Once a date is set, the Bureau of Health Workforce (BHW)’s Division of Regional Operations (DRO) staff will request you provide them with the following documents:
Policies on Non-Discrimination. Submit a copy of the site’s policies on non-discrimination of patients based upon the individual’s inability to pay; whether payment for services would be made under Medicare, Medicaid, or CHIP; and the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity.
Sliding Fee Discount Program Documents. Submit the following:
- Policy on the Sliding Fee Discount Program
- Applies to all residents of your site’s HPSA(s)
- Includes the following information:
- Definitions of income and family size
- Patient eligibility procedures
- Frequency of re-evaluation of eligibility
- Advertisement of the sliding fee discount program to the patient population
- Nominal charge, if applicable
- Collections policy, if applicable
- Sliding Fee Schedule.
- Based on most current Federal Poverty Guidelines (FPG)
- It is calculated based on Family Size/Income
- Goes up to at least 200% of FPG
- Offers full discount for families with income at or below 100% of FPG
- Adjust fees based on family size and income for families with incomes above 100% and at/below 200% of the FPG.
- Patient Application for Sliding Fee Discount Program.
- Posted Signage Notifying Patients about the Sliding Fee Discount Program. Submit two photographs of the posted signage. The sign must explicitly state that “no one will be denied access to services due to inability to pay; and there is a discounted/sliding fee schedule available based on family size and income,” in accordance with the NHSC Site Agreement item #2e.
- The first photograph must show the sign prominently displayed in a common area visible to patients.
- The second photograph must be a close-up photo so the text is legible.
- Sites may not use the NHSC poster and/or logo until after they are approved by the NHSC.
- Online Signage Notifying Patients about the Sliding Fee Discount Program. Submit a document with the screenshot and link to the published online statement on the site’s official website (if one exists) and social media platforms (if applicable.) The screenshot must explicitly state that “no one will be denied access to services due to inability to pay; and there is a discounted/sliding fee schedule available based on family size and income,” in accordance with the NHSC Site Agreement item #2e.
Note, if the Sliding Fee Discount Program does not apply to your site, you must provide documentation explaining that no one is charged or billed for services, and individuals are not denied service because of inability to pay.
Proof of Access to Ancillary, Inpatient, and Specialty Care. Submit proof of referral arrangements not available on-site. Behavioral health sites must also submit documents outlined in item #4 below.
- Acceptable documents include:
- Signed Memorandums of Understanding (MOU)
- Signed Memorandums of Agreement (MOA)
- Signed contracts with ancillary, inpatient, and specialty facilities
- If formal referral arrangements do not exist, the applicant site should provide a dated and signed description of how it refers patients to ancillary, inpatient, and specialty care.
NHSC Comprehensive Behavioral Health Services Checklist and Supporting Documentation. Submit the following:
- NHSC Comprehensive Behavioral Health Services Checklist (PDF - 542 KB)
- Documentation that verifies all information included in the Checklist. Site policies or other internal documents must be submitted to reflect services provided directly on-site. In addition, sites must submit formal affiliation agreements for all other services provided off-site by a third party.
NHSC Site Data Tables. Submit NHSC Site Data Tables (PDF - 393 KB) with information on the individual site location that:
- Includes data from the previous six continuous months
- Demonstrates site’s sound fiscal management policies
Substance Use Disorder (SUD) Documentation. Facilities providing opioid treatment and/or SUD treatment must provide the following documentation:
- Opioid Treatment Programs (OTPs): SAMHSA OTP certificate; OR
- Office-based opioid treatment (OBOT): documentation of services and medication assisted treatment (MAT) attestation letter describing size of MAT patient panel for last 6 months; OR
- Non-opioid outpatient SUD facilities: documentation of services.
Clinician Recruitment and Retention Plan. The document must clearly state the policies and processes to recruit and maintain clinical staffing levels needed to appropriately serve the community, including specific strategies aimed at promoting clinician resiliency and reducing burnout.
DRO staff reviews these materials in advance of the actual site visit.