Sliding Fee Scale Policy Summary

As a Federally Qualified Health Center (FQHC), Goshen Medical Center, Inc. is required to provide a sliding fee scale discount to patients who meet the eligibility guidelines. Sliding fee scale patients are those with household incomes that fall at 100% and below poverty up to 200% of federal poverty. The eligibility requirements are based on the federal poverty guidelines published annually by the U.S. Department of Health and Human Services.

Download Eligibility Form
Persons in Family / Household Annual Household Income for 100% of Poverty level Annual Household Income for 200% of Poverty level
1 $13,590 $27,180
2 $18,310 $36,620
3 $23,030 $46,060
4 $27,750 $55,500
5 $32,470 $64,940
6 $37,190 $74,380
7 $41,910 $83,820
8 $46,630 $93,260

Families with more than 8 persons in the household, add $4,720 for each additional person.

Goshen Medical Center has established a schedule(s) of sliding fee scale discounts based on Figure 1 above. The schedule of discounts is available for patients at the medical or dental site where the patient will receive services. The schedule of discounts varies based on service type, i.e. medical or dental, and procedure type, for example, a cosmetic dental procedure does not qualify for the sliding fee scale.

If the patient is able to demonstrate that total household size and income results in 100% discount, there is however a nominal fee. if the patient is verifiably homeless, presently a resident of a homeless, transitional, doubling up or truly living on the street, then they are only required to pay $1.00 for services.

SLIDING FEE SCALE PROOF OF INCOME

In order to determine if a patient qualifies for the sliding fee scale, proof of income and household size must be presented to the patient representative during intake. The best form of proof of income is your federal tax return (1040,1040A,or 1040EZ) or your food stamp eligibility statement because these documents provide all that is needed in one source. However, the following items are acceptable forms of proof of income and family size. Please bring at last one item from each of the two columns below. It may be necessary to bring more than one item in order to provide all the information needed to determine the patient’s eligibility for the slide scale. The discount cannot be assigned until you have provided sufficient documentation to determine total household income and total household size which is the total number of individuals living under one roof.

Examples of Proof of Income Documents

 

  • Current Federal Tax Return (individual or joint)
  • W-2 Forms for each member of the household (cannot be used as only proof of income)
  • Pay stubs (4 if you get paid once per week, 2 if you get paid biweekly, and one if you only get paid once per month)
  • Employer Statement (must include a contact name and number)
  • Alimony Agreement
  • Child Support Agreement
  • Award Letter from the Veterans Administration
  • Bank Statement (Direct Deposit)
  • Compensation Award Letter
  • Court Award Letter
  • Pension Statement
  • Public Assistance Records
  • SSI Child Disability Benefits
  • Social Security Benefits
  • Housing Authority Verification
  • TANF – Temporary Assistance for Needy
  • Families/Work First
  • Cash Public Assistance
  • Other verifiable sources are considered

Examples of Household Size Documents

 

  • Current Federal Tax Return (individual or joint)
  • Birth Certificate
  • Decree of Court (to show number in household)
  • Divorce Decree (change in household size)
  • Landlord Statement must include contact name and phone number.
  • Lease Agreement
  • Marriage Certificate
  • Medical Card
  • Public Assistance/Social Service Agency Records
  • Public Housing Authority (if Resident or on Waiting List)
  • Telephone Verification
  • Other verifiable sources of proof of household size will be considered

Our mission

“Our mission is to provide access to health care for all people in our service area.”

Goshen Medical Center has the ability to reduce your cost of health care through our Sliding Fee Discount Program. This program is designed to offset a portion of your out-of-pocket expenses for selected medical and dental services. To see if you qualify for our Sliding Fee Discount Program, please ask the receptionist.

THE FOLLOWING DOCUMENTS MAY SUPPORT PROOF OF INCOME:

  1. Copy of most recent paycheck or paycheck stubs
  2. Copy of Federal tax return or W-2’s
  3. Dated letter from employer stating amount of gross wages (does not need to be notarized)
  4. Alimony and/or Child Support amount reported on sliding fee document
  5. Temporary Assistance for Needy Families documentation
  6. Letter on agency letterhead verifying financial status (i.e., Social Security, Housing Authority)
  7. Student Grant Information / Student Aid Report (self-declare on sliding fee)
  8. If self-employed, tax forms from most current year (W-2’s or 1099)
  9. Dated letter from head of household/family where patient resides stating financial responsibility
  10. Self-Declaration

Frequently Asked Questions

Use our FAQ section below to get the answers you need or contact us if you need more help.

  1. 01

    What is the Sliding Fee Discount Program (SFDP)?

    The Sliding Fee Discount Program is a federal grant that allows our healthcare facility to reduce or "slide" the fees of medical services for patients that reside at or below 200% of the Federal Poverty Guideline.
  2. 02

    Who is eligible for the SFDP?

    Any GMC patient is eligible that is at or below 200% of Federal Poverty Guidelines.
  3. 03

    How is eligibility determined?

    (1.) Income "income" is defined as all payments received by total family or household members over a period. Assets are not included. (2.) Household/Family Size "Household"/"Family" is defined as all persons physically residing in the same home who are the legal responsibility of the guarantor. The "guarantor" is the financially responsible person within the household/family. An individual can be claimed on the sliding fee by the guarantor if they provide more than 50% of that family member support.
  4. 04

    How does a patient apply?

    Provide one of the documents as proof of income. This income documentation will need to be reviewed and updated annually.
  5. 05

    Who pays for the services that are discounted?

    Our federal grant pays for the remainder of the balance for patients that qualify for the Sliding Fee Discount Program.
  6. 06

    Does the patient have to be a citizen to apply for the program?

    No.
  7. 07

    What if the patient has no income at all?

    They can still apply. We need a brief note from the person or facility covering the patient’s cost of living.
  8. 08

    If the patient has insurance with deductible, co-insurance and /or co-payment, can they still apply for the program?

    Yes. if the patient qualifies for the program, the patient's insurance will be filed, and if the insurance contract allows for a reduced co-payment, then GMC will apply the discount. Please see the receptionist if you have further questions.

https://aspe.hhs.gov/poverty-guidelines       This table is updated by April 30th of every year

You are encouraged to download a copy of the sliding fee application and complete to the best of your ability, bring the form with you along with your proof of income and household size. A patient representative will be happy to assist you in determining if you are eligible for a discount. The sliding fee application is used to determine eligibility for the slide scale and to assess the level of discount assigned to the patient.