Sliding Fee Scale
HRSA-compliant sliding fee schedule based on Federal Poverty Level — FY 2026
FPL Income Bracket Schedule
Updated Jan 1, 2026
| FPL Range | Tier | Discount | Medical Copay | Dental Cleaning | Mental Health | Lab Draw |
|---|---|---|---|---|---|---|
| 0 – 100% FPL | Tier 1 | Full Discount | $0 | $0 | $0 | $0 |
| 101 – 125% FPL | Tier 2 | 80% Discount | $20 | $15 | $20 | $10 |
| 126 – 150% FPL | Tier 3 | 60% Discount | $40 | $30 | $40 | $15 |
| 151 – 175% FPL | Tier 4 | 40% Discount | $60 | $45 | $60 | $20 |
| 176 – 200% FPL | Tier 5 | 20% Discount | $80 | $60 | $80 | $25 |
| >200% FPL | Full Fee | No Discount | Full fee per schedule | Full fee | Full fee | Full fee |
Full Fee Schedule: Medical Visit $487 | Dental Cleaning $185 | Mental Health $320 | Lab Draw $95 | These represent charges before sliding fee discount application.
Fee Schedule by Service Type
| Service Type | Full Fee | Tier 1 ($0) | Tier 2 Copay | Tier 3 Copay | Tier 4 Copay | Tier 5 Copay |
|---|---|---|---|---|---|---|
| Medical Visit | $487 | $0 | $20 | $40 | $60 | $80 |
| Dental Cleaning | $185 | $0 | $15 | $30 | $45 | $60 |
| Mental Health (50 min) | $320 | $0 | $20 | $40 | $60 | $80 |
| Lab Draw (routine) | $95 | $0 | $10 | $15 | $20 | $25 |
| Vision Exam | $215 | $0 | $15 | $30 | $45 | $60 |
| Substance Use Counseling | $280 | $0 | $20 | $40 | $60 | $80 |
| Enabling Services | $60 | $0 | $0 | $5 | $10 | $15 |
HRSA Compliance Checklist
All Items MetNo patients turned away for inability to pay
All patients receive services regardless of ability to pay — HRSA PIN 2014-02 compliant
Fees based on ability to pay (FPL determination)
Income verification process in place; annual re-attestation required
Sliding fee scale publicly available
Posted in clinic lobby, on website, and provided at registration — English / Spanish
Schedule reviewed and updated annually
Last updated January 1, 2026 per HHS FPL guidelines. Next review: Jan 1, 2027
Board-approved sliding fee policy
Approved by Board of Directors on December 18, 2025. Resolution #2025-14 on file
FPL Income Calculator
Calculate patient's FPL percentage and sliding fee tier based on household size and income.
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2026 FPL Reference
| Size | 100% FPL | 200% FPL |
|---|---|---|
| 1 | $14,580 | $29,160 |
| 2 | $19,720 | $39,440 |
| 3 | $24,860 | $49,720 |
| 4 | $30,000 | $60,000 |
| 5 | $35,140 | $70,280 |
| 6 | $40,280 | $80,560 |
Source: HHS 2026 Poverty Guidelines. Each additional person: +$5,140.