Affirmations is committed to providing accessible and affordable mental health services to our community. We offer a sliding fee scale to clients who meet program eligibility. This policy outlines the criteria for eligibility and how the sliding fee is determined. Affirmations will not discriminate on the basis of an individual’s 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.

Eligibility:

The sliding fee scale is available to clients who meet the following criteria:

• Do not have health insurance or have health insurance with high deductibles or co-pays that create a financial hardship, and/or
• Meet the income guidelines outlined in the Sliding Fee Scale Chart (see below).

Please note: Affirmations will make every reasonable effort to secure payment in accordance with the schedule of fees or schedule of discounts from the client and/or any other third party. Individuals with third party insurance coverage are eligible for the Sliding Fee Program unless the third-party insurance contract prohibits the application of the Sliding Fee Discount Program.

Documentation Required:

To be considered for the sliding fee scale, clients must provide documentation of their income.

Acceptable forms of documentation include:

• Most recent federal tax return (Form 1040)
• Pay stubs for the past 3 months
• Social Security or disability income statement
• Unemployment benefit statement or record of termination
• Other documentation that verifies income (e.g., letter from employer, bank statement showing direct deposits)

*** If you have no income, please provide a written statement explaining how you are meeting your basic needs.

Please note: “Other documentation that verifies income” is intended to reduce barriers in completing the Sliding Fee Scale application. Bank statements showing direct deposits are used only to document income, not as a means of asset testing.

Affirmations LGBTQ+ Sliding Fee Scale - 2025

*** Important Note: Individuals whose household income falls below 100% of the Federal Poverty Level (based on their household size and income level), service charges are not applicable. Affirmations Behavioral Health services (including but not limited to Case Management and other Peer Services) will support participants in obtaining MDHHS Medicaid approval for those that qualify, however application pending/approval is not required for participation in SFS program. 

The sliding fee is determined based on annual gross household income and household size. The chart below is based on the 2025 Federal Poverty Guidelines, adjusted for our local cost of living. We review and update this chart annually. See below:

https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines

Important Information:

1. Administration: The Sliding Fee Program procedure will be administered through Affirmations’ Behavioral Health Program Coordinator or their designee. Information about the Sliding Fee Program policy and procedure will be provided to all clients. Behavioral Health 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.

•  Notification: Affirmations Community Center will notify patients of the Sliding Fee Program by:  

•  Payment Policy will be available to all clients at the time of service via “Practice Agreements” document in Simple Practice.
•  Notification of the Sliding Fee Program will be sent to each client upon admission, including Sliding Fee Program Application.
•  Sliding Fee Program application will be offered to individuals in all communication regarding attempts to collect client balances - sent out by Behavioral Health Coordinator.
•  An explanation of our Sliding Fee Program and our application form are available via link on Affirmations Community Center’s website.
• Affirmations places notification of Sliding Fee Program in the center’s waiting area.

2. Application Process: To apply for the sliding fee scale, individuals are to complete the Sliding Fee Application Form and provide the required documentation to office staff or through the Simple Practice patient portal.

• Individuals/their responsible party must complete the Sliding Fee Program application in its entirety. Staff are available, as needed, to assist individuals/responsible party with applications. By signing the Sliding Fee Program application, persons are confirming their income to Affirmations Community Center as disclosed on the application form.  
• Discounts will be based on income and family size only. We do not require clients to apply to Medicaid/health insurance or do asset testing to qualify for the sliding fee program.  

3. Approval: Applications are typically reviewed within 5-7 business days. Individuals will be notified, in writing, of the outcome of their application as well as the percentage of Sliding Fee Program write off, or, if applicable, the reason for denial.

• 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. Affirmations will also accept non-related household members when calculating family size.
• Income includes: gross wages; salaries; tips; income from business and self-employment; 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.
• If the application is approved for less than a 100 percent discount or denied, Affirmations Community Center will work with the individual and/or responsible party to establish payment arrangements. Sliding Fee Program applications cover outstanding client balances any balances incurred within 6 months after the approved date, unless their financial situation changes significantly.

4. Changes in Income: Clients are responsible for notifying Affirmations Community Center immediately if their income changes significantly. We reserve the right to adjust the fee accordingly.
5. Renewal: Clients approved for the sliding fee scale must reapply every 6 months and provide updated income documentation.
6. Payment Policy: The sliding fee amount is due at the time of service. Affirmations will make every reasonable effort to secure payment in accordance with the schedule of fees or schedule of discounts from the client and/or any other third party.

• Nominal Fee: Patients with incomes above 100 percent of the Federal Poverty Guidelines, but at or below 500 percent of the Federal Poverty Guidelines will be charged a nominal fee according to the attached sliding fee schedule and based on their family size and income. Individuals 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 copayment.
• Exceptions: In exceptional circumstances, Affirmations Community Center may consider adjusting the sliding fee on a case-by-case basis. Please discuss any extenuating circumstances with your therapist or our office manager
• Waiving of Charges: In certain situations, individuals may not be able to pay the nominal or discount fee. Waiving of charges must be approved by Affirmations Community Center’s designated official. Any waiving of charges is documented in the individual’s file along with an explanation, in accordance with insurance contracts. If an individual has an insurance policy whose contractual obligations prohibit participation in this SFS policy, Affirmations will comply with all legal and contractual obligations.

7. Missed Appointments: Our standard missed appointment policy applies to all clients, including those on the sliding fee scale, unless otherwise prohibited by legal or contractual agreement.
8. Refusal to Pay: If a client verbally expresses an unwillingness to pay or vacates the premises without paying for services, the client will be contacted in writing regarding their payment obligations. If the client 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 effort to pay or fails to respond within 60 days, this constitutes refusal to pay. At this point in time, Affirmations Community Center can explore options not limited to, but including:

• Offering the client a payment plan
• Waiving of charges
• Discharge
• Referring the client to collections

9. Record keeping: Information related to Sliding Fee Program decisions will be maintained and preserved in a centralized confidential file located in our electronic health record and/or HIPAA complaint and secure electronic platform. This includes but is not limited to the following protocols:

• Applicants that have been approved for the Sliding Fee Program will be logged in Affirmations’ practice management system (Simple Practice), noting names of applicants, dates of coverage and percentage of coverage.
• HIPAA complaint and secure electronic platform, managed by the Behavioral Health Program Coordinator, will maintain an additional monthly log identifying Sliding Fee Discount Program recipients and dollar amounts. Denials and applications not returned will also be logged.

10. Policy and procedure review: The Sliding Fee Schedule will be updated based on the current Federal Poverty Guidelines. Affirmations 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.

• 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.

11. Right to Amend: Affirmations Community Center reserves the right to amend this sliding fee policy at any time. Clients will be notified of any changes.

Compliance

Our practice is committed to providing HIPAA compliant, person-centered behavioral health services supported by the quality and compliance standards set forth by CMS, MDHHS, and all other governing bodies. Programs and services must adhere to these standards as well as in alignment with Affirmations’ Behavioral Health Program values of comprehensive, person-centered care, medical necessity and evidence-based practices.

All staff involved in the Affirmations Behavioral Health Program are required to adhere to these policies, which will be reviewed annually for relevance and effectiveness. Through our commitment to clear, timely communication and comprehensive care, we aim to enhance community engagement and participation in our programs.