Sliding Scale
and
Good Faith Estimate Forms

Sliding Fee Discount Program (Sliding Scale)

What is the Sliding Fee Discount Program?

The Sliding Fee Discount Program helps patients who cannot afford to pay full price. How much you pay depends on how many people are in your household and how much money your household makes each year. These amounts are compared to federal poverty guidelines to decide your discount.

Once a patient is registered, the patient or their representative may apply for Langley Health Services’ Sliding Fee Discount Program.

Whether a patient qualifies is based only on two things: how much money the household earns and how many people live in the household. A household includes the patient, their spouse (if married), and any dependents claimed on taxes.

The income and household size are compared to the Federal Poverty Guidelines from the U.S. Department of Health and Human Services. Patients whose household income is at or below 100% of these guidelines will pay a small, reduced fee for covered services.

Patients who qualify will be placed into one of the Sliding Fee Discount categories (A, B, C, D, E, or F) for 12 months.

The assigned discount can also be applied to eligible bills from the past 90 days, based on the service date and when the discount becomes effective.

How often do I have to apply?

Patients are reviewed every 12 months. Patients who are not in the program may apply at any time. Patients who are already approved will be notified within 30 days when the Federal Poverty Level (FPL) guidelines change and may ask to have their discount reviewed again.

Patients who have a major life change (such as job loss or family changes) may ask to be reviewed before their discount period ends.

What is accepted as proof of income?

A recent full tax return
A Social Security, Disability, or VA benefit letter
Retirement or pension income documents
Pay stubs from the last month, workers’ compensation, unemployment pay stubs, or an unemployment award letter
Proof of SNAP benefits showing the monthly amount
A TANF letter showing the benefit amount
Court orders or payment records for child support
An employment verification form showing four pay periods

Patients who do not provide income documents cannot receive the Sliding Fee Discount and must pay the full cost of services at the time of the visit. If documents are later provided, discounts may be applied to eligible visits from the past 90 days. Patients will not be denied care because they cannot pay.

Patients who cannot provide written proof must sign a statement explaining their income and why documents are not available. A financial counselor will review this information and make the final decision. Until a decision is made, these patients must pay the full cost of services.

I have insurance. Would I still be able to apply?

Patients with insurance may still apply for the program. The discount may be used for Medicare copays, Medicaid share of cost, commercial insurance copays, or services not covered by insurance, unless the law or insurance rules do not allow it.

Are all dental services covered under the Sliding Fee Discount Program?

Dental discounts do not cover specialty services such as crowns, dentures, or root canals. The discount only applies to basic and routine dental care.

We also offer a Prompt Payment Self-Pay Discount Program. The Prompt Payment Self-Pay Discount Policy offers a standard flat rate of $100.00 to eligible patients who do not qualify for the Sliding Fee Discount Program, specifically Slides B, C, D, E, or F. Patients approved for Slide A are eligible for a reduced prompt payment rate of $35.00.

If you have any further questions, please reach out to us via phone at 352-569-2904 or email at LangleySlide@telmedical.com.