Sliding Fee Discount Program Triennial Evaluation

A form template to review and document the sliding fee discount program at least every three years using pay class data, patient input, and program performance findings.

Evaluation Overview

• Evaluation Period Start Date
  Start date of the three-year review period.
• Evaluation Period End Date
  End date of the three-year review period.
• Evaluator Name
  Name of the person completing the evaluation.
• Evaluator Role or Department
  Role, team, or department responsible for the review.
• Review Completion Date
  Date the evaluation was completed.

Program Structure Review

• Pay Class Structure Reviewed?
  Confirm whether current pay class definitions were reviewed.
• Number of Pay Classes
  Enter the current number of pay classes used in the program.
• Policy Changes Since Last Review
  Select any changes made since the prior triennial evaluation.
• Describe Other Policy Changes
  Provide details only if 'Other' was selected.
• Accessibility Assessment
  Rate how easy it is for patients to understand and access the program.

Pay Class Data Analysis

• Total Applications Reviewed
  Number of sliding fee applications included in the review.
• Approved Applications
  Number of applications approved during the review period.
• Denied Applications
  Number of applications denied during the review period.
• Most Common Pay Class
  Select the pay class assigned to the largest share of eligible patients.
• Pay Class Trend Summary
  Summarize notable trends, shifts in distribution, or concerns identified in the pay class data.
• Discount Structure Effectiveness
  Rate how well the current discount structure matches patient need and program goals.

Patient Input and Access Barriers

• Was Patient Input Collected?
  Indicate whether patient feedback was gathered for this evaluation.
• Patient Input Method
  Select the methods used to gather patient input.
• Patient Feedback Summary
  Summarize what patients said about eligibility, application steps, communication, and fairness.
• Identified Access Barriers
  Select any barriers identified through patient input.
• Barrier Details
  Provide specific examples or context for the barriers identified.

Findings, Actions, and Approval

• Overall Findings
  Summarize the evaluation findings and whether the program remains appropriate.
• Recommended Actions
  List action items needed to improve the program.
• Implementation Priority
  Select the overall priority for follow-up actions.
• Approval Status
  Current approval status for the evaluation record.
• Approver Comments
  Add comments if the evaluation needs revision or is pending approval.