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LiveStrong: What Is a Sliding Scale, and How Can It Help You Get More Affordable Health Care?

What’s in a person’s wallet or bank account shouldn’t affect the quality or quantity of health care they receive. And yet anyone who has ever debated between ponying up a $50 copay or paying for groceries, rent or other necessities knows that’s not the case. Sometimes, health care is out of reach financially.

Sliding fee scales aim to introduce equity to health care decisions, by offering a discounted rate. “The advantage of using a sliding fee scale is that health care becomes a lot more affordable because how much you need to pay for each procedure becomes relative to your income,” says David Chen, DDS, a dentist in Long Island City, New York.

Here’s what you need to know about the sliding fee scale and how it might help you.

What Is a Sliding Fee Scale?

Sliding fee scales are typically determined by income. They aim to cut the cost of health care services for people who meet certain income requirements, explains Christa Holmes, the practice manager at Cornerstone Care Community Health Center of Washington.

Essentially, it allows health care providers to “reduce your out-of-pocket expenses for your services, based upon your household’s income,” Holmes says.

Sliding fee scales are required at Federally Qualified Health Centers (FQHC), which get federal funding and provide health care to underserved areas or populations, according to the U.S. Centers for Medicare & Medicaid Services.

But FQHCs aren’t the only health institutions to offer a sliding scale — other clinics, hospitals and private practices may offer sliding fee scales as well. (More on that in a moment.)

How Sliding Fee Scales Work

Eligibility

Your eligibility for the sliding fee scale at a FQHC is determined by two things: the size of your family and your income level. To qualify, your income needs to be at or below 200 percent of the Federal Poverty Guidelines, Holmes explains.

For D.C. and all states aside from Hawai’i and Alaska, the poverty guideline for an individual in 2024 is $15,060, according to the Office of the Assistant Secretary for Planning and Evaluation (ASPE). For a family of four, the income level is $31,200, per ASPE. So, 200 percent of the federal poverty guidelines for a single person is $30,120, and for a family of four, it’s $62,400.

Clinics typically request proof of income, Holmes says. “That can be in the form of a pay stub, most recent income tax return or W-2 or proof of any form of income not reportable on a tax return,” she says. You’ll need to include information for yourself and anyone else in your household, because the guidelines vary accordingly.

You can ask the health care organization or provider for a list of documents required for proof of income.

Do You Need Health Insurance?

Put simply: No, not at a FQHC.

“The sliding fee scale can be offered to patients regardless of their insurance status,” says Elizabeth Workinger, controller for Family First Health, a FQHC in Pennsylvania. “If you qualify for the program and have insurance, there is a possibility it can help with out-of-pocket costs,” she says.

Outside of FQHCs, health insurance requirements may vary.

Fees Vary From One Clinic to Another

If you’re going to a FQHC, it must follow the Federal Poverty Guidelines to determine if you’re qualified for a sliding fee scale, Workinger says. But, “each health center can establish their own fees,” she notes. Consider comparing the fees at multiple health care providers to find the best deal.

Are Sliding Fee Scales Available Elsewhere?

It’s not only FQHCs that offer sliding fees. Other health clinics, hospitals and private practitioners may offer them as well.

For instance, the Chicago Women’s Health Clinic (CWHC), which offers service to women, transgender individuals and youth, has a sliding scale based on income and household size, and it doesn’t require any documentation or proof of income to access the sliding scale.

At Memorial Sloan Kettering Cancer Center (MSKCC), there’s a financial assistance program available “for people with household incomes up to 5 times the federal poverty level who cannot pay for their medical care.” If you’re eligible for this program, it can lead to lowered fees (like a sliding scale) or the balance being paid after you pay the amount you can afford, per MSKCC.

There’s a sliding fee program available at Northwell Health solely for uninsured patients. And at Cedars-Sinai, you can receive medical care without any charge if your income is at or below 400 percent of the federal poverty level, or get a discounted rate if your income is between 401 and 600 percent of the federal poverty level.

And some — but not all — private practices may offer a sliding fee scale.

As the owner and founder of Nutrethos, a nutrition counseling practice, Carlos Fragoso, RD, CDN, doesn’t accept insurance, explaining “as a single-member private practice it is extremely difficult to become in-network with insurance companies” and noting that “navigating the world of insurance billing is like learning a new language.”

Instead, his clients pay out of pocket. Insured patients with out-of-network benefits sometimes are reimbursed for these payments by their insurance.

“For those clients who do not have out-of-network benefits and may not have the financial means to pay weekly to see me, I offer a sliding scale which is approximately a 10 to 35 percent discount off my usual rate, depending on their needs,” Fragoso says.

Needs are determined based on income and financial obligations, and through “an open and honest discussion,” he says. “I do not ask to see financial statements, I think that is too invasive.”

For therapists, a sliding fee scale is quite common, but not required, says Stephanie Barca, LMSW, of Benjamin Holmes Counseling, in Nashville, Tennessee. That means “there is no uniform process,” she says. “Some therapists choose to have prospective clients fill out a form asking for specific financials. Others may ask what the individual is comfortable paying and discuss how they got to that amount.”

Offering a discounted rate can be easier for private practitioners, Barca says, echoing Fragoso. But not all practices offer this. Dr. Chen doesn’t offer a sliding fee schedule at his dental office. Some private practices can be reluctant to do so, he believes, because it can require requesting pay stubs or tax returns. “Dentistry is pretty personal, but that’s a little too personal in my opinion,” Dr. Chen says.

Setting up a sliding fee scale is a challenging task. You either take people at their word (as Fragoso does) or require paperwork, which means an administrative burden.

There’s another reason private practitioners may hold off on establishing a sliding scale: They need to cover their costs and earn a living. “I usually reserve 20 percent of my spots for clients who require a sliding scale,” Fragoso says. He operates with a sense of how much he needs to take home each month. “If I take on more clients one month, I can offer more sliding scale spots,” he says.

Tips for Using a Sliding Scale

Find a Provider

One smart starting place: Look for a FQHC located near you, Workinger says. Visit findahealthcenter.hrsa.gov to find locations, she suggests.

You can search online for providers or clinics using keywords like “sliding scale” or “financial assistance” and the type of doctor or health care you need. You can also search major hospitals located nearby.

For therapists, Psychology Today and Good Therapy offer directories with a filter for therapists offering a sliding scale, Barca says. Keep in mind that not all therapists will advertise their negotiating ability.

Be Prepared for Paperwork and Conversations

Expect that many health care offices will want you to fill out some paperwork, and bring along some proof of income. (Again, it won’t be required by all health care providers, but FQHCs will need documentation.)

It can help to call before your appointment, so you can be clear on if you’re covered, and what fee you’ll owe prior to receiving care. You can also check on the clinic’s website to understand what information you’ll need to provide and review the application.

For practitioners who aren’t part of a FQHC, there are a lot of ways to handle the sliding fee scale. Some, like Fragoso, may reserve a set amount of appointments for patients. “Some therapists choose to have prospective clients fill out a form asking for specific financials. Others may ask what the individual is comfortable paying and discuss how they got to that amount,” Barca says.

You Can Always Ask

That classic saying is true: If you don’t ask, you don’t get.

“The best way to ask a provider about a sliding scale fee is to just be straightforward with them,” Fragoso says. You can tell the health care provider that you’d love to work with them, but aren’t able to pay their standard rate, he says. “And then simply ask: ‘Do you offer a sliding scale?'” he suggests.

It can help to have a sense of what you can afford beforehand, Barca says. “Be ready to share information honestly and authentically,” she says. “That feels vulnerable, but know that it is vulnerable for the therapist to engage in the discussion, too. Our practice is our livelihood,” Barca notes.

It’s possible the health care provider will say a sliding fee scale is not an option. “While this may seem like a rejection, it is not personal. It is a business decision often based on factors out of both parties’ control,” Barca says.

Consider a few potential follow-up ideas if a sliding fee scale isn’t possible:

  • ‌Inquire about a waitlist:‌ Some providers may only reserve a few slots for patients who need a sliding scale, Fragoso says. If that’s the case, ask if there’s a waitlist you can join.
  • ‌Ask for a referral:‌ Whether you’re looking to see an MD, RD, PhD or any other specialist, you can feel confident that the health care practitioner — or the front desk or financial department — may have more connections than you in the field. They might be able to offer some suggestions for where you can receive lower-cost care or access a sliding scale. “If a provider isn’t able to offer a sliding scale, ask if they can refer you to another provider who can,” Fragoso says.
  • ‌See them less frequently:‌ In some cases, it may be an option to see the provider every other week to ease the burden of the cost, Fragoso says. You could also ask about financing options or if the provider has any suggestions for other ways to lower the fee.

ABC27: Mommy Minute: Space story educates kids about vaccines

No kid likes to get shots.

That’s something Dr. Hetal Petal has seen firsthand; from her patients and her own daughter.

“She always says ‘mommy, we can go to the doctor, but no shots,” Patel said.

That’s why Family First Health came up with a new way to teach kids about vaccines and why those shots are necessary. It’s a book called Little Heroes: Attack of the Galactic Grime. It’s an out-of-this-world story with an important earthly message.

“It’s a journey that we start – and it’s a long journey – and the book does that with all the stations,” Patel said. “We start in infancy and go all the way to 12.”

“They see these characters get these shots and realize ‘oh, they’re protected, so maybe it’s not so bad for me to get my shots and I’ll be protected, too,” said Lori Garman, manager of clinical services.

Garman and her daughter, Greta, were the creative forces behind the story.

Family First says routine vaccine visits waned during the pandemic and many are still not caught up yet. The book addresses the different types of shots, boosters and even the concept of herd immunity.

“It’s sort of like, ‘yes, we should do this so I am healthy, but I should also do this to protect everyone around me,” Patel said. “The book does a really good job of pointing that out.”

The book is available in English, Spanish and Haitian Creole.

“We felt it was pertinent to have it in all three languages,” Garman said.

You can pick up a free copy of the book at any Family First Health location. They also have an online version, which is interactive.

You can find the online version of the book here.

You can find more vaccine resources by clicking here.

Watch the video here.

York Dispatch: This is how Family First Health is removing the barrier to dental care in York’s school

Bright and early Thursday morning, as students filed into Hannah Penn K-8 for another day of learning, a small team transformed the school’s library into a mobile dentist clinic.

The initiative is part of Family First Health’s school dentist program, offering in-school dental care for all ages and grade levels. LaJuan Mountain, the vice president of dental services for Family First Health, said the clinic helps provide better accessibility to both students and parents who would otherwise be unable to visit the dentist.

“There was a barrier with parents not being able to get off work to get their kids into the office,” Mountain said. “So seeing them in a school setting prevents the parent from losing a day at work, and it prevents the child from missing a day at school.”

In addition to closing the divide for access, Family First Health is working to change the overall dental culture in the York community.

Oftentimes, Mountain said, individuals might only see a dentist when something is wrong. The same goes for kids, too, when it’s often too late.

These routine screenings provide essential care to ensuring a child’s teeth are healthy and strong, she added.

Family First Health’s dental unit partners with a number of schools in York, Adams and Lancaster counties. On Thursday at Hannah Penn, the team had 176 scheduled services with students.

Nicole Tome, the school-based health center manager at Family First Health’s Hannah Penn Center, said the program is a wonderful way to provide essential care while missing little class time.

“Attendance is a nationwide issue for schools — and it’s no different here in York,” Tome said. “But when we have students here, we want them to be in class and learning. So mobile school dentistry events really cut down significantly on the time that students are away from their seats.”

The entire process takes roughly 20 to 30 minutes and includes dental screenings, cleanings, X-rays and a fluoride rinse. Health professionals will then use the data collected during exams to determine how often they should return to school.

If a student requires additional care — filling cavities for instance — Family First Health will schedule those appointments, too.

The cost of care is covered by the parent’s insurance. In instances where a family might not have insurance, though, Family First Health will work to get them insured.

This could mean being covered by state-funded insurance, for example, Mountain said.

Though being called down to get dental care at school might be an embarrassing situation for children, Tome said the kids often come out of appointments feeling confident and empowered.

“I think they’re more proud of the moment and they feel good about themselves,” Tome said. “I think it’s helping to boost their self-esteem and they leave with smiles on their faces because they know that they now know a little bit more about how to take care of their bodies.”

You can learn more about Family First Health and its programs at www.familyfirsthealth.org.

Watch the video here.

York Dispatch: Pa. officials praise school-based health center at Hannah Penn

State officials recognized the work of Family First Health Center in coordinating school-based health services as an outreach for students who may not otherwise be able to access dental, medical and vision care.

“Family First Health’s school-based health center is working to reduce barriers for families by providing critically needed services directly in school so that all young people, no matter their zip code, have equal opportunity to learn and grow,” said Val Arkoosh, secretary of the state Department of Human Services, in a news release after a visit to York City’s Hannah Penn K-8 School last week.

Hannah Penn K-8 is the location of a satellite office that provides students with a variety of services. Health officials pointed to the partnership that helped create the center as a potential model for increasing health care access.

“As a pediatrician, I’ve seen first-hand how school-based health clinics help children who otherwise may have gaps in their healthcare get the medical, behavioral, dental and vision services they need,” said Debra Bogen, the state’s acting health secretary, in the news release.

The Family First Health Center is open Monday through Friday with varying hours and offers health services to students. Adult and pediatric care are available as well as health exams, immunizations, preventative care and more, according to the center’s website.

This health center has Spanish interpreters on staff and trained staff members that assess eligibility for insurance assistance programs, in addition to various on-call staff to deal with emergencies 24/7.

In 2020, the health center received $2 million in grant funding from the United Health Foundation that allowed Family First Health to “significantly expand” its offerings, according to the state officials. The health center first opened in 1997 with help from the city, the school district and WellSpan Health.

The 2020 grant also funds health navigators who get families connected to more social services and home visits.

ABC27: Representatives discuss improving healthcare access for underserved communities

YORK, Pa. (WHTM) – Representatives from Hannah Penn School, Family First Health, and the United Health Foundation were joined by Pennsylvania Department of Human Services (DHS) Secretary Dr. Val Arkoosh and Pennsylvania Department of Health (DOH) Acting Secretary Dr. Debra Bogen Wednesday to discuss improving health care access for underserved communities through school-based health centers.

Services provided by school-based health centers include:

  • Medical
  • Behavioral
  • Dental
  • Vision

Such healthcare centers are places where Medicaid has higher rates in the community.

The health centers that are embedded in schools are used to ease barriers to care and achieve health equity among children.

“As a physician, I worked with families whose health was negatively impacted by the lack of access to health care and other essential services. This is a complex issue, and I am thrilled to be here with partners in health care, government, and education to be a part of the solution,” Secretary Arkoosh said. “Family First Health’s school-based health center is working to reduce barriers for families by providing critically needed services directly in school so that all young people, no matter their zip code, have equal opportunity to learn and grow.”

“As a pediatrician, I’ve seen first-hand how school-based health clinics help children who otherwise may have gaps in their healthcare get the medical, behavioral, dental, and vision services they need,” Acting Secretary of Health Dr. Debra Bogen said. “During National Health Center week, it is important to showcase how clinics such as Family First Health work to bridge the health equity divide and create a healthier Pennsylvania for all.”

In 2020, Family First Health’s school-based health center received $2 million in grant funding from the United Health Foundation.

This grant helped expand primary care that includes behavioral health care and wellness services.

The school-based center can be used by students, their families, and the York community.

Health navigators who connect families to social services and provide home visits where needed were funded by the grant as well.

“The United Health Foundation and Family First Health partnership has created incredible community impact across York,” said Blair Boroch, CEO, of UnitedHealthcare Community Plan of Pennsylvania. “Nearly 2,000 families have been engaged in wellness programs at Hannah Penn’s school-based health center, and students now have expanded access to primary care and behavioral health screenings. Community health workers are also providing in-home support to families, helping individuals manage chronic conditions, and screening and providing referrals to social supports.”

“The team at FFH is so pleased to welcome Secretaries Arkoosh and Bogen to our health center location at Hannah Penn K-8 School. In a school-based location, we are uniquely able to deliver on our mission of improving lives by addressing the root causes of health disparities. With partners like UnitedHealth Foundation, we have been able to expand our programs and services at the school to provide much-needed care for our community. National Health Center Week is the ideal time to highlight the impact of this model. We believe there is no more important time to work closely with schools and families to improve health and are grateful for the opportunity to share our work.”

Watch the video here.

CBS21: School-based health centers help to make treatment accessible

York, PA – Meeting the medical needs of the community in a comfortable, familiar setting. Family First Health, partnering with the York City School District, to provide a school-based health center for all.

“It is crucial,” said Secretary Dr. Val Arkoosh, Pennsylvania Department of Human Services.

In honor of National Health Center Week, Dr. Arkoosh toured the center at Hannah Penn Middle School. For 26 years, the school-based health center has offered exams, shots, lab capabilities and overall access to healthcare.

Serving 1,100 patients a year, from students to family members, the center makes healthcare more accessible.

“To have a place like this, that is convenient right at the family school, that has a sliding scale for payments, depending on the income status … those are services that not every doctor’s office can provide,” said Dr. Arkoosh.

Funding for the center comes from Medicaid reimbursement, individual payments and grants from private donors.

Gettysburg Connection: Empowering Parents who breastfeed

By C. Lisa Lathrop RN, BSN, IBCLC, Program Manager/Nurse Supervisor Nurse-Family Partnership at Family First Health

August is National Breastfeeding Month, 2023

The breastfeeding journey should begin during pregnancy.

Expectant moms can and should prepare for breastfeeding before giving birth. There is much to learn and understand about the first few days and months postpartum. At Family First Health, we have the Nurse-Family Partnership (NFP) Program which supports moms to have a healthy pregnancy and healthy baby by partnering the mom with a personal registered nurse. This nurse offers support advice, and information in many areas and is available to the mom until the baby turns two years old.

Most nurses in the NFP program have undergone a certified lactation counselor training certificate which means they can support moms prenatally with education and then postpartum through feeding assessments and skilled hands-on assessments. We also have two International Board-Certified Lactation Consultants (IBCLCs) on staff who can help with complicated cases. There can be many barriers to a mom’s success with breastfeeding and we’ve found that educating the mom on those topics before they deliver increases the number of moms who choose to breastfeed and the length of how long they continue that breastfeeding journey.

Supply and demand

The first hours and days of a baby’s life are crucial to a mom’s milk supply. Early, frequent skin-to-skin can impact breastfeeding and how often the baby eats can also influence it. The frequency of feedings in those first few weeks determines milk supply months down the road. Some will misinterpret the baby’s cluster feedings and assume the baby isn’t getting enough milk during feeding sessions. Sometimes, this results in parents offering a bottle of formula instead of continuing with frequent feedings. If mothers are educated and know what is normal, they are prepared when the time comes.

Milk myths

Did you know milk supply can be influenced by the mother’s calorie intake or stress level? That moms burn up to 500 calories per day as their body creates milk? Or that a baby’s latch is not supposed to be painful?

Lactation consultants and IBCLCs can help moms navigate these topics. Many moms are seen by a lactation consultant while in the hospital, but ongoing education and support are invaluable. While breastfeeding has a longstanding place in history – it isn’t always easy and that is why support exists.

Community resources for all parents

Even if you’re not part of the NFP program, which requires a woman to be less than 28 weeks pregnant with her first child and meet income requirements, resources like WIC (Women, Infants, and Children) and private or public lactation consultants are available. Breastfeeding education classes, both online and in person, also offer valuable insights for expectant mothers. I encourage every parent to bring up the topic of breastfeeding early and often to their doctor during prenatal visits. Ask for educational materials, support or online classes the physician may recommend.

Education Is empowerment

If a parent chooses to breastfeed, they should have every resource available to support that experience. It is critical that they understand the changes in their body and how to help meet the needs of the baby. We are working at Family First Health’s Nurse-Family Partnership to bridge the knowledge gap and make breastfeeding a rewarding journey for every parent and every baby, but if someone is not in our program or in our service area, we want them to know they, too, can find resources to support them.

So, if you’re newly pregnant and seeking a nurturing community, consider these incredible avenues for guidance and care and know that Family First Health’s NFP community stands ready to uplift and empower you every step of the way.

Family First Health Gettysburg Center is located in the Marshall’s Plaza (formerly Peebles Plaza) in Gettysburg. The health center was launched in 2009 following a community needs study and initiation by Healthy Adams County.  Phone (717) 337-9400

York Daily Record: York County leaders look for community feedback on navigating health and human services

Leaders in York County are trying to make the local healthcare and human services coordination systems better and easier to navigate, but they need help from residents of York County.

The project, funded by the County of York, aims to find new ways to work together to improve community health and well-being, said Kevin Jackson, a consultant working with Family First Health.

“We have all navigated health and human service systems, and during COVID we saw that organizations both large and small were more innovative to get to needs quickly, but coming out of COVID people are settling back into old inefficient and siloed ways,” he said. “We want to make sure we don’t lose this innovative spirit with how we serve community members.”

Jackson said that a person’s overall health and well-being requires a connected and coordinated network of systems and services. Where we live, what we have access to, what we can afford and how we socially connect all matter. Many community members continue to find it challenging, frustrating and inequitable to access essential resources such as food, housing, transportation and healthcare.

“Everyone wants to be healthy and have access to what they need to be healthy,” he said. “So that’s why everyone needs to work together to make sure referrals, hand-offs, resources and funding go where they need to go in York County. We can and must do better.”

Jackson said the goal for this project is to bring together health and human services from various healthcare systems and community organizations to create a better experience for community members as they move through these systems.

To do this, Healthy York Coalition brought together over 130 health organizations, government officials, and community-based organization leaders to discuss ways that everyone could work together for better health in the county.

“There are no shortages of people who care, so we brought them together and out of this meeting we created three teams to help us understand the community member experience, their journey as they go through our systems, where communication and process breakdowns happen, and how we can make a positive impact in their experience,” Jackson said. “But you can’t do that without asking for the experience of the community member, so that’s where we need help. We want to know their candid experiences, what they would suggest, what their ideas may be. We want to engage them in the process, not have directors and executives solely make decisions for them.”

Those who would like to send feedback or ideas can email yourvoicematters@familyfirsthealth.org. They can also call and leave a message at 717-356-2226. Additionally, they can use the attached QR code to complete a quick survey.

To view the code, please visit here.

FOX43: Up to 700,000 Pa. patients could lose Medicaid coverage this year

YORK, Pa. – Hundreds of thousands of Pennsylvania Medicaid and CHIP patients could lose coverage this year due to the end of a federal pandemic-era policy.

During the COVID-19 pandemic, Medicaid patients remained in the program regardless of whether they had changes in their eligibility, such as getting a higher-paying job that put them above Medicare’s maximum income requirements.

Beginning on April 1, the Medicaid continuous coverage requirement ended, meaning patients now ineligible for Medicare will risk losing their health coverage at the time of renewal. Renewal times vary by patient, so coverage losses will happen throughout the next year.

Officials estimated that 600,000 to 700,000 Medicaid patients may have become ineligible in the roughly three years since the continuous coverage requirement began.

On June 6 the Pennsylvania Department of Human Services detailed its plan to ensure those losing Medicaid coverage continue to have health insurance.

Current Medicaid patients who either don’t fill out their annual renewal or fill it out but are no longer eligible will receive a letter directing them to Pennie, the state’s official health coverage marketplace. Their personal information will automatically be transferred to the site, where patients can find another affordable health insurance plan.

“Everyone deserves the dignity and peace of mind of having access to affordable, high-quality health care and knowing they can go to the doctor when they need it. DHS’ goal throughout the renewal process is to make sure that all Pennsylvanians stay covered so they have that peace of mind,” said DHS Secretary Val Arkoosh.

Pennie is not an insurance provider, but helps patients shop for insurance policies. It also lets patients know if they qualify for tax savings to help reduce the cost of monthly premium payments and out-of-pocket costs.

“Those who lose medical assistance and come over to us often can find health plans that are quality for under $10 a month,” said Pennie executive director Devon Trolley.

Those who need help through the process can set up an appointment with a “Pennie assister” such as Emily Saare, an eligibility specialist with Family First Health in York. Saare, who specializes in assisting patients who are HIV positive, said many patients feel they have no options when they become ineligible for Medicaid.