Tulare Community Health Clinic, Inc by fDQ7Zq

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									                                                                       Policy #: 02-0003

                     Tulare Community Health Clinic, Inc.

                                    Policy Manual
Subject:   Medical Sliding Fee Scale

From:      Finance

   I.      Policy
           The sliding fee scale provides information on financial poverty guidelines as
           indicated by the United States Department of Health and Human Services
           (HHS). It will assist in assessing eligibility for individuals at and/or below
           Federal Poverty Level. The minimum payment, schedule A (see attachment
           A) will be determined by Tulare Community Health Clinic’s Board of
           Directors.

           Patients on Sliding Fee Scale will receive all lab work performed at Tulare
           Local Health Care District (TLHCD) free of charge (paid by the clinic
           utilizing Section 330 funds). TLHCD provides the clinic with a discount
           below Medicaid charges. All charges for services performed at the clinic will
           be based on the HHS Poverty Guidelines. Services rendered outside of the
           clinic are not covered by the Sliding Fee Scale (i.e. hospital in-patient days, x-
           rays and etc.). Non-covered services are the financial responsibility of the
           patient.

   II.     Purpose
           A step towards fulfilling the Bureau of Primary Health Care’s(BPHC) and
           Tulare Community Health Clinic’s mission of increasing health care access to
           underserved and uninsured patients at an affordable cost.

   III.    Procedure(s)
           a. At the time of patient registration and orientation, patients shall be
               informed of the Sliding Fee Scale, or when the patient calls for an
               appointment. All private pay patients shall be informed of the Sliding
               Fee Scale and asked to bring in proof of income at the time of their
               appointment.
           b. Proof of income and an application (see attachment B) form is required to
               determine patient’s eligibility. The following items may be used as proof
               of income:
                    1. W-2 forms
                    2. Pay stubs
                    3. Income tax returns or any
                    4. other income documentation (i.e. statement of unemployment
                        benefits and etc.)
                    5. Letter from a sustaining party.

Effective Date: 03/16/06
Board of Directors Date: 03/15/06
                                        Page 1 of 5
                                                                   Policy #: 02-0003

          c. The application form shall be filled out and signed by the patient applying
              for the Sliding Fee Scale, and witnessed by the staff person assisting the
              patient in filling out the form. The proof of income documents shall be
              photocopied and attached to the application form. The application forms
              with attachments shall be filed and retained.
          d. Eligibility shall be determined once a year.
          e. No patient shall be given a discount without presenting the required
              documentation, and completing the application form.
          f. Tulare Community Health Clinic, Inc. has elected to divide the Sliding
              Fee Scale classification into four (4) categories of payment as follows
              (see attachment A):

                   1. A= Minimum Fee- includes all patients who in accordance with
                      the Sliding Fee Scale are at or below the 100% poverty level.
                      Minimum fee amount is $20.00.

                   2. B-Category B-25% of charges; includes all patients who have
                      incomes between 100% and 125% of poverty level.

                   3. C-Category C-50% of charges; includes all patients who have
                      incomes between 125% and 150% of poverty level.

                   4. D-Category D-75% of charges; includes all patients who have
                      income between 150% and 175% of poverty level.




Effective Date: 03/16/06
Board of Directors Date: 03/15/06
                                      Page 2 of 5
                                                                           Policy #: 02-0003

Respectfully Approved By:



_______________________________                __________________________________
Board President         Date                   Vice President             Date



This policy and procedure shall be periodically reviewed and updated consistent with the
requirements and standards established by the Board of Directors and by Tulare Community Health
Clinic, Inc. management, Federal and State law and regulations, and applicable accrediting and
review organizations.

Questions concerning any aspect of this policy should be referred to Administration.

This policy replaces and supersedes all previous policies and is effective immediately.


                                      Policy Information

Subject:                    Medical Sliding Fee Scale
Document #:                 02-0003
New/Revised Policy:         Revised 01/31/06 Last Approved 04/20/06


Author:                     Unknown
Revised By:                 Graciela Soto-Perez, CEO
Typist:                     Graciela Soto-Perez, CEO


Forward To:
Attachments:                2006 Health and Human Services (HHS) Poverty Guidelines-
                            Annual Income and Sliding Fee Scale Application.

Revision Notes:




Effective Date: 03/16/06
Board of Directors Date: 03/15/06
                                           Page 3 of 5
                                                                             Policy #: 02-0003

                                                                                  Attachment A



                            Tulare Community Health Clinic, Inc.
                                  Medical Sliding Fee Scale
                         2006 HHS Poverty Guidelines-Annual Income
                            A                B              C                              D

                                      125% of      150% of      175% of
                   United States       Poverty      Poverty      Poverty
                   Poverty Level     Guidelines   Guidelines   Guidelines
                 $20.00
 Family Size     Minimum           Discount=75% Discount=50% Discount=25%
     1                      $9,800        $12,250      $15,313      $19,141
     2                    $13,200         $16,500      $20,625      $25,781
     3                    $16,600         $20,750      $25,938      $32,422
     4                    $20,000         $25,000      $31,250      $39,063
     5                    $23,400         $29,250      $36,563      $45,703
     6                    $26,800         $33,500      $41,875      $52,344
     7                    $30,200         $37,750      $47,188      $58,984
     8                    $33,600         $42,000      $52,500      $65,625
Each
additional
person, add                    $3,400              $4,250               $5,313                 $6,641

Source: Federal Register, Vol. 71, No. 15, Tuesday, January 24, 2006, pp. 3348-3349. United States
Department of Health and Human Services online January 31, 2006
http://aspe.os.dhhs.gov/poverty/06poverty.shtml and
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/06-624.pdf

Notes:
Financial Class (FC) 8
                                                                 MegaView
                                                                 Insurance
                                                                 Company
                         Category            Discount            Numbers
                 A                          $20.00/visit             50
                 B                             75%                   51
                 C                             50%                   52
                 D                             25%                   53




Effective Date: 03/16/06
Board of Directors Date: 03/15/06
                                            Page 4 of 5
                                                                               Policy #: 02-0003

                                                                                   Attachment B
                           Tulare Community Health Clinic, Inc.
                                Sliding Scale Fee Application
Section A: Personal Information
Name (Last, First):                                             Acct. No.:
Address:                                          City:
State:          Zip Code:                          Phone No:(   )      -
Section B: Family Information

Number of family members living at current address: #
Family Member                   Name                             Acct. No.   D.O.B.           Soc.Sec.
Family Member 1

Family Member 2

Family Member 3

Family Member 4

Family Member 5

Family Member 6

Section C: Signature
I certify that the above information is correct.

Applicant Signature: X                                                        Date

Witness Signature: X                                                           Date
                                            Office Use Only
Sliding Fee Scale Category (please circle)          A       B      C               D
*Certain restrictions apply
Income:                                                 Month $                       Year   $
(Please attach check stubs or recent tax information)
Computer Entry Date:       /     /      Time :          Employee Name:
      Medical Services Only
         Tulare District Hospital (TDH) labs and all services performed in the clinic qualify for a
            discount.
         Services rendered outside of the clinic are not covered by this discount (Examples:
            hospital stays, x-rays, pathology fees, and etc.).
         Non-covered services are the responsibility of the patient.

                          Dental discounts are different from medical discounts.
                          Dental charges are more costly than medical charges.
                            See Dental Department for discount information.
      Effective Date: 03/16/06
      Board of Directors Date: 03/15/06
                                                   Page 5 of 5

								
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