Sliding Fee Scale

Schedule policy purpose: This program is designed to provide discounted care to those who have no means, or limited means, to pay for their services (Uninsured or Underinsured). Marci Hinchey will offer a Sliding Fee Discount Program to clients who can’t afford a health insurance plan or if your current plan does not cover mental health services, you can make request to determine if you are eligible for a reduced session fee rate via our sliding scale. Marci Hinchey will base program eligibility on a person’s ability to pay and will not discriminate based on age, gender, race, sexual orientation, creed, religion, disability, or national origin.

The Federal Poverty Guidelines (http://aspe.hhs.gov/poverty) are used in creating and annually updating the sliding fee schedule (SFS) to determine eligibility.

Procedure: These guidelines are to be followed in providing the Sliding Fee Discount Program. Provision of Services: All patients seeking services at Marci Hinchey are assured that they will be offered a reduced fee rate upon qualification of such through the sliding fee schedule, so long as they complete and are found eligible in the application process.

Requests for Discount: Requests for discounted services may be made by clients or family members who are aware of existing financial hardship. Discounted services would apply effective the date of application approval going forward. Information and forms can be obtained from Marci Hinchey. All alternative payment resources must be exhausted, including all third-party payment from insurance(s). Another beneficial option is to pay out of pocket and be reimbursed — at least in part — by your insurance company.

While many insurances companies provide a list of in-network therapists, you may find that your preferred therapist is not on that list. This doesn’t mean that you must forego seeing your favorite therapist. Instead, call your insurance company to find out if they offer some reimbursement for seeing an out-of-network provider for psychotherapy. This would allow you to continue seeing your favorite therapist without having to pay 100% of the costs out of pocket. We encourage you to check with your insurance to see if they may offer out of network benefits for psychotherapy.

Administration: The Sliding Fee Discount Program procedure will be administered through Marci Hinchey. 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 discounted services.

Application: The client/responsible party must complete the Sliding Fee Discount Program application in its entirety. By signing the Sliding Fee Discount Program application, persons authorize Marci Hinchey 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 client 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 client’s delay in providing information will not be considered for the Sliding Fee Discount Program.

Renewal Applications: A client who receives discounted services under this policy is required to submit an updated application every 12 months or if their financial situation changes. Failure to meet the annual financial information requirement may result in the client no longer being eligible for the Sliding Fee Discount Program. If a client is delinquent in meeting the updated annual application requirement, client will be emailed a notice indicating they are being terminated from the Sliding Fee Discount Program unless they submit the required financial information within the time frame (10 business days) noted in the email notification. If a client does not submit the renewal information, they are no longer eligible for the discounted services per the date in the notice letter.

Discounts: Discounts will be based on income and family size only. Marci Hinchey defines a Family as head of household, spouse, and dependent children. 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.

Requirements: Applicants must provide the following: prior year W-2 or four most recent pay stubs. 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 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 he/she is unable to provide independent verification. This statement will be reviewed and a final determination as to the sliding fee percentage will be made. Self-declared clients will be responsible for 100% of their charges until management determines the appropriate category.

Clients Must provide verification documentation (identification/address); examples of accepted documents include:

• Driver’s license,

• Utility bill

• Employment identification

Clients MUST show most recent proof of income for all family members/individuals living in your household; examples of accepted documents include:

• Previous year’s 1040 tax form

• Two months of pay stubs (four most recent).

• 2 unemployment stubs

• Letter from an employer that states your salary or wages.

Updates: The sliding fee schedule will be updated during the first quarter of every calendar year with the latest federal poverty guidelines, http://aspe.hhs.gov/poverty. Notice: The Sliding Fee Discount Program determination will be provided to the applicant(s) in writing via email 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 client and/or responsible party must immediately establish payment arrangements with Marci Hinchey. 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 lookback period will be the lesser of six months or the expiration of their last Sliding Fee Discount Program application.

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 client does not make an effort to pay or fails to respond within 60 days, this constitutes refusal to pay. At this point in time, Marci Hinchey can explore options not limited to, but including offering the client a payment plan or referring for patient collection’s efforts. Storage of Information: Information related to Sliding Fee Discount Program decisions will be maintained and preserved in an electronic confidential file, in an effort to preserve the dignity of those receiving discounted care.