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SLIDING SCALE FEE DISCOUNT PROGRAM

Frequently Asked Questions

What is the Sliding Fee Scale?

InnerSourced Solutions, Inc offers affordable counseling / therapy and other programs and services through the use of the sliding fee discount program to uninsured and under insured qualified individuals and families.  Eligibility is based on family size and family income.  The Sliding Fee Discount Program Scale is based on the annual definition of federal poverty provided by the Department of Health and Human Services, and is divided into four categories:  A, B, C, D, and E. Below is the scale for Behavioral Health:

This program works in part, in accordance with the Federal Poverty Guidelines, which can be found here.

 

Who can apply for the Sliding Fee Scale?

Any individual may apply for the Sliding Scale Fee Discount; however, eligibility in the program is based on the household annual income and family size. Only individuals living in households with income below 450% of the Federal Poverty Level may qualify for a Sliding Scale Fee discount. 

 

The Sliding Scale Fee Discount is only available to individuals and families who are uninsured or under-insured.​

 

As part of the intake process, if an individual is uninsured, the individual will be informed of the availability of the Sliding Scale Fee Discount and explain the paperwork needed to complete the application.

How is eligibility for the Sliding Fee Scale determined?
Eligibility is determined on the household size, annual gross income (net income for self-employment) for the household, completed application, and proof of income.

We offer a Sliding Fee Discount to patients with income at or below 200% Federal Poverty Levels, set forth by the most recent published HHS Federal Poverty Guidelines. Click HERE go to the current guidelines. 

How do I get an application for this program?
Ask for a Sliding Fee Scale packet at our front desk staff or download below. 

What type of documents do I need to bring to apply for Sliding Fee Scale?
You will need to bring in proof of income for all the household members over age 18 and a completed Sliding Fee Application.

What can be used as Proof of Income?
Accepted documents for proof of income:

  •  Current Federal Income Tax (1040-1040 EZ Form, no W2s)

  •  Paystubs for recent month 

  •  Current bank statement showing direct deposit (SS, SSI, SSD, Child support) 

  •  Social Security/Disability Letter

  •  Unemployment Benefit Letter (no bank statements)

  •  Letter of Support

  •  Court order for alimony or child support or printout for child support payments 

  •  Pension Benefit Letter

  •  Wages (4 pay stubs if paid weekly, 2 pay stubs if paid bi-weekly)

 

Who is considered a “household member”?
Household members are related by blood, marriage or adoption, and financially responsible to each other. Roommates do not qualify as a ‘Household member’. 

When is my Sliding Fee Scale effective?
The sliding fee scale discount, if you qualify, will backdate 14 days from the day which you are given the application.

When does my Sliding Fee Scale expire?
The Sliding Fee Scale discount will expire at the end of month, 1 year from approval date. 
You must re-apply prior to the expiration date in order to continue being covered under the Sliding Fee Scale Program. Failure to do so may result in the patient being responsible for the full amount of any charges incurred during the lapse.

How often do I need to apply for this program?
You must apply quarterly
.  However, you may re-apply within the quarter if there is a change in your current household size or income.

I do not want to provide my financial information. Am I still eligible for the Sliding Fee Scale?
Eligibility for the Sliding Fee Scale is based on your income and household size. If you choose not to provide InnerSourced Solutions with this information
you will be responsible for the total charges for services received.

What services does the Sliding Fee Scale cover?
Behavioral Health visits (individual and family therapy sessions, as well as medication management visits).

How much will I pay if I am approved for the program?
The charge for your visit depends on your income, household size, and the type of service you received. When you are approved for the Sliding Scale Fee you will receive a card that details your financial responsibility for services received. Payments are due at the time of service. If you have private insurance, your normal co-pays still applies

Who should I contact if I have more questions?
Your Program Director or Your Therapist can help you. 

 

Click on the links below to view and/or print. 


Sliding Scale Fee Application

Statement of Support

Employment Verification

Application Review Process

Once the application is reviewed, you will be contacted by InnerSourced Solutions in writing  of the yearly discount granted and the expected amount you will be required to pay for your treatment.

 

If the application is denied, the reason for the denial will be included in the written decision regarding the application.

Once notified of the decision regarding the Sliding Scale Fee Discount Application, you must immediately let Complete Wellness know if you intend to continue your treatment and how you intend to pay the fees for services.  

If you do not contact InnerSourced Solutions within 2 weeks of notification of a Sliding Scale Fee Discount, the discount will be declined and you may reapply for the Sliding Scale Fee Discount in 90 days.

The Fine Print

The Sliding Scale Fee Discount may be applied to services received for psychotherapy and medication management. Group psychotherapy is not eligible for the Sliding Scale Fee Discount Program.

​By signing the application, persons authorize InnerSourced Solutions, Inc. the necessary access to confirm 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.

Sliding Fee Discount Program applications cover outstanding patient balances for six months prior to application date and any balances incurred within 12 months after the approved date, unless their financial situation changes significantly.

2023 Sliding Fee Discount Scale based on income.
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