Sliding Fee Discount Program

In order to provide accessible and affordable health care, ICMS offers reduced fees through the Sliding Fee Discount Program (SFDP). The policy is consistent with the ICMS mission and philosophy, and is required as a condition of receiving Federal 330 CHC grant funding. Federal regulations require that a CHC provide a "reasonable" amount to pay for health care provided within the ICMS scope of services. The intent of this policy is to maximize community access to this benefit while complying with federal regulations governing the provision of free/reduced fee care in CHCs. These policies apply to all services delivered at ICMS facilities, whether provided directly or through contracted arrangements. All in-scope services (Form 5A Columns I and II) are included in the ICMS Sliding Fee Discount Program. The ICMS Sliding Fee Discount Program is structured to assure that all patients are aware of available discounts, that eligibility assessment is performed for all patients who agree to provide information on income and family size, and that patient charges are adjusted based on ability to pay. The Sliding Fee Program is managed by the Billing Department, under the guidance of the Executive Director. The discount guidelines and levels are updated yearly to reflect the updated FPG (Federal Poverty Guidelines), and the policy and discount levels (scale) are then approved by the Board.

At ICMS, fees are set through a process that involves the collection of information and analysis of findings compared to knowledge of fees in the region near our service area. Administrative and financial staff collect information on insurance-allowable charges and Medicare RVUs for the services we provide and the payors with which we participate. The average allowable charge for each service is then used as our fee for that service, with consideration for comparable fees in our market area. All fees are reviewed with and approved by the Board annually.

The Sliding Fee Discount Program is structured to ensure charges are adjusted based on ability to pay; it has three categories to cover patients with incomes from 100% to 200% of the Federal Poverty Guidelines. In addition, a category for those with incomes below 100% of FPG is provided with full forgiveness of the fee and a nominal per visit charge. If the nominal fee is more than the amount that would be due by patients in a higher category, the lower amount will be charged. The three higher categories charge a flat fee for Medical and BH services for patients with incomes between 100% and 200% of FPG. For Dental patients with incomes between 100% and 200% of FPG, we charge a flat fee for non-elective procedures and a discounted charge for elective services. The fees are shown in the FPG tables listed in Attachment A.The nominal fee is reviewed periodically and compared to the nominal amounts charged by other CHCs in Maine in order to keep our fee for our patients with the lowest incomes comparable to other CHCs and affordable for our patients. The nominal fee is then approved by the Board annually along with the discount schedule when FPG are issued.

Signs advising of the availability of the Sliding Fee Program, eligible income levels, family size, and how to obtain an application, are prominently posted in the waiting room areas, Dental Clinic and exam rooms at ICMS.

Notices regarding the availability of the Sliding Fee Program are printed in all collection letters and patients are informed of the availability of the program throughout the collection process.

New patients will receive information on the sliding fee scale discount program. When an appointment is made with a new patient, the following comments should be offered: We offer a program of discounts to individuals with need based upon the family income level. We encourage those eligible to apply. If you think you may qualify, please bring income verification with you to your appointment.

Determinations of financial assistance shall be conducted at least annually and in the event of a change in income or family size. The evaluations will be made in a manner sufficient to identify the patient's inability to pay and applied uniformly to all persons regardless of race, color, natural origin, religion, sex, age (for persons beyond the age of majority), physical challenge, or inability to pay. The Billing Manager, Outreach specialist or, in special cases, the Executive Director, will determine who qualifies for the sliding fee program and the level of discount based on family size and income compared to the current FPG.A written response detailing the Sliding Fee Program decision will be mailed to the primacy applicant and a copy of the letter will be scanned into the patient's electronic health record.

The Executive Director and Billing Manager have the authority to retroactively approve a sliding fee discount on a case-by-case basis if the facts indicate the patient would have qualified for a discount at the time of service. Listed below are some typical reasons:

The patient may not have been aware of the Sliding Fee discount program.

The patient did not apply because he/she thought insurance or Medicaid would cover the charge, but found out later that the service was not covered.

Each patient must complete the Sliding Fee Application and present income verification with their application. Accepted forms of income verification include, but are not limited to: previous year's income tax return, four most recent pay stubs, previous year's W-2, unemployment payment documentation, social security award letter. Income receipts can be paychecks, check stubs, notices of electronic transfer, and ledgers from employers or letters from their employers with proper documentation regarding that employer. If the patient has been currently laid off or their job has been terminated since their last tax return, the patient must also submit proof from their previous employer stating their last day of employment. We must have the total gross income per individual and total family unit.For self-employed individuals, a copy of the previous year's income tax return, including all schedules (C, F, etc.), 1099 forms, and other verifiable records of earnings and expenses, are acceptable forms of proof of income.If a patient has no income, he/she must complete the No Income Form as well as the Sliding Fee Discount Form. No patient will be denied health care services due to an inability to pay.

Family:  For the purpose of determining ICMS sliding fee eligibility, a “family” is defined as all the individuals who live in the same household.Income:  Income to be counted toward sliding fee eligibility includes all forms of income, earned or unearned, by all members of the family/household.Also see Family/Household Income below for expanded explanations and exceptions.Family/Household Income:

Household income is based on all income received into the home.

Unmarried couples living under the same roof are considered a household and both incomes will be counted.

Anyone who is not contributing 50% or more to the household income and is being supported by another person shall be viewed as a dependent and the supporting person's income will be counted as household income.

Anyone who was claimed as a dependent on the prior year's tax return will be considered a member of the household and eligibility will be determined based on that family size.

Child Support payments and alimony payments will be included in monthly income if they are received.

If a person living in his/her parent's/guardian’s home meets ALL of the following conditions: employed, paying rent (fair market value) or living expenses to the parents, and not being claimed as a dependent on the tax return, will be considered a separate household. This person will be considered eligible for the SF Program based on his/her gross income for a single-person.

Some patients may choose not to provide information that the health center requires for assessing income and family size, even after being informed that they may qualify for sliding fee discounts. These patients are declining to be assessed for eligibility for sliding fee discounts and will be considered ineligible for sliding fee discounts.

All information supplied for the purposes of determining eligibility for the Sliding Fee Program is subject to verification and will remain confidential.

Patient eligibility is determined through comparison of total family/household income and family size to the current year FPG (Federal Poverty Guidelines) as issued by the United States Department of Health and Human Services on an annual basis, as approved by the Board of Trustees.  The patient will then be assigned to a Sliding Fee category according to the FPG.Patients applying for the Sliding Fee Discount Program are obligated to contact the health center and supply new information as soon as income or household status changes.

Patient Responsibilities: Patients are responsible for payment of co-pays at point of service.

Patients are responsible for providing timely and accurate information.

The effective date for a qualified applicant is the date that the application is received. However, patients may request coverage for the previous thirty days if they have incurred health care costs at ICMS during that time period.

All Sliding Fee applicants will be screened for eligibility for MaineCare (Maine Medicaid). Those who might qualify will be given an application for the MaineCare program and offered assistance with the application process. If the patient gets information from MaineCare that their eligibility will take more than 30 days, the Billing Manager will review and may extend the eligibility time period accordingly.

For Sliding Fee applicants who have other insurance coverage, sliding fee is a payment of last resort. The sliding fee adjustment will be made after all charges have been submitted through insurance, according to the patient responsibility outlined in the explanation of benefits.

Medical: All non-elective/essential medical services provided at ICMS facilities are covered on the Sliding Fee scale, with the exception of certain elective procedures, any medications (prescriptions or injectable), durable medical equipment, or supplies. All patients will be informed of any service items that are not covered by the sliding fee scale.

Dental: All non-elective/essential preventive, restorative, and emergency dental services provided at ICMS are covered on the Sliding Fee scale. The Nominal fee applies to the non-elective/essential preventative, restorative and emergency dental services only. For these services, patients with income below 100% FPG pays no more than the Nominal flat fee of $30. Patients with incomes above 100%, but below 200% of FPG, pay a flat fee or a graduated percent (25%, 50%, or 75%) of the total patient responsibility, which ever is less. Fees for all other services, including dentures, partial dentures, occlusal guards, bridgework, crowns, and denture repairs are based on the average of the usual and customary amount from our participating dental insurance payors. The patient pays a graduated percent (50%, 55%, 65%, or 75%) of the total patient responsibility for patients with incomes below 200% FPG.

Counseling: For both Mental Health and Substance Abuse, all non-elective/essential services provided at ICMS facilities are covered under the Sliding Fee Program.For all services, if the calculated or flat fee for patients above 100% FPG is less than the Nominal Fee, the patient with income below 100% will pay the lower amount.

Patients who have qualified for the Nominal Fee Category (income less than 100% of FPG) are exempt from collection action. MaineCare recipients and other insured individuals who have qualified for Nominal Fees are exempt from collection action for the patient responsibility portion. All patients in this category will be asked to make their payment at the time of service.EXCEPTIONS:

In certain circumstances, it may be determined appropriate for a co-payment to be waived, and/or exceptions made to certain aspects of the Sliding Fee Program policy. These exceptions will be applied equally and in a manner that is fair and consistent for all eligible patients, in cases where it is determined that collections may create a barrier to care.

The Nominal Fee will be waived if it is determined that the co-pay causes unusual financial burden to the patient, and/or if the co-pay becomes a barrier to care.

Charges to patients who qualify for an Exception will be accounted as a sliding fee adjustment/write off.

The Executive Director makes these decisions based on information from the Billing Manager.

A Clinical Exception is based on either "higher than usual frequency of visits" and/or the patient having a "clinical diagnosis" which may be exacerbated by a formal collections process, both of which would be a barrier to care. Patients given exceptions for high frequency/utilization will be required to pay one minimum copayment per month. Clinical waivers will be initiated by a Medical, Dental or Behavioral Health provider and approved by the Executive Director.

A Financial Exception is based on a finding that the patient has no income, or minimal income, and less than 100% of the FPG. The Billing Manager must follow the protocol for confirming no/low income. Financial waivers may be initiated by any staff, but must be signed off by the Executive Director. Exceptions are reviewed and in the event of a change in family size to determine on-going qualification.

Sliding Fee Program Exceptions will be monitored both externally and internally through the annual audit, as well as through our Quality Improvement and Compliance Programs.​

Approved at a meeting of the Board of Trustees of Islands Community Medical Services on March 25, 2021.