Getting your sliding fee scale policy right is one of the most important things you can do as a Federally Qualified Health Center. It directly affects whether low-income patients walk through your doors or quietly turn away because they assume they cannot afford care.
The truth is, most patients never ask about financial assistance because they expect to be turned down. A clear, well-written sliding fee scale policy changes that. It signals to your community that your center is genuinely accessible, not just technically open.
Whether you are drafting your first policy or refining an existing one to meet HRSA requirements, having the right language, structure, and scope makes all the difference. The samples below give you exactly what you need to work with.
FQHC Sliding Fee Scale Policy Samples
A strong sliding fee scale policy covers eligibility, income verification, discount levels, and the process patients go through to apply. Here are three ready-to-use samples that reflect different organizational tones and structures while staying fully aligned with HRSA expectations.
1. Standard FQHC Sliding Fee Scale Policy
Policy Title: Sliding Fee Discount Program Policy
Policy Number: FIN-001
Effective Date: [Insert Date]
Review Cycle: Annual
Approved By: Board of Directors
Purpose
This policy establishes the sliding fee discount program (SFDP) at [Health Center Name] to ensure that no patient is denied access to services due to inability to pay. The program provides a schedule of discounts based on a patient’s household income and family size, in full compliance with Section 330 of the Public Health Service Act and applicable HRSA Health Center Program requirements.
Scope
This policy applies to all patients receiving services at [Health Center Name], including all sites and service delivery locations operated under the health center’s approved scope of project.
Eligibility
All patients are eligible to apply for the sliding fee discount program regardless of insurance status, immigration status, or residency. Patients with income at or below 200% of the Federal Poverty Guidelines (FPG) are eligible for a discount. Patients with income between 101% and 200% FPG will receive a nominal fee or a reduced fee based on the approved fee schedule. Patients at or below 100% FPG will be charged a nominal fee, which shall not exceed the nominal fee cap established by HRSA.
No patient will be denied services due to inability to pay.
Income Verification
Patients applying for the sliding fee discount program must provide documentation of household income at the time of application or re-determination. Acceptable documentation includes but is not limited to:
- Most recent federal income tax return
- Current pay stubs (two most recent)
- Social Security or SSI award letters
- Unemployment benefit statements
- Self-declaration form for patients who are unable to provide documentation
If a patient is unable to provide documentation, [Health Center Name] will accept a signed self-declaration of income. Staff will not deny an application solely on the basis of missing documentation.
Fee Schedule
The fee schedule is updated annually following publication of the Federal Poverty Guidelines by the U.S. Department of Health and Human Services. The schedule reflects the following discount levels:
| Income Level (% of FPG) | Discount Applied |
|---|---|
| At or below 100% | Full discount (nominal fee only) |
| 101% to 133% | 80% discount |
| 134% to 150% | 60% discount |
| 151% to 175% | 40% discount |
| 176% to 200% | 20% discount |
| Above 200% | Full fee (no discount) |
The nominal fee for patients at or below 100% FPG is set at $[Amount] per visit, per service category, and is reviewed annually by the Board of Directors.
Application Process
- Patients are informed of the sliding fee discount program at registration or upon request.
- Patients complete a SFDP application form, which includes household size and income information.
- Staff review the application and supporting documentation within one business day.
- Approved discounts are applied to the patient’s account and are valid for 12 months from the date of determination.
- Patients are notified of their discount level in writing at the time of approval.
Re-Determination
Patients must re-apply for the sliding fee discount program every 12 months or when there is a significant change in household income or family size, whichever occurs first. [Health Center Name] will send reminders to eligible patients 30 days prior to the expiration of their current discount status.
Appeals
Patients who disagree with their fee determination may submit a written appeal to the Patient Financial Services Manager within 30 days of receiving their determination notice. Appeals will be reviewed and resolved within 10 business days.
Non-Discrimination
The sliding fee discount program is administered without regard to race, color, national origin, sex, age, disability, religion, or any other characteristic protected by applicable federal or state law.
Board Oversight
The Board of Directors reviews and approves the fee schedule and this policy on an annual basis. The Chief Financial Officer is responsible for ensuring compliance with HRSA requirements and reporting program metrics to the Board quarterly.
2. Patient-Centered FQHC Sliding Fee Scale Policy
Policy Name: Financial Assistance and Sliding Fee Program
Department: Patient Financial Services
Effective Date: [Insert Date]
Last Reviewed: [Insert Date]
Our Commitment to You
At [Health Center Name], we believe that cost should never be a barrier to quality healthcare. Our sliding fee program is built on the principle that every patient deserves access to the care they need, regardless of income or financial circumstances.
Who Qualifies
Any patient who receives services at [Health Center Name] may apply for financial assistance under this program. There are no citizenship, residency, or insurance requirements to qualify. Eligibility is determined solely by household income and family size relative to the current Federal Poverty Guidelines (FPG).
Patients with a household income at or below 200% of the FPG are eligible for a discounted fee. Patients at or below 100% FPG are charged only a nominal fee per visit, which is the lowest amount we can charge while maintaining compliance with federal health center requirements.
How We Calculate Your Fee
Your fee is based on two pieces of information: the total income of everyone in your household, and the number of people living in your household. We compare this information to the Federal Poverty Guidelines, which are updated each year by the federal government.
Once we know where your income falls on the scale, we apply the appropriate discount from our approved fee schedule.
Sliding Fee Discount Schedule:
| Household Income as % of FPG | Your Discount |
|---|---|
| 100% or below | Nominal fee only (full discount applies) |
| 101% to 140% | 75% off the full fee |
| 141% to 160% | 50% off the full fee |
| 161% to 180% | 30% off the full fee |
| 181% to 200% | 15% off the full fee |
| Above 200% | Standard fee applies |
The nominal fee is currently $[Amount] per visit. This amount is reviewed and approved by our Board of Directors each year.
What You Need to Bring
To apply for the program, you will need to share information about your household income. We keep this information strictly confidential. Accepted documentation includes:
- Recent pay stubs (within the last 30 days)
- Your most recent tax return
- A benefits award letter (SSI, SSDI, unemployment, etc.)
- A written self-declaration if you have no income or are unable to provide documents
We will never turn you away for lacking paperwork. If you have no documents to share, our staff will assist you in completing a self-declaration form.
Applying Is Simple
You can apply at any point during your visit, including before or after your appointment. Here is what to expect:
- Ask any front desk staff member about the financial assistance program.
- Complete a short application form with your household and income information.
- Provide any available income documentation.
- Receive your fee determination the same day in most cases.
- Your discounted fee will be applied to all eligible services for the next 12 months.
Annual Renewal
Your discount is valid for 12 months. We will reach out to you before your determination expires so you can renew without any lapse in coverage. If your income or household size changes significantly during the year, please contact us so we can update your status.
Your Rights
You have the right to appeal any fee determination you believe is incorrect. Submit a written request to our Patient Financial Services office within 30 days of your determination. We will review your case and respond within 10 business days.
You also have the right to receive care regardless of your ability to pay. Patients will not be turned away, refused services, or treated differently based on their fee category.
3. Comprehensive FQHC Sliding Fee Scale Policy with Governance Framework
Policy Title: Sliding Fee Discount Program (SFDP) Policy and Procedure
Policy Owner: Chief Financial Officer
Applies To: All clinical and administrative staff, all program sites
Effective Date: [Insert Date]
Supersedes: [Previous Policy Number and Date, if applicable]
I. Policy Statement
[Health Center Name] operates a Sliding Fee Discount Program (SFDP) in accordance with the requirements set forth in Section 330(k)(3)(G) of the Public Health Service Act (42 U.S.C. § 254b) and the HRSA Health Center Program Compliance Manual. This policy ensures that services are made available to all patients, with fees adjusted based on the patient’s ability to pay. No patient will be denied services due to an inability to pay.
II. Definitions
- Federal Poverty Guidelines (FPG): Annual guidelines published by the U.S. Department of Health and Human Services used to determine financial eligibility for federal programs.
- Household: All individuals sharing a primary residence and contributing to or benefiting from shared income and expenses.
- Household Income: All gross income received by members of the household, including wages, self-employment income, Social Security, unemployment benefits, and other recurring income sources.
- Nominal Fee: The minimum fee charged to patients at or below 100% FPG, as approved by the Board of Directors and consistent with HRSA guidance.
- Full Fee (Sliding Scale Fee): A reduced fee charged to patients between 101% and 200% FPG based on the approved discount schedule.
III. Eligibility and Scope
The SFDP applies to all patients receiving services within [Health Center Name]’s approved scope of project. Eligibility is open to all patients regardless of:
- Insurance coverage or lack thereof
- Citizenship or immigration status
- County of residence
- Race, ethnicity, gender, age, or disability status
Eligibility for a discount is based solely on household income as a percentage of the current Federal Poverty Guidelines and household size at the time of application.
IV. Fee Schedule
The Board of Directors approves the fee schedule annually, no later than 60 days after the publication of updated Federal Poverty Guidelines. The approved fee schedule is publicly posted at all health center sites and on the health center’s website.
Current Approved Sliding Fee Schedule:
| Income Bracket (% FPG) | Discount Level | Patient Responsibility |
|---|---|---|
| ≤ 100% | Nominal Fee | $[Amount] per visit |
| 101% to 125% | Tier 1 | 20% of full fee |
| 126% to 150% | Tier 2 | 40% of full fee |
| 151% to 175% | Tier 3 | 60% of full fee |
| 176% to 200% | Tier 4 | 80% of full fee |
| > 200% | No discount | 100% of full fee |
The nominal fee applies across all service categories for patients at or below 100% FPG and does not exceed the HRSA-established nominal fee limit. Separate nominal fees may be established for distinct service categories (medical, dental, behavioral health, vision) with Board approval.
V. Income Verification Procedures
Step 1: Application All patients seeking a sliding fee discount must complete the SFDP Application Form at the time of initial enrollment and at each annual re-determination. The form collects household size, relationship of household members, and total gross household income.
Step 2: Documentation Staff will request income verification documents. Acceptable documentation includes:
- Federal income tax returns (most recent year)
- W-2 or 1099 forms
- Pay stubs (two most recent, within 60 days)
- Benefit award letters (SSI, SSDI, TANF, unemployment)
- Employer verification letter on company letterhead
- Bank statements (last 60 days) for self-employed individuals
- Signed Self-Declaration of Income Form
Step 3: Self-Declaration If a patient cannot produce documentation, staff will assist the patient in completing a Self-Declaration of Income Form. This form must be signed by the patient and countersigned by the staff member facilitating the process. Self-declarations are valid for the standard 12-month period.
Step 4: Determination and Notification Staff will calculate the patient’s income as a percentage of the current FPG using household size and gross income. Determinations will be completed at the point of service where possible. Patients will receive written notification of their fee category on the same day. If a determination cannot be completed at the time of the visit, the patient’s full fee will be held pending determination, and the discounted amount will be applied retroactively upon completion.
VI. Re-Determination
SFDP determinations are valid for 12 months from the date of approval. Patients must undergo re-determination annually. The following also trigger an interim re-determination:
- A reported change in household income of 10% or more
- A change in household size
- Patient request
[Health Center Name] will proactively notify patients 45 days before their determination expires via mail, phone, or electronic communication based on patient preference.
VII. Confidentiality
All income and financial information collected as part of the SFDP is confidential and protected under applicable federal and state privacy laws, including HIPAA. This information is used solely to determine fee eligibility and is not shared with outside parties without patient written consent, except as required by law.
VIII. Appeals Process
Patients who believe their fee determination is incorrect may appeal by submitting a written request to the Director of Patient Financial Services within 30 calendar days of receiving their determination notice.
The appeals process includes:
- Written acknowledgment of receipt within three business days
- Review by a designated appeals committee (minimum two members, excluding original determination staff)
- Written response to the patient within 10 business days of receiving the appeal
- If the appeal is upheld, retroactive adjustment of any fees charged during the pending review
IX. Compliance and Oversight
The Chief Financial Officer is responsible for overall SFDP compliance. The following oversight activities are performed on a regular basis:
- Monthly: Review of SFDP application volumes, approvals, and denials
- Quarterly: Board reporting on program metrics, including number of patients served by fee category and nominal fee revenue
- Annual: Full policy review, fee schedule update, and Board approval prior to implementation
- Biennial: Internal audit of a random sample of SFDP applications to verify documentation accuracy and appropriate fee assignments
Any HRSA site visit or Program Audit findings related to the SFDP will be addressed within the timeframes specified in the corrective action plan.
X. Staff Training
All front desk, registration, and billing staff must complete SFDP training upon hire and annually thereafter. Training covers eligibility criteria, documentation requirements, the determination process, patient communication standards, and the appeals process. Training completion is documented in each employee’s personnel file.
Wrapping Up
A well-written sliding fee scale policy is not just a compliance checkbox. It is a direct statement about who your health center serves and how seriously you take that responsibility. Patients who see a clear, fair, and accessible policy are far more likely to ask for help, stay engaged with care, and trust your organization over the long run.
Use these samples as a foundation. Adjust the fee tiers, nominal fee amounts, and procedural details to match your center’s approved scope and your Board’s decisions. The structure is here. The rest is yours to make your own.