Sliding-scale brackets built on a published index, not a feeling

What the brackets are a percentage of

Every band on a sliding scale is a percentage of one published number: the HHS poverty guideline for that patient's household size. For 2026, in the 48 contiguous states and the District of Columbia, that guideline is $15,960 for a one-person household and $33,000 for a household of four 1Ref 1U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) (2026).2026 Poverty Guidelines for the 48 Contiguous States and the District of Columbia.The 2026 poverty guideline figures for the 48 contiguous states and D.C. ($15,960 for a one-person household, $33,000 for a household of four) that the bracket percentages and the worked dollar column are computed from.. Divide annual household income by the figure for the right household size, and the answer is the percentage that places the patient in a band.

The guidelines come in three versions. HHS publishes one set of figures for the 48 contiguous states and D.C., one for Alaska, and one for Hawaii 2Ref 2U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) (2021).Frequently Asked Questions Related to the Poverty Guidelines and Poverty.Three procedural facts: the guidelines are published as three separate tables (48 states and D.C., Alaska, Hawaii); rounding and the annual-to-monthly conversion are left to the program applying them; and a new year's figures may be used as soon as they are posted, usually in late January, unless a program sets a later effective date., so a table copied from a colleague across a state line can be wrong before the first patient is seen.

A household of four earning $59,400 sits at 180 percent of the 2026 guideline. The same household earning $69,000 sits above 200 percent and off the scale entirely. Household size does as much work in that arithmetic as income does, which is why the intake question asks for both in one line.

Where the floor and the ceiling come from

From a federal rule that does not govern a private practice. 42 CFR 51c.303 sets the sliding-fee requirements for community health centers funded under the federal community health services grant program, and it fixes both ends of the scale: a full discount for households at or below 100 percent of the poverty guidelines, and no discount at all above twice those guidelines 3Ref 3U.S. Department of Health and Human Services (codified rule; text carried in the Code of Federal Regulations) (2024).42 CFR § 51c.303 — Project elements (Grants for Community Health Services, Subpart C — Grants for Operating Community Health Centers).The two ends of the sliding-fee structure a private practice borrows: a full discount at or below 100 percent of the poverty guidelines, no discount above 200 percent, and a nominal charge at the bottom tier that is permitted rather than required. Cited with the limit that the rule binds HRSA grantees.. Private practices borrow those ends because they are the published ones.

The bottom tier carries one more option. The same rule permits a nominal charge from households at or below 100 percent where collecting one is consistent with the program's own goals, and it does not require the charge 3Ref 3U.S. Department of Health and Human Services (codified rule; text carried in the Code of Federal Regulations) (2024).42 CFR § 51c.303 — Project elements (Grants for Community Health Services, Subpart C — Grants for Operating Community Health Centers).The two ends of the sliding-fee structure a private practice borrows: a full discount at or below 100 percent of the poverty guidelines, no discount above 200 percent, and a nominal charge at the bottom tier that is permitted rather than required. Cited with the limit that the rule binds HRSA grantees.. A practice adopting the structure makes that call itself, and states in writing which way it went.

But borrowing the structure buys no shelter this reading could find. No OIG advisory opinion addressing an income-based scale at a private, non-grantee practice turned up, so the 100-to-200 frame is a convention with a published source behind it rather than a safe harbor. Where a payer contract or a Medicare-enrolled patient is in the picture, that question belongs with health-care counsel before the table goes on the website.

How many bands go between 100 and 200 percent

Nothing federal answers that. The regulation fixes the two ends and says nothing about what sits between them 3Ref 3U.S. Department of Health and Human Services (codified rule; text carried in the Code of Federal Regulations) (2024).42 CFR § 51c.303 — Project elements (Grants for Community Health Services, Subpart C — Grants for Operating Community Health Centers).The two ends of the sliding-fee structure a private practice borrows: a full discount at or below 100 percent of the poverty guidelines, no discount above 200 percent, and a nominal charge at the bottom tier that is permitted rather than required. Cited with the limit that the rule binds HRSA grantees., and ASPE, which publishes the index, leaves rounding conventions and the conversion of an annual guideline into a monthly income test to whichever program is applying the guidelines 2Ref 2U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) (2021).Frequently Asked Questions Related to the Poverty Guidelines and Poverty.Three procedural facts: the guidelines are published as three separate tables (48 states and D.C., Alaska, Hawaii); rounding and the annual-to-monthly conversion are left to the program applying them; and a new year's figures may be used as soon as they are posted, usually in late January, unless a program sets a later effective date.. The number of bands, the rounding rule, and the monthly-or-annual test are the practice's own decisions, written down before the first patient asks.

Four bands is a workable shape for one person to administer. What follows is a worked example built on the 2026 four-person guideline, and no agency has blessed it.

The dollar column is arithmetic on one cited figure, and it has to be recomputed for every household size the practice sees 1Ref 1U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) (2026).2026 Poverty Guidelines for the 48 Contiguous States and the District of Columbia.The 2026 poverty guideline figures for the 48 contiguous states and D.C. ($15,960 for a one-person household, $33,000 for a household of four) that the bracket percentages and the worked dollar column are computed from.. The discount column is a choice. Any set of steps that starts at a full discount and reaches zero by 200 percent is as defensible as this one, and a practice running three bands instead of four has an easier table to explain at the front desk.

Discounts come off your fee schedule, so the schedule has to exist and be the same one every patient is quoted from. Where it prices 90832, 90834, 90837 at three different rates, the band's percentage applies to each of them, so the shorter visit stays cheaper than the longer one at every income level and nobody has to price a discounted visit by hand.

Write the criteria down and apply them the same way

A sliding scale is a written policy applied to everyone who meets it, and the alternative is a run of individual favors that each have to be justified on their own. OIG's alert on waiving Medicare Part B copayments and deductibles states the principle: forgiving a charge for financial hardship is defensible as an occasional exception addressing a particular patient's need, documented individually, with a good-faith collection effort otherwise 4Ref 4U.S. Department of Health and Human Services, Office of Inspector General (1994).Routine Waiver of Part B Co-payments/Deductibles.The stated principle that forgiving a charge for financial hardship is defensible as an occasional, individually documented exception with a good-faith collection effort otherwise, used here to frame why sliding-scale criteria are written and applied uniformly. Cited by extension of that principle, not as a rule about cash-pay fees..

That alert governs Medicare cost-sharing. It binds nothing about what a private practice charges an uninsured patient, and what travels across is the shape of the reasoning. A discount handed out case by case has to be justified case by case, while a published rule applied to every patient who meets it is one document that answers for all of them.

Every discount comes off the published table, and every exception to the table is documented on its own.

Written sliding scale fee criteria run to four lines: what counts as income, whose income counts toward the household, what the practice asks to see, and how often a band is revisited. Settle all four before publishing, because each one invites an argument if it gets decided patient by patient at the desk.

HRSA's compliance manual is where health centers get their proof-of-income conventions, and nothing here restates them. A practice writing its own proof rule is writing it from scratch, and what matters more than which documents it names is that the same list is asked of everyone.

Two neighboring questions sit outside this page. Reducing what an insured patient owes on a claim is a separate question from setting a cash price, and the FCA and the solo practice is where that one gets taken up. Where the practice gives a self-pay patient a written estimate before the visit, the sliding scale good faith estimate carries the band's discounted price rather than the standard fee.

What the discount does to the books

A discount given at the time of service is revenue the practice never books, and there is no later deduction that gives it back. The IRS states the rule for unpaid fees directly: a bad-debt deduction requires that the amount was previously included in income, which a cash-method taxpayer's forgiven or never-billed fee never was 5Ref 5Internal Revenue Service (2026).Topic no. 453, Bad debt deduction.The narrow bookkeeping point that a cash-method taxpayer cannot take a bad-debt deduction for a fee that was never included in income, so an upfront sliding-scale discount creates no deductible loss.. The money is real and it leaves no tax artifact behind it.

So the scale gets sized against collections. Run the proposed bands over last year's actual visit mix, count what that same year would have collected under them, and take the difference to your CPA rather than treating a discount tier as a write-off.

Four steps of 25 points look modest on one visit and compound across a full panel.

Where the income record lives

In the practice's own files, and possibly inside the record set a patient can ask to see. HIPAA defines the designated record set to include any record used, in whole or in part, by or for the covered entity to make decisions about individuals, which reaches past the chart note 6Ref 6U.S. Department of Health and Human Services (2025).45 CFR § 164.501 — Definitions.The definitional point that a designated record set includes any record used, in whole or in part, to make decisions about individuals, and so reaches past the chart note.. The sheet carrying household size, the income figure used, the date, and the band assigned is, on that definition, a record used to decide what the patient is charged.

Keep it retrievable and keep it short. Store the four facts and the date the band was set. Whether the practice also keeps copies of what the patient showed is a policy choice worth making once instead of per patient, and it is one of the four lines above.

Reset the table when the guidelines move

Once a year, on a changeover date the practice names in its own policy. A new year's guidelines may be used as soon as HHS posts them, which ASPE says usually happens in late January, unless a program sets a later effective date of its own 2Ref 2U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) (2021).Frequently Asked Questions Related to the Poverty Guidelines and Poverty.Three procedural facts: the guidelines are published as three separate tables (48 states and D.C., Alaska, Hawaii); rounding and the annual-to-monthly conversion are left to the program applying them; and a new year's figures may be used as soon as they are posted, usually in late January, unless a program sets a later effective date.. So the practice picks its month, prints the guideline year on the table, and recomputes the dollar column for every household size at the same time.

The index moves every year, and the sliding scale moves with it. A household of four earning $67,000 sits above the 2026 ceiling of $66,000 and pays the full fee. If the four-person guideline rose to $34,000 for the following year, the ceiling would move to $68,000, and that same household at that same income would be inside the scale.

The recomputation is a few minutes of arithmetic once the policy names the month it happens in, and the patients sitting within a band of a boundary are the ones to tell first.