Sliding Fee Discount Program (SFDP) Policy

1. Policy Statement

Minis Walk-In Clinic is committed to ensuring access to care regardless of a patient’s ability to pay.

“No one will be denied access to services due to inability to pay. A sliding fee schedule is available based on family size and income.”

2. Purpose

This policy establishes a Sliding Fee Discount Program (SFDP) and corresponding Sliding Fee Discount Schedule (SFDS) in alignment with the requirements of the Health Resources and Services Administration (HRSA) for NHSC site readiness.

3. Scope of Services

The SFDP applies to all in-scope services provided by Minis Walk-In Clinic.

The SFDP applies to:

· Uninsured patients

· Self-pay encounters

· Non-covered services

The SFDP excludes:

· Services billed to Medicaid or Medicaid Managed Care plans

· Services billed to other third-party payers where contractual obligations prohibit discounting

4. Medicaid & Third-Party Billing Compliance

Sliding fee discounts are not applied to services covered under Medicaid or Medicaid Managed Care plans.

All such services are billed in accordance with payer contracts and applicable regulations.

Under no circumstances will a discount be applied to services that have been or will be billed to a third-party payer.

5. Uniform Application

The SFDP is applied uniformly and consistently to all eligible patients.

Discounts are not determined on a case-by-case or discretionary basis.

All staff must follow the SFDS exactly as written.

6. Eligibility Criteria

Eligibility is based on family size and gross household income.

Family size includes all dependents supported by household income.

Eligibility is determined using the current Federal Poverty Guidelines (FPG).

Eligibility for the SFDP is based only on family size and income and is not based on assets, citizenship, insurance status, diagnosis, or patient category.

Acceptable verification methods include:

· Recent pay stubs

· Tax returns

· Employer letter

· Bank statements

· Unemployment benefit statements

· Proof of public assistance

· Self-declaration if no documentation is available, with justification

Lack of documentation alone will not prevent a patient from being screened for SFDP eligibility.

No Social Security Number (SSN) is required.

No credit checks are performed.

7. Sliding Fee Discount Schedule (SFDS)

Federal Poverty Guidelines Table

Sliding Fee Discount Schedule

8. Nominal Fee Structure

For patients at or below 100% FPG, a $10 nominal fee applies per visit/encounter.

The $10 nominal fee is not a minimum fee, copayment, or threshold for receiving care. Patients will not be denied access to services due to inability to pay the nominal fee.

The $10 nominal fee for patients at or below 100% FPG is less than the amount charged to patients in the first sliding fee discount category above 100% FPG.

The $10 nominal fee applies to:

· Sick visits

· Follow-up visits

· Telehealth visits

· Other standard office encounters

Included services:

· Provider evaluation

· Basic exam

Additional services are billed separately and discounted according to the SFDS, including but not limited to:

· Laboratory testing

· Procedures

· Medications or supplies

9. Application Process

Patients may apply for SFDP at any time.

1. Patient completes SFDP application.

2. Authorized staff verifies income and family size documentation.

3. Eligibility level is assigned according to the SFDS.

4. Determination is documented in the medical record.

5. The visit will be billed after the encounter once authorized staff have had enough time to review the SFDP application, eligibility documentation, family size, income, and applicable charges.

Patients will be notified of their SFDP determination in writing, including the approved discount category or reason for denial.

The patient/parent or guardian will be informed that approval is not guaranteed and that the final amount due will be determined after staff review. The patient/parent or guardian is not required to pay the final SFDP amount before the review is completed.

Submission of an SFDP application does not guarantee approval. If the application is approved, the applicable discount, reduced responsibility, or nominal fee will be applied before the patient is billed. If the application is denied, incomplete, or the patient does not qualify for a discount, the patient/parent or guardian will be responsible for the regular self-pay/full charges.

10. Re-Evaluation & Renewal

Eligibility must be re-evaluated every 12 months, or when the patient reports a change in income or household size.

Patients are responsible for notifying the clinic of material changes in household income or family size.

Expired eligibility may result in reclassification to full-pay status until updated documentation is received.

11. Billing Safeguards

Discounts are applied only to self-pay balances.

Discounts are not applied to insurance claims.

Medicaid billed charges may not be altered.

Insurance billing and SFDP adjustments must remain separate.

SFDP adjustments are applied only after insurance adjudication, when applicable.

12. Documentation Requirements

Minis Walk-In Clinic will maintain:

· Completed SFDP applications

· Income verification or self-declaration forms

· Eligibility determinations

· Current SFDS documentation

· SFDP policy documentation

Records will be retained in accordance with applicable regulatory requirements and made available during HRSA/NHSC audits or compliance reviews upon request.

13. Required Signage

The following statement must be clearly posted in patient-accessible areas and included in applicable materials:

“No one will be denied access to services due to inability to pay. A sliding fee schedule is available based on family size and income.”

14. Operational Readiness Documents

Minis Walk-In Clinic will maintain the following supporting documents:

· SFDP application form

· Staff workflow/training guide

· Billing adjustment SOP

· Tracking log for SFDP determinations

15. Approval & Review

Approved By: Dr. Ayman Rawda

Last Reviewed Date: 05/13/2026

Last Updated Date: 05/20/2026

Next Review Date: 05/13/2027