Sliding-Fee Community Health Centers: What You'll Pay Without Insurance
If you don't have insurance, or your deductible is so high it might as well not exist, a community health center can be an affordable place to get regular care. Federal rules decide how their sliding fees work. Once you know those rules, you can estimate your bill before you go and push back if a charge looks wrong.
AT A GLANCE
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What a community health center is
HRSA describes health centers as local clinics that treat "medical, dental, mental health, substance use, and other health care needs." They're community-based and partly led by patients: a majority of each center's governing board must be patients. All health centers adjust fees based on income and family size, and they must serve everyone, even people who can't pay. About 90% of their patients have incomes under 200% of the federal poverty level.
Many health centers also offer support services, help with transportation, and on-site pharmacies with discounted prescription drugs. Health centers are required to take part in Medicaid, CHIP and Medicare. That means a center can bill your coverage if you have it.
No patient can be turned away from a health center because they can't pay. That rule comes from federal law, not the clinic's goodwill.
How the sliding fee scale works
Every health center sets a regular fee schedule based on local prices and its own costs. It then applies a "sliding fee discount schedule" based only on your household income and family size. HRSA's Compliance Manual, Chapter 9, sets the floor and the ceiling:
At or below 100% of the federal poverty guidelines (FPG): a full discount. A center may instead charge a flat "nominal" fee. It must be lower than what patients in the next tier up pay, and HRSA says nominal charges aren't "minimum fees" or "co-pays."
Above 100% and up to 200%: partial discounts that shrink as income rises, in at least three income tiers.
Above 200%: no discount required under the sliding fee rules.
Each center chooses its own tier ranges and discount method, either a percentage off or a flat fee per tier. It may also keep separate schedules for medical and dental care. HRSA gives an example of four tiers between 100% and 200%: 101–125%, 126–150%, 151–175% and 176–200%. Your center's tiers may differ, so ask for its schedule.
What the 2026 income lines look like
Centers must use the most recent federal poverty guidelines. Here are HHS's 2026 guidelines for the 48 contiguous states and D.C., with HRSA's example tier cutoffs worked out. Alaska and Hawaii have higher guidelines.
Household size | 100% | 125% | 150% | 175% | 200% |
|---|---|---|---|---|---|
1 | $15,960 | $19,950 | $23,940 | $27,930 | $31,920 |
2 | $21,640 | $27,050 | $32,460 | $37,870 | $43,280 |
3 | $27,320 | $34,150 | $40,980 | $47,810 | $54,640 |
4 | $33,000 | $41,250 | $49,500 | $57,750 | $66,000 |
5 | $38,680 | $48,350 | $58,020 | $67,690 | $77,360 |
For example, a family of three earning $45,000 a year falls between 150% and 175% of the 2026 guideline. At a center using HRSA's example tiers, that family would be in the 151–175% tier and get a partial discount.
If you have insurance with a high deductible
Many people assume sliding fees are only for the uninsured. HRSA's rules say otherwise. If you qualify for a sliding discount and also have insurance, the center can't charge you more out of pocket than you'd pay under your sliding fee tier. The only exception is when the insurance contract or a federal or state program doesn't allow it.
HRSA gives a worked example:
Step | Amount |
|---|---|
Health center's full fee for the visit | $80 |
Patient's insurance co-pay | $60 |
Patient's income | 150% of FPG |
Sliding fee discount at that tier (in this example) | 50% of the $80 fee |
Sliding fee charge | $40 |
What the patient pays | No more than $40 |
So if your plan's deductible or co-pay would cost more than your sliding fee amount, tell the front desk you want to be assessed for the sliding fee.
Extra charges to ask about
Some things sit outside the visit itself. HRSA's billing chapter names eyeglasses, prescription drugs and dentures as examples. If a center charges for items like these, it must tell you about the cost before you get the service, and it decides how to price them. It might use flat discounts, at-cost pricing or the sliding scale. Ask about these costs up front, especially for dental work.
Services a center sends you elsewhere for are handled differently. For care the center pays an outside provider to deliver under a contract, the same sliding discounts apply. For formal referrals that the other provider bills directly, patients from 100% to 200% must get at least as large a discount as the center's own scale would give. Patients at or below 100% get a full discount or a nominal charge. Ask whether a referral is covered by one of these arrangements before you go.
When you can't pay, or are asked to
Health centers must have board-approved policies that spell out when they'll waive or reduce fees for patients who can't pay. A center may limit services to someone who refuses to pay, but only under a board-approved policy that separates refusal from inability to pay. Under that policy, it must tell you:
how much you owe and how long you have to pay
what collection steps it will take, such as meeting with a financial counselor or setting up a payment plan
how services would be limited
If a center offers payment plans, grace periods or prompt-pay discounts, HRSA requires that they be open to all patients regardless of income or sliding fee tier.
How to sign up for the sliding fee
Find a center. Use HRSA's Find a Health Center tool with your address or ZIP code. It lists contact details and directions for each site.
Call before your first visit. Ask for the sliding fee schedule, the documents they accept and the cost of a basic visit at your tier.
Bring proof of income and household size. Each center decides what proof it needs. HRSA says centers may allow you to self-declare income and family size, and may consider that homeless patients often lack paperwork.
Ask to be assessed at registration. Centers must assess every patient for sliding fee eligibility and tell patients the discount exists. Don't wait for the bill.
Ask about extra charges. Ask what labs, medicines, dentures or glasses cost before you agree to them.
Update your income if it changes. Centers re-check eligibility on their own schedule. If you lose hours or a job, ask to be reassessed.
Apply for coverage too. Centers must help patients learn about insurance options. Ask whether you may qualify for Medicaid or CHIP.
Before you call
☐ Your household size and who counts in it
☐ Recent pay stubs, last year's tax return, or benefit award letters
☐ Your insurance card, if you have one, and your deductible amount
☐ A list of medicines you take
☐ A list of any care you've been told you need (labs, dental work, specialist visits)
WHAT TO DO THIS WEEK
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Related help
For dental work, see our guide to low-cost dental care. If a hospital bill is the bigger problem, read about hospital charity care. For brand-name prescriptions, check drugmaker patient assistance programs.
Official sources
Last checked: October 23, 2026 (HRSA Health Center Program pages and Compliance Manual chapters 4, 9 and 16; HHS 2026 poverty guidelines).
Each health center sets its own fee schedule, discount tiers and documentation rules within HRSA's requirements. Ask your center for its current sliding fee schedule.
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