Sliding Fee Scale & Patient Cap on Charges
Policy & Procedurelast updated 2/22/2016
Purpose:In order to comply with legislative requirements, XXPart C/D network clinics offer a sliding fee scaleto assist uninsured/underinsured patients who have difficulty paying for HIV primary care services. People living with HIV/AIDS (PLWHA) whose incomes areat or below100% of the federal poverty level (FPL) willnot be charged for HIV primary care, while PLWHA with incomes at 101% FPL or above who rely on Ryan White for access to HIV primary care willbe charged for the services they receive, based on a sliding fee scale. PLWHA who are charged for the services they receive will have their annual charges capped at a percentage determined by their level of income. Only charges for outpatient services are applicable to this policy.
Policy: It is the policy of XX Part C/D network clinics to provide essential HIV primary care services and access to limited HIV-related specialty care services regardless of the patient’s ability to pay. A sliding fee scale is used to calculate the patient’s nominal chargeaccording to the most recent FPL. The patient’s nominal fee is calculated using individual annual income. Once a patient is approved for the sliding fee scale, the chargewill be honored for six months or until the patient’s next RWHAP case management re-certification due date, whichever is sooner.
Sliding Fee Scale Procedure:
PLWHA who have no insurance and are enrolled in Ryan White case management are considered automatically enrolled in the XX Part C/D network sliding fee scale. Patients will be notified of the sliding fee scale and required nominal fees at the time of enrollment into RWHAP case management and/or at 6-month re-certification. Literature about sliding fee scale and required nominal charges will also be available in Part C/D network clinic exam rooms (Attachment A).
Patients with an income at 101% FPL or above, based on Ryan White case management documentation, will receive a Ryan White billing statement (Attachment B) by mail from a Part C/D program director every 6 months (e.g., August statement to cover January-June visits; February statement to cover July-December visits).
- This statement will summarize the dates of service on which the patient received HIV-related care funded by Ryan White and a nominal fee for each visit based on the sliding fee scale.
- This statement is generated from SCOUT – separatefrom the clinic’s billing system – to ensure a patient will not go into collections if unable to pay the charges.
- Patient payments are to be remitted to the program director noted on the statement to ensure appropriate tracking and capture of the payment as program income.
RWHAP Part C/D Network Sliding Fee Scale
Individual Income / RWHAPNominal Fee/Copay
(per visit) / MaximumCharge
(% of annual gross income)
100% FPL or Below / $0.00 / 0%
101-200% / $5.00 / 5%
201-300% / $7.00 / 7%
Above 300% / $10.00 / 10%
FPL is updated annually and available online at:
Cap on Charges Procedure:
PLWHA at XX Part C/D network clinics will pay nominal fees for HIV primary care visits, labs ordered by HIV care providers, or HIV-related specialty care visits until their maximum charge threshold is met.
Patients with an income at 101% FPL or above, should complete a short application (Attachment C) and provide receipts and/or copies of billing statements to demonstrate they have met the annual cap on charges based on the FPL and percentage of their gross income as described in the sliding fee scale.
- Eligible charges that may count toward the cap include:
- Insurance premiums paid by the patient
- Deductibles for outpatient HIV primary care visits or labs paid by the patient
- Co-pays for outpatient HIV primary care visits or labs paid by the patient
- RWHAPcharges (nominal fees) paid by the patient
- If a patient is not enrolled in Ryan White case management, the patient will be required to provide proof of income along with the cap on charges application.
- Patients will be counseled that they should keep track of charges imposed across RWHAP providers, if they also seek care outside the XX Part C/D network.
- Once a patient has reached the limit for the cap on charges, the patient will not be responsible for out-of-pocket charges for HIV-related care at any RWHAP clinicsuntil the next year. Clients will continue to receive services.
- Patients may re-apply for the cap on charges every 6 months or sooner if a change in FPL has occurred.
Patients with documented income at or below 100% FPL, based on Ryan White case management documentation, willreceive no charges at all, so the cap is 0%.
Tracking & Monitoring:
The Part C/D program director or a designee is responsible for reviewing Physician Billing data and SCOUT data on a regular basis to ensure patients at or below 100% FPL do not receive first-party charges for HIV care as described in this policy. Any billing errors identified should be communicated in writing to Physician Billing in order to get charges reversed and billed to the proper Ryan White FSC (e.g., 309 for Part C, 439 for Part D). SCOUT should be the preferred mechanism for tracking:
-SCOUT encountersshould track billing statement sent and patient payment received.
-Cap on Charges applications and supporting documentation should be scanned into the SCOUT Documents Module.
-SCOUT referral should track start and end date of the approved cap on charges period.
Communication & Policy Review:
Part C/D program directors should coordinate communication strategies with other regional Ryan White grantees to ensure consistency in addressing this legislative requirement, regardless of where a patient receives care in the St. Louis region. Input from Consumer Advisory Board (CAB) members should be included in the review of this policy. Case managers and clinic staff should be educated at least annually on this policy and procedure.
Attachment A: Client Handout
Insert1-pager description for use in CM enrollment/re-certification and in clinic exam rooms.
Page 1 of 3Policy_SFSandCaponCharges_20160222.docx