README

A sliding fee discount program for OpenEMR, as HRSA requires of every Health Center Program awardee and look-alike (Compliance Manual, Chapter 9), and as free clinics and Title X sites also run.

It covers four things:

the clinic's schedule, checked against Chapter 9's requirements;
each patient's income assessment;
the discount each visit is owed;
the utilization figures the program's evaluation needs.

It posts nothing to accounts: staff post each discount, with its Adjustment Reason, where they post adjustments now.

Status: 0.4.1, a pre-release. This module needs OpenEMR 8.1.0 or later; on an older release it stays switched off. Tested on OpenEMR 8.4.1 with synthetic data only. The schedule, the discount arithmetic and HRSA's rules are as read on 2026-10-18; check them against your board-approved policy before staff rely on them.

What installing it changes in your database, what it reads and writes, and what it hooks into are listed in FOOTPRINT.md, generated from the source.

What it does

Fees › Sliding Fee Discount: the schedule in force, its compliance check, and links to the pages you may open.

Schedule (administrators):

the poverty guidelines region and year;
what happens at or below 100% of the guidelines: a full discount, or a flat nominal charge per visit;
the pay classes above it, each up to a percentage of the guidelines, as a percentage off the fee or a flat charge per visit;
how often patients are re-assessed;
which Adjustment Reasons are sliding fee discounts.

It's checked as it's saved, and a schedule with errors isn't saved:

Check	Basis
A full discount or a nominal charge at or below 100%	Chapter 9, element c
At least three pay classes between 101% and 200%, reaching 200%	element c
No discount above 200%, unless the clinic says other funding pays for it	element c
Discounts that shrink as income rises	element c ("adjust based on gradations in income levels")
A nominal charge below what the first pay class pays. For a percentage class, the fees in your fee schedule for which it wouldn't be are counted	element c
The newest guidelines year loaded	element e
When the board approved it, and whether that was more than three years ago	element l and Chapter 19

Schedules by service (element d: only by service or delivery method, such as medical and dental, never by site or population):
- The main schedule covers every visit no other schedule claims.
- A service schedule covers the visit categories you choose. It has its own pay classes, charge at or below 100% (HRSA: one nominal charge per schedule), Adjustment Reasons and approval date.
- Shared settings: a service schedule takes the guidelines region and year and the re-assessment period from the main one, since a patient's income assessment covers every service.
- Rules: each visit category belongs to one schedule at most. Each schedule gets the compliance check for its program's rules.

Title X schedules (0.4.0): a schedule can follow Title X's rules instead of HRSA's. A health center with a Title X project gives its family planning visits a service schedule on Title X rules; a Title X-only clinic sets its main schedule so.

Check, on a Title X schedule	Basis
No charge at or below 100%: a nominal charge is refused, and none is charged	42 CFR 59.5(a)(7)
Discounts based on ability to pay up to 250%, so the last pay class reaches 250%	59.5(a)(8)
A warning for a discount above 250%, where fees recover the reasonable cost	59.5(a)(8)
Discounts that shrink as income rises, and the newest guidelines year loaded	as for HRSA

HRSA's own checks (three classes to 200%, no discount above 200%, board approval) don't apply to a Title X schedule. The insured cap of 59.5(a)(8)(ii), no more in copays than the discount schedule charges at or below 250%, is how every visit's discount already works (element k).

Assessment (from the patient's dashboard card):
- Recorded: annual income, family size, the date, and how it was documented (documents seen, self-declared, or declined), with a note.
- Shown: the percentage of the guidelines and the pay class.
- Kept: every assessment, as element g asks.
- Demographics: saving one also updates family size, monthly income and Financial Review Date there, through OpenEMR's own updatePatientData(). Everything that reads those fields, such as a UDS Table 4 report, sees the same income.
- Based on (Title X, 0.4.0): with a Title X schedule in force, an assessment also records what it rests on: the family's income (as before); the own resources of an unemancipated minor seeking confidential services; or the project director counting the patient as low-income, unable for good reasons to pay, with the reason in the note (42 CFR 59.2). On a Title X schedule, the director's patient is placed at or below 100% whatever the income; on an HRSA schedule, by income. A minor's own-resources assessment leaves Demographics with the family's figures.
- The policy is yours: the clinic decides what counts as income and family, what proof to ask for, and how often to re-assess. HRSA leaves all of that to the health center.
Dashboard card: the patient's pay class, the percentage, how it was documented, and when re-assessment is due.
A visit's discount: the schedule for the visit's category, the pay class in force on the date of service (the patient's income placed on that schedule's classes), the charges at full fee, what insurance and the patient have paid, the most the patient pays, and the discount to post now.
- Uninsured: the discount is the charges less the class's charge.
- Insured: the class's charge, worked out on the full fee, is the most the patient pays in all, copays and deductibles included (element k). HRSA's own example: an $80 fee, a $60 copay, a class that pays half; the patient pays $40. Until insurance has finished with the visit, the page gives that most-the-patient-pays figure and holds the discount.
- Insurers are billed the full fee (Chapter 16), so the discount is never a lower price on the fee sheet.
Evaluation: for a period, patients, visits, charges and sliding fee discounts posted, within each pay class and at or below 100%, with a CSV. With more than one schedule, there is a report for each, covering its own visits.
- What it's for: element l asks for this data at least once every three years, with other data such as patient surveys.
- How visits are placed: each visit goes in the pay class of the assessment in force on its date, on the schedule in use. Visits with no assessment, or a declined one, have rows of their own.
Re-assessments due: patients seen in the last 12 months whose assessment runs out within 30 days, has run out, or who were never assessed. Each opens the patient's assessments.
With Clinic Forms (0.3.0): Clinic Forms' sliding fee notice prints the discounts of the schedule in force. For household sizes 1 to 8, it gives the income up to which the full discount applies (100% of the guideline) and up to which a partial one does (the highest pay class), in English or Spanish, saying which year's guidelines. The patient page links to Clinic Forms with the application and the notice ticked and the patient filled in. Without Clinic Forms, nothing changes here.

Posting the discount

The visit page says how much to post and under which Adjustment Reason.

The reason: installing the module adds one to Admin › Forms › Lists › Adjustment Reasons, Sliding fee discount, as a charge adjustment. If one by that name already exists, it's left alone.
On OpenEMR 8.5 and later: checkout's discount records a reason (openemr/openemr#14583), so the discount can be entered at checkout with that reason.
On 8.4 and earlier: checkout's discount is recorded only as "Discount". Post it in payment posting instead, where the reason is kept.
The UDS module: its Table 9D worksheet treats any reason starting with "Sliding" as a sliding fee discount (Column D).

Who can open what

Each page makes the same check as the OpenEMR page it stands beside, and nothing more:

Page	Check	Same as
Overview and menu entry	`acct/bill`	Fees
Schedule	`admin/super`	the UDS module's settings
Assessments (writes Demographics)	`patients/demo` write	the Demographics editor
A visit's discount	`acct/bill` write	checkout
Evaluation (reads payments)	`acct/rep_a`	the Collections report
Re-assessments due	`patients/demo`	reading Demographics
Dashboard card	`patients/demo`	the dashboard's other cards

Viewing a patient's assessments, a visit's discount or the re-assessments due list, and recording an assessment, are written to OpenEMR's audit log.

Not done yet

Posting the discount itself. It writes to accounts receivable, so it waits until the calculator has been checked against real visits.
Discounts above 200% funded from other sources, beyond the flag on the schedule.
Re-assessments due as a Staff Worklist tab of this module's own. The Staff Worklist reads this module's tables for its tab today. Moving the tab here changes its row keys, which would bring back every row staff have dismissed, so it waits until a change to re-assessment needs it; Title X doesn't.
Title X's confidentiality (42 CFR 59.10): what a policyholder may see of a confidential visit is a question for statements and claims, which are OpenEMR's.

Install

composer require anun333/oe-module-sliding-fee

Then in OpenEMR, Modules › Manage Modules: Register, Install and Enable Sliding Fee Discount. Set up the schedule from your board-approved policy before assessing patients.

Compatibility

PHP security. PHP's php2shell advisory (2026-10-21; CVE-2026-109618 and CVE-2026-109619) is remote code execution without logging in, and it is being exploited. Run OpenEMR on PHP 8.2.35, 8.3.36, 8.4.27, 8.5.12 or later, whatever the module needs. The official OpenEMR 7.0.2 and 7.0.3 Docker images can't get that fix: they carry PHP 8.2.16 and 8.3.15 on Alpine releases that no longer get updates. Run 7.0 only on a patched PHP, or upgrade OpenEMR. OpenEMR rebuilt its 8.4.1, 8.3.0, 8.2.0 and 8.0.0.3 images with the fix on 2026-10-22 (forum t/27157); a container started before then needs pulling again.

Older OpenEMR: on 7.0.3 and older (no OEGlobalsBag), the module stays switched off rather than stop OpenEMR's pages; checked on fresh 7.0.2 and 7.0.3 installs with every module enabled. On fresh official 8.1.0, 8.3.0 and 8.5.0 images (2026-10-23) it installs through Module Manager and its pages that need no patient load, with every module enabled and with it alone (dev/module_compat_check.sh). 7.0.4 to 8.0 haven't been tried.

Tested with synthetic data on OpenEMR 8.4.1 (Docker image openemr/openemr:8.4.1), with dev/sliding_fee_check.py in the openhealthcare repository. That check:

installs the module through Module Manager;
refuses a schedule with two pay classes between 101% and 200%, and saves a compliant one;
records assessments for four patients through the page (one declined) and refuses one with no income;
confirms Demographics and the UDS module's Table 4 then read the same income;
shows the card on the dashboard;
works out the discount for an uninsured visit, before and after it's posted, and for an insured one, pending and then with insurance's payment;
produces the evaluation report and its CSV;
removes everything and puts Demographics back.

The same check passes on current master (8.5.0-dev, 1faefbbeb9, 2026-10-18). There the visit page says to post the discount at checkout, which records its reason from 8.5. It uses OpenEMR features present since 8.1.0. It installs and its pages load on 8.1.0 and 8.3.0 (above); the full end-to-end check runs on 8.4.1 and master. It needs PHP 8.3 or later.

Development

composer install
vendor/bin/phpunit
php tools/footprint.php          # regenerate FOOTPRINT.md after changing the module
php tools/footprint.php --check  # what CI runs

The unit tests need no database or OpenEMR install. CI runs them, and the footprint check, on PHP 8.3, 8.4 and 8.5.

Sources

HRSA, Health Center Program Compliance Manual, Chapter 9: Sliding Fee Discount Program, with Chapters 16 and 19, the Site Visit Protocol and the compliance FAQ, read 2026-10-18.
42 CFR 59.2 and 59.5(a)(7) to (9), Title X, read from the eCFR as of 2026-10-20.
HHS poverty guidelines for 2026, 91 FR 1797 (January 15, 2026), in data/poverty-guidelines.json. A year and region whose figures aren't filled in are shown as not loaded, never estimated.

Other modules for OpenEMR

From the same project. Each installs with composer require anun333/<module> and is then enabled in Modules › Manage Modules.

Module	What it does
Clinic Forms	Printable clinic paperwork: consents, privacy notices, referral letters and validated screening questionnaires, with the clinic's own details, in English and Spanish
UDS Report	HRSA's Uniform Data System report for health centers: the patient, visit and diagnosis tables, eCQM readiness, a Table 9D worksheet and grant evidence
Staff Worklist	One queue of outstanding staff work: unsigned results, orders with no result, referrals with no reply, screening and claims follow-up
Care Management	CCM, PCM and BHI enrollment with CMS's consent elements, monthly time logging, and the codes each month meets
Migration	Records from another EHR, read from the FHIR export certified EHRs offer, checked before import and safe to rerun
Layout Export	Layouts and lists exported to files you can keep in version control, compared with the site or another file; reads the old Backup page's SQL files without running them

License

GPL-3.0-or-later. See LICENSE.

anun333 / oe-module-sliding-fee

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