Millennial Networks

    330 Compliance

    Sliding fee at a 330 center: the schedule, the discount, and the visit that has to match

    A sliding fee discount program is not a PDF in the policy binder. It is a decision at the visit.

    If the front desk parks an insured walk-in on sliding fee "for now," you do not have a kindness. You have a 330 problem wearing a check-in shortcut. The claim, the UDS insurance mix, and the Operational Site Visit will all read the same lie.

    This is written for the CFO, board chair, billing lead, and office manager at a 330 center in Puerto Rico or the USVI.

    Fee schedule vs sliding fee discount schedule

    Auditors ask for both. Operators who treat them as one document fail the first question.

    Fee schedule. What the service costs. Consistent with locally prevailing rates. Designed to cover reasonable costs of operation. Board-approved. This is the full charge, not the patient's bill.

    Sliding fee discount schedule (SFDS). The discounts applied to that fee schedule, based on income and family size. This is ability to pay. Not a therapy session menu. Not a "nominal for everyone" poster at registration.

    The program is the policy, the procedures for eligibility, the schedules themselves, and the visit where someone actually applies the class. A pretty 2026 table that never hits the charge is not a program.

    If you cannot open both documents, plus a chart that shows the class used on a date of service, you do not have a sliding fee discount program. You have a file.

    Chapter 9 structure: 100%, 100 to 200%, none above

    HRSA Compliance Manual Chapter 9 is not optional copy. It is the structure.

    No patient is denied service because they cannot pay. That is the first rule.

    The SFDS has to look like this:

    • At or below 100% of current Federal Poverty Guidelines: full discount. You may collect a nominal charge. Nominal is from the patient's point of view, not a "minimum fee" and not a co-pay. If you set a nominal, it has to be less than the fee in the first pay class above 100% FPG.
    • Above 100% and at or below 200% FPG: partial discounts. At least three discount pay classes, tied to gradations in income. Percentage of the fee or a flat fee per class. Your choice. Three is the floor, not the ceiling.
    • Above 200% FPG: no sliding fee discount.

    You may run more than one SFDS (medical versus dental is the usual split). Current FPG has to be in the schedule. Last year's poverty line is a finding waiting for a date.

    Insured patients who still qualify for a class are charged no more out-of-pocket than that class would have paid, unless a contract forbids it. Sliding the uninsured and billing the insured the full co-pay is how centers fail this in production.

    Chapter 9 also wants procedures for assessing income and family size, records of those assessments (unless the patient refused), and a way patients learn the discount exists: intake, language they can read, the website.

    Chapter 19: the board owns the program

    Chapter 9 is the structure. Chapter 19 is who is allowed to change it.

    The board adopts the sliding fee discount program. Staff do not. A schedule a billing manager updated in Excel is not adopted.

    The board evaluates the program at least every three years. Utilization by class. Whether the discount is actually reducing financial barriers. Changes if it is not. Three years is the floor. Annual FPG updates are not that evaluation. They are maintenance.

    The board approves the FPG updates that keep the schedule current. Poverty guidelines move. If your 2024 classes are still in eClinicalWorks because nobody put a packet on the agenda, the visit is already wrong.

    A reviewer can ask for the policy, the current SFDS, and the minutes. If the minutes never mention it, you have a PDF, not a living program.

    Re-assessment is not we screened them at registration

    Chapter 9 requires procedures for assessing and re-assessing income and family size. Frequency is yours to set. "We got a form on the first visit" is not a procedure.

    Income changes. Family size changes. A patient who was uninsured in March can be Plan Vital in July. A patient who was over 200% can drop under 100% after a job loss. If you never look again, the class on the charge is a guess with a date stamp.

    What this looks like in clinic: a form never filed to the chart; a 2023 class inherited onto today's visit; a patient who declined income still slid because full fee takes longer to explain; a complete packet and a charge that still went out at full fee because the SFDS was never mapped in eCW.

    Re-assessment is a dated event with an owner. If you cannot show the last one, you cannot defend the discount.

    How a wrong eligibility check becomes a wrong slide, a wrong UDS mix, and an OSV finding

    Sliding fee is a 330 control. It is not a drawer you open when the portal is slow.

    Three failure modes, same as the eligibility work:

    You bill a payer that is not active. Denial. Rework. The visit already happened.

    You register an insured patient as uninsured and slide the fee. Faster at the window. Wrong for 330 policy. Wrong for UDS insurance mix. Wrong when HRSA asks how you verify coverage before you discount.

    You hold the visit until portals answer. Access drops. Health outcomes take the hit. The patient with health-related needs who already fought for this slot is the one who leaves.

    UDS cares what insurance status was at the visit. Sliding fee cares whether the patient qualified on that date. An Operational Site Visit cares whether the binder matches the charge. What HRSA reviewers open in the cybersecurity file is a different chapter. Sliding fee still shows up when they sample visits and minutes.

    If eligibility is still a morning portal hop, the slide is only as good as whoever had time to finish the clicks.

    Puerto Rico and USVI: Plan Vital vs Advantage plastic vs last year's eCW insurance line

    Mainland sliding-fee copy never names the card in the patient's hand.

    Here, coverage sits with Medicaid MCOs. The stack we work against is Assertus, IMC, MCS, PSM, Triple-S. A 271 that says active does not tell you the patient changed MCO on the 1st, recertified onto a different product, got assigned to another centro, or is holding Advantage plastic while eCW still has last year's commercial line.

    That mismatch is how an insured patient lands in the sliding-fee drawer "for now."

    Bilingual intake is not a poster. The patient has to understand the discount exists and what documents you will accept. A satellite on generator still has to apply the same class as the main site. Chapter 9 does not pause for last-mile.

    At Corporación SANOS, César Montijo, Executive Director, described side-by-side work through restructuring, a new EHR, and automation of processes that were eating the day. Magaly López at the PR Primary Care Association (HCCN for Puerto Rico and the Virgin Islands) has said the same at network level: systems that hold up in clinic. More case studies are public.

    What MN automates vs what the board still owns

    Millennial Networks is healthcare IT and MSP for FQHCs and CHCs in Puerto Rico and the USVI. Founded 2017. Ten-year mark: January 2027. Humans First, Tech Second.

    We automate the coverage decision overnight. MediBOT is digital staff with a named eClinicalWorks account. It checks the payer portals that actually answer here, writes the result back to the chart, and leaves a report at 7:20 a.m. Morning is exceptions. Walk-ins still belong to a human. When it cannot validate, it does not guess.

    At SANOS, those automations have been in production since January 2025 against eClinicalWorks and five payer portals.

    What the board still owns:

    • Adopting the SFDP policy.
    • The fee schedule and the SFDS structure (nominal charge, number of classes, medical versus dental).
    • Evaluating the program at least every three years.
    • Approving current FPG.
    • The rule for how often you re-assess income and family size.

    We will not vote for you. We will tell you whether a reviewer can open a living program or a PDF, and whether the insurance line in eCW is true before anyone applies a class.

    Who this is for

    • CFOs, billing directors, and office managers at 330 centers who already live in eClinicalWorks.
    • Board chairs who will be asked for minutes, not a slogan.
    • Teams whose real eligibility stack is island Medicaid MCOs, not a generic mainland 270.

    FAQ

    What is a sliding fee discount program

    The 330-center system that adjusts charges based on income and family size: fee schedule plus SFDS, eligibility procedures, and the 100% / 100 to 200% / none-above-200% structure. It applies to in-scope services with a distinct fee. It is not a "we discount" poster.

    What is a sliding fee scale for an FQHC

    Operators say "sliding fee scale." HRSA says sliding fee discount schedule. Same job: classes tied to current FPG, applied to the fee schedule, recorded on the visit. A scale that does not hit the charge in eClinicalWorks is not in production.

    Do insured patients get a sliding fee discount

    If they qualify by income and family size, they are charged no more out-of-pocket than their SFDS class, unless a payer contract forbids it. You still verify coverage. You do not park an insured patient on sliding fee because the portal was slow. That is how Table 4 and the SFDS both fail.

    How often does the board have to look at sliding fee

    Adopt the program. Approve FPG updates so the schedule stays current. Evaluate the program at least every three years using utilization by class and whether the discount is reducing financial barriers. Staff can draft the packet. The board still has to vote.

    Book a discovery call

    Send this year's SFDS and last board minutes that mention it. We will say if a reviewer can open a living program or a PDF.

    Request a discovery call. Talk to Alberto. Thirty minutes.

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