EFFECTIVE DATE: Jan 1, 2024

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

PURPOSE: All patients seeking health care services at Mosaic Counseling and Wellness 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. 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).

Mosaic Counseling and Wellness will offer a Sliding Fee Discount Program to all who are unable to pay for their services. Mosaic Counseling and Wellness will base program eligibility on a person’s ability to pay and will not discriminate on the basis of 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.

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

1. Notification: Mosaic Counseling and Wellness 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 Mosaic Counseling and Wellness

An explanation of our Sliding Fee Discount Program and our application form are available on Mosaic Counseling and Wellness website.

Mosaic Counseling and Wellness 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 confidentiality will be respected for all who seek and/or are provided 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 patient/responsible party with applications. By signing the Sliding Fee Discount Program application, persons are confirming their income to 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; all such people (including related subfamily members) are considered as members of one family. Mosaic Counseling and Wellness will also accept non-related household members when calculating family size.

b. Income includes: gross wages; salaries; tips; income from business and selfemployment; unemployment compensation; workers' compensation; Social Security; Supplemental Security Income; veterans' payments; survivor benefits; pension or retirement income; interest; dividends; royalties; income from rental properties, estates, and trusts; alimony; child support; assistance from outside the household; and other miscellaneous sources.

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 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 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 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 Mosaic Counseling and Wellness’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, Mosaic Counseling and Wellness 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 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.

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. 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, Mosaic Counseling and Wellness can explore options not limited to, but including offering the patient a payment plan, waiving of charges, or referring the patient to collections.

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.

a. Applicants that have been approved for the Sliding Fee Discount Program will be logged in Mosaic Counseling and Wellness’s practice management system, noting names of applicants, dates of coverage and percentage of coverage.

b. The business office manager will maintain an additional monthly log identifying Sliding Fee Discount Program recipients and dollar amounts. Denials and applications not returned will also be logged.

13. Policy and procedure review: The Sliding Fee Schedule will be updated based on the current Federal Poverty Guidelines. Mosaic Counseling and Wellness will also review possible changes in our policy and procedures and for examining institutional practices which may serve as barriers preventing eligible patients from having access to our community care provisions.

14. Budget: During the annual budget process, an estimated amount of Sliding Fee Discount Program service will be placed into the budget as a deduction from revenue.