Sliding Fee Discount Program

Augusta Children’s Dental Center Business Office Policies

Sliding Fee Discount Program (Augusta Location Only)

EFFECTIVE DATE: January 1, 2023

POLICY: To make free or discounted services available to those in need.

PURPOSE: All patients seeking health care services at AUGUSTA CHILDREN’S DENTAL CENTER are assured that they will be served regardless of their ability to pay. No one is refused service because of a lack of financial means. 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).

AUGUSTA CHILDREN’S DENTAL CENTER will offer a Sliding Fee Discount Program to all who are unable to pay for their services. AUGUSTA CHILDREN’S DENTAL CENTER will base program eligibility on a person’s ability to pay. It will not discriminate based on an individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity, ability to pay, or whether payment for those services would be made under Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). The Federal Poverty Guidelines are used in creating and annually updating the sliding fee schedule to determine eligibility. AUGUSTA CHILDREN’S DENTAL CENTER can provide access to inpatient care through Dr. Obebe’s privileges at local hospitals.

Procedure

The following guidelines are to be followed in providing the Sliding Fee Discount Program:

1. Notification: AUGUSTA CHILDREN’S DENTAL CENTER will notify patients of the Sliding Fee Discount Program by:
   • Payment Policy Brochure will be available to all patients at the time of service.
   • Notification of the Sliding Fee Discount Program will be offered to each patient upon admission.
   • Sliding Fee Discount Program application will be included with collection notices sent out by AUGUSTA CHILDREN’S DENTAL CENTER.
   • An explanation of our Sliding Fee Discount Program and our application form are available on AUGUSTA CHILDREN’S DENTAL CENTER’s website.
   • AUGUSTA CHILDREN’S DENTAL CENTER places notification of Sliding Fee Discount Program in the clinic waiting area.
2. Request for Discount: Requests for discounted services may be made by patients, family members, social services staff, or others who are aware of existing financial hardship. The Sliding Fee Discount Program will only be made available for clinic visits. Information and forms can be obtained from the front desk and the business office.
3. 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 to patients. Staff are to offer assistance for completion of the application. Dignity and confidence will be respected for all who seek and/or are provided with health care services.
4. Completion of Application: The patient/responsible party must complete the Sliding Fee Discount Program application in its entirety. Staff will be available, as needed, to assist the patient/responsible party with applications. By signing the Sliding Fee Discount Program application, persons are confirming their income to AUGUSTA CHILDREN’S DENTAL CENTER as disclosed on the application form.
5. Eligibility: Discounts will be based on income and family size only. We do not require patients to apply to Medicaid/health insurance or do asset testing to qualify for the sliding fee discount program.
   • 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; and such people (including related subfamily members) are considered members of one family. AUGUSTA CHILDREN’S DENTAL CENTER will also accept non-related household members when calculating family size.
   • b. Income includes: gross wages; salaries; tips; income from business and self-employment; unemployment compensation; workers’ compensation; Social Security; Supplemental Security Income; veterans’ payments; survivor benefits; pension or retirement income.
6. Income Verification: Applicants may 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 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 be used. Patients who are unable to provide written verification may provide a signed statement of income.
7. Discounts: Those with incomes at or below 100 percent of poverty will receive a full 100 percent discount for health care services. Those with incomes above 100 percent of poverty, but at or below 200 percent of poverty, will be charged a nominal fee 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 Line Guidelines.
8. Nominal Fee: Patients with incomes above 100 percent of poverty, but at or below 200 percent of poverty, will be charged a nominal fee according to the attached Sliding Fee Schedule and based on their family size and income. 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.
9. Waiving of Charges: In certain situations, patients may not be able to pay the nominal or discount fee. Waiving of charges must be approved by AUGUSTA CHILDREN’S DENTAL CENTER’s designated official. Any waiving of charges should be documented in the patient’s file along with an explanation.
10. 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 percent discount or denied, AUGUSTA CHILDREN’S DENTAL CENTER will work with the patient and/or responsible party to establish payment arrangements. Sliding Fee Discount Program applications cover outstanding patient balances for six months before the application date and any balances incurred within 12 months after the approved date, unless their financial situation changes significantly.
11. 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.
12. Record Keeping: Information related to Sliding Fee Discount Program decisions will be maintained and preserved in a centralized confidential file located in the office of the business manager, in an effort to preserve the dignity of those receiving free or discounted care.
13. Policy and Procedure Review: The Sliding Fee Schedule will be updated based on the current Federal Poverty Guidelines.
14. Budget: During the annual budget process, an estimated amount of the Sliding Fee Discount Program service will be placed into the budget as a deduction from revenue.

2026 HHS Poverty Guidelines (48 Contiguous States & District of Columbia)

For families/households with more than 8 persons, add $5,680 for each additional person.