Sliding Fee Discount policy

 This program is designed to provide free or discounted care to  those who have no means, or limited means, to pay for their medical  services (Uninsured or Underinsured). In addition to quality healthcare,  patients are entitled to financial counseling by someone who can  understand and offer possible solutions for those who cannot pay in  full. The Patient Account Representative’s role is that of a patient  advocate, that is, one who works with the patient and/or guarantor to  find reasonable payment alternatives. Fulton Family Medicine will offer a Sliding Fee Discount Program to all who are unable to pay  for their services. The program’s eligibility is on a  individual’s  inability to pay and will not discriminate based on whether payment for  those services would be made under Medicare, Medicaid, or CHIP; the  individual’s race, color, sex, national origin, disability, religion,  age, sexual orientation, or gender identity. The Federal Poverty  Guidelines are used in creating and annually updating the sliding fee  schedule (SFS) to determine eligibility.   

Eligibility:  Discounts will be based on income and family size only. Fulton Family Medicine  uses the Census Bureau for definitions of the  following: a. Family is defined as: a group of two people or more (one  of whom is the householder) related by birth, marriage, or adoption and  residing together; all such people (including related subfamily members)  are considered as members of one family. b. Income includes earnings,  unemployment compensation, workers' compensation, Social Security,  Supplemental Security Income, public assistance, veterans' payments,  survivor benefits, pension or retirement income, interest, dividends,  rents, royalties, income from estates, trusts, educational assistance,  alimony, child support, assistance from outside the household, and other  miscellaneous sources. Noncash benefits (such as food stamps and  housing subsidies) do not count. c. Uninsured: The patient has no level  of insurance or third-party assistance to assist with meeting his/her  payment obligations.  d. Underinsured: The patient has some level of  insurance or third-party assistance but still has out-of-pocket expenses  that exceed his/her financial abilities.  e. Poverty Guidelines: The  poverty guidelines are a simplified version of the Federal Government's  statistical poverty thresholds used by the Bureau of Census to prepare  its statistical estimates of the number of persons and families in  poverty. The poverty thresholds are used primarily for statistical  purposes. However, the Department of Health and Human Services uses the  thresholds for administrative purposes to determine whether a person or  family is financially eligible for assistance or services under a  particular federal program. Our poverty guidelines are based on last  (calendar) year's increase in prices as measured by the Consumer Price  Index. The poverty guidelines are published in the Federal Register and  are revised yearly.  Following is the link to the 2022 poverty  guidelines - https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines

Income verification: Applicants must provide the following: prior year W-2, two most recent  pay stubs, letter from employer, or Form 4506-T (if W-2 not filed).  Self-employed individuals will be required to submit details of the most  recent three months of income and expenses for the business. Adequate  information must be made available to determine eligibility for the  program. Self-declaration of Income may only be used in special  circumstances. Specific examples include participants who are homeless.  Patients who are unable to provide written verification must provide a  signed statement of income, and why (s)he is unable to provide  independent verification. This statement will be presented to Fulton Family Medicine LLC Owner or his/her designee for review and final  determination as to the sliding fee percentage. Self-declared patients  will be responsible for 100% of their charges until management  determines the appropriate category. 

 Completion of Application: The  patient/responsible party must complete the Sliding Fee Discount Program  application in its entirety. By signing the Sliding Fee Discount  Program application, persons authorize Fulton Family Medicine access in confirming income as disclosed on the application form.  Providing false information on a Sliding Fee Discount Program  application will result in all Sliding Fee Discount Program discounts  being revoked and the full balance of the account(s) restored and  payable immediately. If an application is unable to be processed due to  the need for additional information, the applicant has two weeks from  the date of notification to supply the necessary information without  having the date on their application adjusted. If a patient does not  provide the requested information within the two-week time period, their  application will be re-dated to the date on which they supply the  requested information. Any accounts turned over for collection as a  result of the patient’s delay in providing information will not be  considered for the Sliding Fee Discount Program.   

Administration: The Sliding Fee Discount Program procedure will be administered through  the Business Office Manager or his/her designee. Information about the  Sliding Fee Discount Program policy and procedure will be provided, and  assistance offered for completion of the application. Dignity and  confidentiality will be respected for all who seek and/or are provided  charitable services.