Arthur Center seeks to support the health and wellness of our communities by providing access to quality health, dental and behavioral health services to persons below 200% of the current Federal Poverty Level. All approved services within the Center’s Scope of Project are subject to the Sliding Fee Discount Policy. These sliding fee discount policies are based on income and family size and also apply to persons who have insurance or other third party payers. In other words, persons with insurance will pay the lessor of the applicable co-payment, deductible, nominal fee or sliding fee.
Medical and Behavioral Services
- Up to 100% of current Federal Poverty Level – a nominal fee of $20 per visit including approved* lab fees
- From 101-133% of the current Federal Poverty Level – $30 per visit including approved* lab fees
- From 134-166% of the current Federal Poverty Level – $35 per visit including approved* lab fees
- From 167-200% of the current Federal Poverty Level – $40 per visit including approved* lab fees
*Approved lab fees are medically necessary labs for a primary (non-specialty) setting to treat the underlying condition being treated in the visit.
Dental
Preventative Care
- Up to 100% of the current Federal Poverty Level – a nominal fee of $40 per visit including x-rays
- From 101-133% of the current Federal Poverty Level – $50 per visit including x-rays
- From 134-166% of the current Federal Poverty Level – $55 per visit including x-rays
- From 167-200% of the current Federal Poverty Level – $60 per visit including x-rays
Restorative Care – Fillings, extractions, root canals and minor procedures
- Up to 100% of the current Federal Poverty Level – a nominal fee of $50 per visit including x-rays
- From 101-133% of the current Federal Poverty Level – $80 per visit including x-rays
- From 134-166% of the current Federal Poverty Level – $90 per visit including x-rays
- From 167-200% of the current Federal Poverty Level – $100 per visit including x-rays
Rehabilitative Care – Crowns, bridges, dentures and major surgical procedures
- Up to 100% of the current Federal Poverty Level – $100 per visit
- From 101-133% of the current Federal Poverty Level – 35% of the Charge* per visit
- From 134-166% of the current Federal Poverty Level – 40% of the Charge* per visit
- From 167-200% of the current Federal Poverty Level – 45% of the Charge* per visit
*Charges for dental visits are based 70th percentile of the most current National Dental Advisory Service Comprehensive Fee Report.
Pharmacy Discounts- Health Center patients who do not have prescription drug coverage are eligible to receive drugs at the Health Center’s cost for drugs prescribed by Health Center providers at Health Center. These discounts are available only through 340B approved pharmacies of the Health Center for prescriptions by health center providers for health center patients (currently Jackson Street Drug, Webber Pharmacy, or Parkway Pharmacy)
Cost is 340Basics Fee + Pharmacy Fill Fee + 340B medication cost. The minimum cost for a drug is currently $15.01 since the cost for 340Basics eligibility screening is $5 for uninsured patients + $10 fill fee for the pharmacy. The cost of the medication varies based upon the drug. The pharmacy may make some low-cost generic drugs that it makes available to its customers at prices lower than the minimum 340B drug cost. Check with the pharmacy for current fees.
When the Health Center does not directly provide services required by the Health Resources and Services Administration, referral agreements are in place for providers who also provide sliding fees that meet or exceed the Health Center’s sliding fee scale. In the event that the fee exceeds the sliding fee for a required or additional service as defined by the Health Resources and Services Administration for the Health Center, the patient may bring a copy of the invoice and payment receipt and the Health Center will reimburse the patient for the difference.
Fee Schedule
On at least an annual basis in the December Board Meeting, the Board will approve a Fee Schedule based upon a combination of the actual cost of providing services and local prevailing charges. The Board has chosen to base the current Fee Schedule on the latest available Practice Management Information Corporation’s Context Healthcare Inc. Medical Fees “Usual, Customary and Reasonable Fee at the 75th percentile” for medical and behavioral health or the most current edition. For dental services, fees will be based upon 70th percentile for dental charges from the most current edition of the National Dental Advisory Service Comprehensive Fee Report. The 75th percentile was chosen for medical and behavioral rather than 50% because there are additional enabling services and clinical tracking that are not a part of competing practices that add to the cost of services.
At least annually in December, the Board will re-evaluate its fee schedule based upon the following:
- Cost of delivering services
- Percentage of Nominal Fees and Sliding Fees collected in the past year
- The results of the annual survey of patients paying the nominal fee to assess the affordability of fees for persons under 100% of the current Federal Poverty Level.
- The Local Prevailing Charges for services taking into account that the services provided by the health center include enabling and other support services that are not typically provided by other providers who are not community health centers.
Nominal Fees and Collection
Arthur Center Community Health seeks to make services accessible to families whose annual incomes are below 100% of the current Federal Poverty Level. Fees are evaluated based the population of persons presenting for services to assure that it is affordable while at the same seeking to minimize the potential for inappropriate utilization of services. On an annual basis, a survey of a representative random sample will be conducted of patients receiving services at the nominal fee to obtain the patient’s perception of affordability.
On at least an annual basis, the Board of Directors will review a survey of patients receiving services at the nominal charge and also review the percentage nominal charges that are actually collected as a percentage of the total patients qualifying for the nominal fee. The trend will be evaluated to assure that it strikes an appropriate balance in access and financial viability.
Waiving Nominal Fees or Charges
The organization will attempt to secure funds to assist persons with special circumstances to access urgently needed services. When these funds are not available, the Board of Directors grants the CEO and CFO authority to waive charges to qualified patients who have special circumstances that paying the nominal fee/sliding fee discount would constitute a barrier to access for urgently needed services. These waivers will be reviewed by the Board on a periodic basis to assure that waivers of charges are being handled in accordance with this policy. Situations that might qualify for a waiver include such things as emergency room referrals where there is very little or no household income, the individual/family is relying solely on the charitable giving of persons other than family members, partner violence situations, homelessness or similar situations.
Refusal to Pay verses Inability to Pay
The health center recognizes that there are persons who have an inability to pay due to current circumstances and poverty. The following is a list of circumstances where the person would be considered to have inability to pay:
- Persons who are unemployed and homeless
- Persons residing in a community supervision center operated by MO Probation and Parole
- Person residing in a domestic violence shelter with no income
- Persons who have special circumstances that the CEO/CFO have waived charges
Refusal to pay occurs when after the patient has been seen for two visits and has not made any payment toward the nominal fee, sliding fee discount, co-payment, deductible or charges. In addition, it is considered refusal to pay when financial staff set up a payment plan and the patient makes no payment for two consecutive months. When it is determined that that it is “refusal to pay,” the following process will be followed:
- If the patient is not currently on a payment plan, financial staff will call the patient and ask the patient to initiate a payment plan or schedule an appointment with a financial counselor.
- If, in the course of reviewing the individual situation, it may be appropriate to make a referral to CEO or CFO to seek waiver of charges for special circumstances.
- If after establishing a payment plan, the patient does not make some payment for two months, the primary provider of the patient will be contacted and a 30-day notice of discharge will be sent to the patient’s last known address. The discharge letter will provide additional options for health care but we will continue to provide assistance with re-fills or medical care during that 30-day period.
- The patient will be discharged after the 30-day period. In this situation, the provider will be notified of the patient’s discharge status.
Reinstatement of Discharged Patients
A former patient who has been discharged for refusal to pay, may re-enroll as a patient after meeting with a financial counselor and paying the balance in full or having made at least two payments of approved payment plan.
Billing and Collections
Arthur Center Community Health is not a free clinic and therefore expects that patients will come prepared to pay the nominal fee or siding fee at the time of the visit. While we do not deny care based upon ability to pay, if a patient arrives without the sliding fee, we will have a nurse triage patient’s presenting situation. If the situation is not urgent or emergent, the patient will be asked to reschedule when they have the payment available.
The center will ensure access and long-term viability through sound billing and collection practices. Our intent is to maximize the revenue from public and private third payers through assuring that we contract with and receive appropriate reimbursement from Medicaid, CHIP, Medicare, private payers and other public assistance programs such as MO Department of Mental Health. We will collect reimbursement “on the basis of the full amount of fees and payments for services with application of any discounts” to the extent of the health center’s ability to negotiate reimbursement rates.
Payment is expected at the time of service to assist in minimizing the cost of billing and follow-up. The health center will make reasonable efforts to collect by making at least three documented attempts to collect payment.
Documentation of both family income and family size is required.
- Income Verification: Documentation of current family income is required and may be in the form of a current benefit check, paystub, or prior year income tax return and a signature that this represents all income received by all family members including children. Family income includes employment income, self-employment income, benefit income, child support, alimony, trust fund distributions, unemployment or other income whether taxable or not. Patients will be given thirty (30) days to provide documentation of income or they will be charged the full rate until the documentation is received. This will be documented on the Sliding Fee/Nominal Fee Eligibility Documentation Form.
- Family Size Verification: Family size can be initially verified by the last income tax return filed. However, for the purpose of determining family size, “family” is spouses and dependent children under the age of 26 or disabled adult children of any age living in the household. Unmarried adults living together as a family would be considered part of the family. Any child living with the couple under the age of 26 would be considered a member of the household. A child living in the household and one of the parents receives child support would be considered a member of the household and the income included, regardless of the dependency deduction on the patient’s income tax return.
- First Visit: Patients are encouraged to bring documentation of income on the first visit, however, the center allows patients to sign an attestation of monthly or annual income and they will be charged the Sliding Fee associated with that income level. If income verification is not received by the second visit or within 30 days, whichever is more, they will be charged the full rate for any future visits until documentation is received.
- Income Re-verification: Should income for the family change, patients are expected to inform the center at the next visit. Patients will be asked to document their current income on an annual basis using the same requirements as the initial Income Verification process.
- Patients with third-party coverage: Patients who are eligible for a sliding fee discount and have third-party coverage are charged no more than any out-of-pocket costs than they would have paid under the applicable sliding fee discount pay class. Such discounts are subject to potential legal and contractual restrictions or limitations based on applicable Federal or state programs, or private payer contracts.
- Payment of Nominal Fee or Sliding Fee: Patients are expected to come to visits prepared to pay the nominal fee or sliding fee. Patients who do not to pay the applicable charge or nominal fee, will be triaged by a nurse or behavioral health professional and if the situation is not urgent or emergent, the patient will be referred to a financial counselor to see if there are any special circumstances preventing the patient from paying the expected charge or fee. A second visit will be scheduled and they will be expected to pay by the second visit. If payment is not received after the second visit, the patient must set up a payment plan before being allowed to make future appointments. If the patient does not follow the terms of the payment plan, they will receive a 30-day notice of discharge. Referrals will be made to other providers. Patients may be re-instated at any time when payment for prior services is received.
- Behavioral Health Patients: Certain persons are given priority access to additional discounts through the Standard Means Test of the MO Department of Mental Health. Arthur Center is an administrative agent for the Division of Behavioral Health for the counties of Audrain, Callaway, Montgomery, Pike, Ralls and Monroe counties. For individuals residing in these counties, priority for Standard Means Test funding will be given to persons who are being monitored by a forensic case monitor, are homeless or immanently at risk of becoming homeless, persons being discharged from state long-term facilities for a period of one year, unemployed persons in specialty court programs, persons being discharged from acute psychiatric facilities for a 6-month period following discharge and persons being referred by law enforcement for a 6-month period. For persons 18 years or younger, priority population includes youth being discharged from residential treatment facilities and those being referred by System of Care teams in the catchment area. Discounts through the Standard Means Test, are subject to availability of funds and income verification.
- Adult Dental Patients: priority will be given to pregnant women, children and referrals from the a local emergency department who are in the target population of persons under 200% of the current Federal Poverty Scale.