How does a local board of health go about setting fees?

County and district boards of health and consolidated human services boards must base their fees on a plan proposed by the local health director, and any fees adopted by the board must be approved by the county commissioners (in the case of a district health department, all applicable boards of county commissioners).[1] Public health authority boards may establish fee schedules and are not required to obtain commissioner approval.[2]

There are several limitations to the board’s fee-setting authority. First, a board of health may not charge fees when the health department employee is acting as an agent of the state. This covers most environmental health programs, but there are four exceptions: fees may be charged for services provided under the on-site wastewater treatment program, the public swimming pools program, the tattooing regulation program, and the local program for inspecting and permitting drinking water wells. [3]

Second, while local health departments may charge fees for some of their clinical services, the board of health has limited discretion in determining the amount of the fee. Fees may reflect Medicaid reimbursement rates established by the state Division of Medical Assistance, or fees set by a state or federal program that provides funds for a particular service. Also, local health departments are specifically prohibited by state law from charging health department clients for some services:

• testing and counseling for sickle cell syndrome[4]
• examination for and treatment of tuberculosis[5]
• examination for and treatment of certain sexually transmitted diseases[6]
• testing and counseling for HIV[7]

Additionally, immunizations that are required by law and supplied by the state must be provided at no cost to uninsured or underinsured patients with family incomes below 200 percent of the federal poverty level.[8] 

Finally, some federal laws affect whether or to what extent a local board may impose fees for particular services. For example, Title VI of the federal Civil Rights Act of 1964 prohibits recipients of federal financial assistance from charging their limited-English proficient clients for interpretation services.[9] Similarly, the federal HIPAA medical privacy rule limits the fees that may be charged for copies of medical records.[10]