Northland Counseling Center Inc. Sliding Fee Discount Program Policy
To make available discount services to those in need.
This program is designed to provide discounted care to those who have no means, or limited means, to pay for their medical/mental health services (Uninsured or Underinsured). In addition to quality healthcare, patients are entitled to financial counseling by someone who can understand and offer possible solutions for those who cannot pay in full. Intake and/or Accounts Receivable Staff will work with you and/or guarantor to find reasonable payment alternatives.
Northland Counseling Center, Inc. will offer a sliding fee discount program to all who are unable to pay for their services. Northland Counseling Center, Inc. will base program eligibility on a person’s ability to pay and will not discriminate on basis of inability to pay, race, color, sex, national origin, disability, religion, age, gender identity or sexual orientation. The Federal Poverty Guidelines, http://aspe.hhs.gov/poverty, are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility.
Procedure: The following guidelines are to be followed in providing the Sliding Fee Discount Program.
1. Notification: Northland Counseling Center, Inc. will notify patients of sliding fee discount program by:
Notification of the Sliding Fee Discount Program will be offered to each patient.
Sliding Fee Discount Program application will be included with collection notices sent out by Northland Counseling Center, Inc.
An explanation of our Sliding Fee Discount Program and our application form are available at intake.
Northland Counseling Center Inc. places notification of Sliding Fee Discount Program in the waiting area.
2. All patients seeking services at Northland Counseling Center, Inc are assured they will be served regardless of ability to pay. No one is refused services because of lack of financial means to pay.
3. Request for discount: Requests for discounted services may be made by patients, family members, social services staff or others who are aware of existing financial hardship. The Sliding Fee Discount Program will only be available for clinic visits. Information and forms can be obtained from the front desk.
4. Administration: The Sliding Fee Discount Program procedure will be administered through the business Office Manager or designee. Information about the Sliding Fee Discount Program Policy and procedure will be provided and assistance offered for completion of the application. Dignity and confidentiality will be respected for all who see and/or are provided charitable services.
5. Alternative payment sources: All alternative payment resources must be exhausted, including all third-party payment from insurance(s), Federal and State Programs.
6. Completion of Application: The patient/responsible party must complete the Sliding Fee Discount Program Application in its entirety. By signing the Sliding Fee Discount Program application, persons authorize Northland Counseling Center, Inc access in confirming income as disclosed on the application form. Providing false information on a Sliding Fee Discount Program application will result in all Sliding Fee Discount Program discounts being revoked and the full balance of the account(s) restored and payable immediately.
7. If an application is unable to be processed due to the need for additional information, the applicant has two weeks from the date of notification to supply the necessary information without having the date on their application adjusted. If a patient does not provide the requested information within the two week time period, their application will be re-dated to the date on which they supply the requested information. Any accounts turned over for collection as a result of the patient’s delay in providing information will not be considered for the Sliding Fee Discount Program.
8. Eligibility: Discounts will be based on income and family size only. Northland Counseling Center, Inc uses the Census Bureau definitions of each.
Family is defined as: a group of two people or more (one of who is the householder) related by birth marriage, or adoption and residing together; all such people (including related subfamily members) are considered as members of one family.
Income includes: earnings, unemployment compensation, workers compensation, Social Security, Supplemental Security Income, Public assistance, veterans payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other miscellaneous sources. Noncase benefits (such as food stamps and housing subsidies) do not count.
9. Income verification: Applicants must provide one of the following: prior year W-2, two most recent pay stubs, letter from employer, or Form 4506-T (if W-2 not filed). Self-employed individuals will be required to submit detail of the most recent three months of income and expenses for the business. Adequate information must be made available to determine eligibility for the program. Self-declaration of income may only be used in special circumstances. Specific examples include participants who are homeless. Patients who are unable to provide a written verification must provide a signed statement of income, and why (s)he is unable to provide independent verification. This statement will be presented to Northland Counseling Center, Inc. CEO or designee for review and final determination as to the sliding fee percentage. Self-declared patients will be responsible for 100% of their charges until management determines the appropriate category.
10. Discounts: Those with incomes at or below 100% of poverty will receive a full 100% discount. Those with incomes above 100% poverty, but at or below 200% of poverty, will be charged according to the attached sliding fee schedule. The sliding fee schedule will be updated during the first quarter of every calendar year with the latest federal poverty guidelines, http://aspe.hhs.gov/poverty.
11. Nominal Fee: Patients receiving a full discount will be assessed a $5 nominal charge per visit. However, patients will not be denied services due to an inability to pay. The nominal fee is not a threshold for receiving care and thus, is not a minimum fee or co-payment.
12. Waiving of Charges: In certain situations, patients may not be able to pay the nominal or discount fee. Waiving of charges may only be used in special circumstances and must be approved by Northland Counseling Center, Inc. CEO or designee. Any waiving of charges should be documented in the patients file along with an explanation (e.g., ability to pay, good will, health promotion event).
13. Applicant notification: The Sliding Fee Discount program determination will be provided to the applicant(s) in writing, and will include the percentage of Sliding Fee Discount program write off, or, if applicable, the reason for denial. If the application is approved for less than 100% discount or denied, the patient and/or responsible part must immediately establish payment arrangements with Northland Counseling Center, Inc. Sliding Fee Discount Program applications cover outstanding patient balances for six months prior to application date and any balances incurred within 12 months after the approved day, unless their financial/insurance situation changes significantly. The applicant has the option to reapply after the 12 months have expired or anytime there has been a significant change in family income. When the applicant reapplies, the look back period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program Application.
14. Refusal to Pay: If a patient verbally expresses an unwillingness to pay or vacates the premises without paying for services, the patient will be contacted in writing regarding their payment obligations. If the patient is not on the sliding fee schedule, a copy of the sliding fee discount program application will be sent with the notice. If the patient does not make effort to pay or fails to respond within 60 days, this constitutes refusal to pay. At this point in time, Northland Counseling Center, Inc. can explore options not limited to, but including offering the patient a payment plan, waiving of charges, or referring the patient collections efforts.
Full Policy availble upon request.