McCoy Samples Mattingly Dental Clinic
Sliding Fee Discount Program Policy
June 2018
This program is designed to provide free or discounted care to those who have no means, or
limited means, to pay for their dental 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 patient advocate, that is, one who works with the patient and/or
guarantor to find reasonable payment alternatives.
McCoy Samples Mattingly Dental Clinic (MSMDental) will offer a Sliding Fee Discount Program to
all who are unable to pay for their services. MSMDental will base program eligibility on a
person’s ability to pay and will not discriminate on the basis of age, gender, race, sexual
orientation, gender identity creed, religion, disability, or national origin. The Federal Poverty
Guidelines are used in creating and annually updating the sliding fee schedule (SFS) to
determine eligibility.
PROCEDURE: The following guidelines are to be followed in providing the Sliding Fee Discount
Program.
1. Notification: MSMDental will notify patients of the Sliding Fee Discount Program by:
• Payment Policy Brochure will be available to all uninsured patients at the time
of service.
• Notification of the Sliding Fee Discount Program will be offered to each patient
upon admission.
• An explanation of our Sliding Fee Discount Program and our application form
are available on MSMDental’s website www.msmdental.net
• MSMDental places notification of Sliding Fee Discount Program in the clinic
waiting area.
2. All patients seeking healthcare services at MSMDental are assured that they will be
served regardless of ability to pay. No one is refused service because of lack of financial
means to pay.
3. Request for discount: Patients, family members, social services staff or others who are
aware of existing financial hardship may make requests for discounted services. The
Sliding Fee Discount Program will only be made available for clinic visits. Information
and forms can be obtained from the Front Desk.
4. 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.
5. Alternative payment sources: All alternative payment resources must be exhausted,
including all third-party payment from insurance(s), federal and state programs.
6. 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 MSMDental 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.
7. Eligibility: Discounts will be based on income and family size only. MSMDental uses the
Census Bureau definitions of each.
1. 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.
2. 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.
8. Income verification: Applicants must provide one of 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 detail 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 MSMDental 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.
9. Discounts: Those with incomes at or below 100% of poverty will receive a full 100%
discount. Those with incomes above 100% of poverty, but at or below 200% of poverty,
will be charged according to the attached sliding fee schedule. The sliding fee schedule
will be updated during the first quarter of every calendar year with the latest Federal
Poverty Guidelines.
10. Nominal Fee: Patients receiving a full discount will be assessed a $35 nominal charge
per visit. However, patients will not be denied services due to an inability to pay. The
nominal fee is not a threshold for receiving care and thus, is not a minimum fee or co-
payment.
11. Waiving of Charges: In certain situations, patients may not be able to pay the nominal
or discount fee. Waiving of charges may only be used in special circumstances and must
be approved by MSMDental’s Partners. Any waiving of charges should be documented
in the patient’s file along with an explanation (e.g., ability to pay, good will, health
promotion event).
12. Applicant notification: The Sliding Fee Discount Program determination will be provided
to the applicant(s) in writing, and will include the percentage of Sliding Fee Discount
Program write off, or, if applicable, the reason for denial. If the application is approved
for less than a 100% discount or denied, the patient and/or responsible party must
immediately establish payment arrangements with MSMDental. Sliding Fee Discount
Program applications cover outstanding patient balances for six months prior to
application date and any balances incurred within 12 months after the approved date,
unless their financial situation changes significantly. The applicant has the option to
reapply after the 12 months have expired or anytime there has been a significant
change in family income. When the applicant reapplies, the look back period will be the
lesser of six months or the expiration of their last Sliding Fee Discount Program
application.
13. Refusal to Pay: If a patient verbally expresses an unwillingness to pay or vacates the
premises without paying for services, the patient will be contacted in writing regarding
their payment obligations. If the patient is not on the sliding fee schedule, a copy of the
sliding fee discount program application will be sent with the notice. If the patient does
not make effort to pay or fails to respond within 60 days, this constitutes refusal to pay.
At this point in time, MSMDental can explore options not limited, but including offering
the patient a payment plan, waiving of charges, or referring the patient collections
efforts.
14. Record keeping: Information related to Sliding Fee Discount Program decisions will be
maintained and preserved in a centralized confidential file located in the Business Office
Manager’s Office, in an effort to preserve the dignity of those receiving free or
discounted care.
a. Applicants that have been approved for the Sliding Fee Discount Program will be
indicated within MSMDental’s practice software. Documentation will include date of
approval and percentage of coverage.
b. The Business Office Manager or a designee will log all denials.
15. Policy and procedure review: MSMDental Partners will review the amount of Sliding Fee
Discount Program provided. The SFS will be updated based on the current Federal
Poverty Guidelines.