Community health center sliding fee scale: the federal rule, the 2026 income table and one household worked through

The rule, in the words of the federal sources

The sliding fee requirement comes from the statute that funds health centers, section 330(k)(3)(G) of the Public Health Service Act, and from the federal regulation at 42 CFR 51c.303(f). The regulation requires a schedule of fees designed to cover the center's reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient's ability to pay. The discount schedule must provide a full discount to individuals and families with annual incomes at or below the poverty guidelines updated by the Department of Health and Human Services, and no discount to those with incomes above twice those guidelines. Nominal fees may be collected from people at or below the guideline where imposing them is consistent with project goals.

The Health Resources and Services Administration, which oversees the program, translates that into a compliance manual. Chapter 9, last reviewed in November 2025, requires that the center operate in a manner such that no patient is denied service because of an inability to pay. It requires a board-approved sliding fee discount program that applies uniformly to all patients and covers all required and additional health services within the center's approved scope for which there are distinct fees. Patients are assessed for eligibility based only on income and family size. The manual also sets the structure of the schedule.

• At or below 100 percent of the current poverty guideline, a full discount, unless the center chooses a nominal charge. A nominal charge must be less than the fee paid by a patient in the first discount class above 100 percent, and the manual says nominal charges are not minimum fees, minimum charges or copayments.
• Above 100 percent and up to and including 200 percent, partial discounts that adjust with income and include at least three discount pay classes.
• Above 200 percent, no discount.

The manual's footnote gives an example of what a class can look like: classes of 101 to 125 percent, 126 to 150, 151 to 175 and 176 to 200 percent of the guideline would be four classes between 101 and 200 percent. The example is the manual's illustration of counting classes, and a center may draw its lines elsewhere.

The 2026 income table, by household size

The HHS poverty guidelines for 2026 were published in the Federal Register in January 2026 (document 2026-00755). For the 48 contiguous states and the District of Columbia, they are the first column of the table. The second column doubles them, which is where a center's discounts end, and the third divides that figure by twelve for a monthly view.

People in the household	100 percent of the guideline	200 percent, the end of the discounts	200 percent per month
1	$15,960	$31,920	$2,660.00
2	$21,640	$43,280	$3,606.67
3	$27,320	$54,640	$4,553.33
4	$33,000	$66,000	$5,500.00
5	$38,680	$77,360	$6,446.67
6	$44,360	$88,720	$7,393.33
7	$50,040	$100,080	$8,340.00
8	$55,720	$111,440	$9,286.67

For households of more than eight, HHS adds $5,680 per additional person. Alaska and Hawaii have higher guidelines: for one person, $19,950 in Alaska and $18,360 in Hawaii, with a household of four at $41,250 and $37,950. HHS publishes these as guidelines for administrative use, and a health center must use the most recent figures in its schedule. One way to make the 200 percent line concrete: for one person, $31,920 a year is $15.35 an hour over a 2,080-hour work year, and for a family of four, $66,000 is $5,500 a month. Those are arithmetic conversions of the table, and the center decides what counts as income and how it is documented.

Turning your income into a percent of the guideline

Most centers print their schedule in percent-of-guideline classes, and the dollar lines you need depend on household size. Count the people in the household as the center defines it, find the 100 percent figure for that count in the table above, and divide your annual income by it. The result, times 100, selects the class. Alaska and Hawaii use their own, higher guidelines (for one person, $19,950 and $18,360), so a household there should divide by the figure for its state.

Where the class lines fall is the center's choice. One center publishes them as dollar ranges, which saves the division. Valley Health's 2026 policy does this for four classes: A at 0 to 100 percent, B at 101 to 133, C at 134 to 166 and D at 167 to 200 percent of the guideline.

People in the household	A: up to	B: up to	C: up to	D: up to (no discount above)
1	$15,960	$21,227	$26,494	$31,920
2	$21,640	$28,781	$35,922	$43,280
3	$27,320	$36,336	$45,351	$54,640
4	$33,000	$43,890	$54,780	$66,000
5	$38,680	$51,444	$64,209	$77,360

These are the center's published dollar lines for the 2026 guideline, shown here for households of one to five from its table for one to eight. They are one center's lines, not a federal standard: Family Health Center of Worcester happens to use the same 133 and 166 percent breakpoints for its medical visits, and another center may use different ones.

Two published 2026 schedules, side by side

The federal rule fixes the ends of the scale and leaves the middle to each center, so the clearest way to see it is to read two real ones. Both are 2026 board-approved policies that the centers publish as PDFs. Neither center is typical of anything but itself.

Item	Family Health Center of Worcester (policy approved May 19, 2026)	Valley Health (2026 policy and schedule)
Classes	0 to 100%, 101 to 133%, 134 to 166%, 167 to 200% of the guideline	Slide A to D, on the same four bands
Medical visit, lowest class	$10.00 nominal fee	$10 (class A)
Medical visit, next three classes	20%, 40% and 60% of the full charge	$20, $30 and $40 flat
Pharmacy	No charge at 0 to 100%; then $10, $20 and $25 fees; the patient pays the prescription cost if it is lower	A discount off the cost, by class: 50%, 40%, 30% and 20% off, with a $4 minimum charge in class A
Dental	$40 nominal fee per visit, then 20%, 40% and 60% of the full charge, plus supplies and labs	Basic and preventive dental $20, $40, $60 and $80 a visit; fillings, crowns and extractions $50, $70, $90 and $110
Insured patients	Charged no more than the discount class would charge, within contract limits	The lesser of the sliding fee or the copayment or deductible due
How long an assessment lasts	One year from the application date	Twelve months from the completed application, unless circumstances change
If you cannot document income	A signed self-declaration form	Self-declaration allowed when documents are unavailable

Two things stand out. The same visit is priced as a percentage of a full charge at one center and as a flat dollar fee at the other, so a class letter alone tells you nothing until you see the fee beside it. And the schedule is split by service, not applied as one discount across the whole bill. Worcester's family-planning services add a fifth class at 201 to 250 percent of the guideline, at 80 percent of the full charge, because the program requirements for those services extend discounts to 250 percent. Outside that case, the 200 percent line is the end of the discount.

Four households placed on a real schedule

Using Valley Health's dollar lines, here is where invented households land. A household of 3 with $42,000 of income is at $42,000 divided by $27,320, or 153.7 percent of the guideline, inside class C (the table above shows $36,337 to $45,351 for three people). A single adult with $26,000 is at $26,000 divided by $15,960, or 162.9 percent, also class C, even though the dollars differ, because the guideline scales with household size. A household of 2 with $20,000 is at 92.4 percent of $21,640 and sits in class A. A household of 4 with $70,000 is at 212.1 percent of $33,000, above the 200 percent line, and gets no discount.

What a class is worth depends on the fee beside it. Take one same-day visit made of a medical visit, a diagnostic lab test and a diagnostic radiology exam. On Valley Health's schedule each of those three lines costs $10 in class A, $20 in B, $30 in C and $40 in D, so the visit costs $30, $60, $90 or $120. The household of 3 at $42,000 pays $90. On Worcester's medical-visit schedule, with an invented full charge of $180, the same household in its equivalent band pays 40 percent, which is $72.00; class A would pay $10.00, B $36.00 and D $108.00.

The edges matter as much as the middle. At the top of class D for three people, $54,640, the Valley Health visit above costs $120. A dollar more and the schedule no longer applies, so the household pays the center's full charges, whatever they are. The percentage is the center's, not a smooth curve, and a household near a boundary should ask how the center counts income before it assumes a class.

Who counts as the household, and which income counts

The two inputs to the percent, the headcount and the income, are the two things HRSA leaves to the center. The manual requires board-approved definitions and says assessment is based only on income and family size, but the definitions are the center's. It defines income only as earnings over a given period used to support an individual or household unit, distinct from assets, and lists no inclusions.

The two published policies show how far the choices can differ. Worcester counts a long list: earnings, unemployment and workers' compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, pensions, interest, dividends, rents, royalties, educational assistance, alimony, child support and help from outside the household. It defines family as people living together who are related by birth, marriage, adoption, guardianship or domestic partnership, or who show financial interdependence. Valley Health starts from wages, tips and other pay, self-employment, benefits and investment income, adds child support received, and subtracts alimony and child support paid. It counts as family the people who can be claimed on the patient's tax return, plus relatives largely supported by the patient's income, whether or not they live together.

The same household can therefore land in different classes at two centers. A household with irregular work, a recent job loss, a mix of earnings and benefits, or a relative who is supported but lives elsewhere is the one most affected.

If your income or household changes

The federal rule sets no reassessment interval, so the interval is a fact about the center. Both published policies give an assessment a year, then add their own conditions. Worcester asks every patient at every visit whether income has changed, has staff reassess at least once a year, and tells patients to report changes in income, family size or insurance as soon as possible. If a patient's application is missing information, Worcester gives two weeks to supply it before the application date resets, and it revokes all discounts and restores the full balance if an application contains false information. Valley Health will backdate eligibility if the required documents arrive within 30 days of the application, and lets pending applications expire after that. It charges the full charge to a patient who refuses to be assessed.

Because the guideline is updated every year, a schedule written to the most recent guideline moves its dollar lines each year even when nothing about the household changed. Ask at registration how long the assessment lasts and what triggers an earlier one, and write the answer on the page where the schedule is kept.

What to ask at registration

1. "Do you have a sliding fee discount schedule, and may I have a copy of it, including the income lines for my household size?"
2. "Which poverty guideline year does it use?"
3. "What counts as income and as household for the schedule, and over what period?"
4. "What documents do you accept, and what do you accept if I cannot get a document?"
5. "Which class would I be in, and what would this visit cost in that class? Please write it down."
6. "Does the discount apply to the lab work and to any referral you send me to? If not, who bills for it?"
7. "I have insurance. Does the discount apply to my copayment or deductible?"
8. "When will you reassess me, and what should I tell you if my income changes?"

Eight questions look long, but a registration desk that runs a sliding fee program answers them routinely, and the written answers become the record to compare with the first bill. If the bill later differs from the written price, the document that matters is the one with the class and the fee on it. The guide on how to ask for the cash price has wording for the follow-up if an answer is vague.

Sliding fee scale next to hospital financial assistance

Feature	Health center sliding fee scale	Hospital financial assistance
Where the rule comes from	Public Health Service Act section 330 and 42 CFR 51c.303, administered by HRSA	The hospital's own financial assistance policy; CFPB says nonprofit hospitals and some private hospitals must provide free or reduced-fee care
Income reference	Federal poverty guideline: full discount at or below 100%, none above 200%	Set in each hospital's policy, so the line differs by hospital
What it covers	In-scope services with distinct fees, plus contracted and referred services as described above	Care at that hospital, as the policy defines it
Who applies the discount	The health center, through a board-approved schedule	The hospital, through an application
First step	Ask for the schedule and be assessed at registration	Ask for the policy and the application, ideally before service

The CFPB advises, in its page on medical credit cards and payment plans, to check first whether a provider is required to offer financial assistance based on income level, because signing up for a financing product first can make assistance harder to get. The same order of operations applies here: the income-based route comes before any financing. The guide on medical payment plans and medical credit cards covers the financing side.

If you have insurance: the manual's own example

The scale is not only for the uninsured. The manual says health center patients who are eligible for sliding fee discounts and have third-party coverage are charged no more for out-of-pocket costs than they would have paid under the applicable discount class, and that such discounts are subject to potential legal and contractual restrictions. The manual's footnote gives the arithmetic. A service has a center fee of $80. The insurance plan's copayment would be $60. The center assesses the patient at 150 percent of the poverty guideline, where the schedule gives a 50 percent discount, which makes the sliding fee $40. Rather than the $60 copayment, the center would charge the patient no more than $40, as long as the insurance contract does not preclude or prohibit it.

The last clause is the part to ask about. An insurer's contract can limit what a network provider may charge a member, so a patient with coverage should ask the center whether the sliding fee applies to the copayment, the deductible or neither, and get the answer in writing. The guide on estimating your cost with insurance covers the plan side.

What is federal and what the center decides

Fixed by the federal rule	Left to the health center
Full discount at or below 100% of the guideline, possibly with a nominal charge	Whether to charge a nominal fee at all, and its amount
No discount above 200%	The class boundaries between 100% and 200%, beyond the minimum of three classes
At least three discount classes between 101% and 200%	Whether discounts are a percentage of the fee or a flat fee per class
Assessment on income and family size only	How income is defined and documented, and how family is defined
Use of the most recent poverty guideline	Whether to allow self-declaration of income or family size, for example for people without documents
Board-approved policy that applies uniformly	How often and how patients are reassessed
No one denied service for inability to pay	Whether a patient who refuses to give income information is treated as ineligible for the discount
Evaluation of the program at least every three years	Whether to run separate schedules, for example for medical and dental services

What the discount reaches

The discount program applies to the required and additional services within the center's approved scope of project for which there are distinct fees, which the manual defines as fees for services typically billed separately in the local market. Two further tiers reach beyond the center's own staff. For in-scope services the center provides through a formal written contract, the same structure applies: full discount at or below 100 percent, partial discounts to 200 percent with at least three classes, none above. For services reached through a formal referral arrangement, the center ensures that patients between 100 and 200 percent receive a discount at least as good as applying the center's scale to the referral provider's fees, and that patients at or below 100 percent receive a full discount or a nominal charge.

So the question to ask is which of your services are in scope and, for those that are not, what the referral arrangement says. Laboratory work and specialist visits are the usual places where a bill arrives from outside the center. Valley Health's policy lists medical, behavioral health, dental, obstetric, vision, laboratory, imaging and pharmacy services as eligible, and says contact lenses and hearing-aid batteries are not discounted, which shows how specific a schedule can be about what it leaves out. A written answer for each service on the visit is worth having. The list in questions to ask billing before a procedure works for a health center's billing office as for a hospital's.

Finding a center and keeping the record

HRSA's Find a Health Center locator, at findahealthcenter.hrsa.gov, lists funded centers by address. Hospital financial assistance runs on the hospital's own thresholds and is covered in the guide on hospital financial assistance; if a hospital bill has already arrived, see negotiating a hospital bill. Medicaid eligibility is set by the state, as described in the guide on Medicaid retroactive coverage. Some centers, Worcester among them, ask patients to check state coverage programs before applying for the sliding fee scale, so ask which comes first.

Once a center is chosen, ask for its schedule in writing, the documents it accepts, the date it will reassess you, and which services on your visit are in scope. Keep the schedule with your records so the price you were quoted can be compared with what you are billed.

Sliding fee scale: questions from readers

Where the rule and the numbers come from

HRSA, Health Center Program Compliance Manual, chapter 9, Sliding Fee Discount Program (date last reviewed November 2025), https://bphc.hrsa.gov/compliance/compliance-manual/chapter9. The live page returned an access error to automated requests, so the text was read from the Internet Archive's copy of that page, read October 23, 2026. 42 CFR 51c.303(f) and (g), eCFR current text, read October 23, 2026. HHS ASPE, 2026 Poverty Guidelines (Federal Register document 2026-00755, January 15, 2026), https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines, read October 23, 2026. HRSA, Find a Health Center, https://findahealthcenter.hrsa.gov/, read October 23, 2026. Percent-of-guideline figures in the worked example are the household income divided by the table's 100 percent figure. Family Health Center of Worcester, Federal Sliding Fee Scale policy 2402, board approved May 19, 2026, https://fhcw.org/wp-content/uploads/2026/05/2026-Federal-Sliding-Fee-Scale-Board-Approved-5.19.26.pdf, read October 24, 2026. Valley Health, Sliding Fee Discount Program Policy and Schedule 2026, https://valleyhealth.org/wp-content/uploads/2026/06/Sliding-Fee-Policy-and-Schedule-2026.pdf, read October 24, 2026. Dollar figures in the schedule comparison are the centers' published amounts; the $180 full charge and the four households are invented.