SLIDING SCALE POLICY AND PROCEDURE

Effective: May 22, 2025

Policy 

It is the policy of Spirit Clinic, LLC to offer sliding scale rates to uninsured or out-of-network patients seeking mental health services in the practice. To be eligible for the sliding scale system, patients must be experiencing financial hardship. All sliding scale eligibility determinations will be made using Annual Federal Poverty Guidelines. Individuals with chronic illness expenses, disabilities, or temporary unemployment may also be considered for eligibility. Patients seeking sliding scale rates will be required to complete the practice’s Sliding Scale Application Form. Patients may be asked to present supporting documentation such as proof of income, dependents, or expenses. This sliding scale system will not be used in combination with any managed care plans due to contractual limitations. It is Spirit Clinic, LLC’s hope that this fee flexibility helps make mental health care more affordable to those who would otherwise have to forgo this practice’s resources due to financial considerations. 

Definitions 

Sliding Scale Rate: A fee that changes based on household income and number of dependents.

Federal Poverty Level (FPL): A measure of income issued every year by the Department of Health and Human Services (HHS); Federal poverty levels are used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage. 

Adjusted Gross Income (AGI): Gross income minus adjustments to income; Gross income includes your wages, dividends, capital gains, business income, retirement distributions as well as other income. Adjustments to Income include such items as educator expenses, student loan interest, alimony payments, or contributions to a retirement account; always equal to or lower than gross income.

Modified Adjusted Gross Income (MAGI): This is the figure referred to as “income” with regard to the FPL. MAGI is identical or very close to adjusted gross income (AGI). MAGI is AGI plus untaxed foreign income, non-taxable Social Security Benefits, and tax-exempt interest, if applicable. 

Procedures

    1. The existence of Spirit Clinic, LLC’s sliding scale policy must be public knowledge for all Spirit Clinic, LLC Patients. This does not mean that the practice has to advertise its sliding scale system to the community, referral sources, or otherwise outside of Spirit Clinic, LLC. But, in accordance with federal laws and ethical guidelines, the fact that Spirit Clinic, LLC offers a sliding scale system must be transparent to all of the practice’s patients. 

    2. Spirit Clinic, LLC will inform patients of the sliding scale system by placing signage in the office (if a brick-and-mortar location exists).

    3. Spirit Clinic, LLC may inform potential new patients of the sliding scale system if those potential patients express concerns of financial hardship at the time of scheduling inquiries.

    1. All patients seeking a sliding scale rate must complete the practice’s Sliding Scale Application Form (see Appendix A) to confirm eligibility. 

    2. In some cases, Spirit Clinic, LLC may request supporting documentation, including proof of income, dependents, or expenses in order to determine eligibility. Approved documentation includes, but is not limited to, income tax statements, pay stubs, and expense receipts or statements.

    3. Criteria for Eligibility of Sliding Scale Rates: 

      • The sliding scale system should only be used under extenuating circumstances. 

      • Patients must fall at 200% or less of FPL on the Department of Health and Human Services’ Poverty Percentage Tool (see Appendix B) in order to qualify for the practice’s sliding scale system.

      • Patients seeking sliding scale rates cannot be billing services to insurance, regardless of in-network or out-of-network status, including utilization of superbills. No services listed under the “Ineligible Services” list (see below) will be subject to sliding scale rates.

    4. Patients who are determined to be ineligible may reapply in three (3) months.

    1. Relying upon information provided on the Sliding Scale Application Form, the Poverty Percentage Tool (Appendix B) is utilized to determine the patient’s Percent of FPL based on household income and number of dependents. 

    2. After the patient’s Percent of FPL has been determined, Spirit Clinic, LLC will use Part A of the Sliding Scale Determination Chart (see Appendix C) to select the patient’s slide category. 

    3. Based on the slide category, Spirit Clinic, LLC will use Part B of the Sliding Scale Determination Chart to determine the patient’s fee based on service type.

    1. The Sliding Scale Application Form must be processed and approved prior to the rendering of mental health services in order for the sliding scale rate to apply to the appointment(s). 

    2. Once approved for the sliding scale system, the discounted rate for general therapeutic services will remain in effect for six (6) months or for twelve (12) visits, whichever condition is met first, after which patients must reapply in order to continue utilizing a sliding scale rate.

  • The following services and charges are ineligible for the sliding scale system:

    1. Expert Witness Services / Court Appearances 

    2. Court-Ordered Services 

    3. Services related to Worker’s Compensation claims 

    4. Medical Records Processing Fees 

    5. Any services for which a SuperBill is provided to the patient or guarantor

    6. Any services billed to managed care plans, regardless of network status

    7. Form Completion Fees

    8. Letter Writing Fees

    1. Once an application is processed, a written notification will be sent to the patient or guarantor to inform them of the application denial or approval. See Appendices D and E for the patient notification templates. 

    2. Cristal Sampson, PMHNP-BC must sign the approval notice in order for the approval for a sliding scale rate to be valid.

    1. After determining the patient’s slide category, payment will be expected at the time of service for each appointment. Patients can opt to leave a card on file for convenient, prompt payment processing.

    2. Until the patient’s application for sliding scale rates is approved, the patient will be responsible for payment in full at Spirit Clinic, LLC’s standard direct pay rates for any services rendered. 

    3. Any Good Faith Estimates provided under the No Surprises Act should clearly reflect sliding scale rates as applicable.