PIN : Sliding Fee Discount and Related Billing and Collection Program Requirements, 9/22/14 Bob Russell, DDS, MPH Iowa Department of Public Health

What does success look like through utilization of the Policy Information Notice or PIN for our center? We provide the best quality and quantity (scope of service) for our patients that we can without putting the dental program and/or the rest of the health center programs at risk.

Applicability Applies to all 330 Program grantees and look-alikes PIN does not apply to activities outside of the health center’s federally approved scope of project

General Requirements 1.This system must provide a full discount to individuals and families with annual incomes at or below 100% of the poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.* 2.No discounts may be provided to patients with incomes over 200 % of the Federal poverty level.*

2015 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA Persons in family/household Poverty guideline 1 $11, , , , , , , ,890 For families/households with more than 8 persons, add $4,160 for each additional person. Differing poverty guidelines exists for Alaska and Hawaii

General Requirements All services within the Scope of Practice must be included in the SFS regardless of ability to pay. SFS is based only on family size and income – no other factors. SFS policy must be fully explained to all patients –users within the CHC using consideration for language and cultural barriers.

Governing Board Oversight Health Center Board of Directors set Sliding fee Scale Policy based on the recommendation of the health center’s executive team. Poverty guidelines should be reviewed annually and SFS adjusted. Staff education on the SFS and other policies should be performed. Written policies must be in place including SFS determinants and nominal fee.

Governing Board Oversight (cont.) Alternative methods can be used to determine SFS eligibility when verification documents are unavailable. However validate these methods when verifying information is available Use the same methods for all users within the health center Differing sliding fee schedules are possible based on the particular service center within the health center i.e. medical, dental, mental health, etc… as long as sufficient justifications However, the same sliding fee scale must be applied equality to all users of the services. Nominal charges as not a requirement for a health center, but when established, the charge must not be a barrier to care for the lowest income groups and must be established by the health center’s board of directors.

Fee Schedule Fees are intended to generate revenue to cover the health center’s costs associated with providing services and assists in ensuring the financial viability and sustainability of the health center. The health center must assure that fees are set to cover reasonable costs and are consistent with locally prevailing rates or charges for the service. The health center’s fee schedule must address all in-scope services (required and additional). Fees are used as the basis for seeking payment from patients as well as third party payers.

Sliding Fee Scale Discount (SFDS) All services within the health center’s approved scope of project, whether required or additional, must be provided on a SFDS and without regard to the patient’s ability to pay. Once established, the SFDS must be revised annually, at a minimum, to reflect annual updates to the FPG Eligibility for the SFDS is based on a patient’s annual income and family size under the U.S. Department of Health and Human Services’ (HHS) annual FPG.

Sliding Fee Scale Discount (SFDS) The health center’s governing board must approve in policy, consistent with any Federal, State, or local laws and requirements, its definitions of “family” and “income.” The unique characteristics of target populations (e.g., individuals experiencing homelessness) and service areas (e.g., areas with high cost of living) must be considered in developing policies and supporting operating procedures to ensure that these elements do not become a barrier to care. Once established, these policies and supporting operating procedures must be applied uniformly across the patient population.

Determining Eligibility for SFDS Patient refusal to provide validation information for sliding fee scale determination can result in ineligibility for discounts under the scale. Again, written policies must be in place.

Determining Eligibility for SFDS No discount under the sliding fee scale for those over 200% of the federal poverty scale. An early payment discount separate from the sliding fee discount may be provided, with board approval, but must apply to all users equally An outside grant or subsidy may be applied against the patient’s portion of the sliding fee discount if available.

Sliding Fee Scale Discount Structure Dental nominal fee can be different than the medical nominal fee. Health centers can set their own discount schedule, percentage of discounts, flat fee minimum payments they charge.

Establishing and Collecting Nominal Charges Any health center that chooses to establish a nominal charge must ensure that patients are not impeded in accessing services due to an inability to pay. A nominal charge must be a fixed fee that does not reflect the true value of the service(s) provided and is considered nominal from the perspective of the patient. The nominal charge must be less than the fee paid by a patient in the first “sliding fee discount pay class” beginning above 100% of the FPG.

Insured Patients Who Are Also Eligible for SFSD Important to know your state laws and various insurance plan policies on the application of sliding fee scale discounts. Income and family size make many insured individuals eligible for sliding fee discounts too. Generally if allowed, the insurance is billed at their normal rate and the patient’s copy portion is discounted based on their sliding fee scale percentage. Again, SFS discounts are applicable regardless of insurance status

Multiple Sliding Fee Discount Schedules Health centers can have different sliding fee schedules for different service categories; but must be consistently applied in each category. The SFS must comply with federal rules as to nominal fee, minimal fees, and percentage discounts between 100% and 200% federal poverty levels. The board must determine the nominal fee and assure it doesn’t create a barrier to care for the lowest income populations.

Laboratory Charges Costs for items done outside the health centers (3rd party lab charges) are exempt from sliding fee discounts and the actual cost can be charged to the patient. The professional services performed within the health center are subject to all sliding fee discount conditions. Nominal or minimal fees can be charged to the patient for each visit where lab fees have also been incurred and charged. Payment options and lab or separate eligible service costs must be discussed up front prior to services and referenced in written documentation.

Billing and Collections Collection of all fees must be emphasized and occur within 30 days of charges. Billing of 3rd party insurers must occur within the first 30 days Health centers can’t force enrollment of patients into private or public insurance plans – but should make patients aware of covered options. Health centers must balance maximizing income and not preventing patients from acquiring services due to inability to pay; however reasonable efforts to seek payment must be made.

Provisions for Waiving Charges Waived fees must be clearly identified in written policy and applied equally to all users; authority for the practice of waiving certain fees must be made by the governing board.

Payment Incentives Early payment incentives or discounts can be applied as long as consistent and equally to all users If you offer an early payment discount to insured patients, the remaining balance after the discount becomes your usual rate for insurance purposes.

Refusal to Pay Must have in place written standards for collections and addressing refusal to pay. Dismissal from the practice must be the last option used in the collection activity with documented steps and written communications of all actions taken over time.

Key Points from PIN 1.The HRSA sliding fee policy under PIN does not apply to services performed by a health center outside of their 330 scope of approved services; however, FTCA malpractice coverage for those services do not exist either. 2.A minimum of 3 discount categories must exist within the sliding fee scale between 100% and 200% federal poverty levels.

Key Points from PIN The nominal fee is a distinct base flat fee and not a percentage fee within the sliding fee scale –it stands alone for those 100% or below the federal poverty level. Percentage-based minimal fees apply to those within the sliding fee scale and standard minimal flat fees to those above 200% the federal poverty range. The sliding fee scale and nominal fee must apply to outside providers providing services to health center patients under formal referral written agreement. Providers performed services on behalf of the health center under written agreement or contract must provide the health center’s nominal and sliding fee scale discounts.

Key Points from PIN Health centers can pass along lab costs to uninsured patients. Health centers need a formal policy defining the process of waiving charges. Health centers can offer prompt pay discounts but must be available to all patients (eg, if patients get a 10% discount for paying at the time of the visit, even a nominal fee patient paying $30 would get a 10% discount for paying at the time of the visit). Health centers can discharge patients for refusal to pay but this should be an action of last resort.

Actions to Consider Reviewing all intended or provided dental services, performing a cost analysis on each and making informed decisions about scope, nominal fee, and sliding fees in dental. Decisions should not be made on guess work, instinct or intuition but should be made using timely, meaningful and accurate data to inform those decisions.

Primary Care Drives Governance PINS Because 80-85% of the services provided in health centers are provided in the primary care setting, the formulation of governance PINS are made around that primary care medical service delivery model. It is often not reasonable nor feasible to take all of the governance contained in a PIN and simply apply those to the dental service. Retrofitting these PINS to dental does not always work perfectly. They require that we think them through and through informed justification create policies that do fit. It requires utilizing an informed decision making process. Without this approach we put the dental program at risk.

Key Elements to Making Informed Decisions on Sliding Fee Scales, Nominal Fees and Scope of Service: You need to know how dental costs, staffing, equipment, procedures, and operational expenses impact your program Know HRSA’s practice goals for dental programs and service expectations. Understand that most health center dental clinics are 1/5th as large in volume as their medical clinics. These variances between medical and dental will impact your costs and your sliding fee discount determinants differently than the medical program.

Key Cost Related Data to help Determine Scope of Service Cost per visit (expenses divided by number of visits) Lab, supplies, time and costs for each procedure Reports on services provided by ADA code (transaction report) Calculation of RVUs for all services divided by expenses (determines the cost for each RVU provided)

Where is there Wiggle Room? Remember 330 scope of practice services = required sliding fee scale discount = FTCA federal malpractice defense. Outside of scope of practice = no sliding fee scale requirement = need for private malpractice policy

Bob Russell, DDS, MPH State of Iowa Public Health Dental Director