Nominal Fees, Waivers, and Additional Billing Options

Let’s remove the barriers to understanding discounts for patients.

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At Health Centers we are always removing barriers for patients. It just seems like our efforts to see patients regardless of ability to pay is so complicated!

When reviewing the May 2021 version of the SVP, you may come across a questions about nominal fees that makes you ask questions about waivers (https://bphc.hrsa.gov/sites/default/files/bphc/programrequirements/pdf/site-visit-protocol.pdf), which has this question at (SVP, Chapter 9, Element c., Question 5.1).

The short answer is we need to distinguish waivers from nominal fees and you should answer this questions only in light of our Sliding Fee Discount Program Policy.

The long answer requires precision for us to clarify between the Sliding Fee Discount Policy, Waiver Policy, and Additional Billing Options/Payment Methods the Health Center may choose to provide. Here are the features of the three different types of “discounts” Health Centers may offer.

Sliding Fee Discount Policy

• Based on family size and income ONLY (see SVP, Chapter 9, Element b, Question 3.3)

• Must provide a full discount below 100% FPL OR require a nominal charge (“Nominal Fee”).

• Available for all patients – uninsured and insured alike. If an insured patient qualifies, they should pay the lesser amount between the SFDP and the insurance amount contingent on any contractual obligations with the insurance contract.

• If electing to have a nominal charge, the Health Center must make it a flat fee, ensure that it is nominal from the patient perspective, be less than any charges for the sliding fee categories above 100%, not be based on the actual cost of services and be evaluated routinely.

• This policy should not mention any other discounts or waivers. HRSA is clear that SFDP has strict applications and any other discounts or waivers must be handled separately.

Waiver Policy

• This is separate from other discounts or policies - SVP Chapter 16, Element h, Questions 16 and 17

• Waiver Policy must detail the circumstances or criteria that are used to waive fees

• Must be applicable to ALL patients regardless of income level

• Because this is separate from other discounts, these waived fees should be tracked separately to produce examples for documentation of the correct application of the policy

• Examples of circumstances or criteria could include (but are not limited to): patients experiencing homelessness, patients in active rehab, patients who lost employment in the last 3 months, etc.

• We recommend being precise in your policy or procedures on how these waivers are applied. Are they applied for any patient meeting this criterion? Or do patients have to apply for it? What happens if a patient pays and then qualifies for a waiver? Who decides on if a waiver is possible? How will you track the waivers in your Practice Management system for review and compliance to your own policy?

• When presenting documentation information, be sure to include the patient’s application for the waiver, the supporting documentation for the circumstance and evidence of who the decision maker was.

Additional Billing Options or Payment Methods

• These are optional - the Health Center may not have any additional billing options or payment methods

• These may include options like prompt pay discounts, cash payment incentives, or payment plans (SVP Chapter 16 Element e Questions 9, 10, 11)

• If offered, these options must be available to all patients regardless of income level or sliding fee discount pay class

• In other words, if you have payment plans or prompt pay discounts, these must be clearly defined in the policy as being available for ALL patients

• Now, obviously, most patients who qualify for the sliding fee discounts will not need to take advantage of the additional payment options, but HRSA is making clear that these are not the same thing and must be available to all patients.

In short, remember:

1. Sliding Fee Discounts, Waivers, and Additional Billing Options are 3 distinct discounts and should be separate policies.

2. Review and remove any language about waiver or other payment options from your Sliding Fee Discount Policy

3. Add the language to a new (or existing) Waiver Policy (or some similar policy) and clarify the conditions and criteria the responsible parties would use to grant a waiver of fees. Ensure that this is available regardless of income level.

4. For your nominal fee, ensure that you have documentation on how the Nominal Fee is set and ensure that there is recent evaluation of the SFDP and the Nominal Fee specifically.

5. Additionally, ensure that your SFDP meets the additional requirements around the Nominal Fee.

6. Finally, for any Additional Billing Options make it clear that these are available to all patients regardless of income or sliding fee discount class.

Good luck!