What is a sliding scale clinic and how does it work?

What does "sliding scale" mean?

A sliding scale, also called a sliding fee scale, is a price list that slides up or down depending on your income. Two people can get the exact same visit and pay different amounts. Someone with a very low income pays little, and someone who earns more pays more, up to the clinic's regular price.

Here is a simple picture. Imagine a clinic with a chart on the wall. Down the side is your household size, and across the top are income levels. You find where you fit, and the chart tells you your price for a visit. The goal is to make sure cost does not stop you from seeing a doctor.

Who has to offer a sliding scale

The Health Resources and Services Administration, or HRSA, is the federal agency that funds community health centers. HRSA says these centers adjust their fees based on income and family size and serve everyone, even if they cannot pay. A health center funded by HRSA must run a sliding fee discount program. Our guide on community health centers explains these clinics in more detail.

Other clinics may also use a sliding scale. A charity clinic, a student-run clinic or a private practice may choose to offer one. Their rules can be different from a health center's, because no federal program sets them. That is why it helps to ask each clinic how its own scale works.

How the scale works at a federally funded health center

HRSA's rules for these centers use the federal poverty guidelines, which are the yearly income lines the government uses to measure poverty. Based on HRSA's compliance manual, the program works in three layers.

• If your family income is at or below 100 percent of the federal poverty guidelines, the center must give a full discount. Some centers still ask for a small set fee, called a nominal charge, which must be lower than what the next income level pays.
• If your income is above 100 percent and up to 200 percent, you get a partial discount. The center must have at least three levels of partial discounts, so the discount shrinks step by step as income rises.
• If your income is above 200 percent, the center is not required to give a discount.

HRSA also says no patient may be denied service because they cannot pay. That does not mean everything is free for everyone. It means the center cannot turn you away only because of money. Our guide on community health centers explains more about who a health center can see. HRSA reports that about 90 percent of health center patients have incomes below 200 percent of the federal poverty level.

These discounts apply to the center's fees for services it provides. Things the center sends elsewhere may be billed separately. Examples are an outside specialist or a hospital stay, so ask what is included.

What proof of income will I need?

HRSA leaves it to each center to decide how to document your income and family size. The best step is to call first and ask. Here are common items to ask about.

• Recent pay stubs are the most common proof of income.
• Last year's tax return is often accepted.
• A letter from your employer can also work.
• A statement from someone who supports you, or a signed form, may be accepted if you have no pay stubs.
• A list of who lives in your home and who you support helps the clinic count your household.

If you do not have papers, say so on the phone. Many clinics have a way to help, such as a written statement of your income. Bring a photo ID and a list of your medicines, too. Our guide on free clinics, health centers and cash-pay doctors has a fuller checklist.

Free clinic or sliding scale clinic

A free clinic is usually run by a charity or volunteers. It offers care at no cost or very low cost, often to people who are uninsured. A sliding scale clinic charges a fee that depends on your income.

Some places do both, with free visits for the lowest incomes and a sliding scale for others. Services, hours and rules vary a lot, so ask who is eligible and what is covered.

How do I ask for a sliding scale price?

You can say these lines on the phone or at the front desk.

• "I do not have insurance, so do you offer a sliding scale or a sliding fee discount?"
• "How do I apply, and what proof of income do you need?"
• "What would a regular visit cost for a family of [number] with an income of about [amount]?"
• "Does the discount cover lab tests and medicines, or just the visit?"

Our guide on asking for the cash price has more scripts. If your income is above the sliding scale, a cash-pay or direct primary care doctor may be an option. Search our directory to see what is near you.

Getting the most out of a sliding scale

A few habits make this easier. Apply before you need a big service, so your discount is already set up on the day you need care. Tell the clinic if your income drops, such as after a job loss, because the clinic may be able to look at your situation again. Keep your paperwork in one folder so you can bring it back when the clinic asks you to renew.

Also ask what happens when you need something the clinic does not offer, such as an X-ray or a specialist. Some clinics have partners who give lower prices to their patients, and others do not. It is better to know before the visit than to learn from a surprise bill. If a bill does surprise you, our guide on how to negotiate a medical bill can help.

What if I have an emergency?

A sliding scale clinic is for regular care and not for emergencies. If you think you are having an emergency, call 911 or go to the nearest emergency room right away. Emergencies include chest pain, trouble breathing, heavy bleeding and signs of a stroke.

Federal law requires an emergency room to examine and stabilize you whether or not you can pay. This page is general education and not medical advice.