THE PAIUTE INDIAN TRIBE OF UTAH 440 North Paiute Drive Cedar City, Utah (435) Fax (435)

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THE PAIUTE INDIAN TRIBE OF UTAH 440 North Paiute Drive Cedar City, Utah 84721 (435) 586-1112 Fax (435) 867-1514 SLIDING FEE DISCOUNT POLICY AND PROCEDURE March 7, 2013 Revised April 15, 2015 Policy:

1 THE PAIUTE INDIAN TRIBE OF UTAH 440 North Paiute Drive Cedar City, Utah (435) Fax (435) SLIDING FEE DISCOUNT POLICY AND PROCEDURE March 7, 2013 Revised April 15, 2015 Policy: A schedule of fees or payments that are consistent with locally prevailing rates or charges to cover reasonable cost of operations will be approved annually by the Tribal Council. A discount will be provided to every patient with an annual income below 200% of Federal Poverty Level (FPL) and a nominal fee will be applied for all patients with an annual income below 100% FPL. No patient will be denied services due to the inability to pay or citizenship. This Fee Schedule will be uniformly applied across the Tribe s Health Center patient population without discrimination. All reasonable effort to obtain reimbursement from third party payers either public (Medicaid, Medicare, Chip, etc.) or private health insurance(s) will be made. Third party payers are billed on the basis of full amount of fees and payments for such services without application of any discounts. The Tribe will assure proper signage is posted in all Health Centers to inform patients of the availability of discounts and makes every effort to improve the awareness of the sliding fee discount. Eligibility for the sliding fee discounts is based on income and family size for all patients and no other factors. A. Discount Application Process and Guidelines 1. Patients requesting to receive a discount for services must complete the discount fee application (Attachment A) and provide income verification. A minimum of one form of income verification is required. Once approved, the discount will be honored for one (1) year, after which the patient must reapply. Patients will have ten (10) business days to provide the necessary documentation after submitting the Discount Fee Applications to be eligible for the discounts. Here is a list of acceptable income sources: Last (current year) federal tax returns, quarterly tax statement if self-employed. The last 2 paycheck stubs for each adult working the in the household. A statement from your employer (signed, dated on company letterhead) stating rate of pay, average number of hours worked weekly, and hire date. Unemployment benefit letter. Social Security benefit letter showing your monthly payment (for each person receiving benefits). Verification of Workers Compensation Insurance benefits. Military family allotment verification. Payments made from trusts or estates verification. Documentation of child support (divorce papers, letter from Recovery Services) Copy of pension/retirement benefits. Documentation of State support (letter of approval for food stamps or other benefits) or W-2 statement due to loss of employment.

2 2. Adult patients who do not have medical or dental insurance and cannot provide proof of income from the list above and are not homeless will complete a Financial Support Document (Attachment D). This worksheet requires another adult who is providing financial support to the patient to outline the financial support they are providing with a signature. This form will act as an acceptable proof of income with the patient providing this form annually or until the patient has acquired another PITU approved source of income. 3. Family size is based on the following guidelines for household members: a) Includes yourself, spouse and dependents under the age of 19. b) Significant other are not considered household members c) Any other adult living in the home, even if they are related, would not be included in the family size count. They would need to complete a separate application. 4. Clinic staff will determine the eligibility based on the current years Federal Poverty Level Guidelines based off of family size and income. 5. Clinic staff will inform the client of their eligibility status and discount fee amount. 6. Clinic staff will verify, compile and scan all completed documentation and forward a copy to the business office. 7. If the client is unable or unwilling to provide income verification, the patient will not receive a discount and will be responsible for the total fees as detailed by the Fee Schedule. 8. Adolescent patients seeking confidential care are exempt from the application process, and services are provided at the nominal rate. 9. Clients receiving discounts will not be turned away from medical care for inability to pay. B. Scope of Service. 1. Office visits (including in-house laboratory, injections, routine vaccinations and minor surgical procedures) are covered under the discount fee program. 2. Dental routine exams, cleaning and fillings are covered under the discount fee program. 3. Behavior Health mental health counseling and outpatient substance abuse counseling are covered under the discount fee program. 4. Optical services are excluded from the discount fee program C. Compliance. If the above guidelines are not followed, the client will be deemed ineligible for the discounted fee.

3 Attachment A PAIUTE INDIAN TRIBE OF UTAH DISCOUNT FEE APPLICATION Patient Name: Address: City/State/Zip Phone: Name of each family member Date of Birth Name of Employer Unemployment Benefits, Workers Compensation Welfare Child Support, Alimony Social Security, Pension, Military Family Allotments Other Income (Rents, Royalties, Estate and Trust Payments) TOTAL EARNINGS Gross Earnings I declare that as of the following date, the information in this form is true and if uninsured, I agree to apply for any eligible benefits including the sliding fee discount. I also understand that should the Paiute Indian Tribe of Utah become aware that any of this information has been falsified to fraudulently receive services, including but not limited to medical, dental lab, prescription drug, and Behavioral Health, that my participation will be revoked and I will be responsible for 100% of the usual and customary charges of the Paiute Indian Tribe of Utah. I agree to report any changes to my income or family status to the Paiute Indian Tribe of Utah. Print Name of Guarantor Date Signature OFFICE USE ONLY Employee Witness/Verification Name Date Signature

4 Attachment B Paiute Indian Tribe of Utah Health Department Sliding Fee Discount Schedule Monthly Income Limits - Based on 2015 Monthly Federal Poverty Level (FPL) Guidelines By Family Size Level 1 Level 2 Level 3 Level 4 Level % % % % 201 and up% FEE full fee Family Size Up to Up to Up to Up to and over , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Paiute Indian Tribe of Utah Health Department Sliding Fee Discount Schedule Annual Income Limits - Based on 2015 Annual Federal Poverty Level (FPL) Guidelines By Family Size Level 1 Level 2 Level 3 Level 4 Level % % % % 201 and up% FEE full fee Family Size Up to Up to Up to Up to and over 1 11, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Note: For families with more than 8 persons, add 4,160 for each additional person

5 Attachment C

6 Attachment D

Billing and Collection Standard Operating Guidelines

Tuscarawas County Health Department Billing and Collection Standard Operating Guidelines Medical Clinic and Alcohol and Addiction Program Version 1.0 Effective May 11, 2018 Revision Table Date Revision