1. For certain defined Dental and Eye care supplies and equipment, DHH charges fees
based on reasonable costs and to which the SFDS does not apply. Patients who are
considering these services will be informed in advance of their estimated out-of-pocket
fees and associated payment plans.
Federal funds allocated to DotHouse Health will not be utilized for sliding fee discountover the required guidance of 200% FPL.

Interpretation of this policy should be directed to the Chief Financial Officer or designee.
PROCEDURE: The following guidelines are to be followed in providing the Sliding
Fee Discount Program:
1) Notification: DHH will notify patients of the Sliding Fee Discount Program upon
first time registration, advertisements in clinic waiting areas and on the healthcenter’s website and other electronic media (digital signage.)2) Ability to pay: All patients seeking health care services at DHH are assured they
will be served regardless of ability to pay. No one is refused services because of alack of financial means to pay. DHH acknowledges that there is a difference
between ability to pay and refusal to pay (See #11, Refusal to Pay).
3) Request for Discount and Administration: Requests for discounted services may
be made by patients, family members, staff or others who are aware of the existing
financial hardship. Information and forms can be obtained from the Office ofFinancial Counseling.
Sliding Fee Discount Program (SFDP) Coveragea. All patients of DHH are eligible to apply for the SFDP. For patients who have insurance
coverage and who are eligible for the SFDP, the discounts applied through the program
would be applied to patient out-of-pocket expenses, such as copayments and deductibles,for eligible services.
b. For patients who have applied and deemed eligible to participate in the SFDP and who
have health insurance that does not fully or partially cover the DHH’s fees, their out-ofpocket cost-sharing will be reduced/discounted to ensure that the maximum out-of-pocketPage: 3

amount he/she is charged will be the amount he/she would have paid under his/her
respective pay class, subject to any contractual limitations.
c. The SFDP extends to all services provided directly by DHH that are within our federal
scope of project.
d. For services within our federal scope of project that we do not offer directly (Columns II
and III of Form 5A), patients are offered comparable discounts and are not balance billed.
The Sliding Fee Discount Program (S FDP ) procedure will be administered by the
Financial Counselor Manager. Information about the Sliding Fee Discount Program
policy and procedure will be provided and assistance offered for completion of theapplication. Confidentiality will be respected for all who seek and/or provided with thisservice.
4) Completion of Application: A completed application, including required
documentation of home address, family/household size and income, must becompleted in its entirety, on file and approved by the DHH Financial Counselors
in order to initiate the discount. By signing the Sliding Fee Discount Programapplication, persons authorize DHH access in confirming income as disclosed on
the application form. Providing false information on a Sliding Fee DiscountProgram application form will result in all discounts being revoked and the fillbalance of the account(s) restored and payable.
Eligibility date would be the visit date, upon the application’s approval. If an
application is unable to be processed due to need for additional information, theapplicant has two (2) weeks from the date of notification to supply the necessary
information without having the date on their application adjusted. If a patient
doesn’t provide the requested information within the two week time period, theirapplication will be re-dated to the date which they supply the requested
information. Any accounts turned over for collection as a result of the applicant’s
delay in providing the information will not be considered for the Sliding Fee
Discount Program.
All alternative payment sources will be exhausted including all third-party
payment from insurance(s), Federal and State programs.
5) Eligibility:
Discounts will be based on income and family size, only.
a) “Family/Household” is defined as a group of two people or more (one of whomis the householder) related by birth, marriage, or adoption and physically residingin the same home who are the legal responsibility of the guarantor. The guarantor
is the financially responsible person within the household. All such people areconsidered as members of one family.
b) “Income” is defined as earnings over a given period used to support anindividual/household unit based on a set of inclusions, listed as follows:Page: 4•
Earnings•
Supplemental Security Income•
Retirement payments from Social Security or pension or retirement income•
Public assistance•
Short-term or long-term disability payments•
Veterans’ payments•
Survivor benefits•
Unemployment compensation•
Child support payments•
Alimony•
Workers’ compensation•
Income from rental property, interest, dividends and royalties.
•
Income from estates, trusts, and educational assistance.
•
Assistance from outside the household.
Non-cash benefits (such as food stamps and housing subsidies) do not count.
6)

Income Verification
Applicants must provide one (1) of the following documents to support proof ofincome:
•
•
•
•
•
•
•
•

Prior year W-2 or Form 4506-T (if W2 not filed) or Copy of Federal Tax
ReturnCopies of two most recent employment check stubs
Copy of Federal tax return (W-2 only is not acceptable)
Dated letter from employer
Self-employed individuals will be required to submit detail of mostrecent three (3) months of income and expenses for the business.
Dated letter from homeless shelter (contact shelter for verification ofcontinued residency)
Dated letter from head of hold and/or family member where patient resides
Self-declaration (may only be used for the first visit)

If a patient has no means to prove their income, self-declaration may be accepted
for initial visit only. The patient must sign a Self-Declaration Application
guaranteeing the authenticity of this information. This is to be used as last resort
and must be approved by management. Documentation of application of selfdeclaration is noted in patients’ chart.
7)

Discounts: Below is the patient payment amount and discount amount orpercentage according to the sliding fee schedule. However, patients will not
be denied services based on an inability to pay. The sliding fee schedule
will be updated during the first quarter of every calendar year consistent
with the most recent Federal Poverty Guidelines.

FPL Range
100% or Below
101% to 133%134% to 167%
168% to 200%

Patient Charged
Amount:
$
$
$

$0.00
10.00
15.00
20.00

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Discount
100%
Balance other then $10.00 patient pay amount
Balance other then $15.00 patient pay amount
Balance other then $20.00 patient pay amount

8) Waiving of Fees: In certain situations, patients may not be able to pay certain
fees. Waiving of fees may only be used in special circumstances and must be
approved by DHH’s CEO or their designee. Special circumstances may include
but are not limited to patient’s loss of a spouse, being unhoused, living in a
shelter, loss of employment, displaced due to a fire, or a declared emergency or
pandemic. Any waiving of fees should be documented in the patient’s file alongwith an explanation.
9)

Reducing of Fees: In certain situations, patients may not be able to pay certain
fees. Reducing fees may only be used in special circumstances and must be
approved by DHH's CEO or their designee. Special circumstances may include but
are not limited to patient’s loss of a spouse, homelessness, living in a shelter, loss of
employment, displaced due to a fire, or a declared emergency or pandemic. Any
reducing of fees should be documented in the patient's file along with an
explanation.

10)

Applicant determination and notification: DHH will render a conditional orfinal determination of eligibility upon receipt of a signed and completed
application. The Sliding Fee Discount Program determination will provide inwriting and include the percentage of Sliding Fee Discount Program write-off orreason for denial. If the applicant is approved for less than a 100% discount or
denied, the patient and/or responsible party must immediately establish payment
arrangements with DHH. Reapplication for the sliding scale discount must be
submitted annually for approval or anytime there has been a change in family size
or income. Upon approval, DHH will retain the completed paper application for 1
year within the patient’s record.

11)

Refusal to pay:

All patients seeking health care services at DHH are assured they will be served regardlessof ability to pay. No one is refused services because of a lack of financial means to pay.
DHH acknowledges that there is a difference between ability to pay and refusal to pay.
DHH expects patients to pay their outstanding balances in a timely manner. DHH will
notify all patients regarding: (i) the amount(s) owed by the patient and the time permitted tomake the payments; (ii) request that the patient meet with a representative from thecontracted billing vendor to discuss participating in a payment plan option (either recurringor installments), eligibility for the sliding fee discount program, waiving or reducing fees orrequesting an extension to meet with a representative from the contracted billing vendor
and; (iii) how services will be limited or denied when it is determined that a patient has

refused to pay for services.

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DHH reserves the right to discharge patients who refuse to pay for services, as defined bymeeting all the criteria below:•••

Not making a payment on the amounts owed on their remaining balance within six
months of the date of service and not responding to DHH's requests forcommunication within 60 days of receipt of notification of amounts owed and;Refusing requests by DHH to meet with a representative from the contracted billingvendor to discuss and participate in one of the payment options described above orassessing eligibility for the sliding fee discount program or request reducing or
waiving fees;
Not having submitted an appeal to DHH to request an extension of 60 days in which
they can meet with a representative from the contracted billing vendor.

If these criteria are met, DHH will make at least two documented attempts to contact the patient to
explain the patient's obligations and offer a meeting with a representative from the contracted billingvendor. These attempts will be made via telephone and in writing. If DHH is unable to reachthe patient or encourage them to meet with a representative from the contracted billingvendor, request an extension to meet with a representative from the contracted billingvendor, make a payment directly, establish payment plans,, assess eligibility for the sliding
fee discount program and/or request reduced or waived fees, then as an option of last resort,
DHH will terminate the patient and they will no longer be able to receive additional
services at DHH (except in the case of emergencies) until they are willing to meet thepatient obligations described herein. If the patient is discharged from DHH, DHH will notify
the patient of their discharge by regular and certified mail and that the patient has thirty (30)days to find alternative sources of health care.
The patient may be permitted to rejoin the practice when authorized to do so by the CEO ortheir designee.
This does not apply to patients who have applied for the SFDS, whose incomes are below
100% of the Federal Poverty Guidelines and are not charged a nominal fee for services
and will receive a 100% discount.
12) Record keeping: Information related to Sliding Fee Discount decisions will bemaintained and preserved in a confidential file located in the office of the Manager
of Financial Counseling.
13) Policy and procedure review: Annually the Sliding Fee Discount Program
Policy, Procedures and schedule will be presented to the board for review andapproval.

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Forms:
Attachment A - Current Federal Poverty Guideline Fee Schedule
Sliding Scale Self-Declaration Application
Federal Scope of Project, Form 5A

This policy has been reviewed, approved, and adopted by the Governing Board
and Administration as attested to by the signatures below:

7/24/2024
Michelle Nadow
President and CEO

Date

7/24/2024
Megan Sonderegger
Governing Board Chair

Date

DotHouse Health, Inc.
2024 Sliding Fee Scale Table
Effective March 14, 2024

Source:
1/17/2024 Federal Register2024 Federal HHS Poverty
Guidelines (annual income)

2024 Annual
Poverty Guidelines, all states (except Alaska and Hawaii)
Coverable by Federal Grant Resources
Low Income

Household/Family Size
150%

*100%*

125%

130%

133%

135%

138%

150%

167%

175%

185%

200%

$7,530$15,060$18,825$19,578$20,030$20,331$20,783$22,590$25,150$26,355$27,861$30,1202

10,22020,44025,55026,572

27,18527,59428,20730,66034,13535,77037,81440,880

3

12,91025,82032,27533,56634,341

34,85735,632

38,73043,11945,18547,76751,6404

15,60031,20039,00040,56041,49642,12043,05646,80052,10454,60057,72062,4005

18,29036,58045,72547,554

48,651

49,38350,48054,87061,08964,01567,67373,160

6

20,98041,96052,45054,54855,80756,64657,90562,94070,07373,43077,626

83,920

7

23,67047,34059,17561,542

62,962

63,90965,32971,01079,05882,84587,57994,6808

26,36052,72065,90068,536

70,11871,17272,75479,08088,042

92,26097,532

105,440

929,05058,10072,62575,53077,27378,43580,17887,15097,027

101,675

107,485

116,200

10
11
12
13
14

31,74063,48079,35082,52484,42885,69887,602

95,220106,012

111,090

117,438

126,960

34,43068,86086,07589,51891,584

92,961

95,027103,290

114,996

120,505

127,391

137,720

37,12074,24092,80096,512

98,739100,224

102,451

111,360

123,981

129,920

137,344

148,480

39,81042,50079,62085,00099,525106,250

103,506
110,500

105,895
113,050

107,487
114,750

109,876
117,300

119,430
127,500

132,965
141,950

139,335
148,750

147,297
157,250

159,240
170,000$6,725$6,994$7,155$7,263$7,424$8,070$8,985$9,415$9,953$10,760

Each Additional
Family Member
add:
FPL Range
100% or Below
101% to 133%134% to 167%
168% to 200%

$5,380Patient Charged
Amount:
$
$
$

$0.00
10.00
15.00
20.00

Discount
100%
Balance other then $10.00 patient pay amount
Balance other then $15.00 patient pay amount
Balance other then $20.00 patient pay amountNo federally-funded discounts will be provided to individuals and families with annual incomes greater than 200% of thecurrent Federal Poverty Guidelines

1

DotHouse Health, Inc.
2024 Sliding Fee Scale Table
Effective March 14, 2024

Source:
1/17/2024 Federal Register2024 Federal HHS Poverty
Guidelines (annual income)

2024 Monthly
Poverty Guidelines, all states (except Alaska and Hawaii)
Coverable by Federal Grant Resources
Low Income

Household/Family Size

50%

*100%*

125%

130%

133%

135%

138%

150%

167%

175%

185%

200%

$628

$1,255$1,569$1,632$1,669$1,694$1,732$1,883$2,096$2,196$2,322$2,510

2

852

1,703

2,129

2,214

2,265

2,300

2,351

2,555

2,845

2,981

3,151

3,407

3

1,076

2,152

2,690

2,797

2,862

2,905

2,969

3,228

3,593

3,765

3,981

4,303

4

1,300

2,600

3,250

3,380

3,458

3,510

3,588

3,900

4,342

4,550

4,810

5,200

5

1,524

3,048

3,810

3,963

4,054

4,115

4,207

4,573

5,091

5,335

5,639

6,097

6

1,748

3,497

4,371

4,546

4,651

4,721

4,825

5,245

5,839

6,119

6,469

6,993

7

1,973

3,945

4,931

5,129

5,247

5,326

5,444

5,918

6,588

6,904

7,298

7,890

8

2,197

4,393

5,492

5,711

5,843

5,931

6,063

6,590

7,337

7,688

8,128

8,787

9

2,421

4,842

6,052

6,294

6,439

6,536

6,682

7,263

8,086

8,473

8,957

9,683

1

10
11
12
13
14

2,645

5,290

6,613

6,877

7,036

7,142

7,300

7,935

8,834

9,258

9,787

10,580

#

2,869

5,738

7,173

7,460

7,632

7,747

7,919

8,608

9,583

10,042

10,616

11,477

#

3,093

6,187

7,733

8,043

8,228

8,352

8,538

9,280

10,332

10,827

11,445

12,373

#

3,318

6,635

8,294

8,626

8,825

8,957

9,156

9,953

11,08011,611

12,275

13,270

#

3,542

7,083

8,854

9,208

9,421

9,563

9,775

10,625

11,82912,396

13,104

14,167

$560

$583

$596

$605

$619

$673

$749

$785

$829

$897

Each Additional
Family Member
add:
FPL Range
100% or Below
101% to 133%134% to 167%
168% to 200%

$448
Patient Charged
Amount:
$
$
$

$0.00
10.00
15.00
20.00

Discount
100%
Balance other then $10.00 patient pay amount
Balance other then $15.00 patient pay amount
Balance other then $20.00 patient pay amountNo federally-funded discounts will be provided to individuals and families with annual incomes greater than 200% of thecurrent Federal Poverty Guidelines2