Sliding Fee Program

"Awesome as always. Nice and understanding."

-HH Patient

Sliding Fee Program:

All patients are eligible for our sliding fee scale. A sliding fee scale means that fees charged to you for services provided may be discounted based upon household income and family size. These discounts are available to patients based on the guidelines provided annually by the federal government.

To apply and qualify for the sliding fee scale we will need (one) of the following listed below for each applicable member of the household:

  • Paystubs from all employed individuals in the household: Valid within the previous twelve (12) months.
  • Prior Year W-2 tax form: Valid until April 15th of the following tax year (e.g.- 2015 W-2 is valid until April 15, 2017).
  • Prior Year Tax Return: Valid until April 15th of the following tax year (e.g.- 2015 tax return is valid until April 15, 2017).
  • Work Verification Form: Valid Health and Welfare work verification form or current Unemployment/No-Work Verification Form: Valid within 60 days of the issue date.
  • Social Security Benefit Form: Valid within previous 12 months.
  • Medicaid Eligibility: Proof of current Medicaid enrollment via online verification of eligibility.

Please provide these documents at the time of your appointment as we will be unable to apply any discounts without proper documentation. Please refer to the table on the following page for a summary of the nominal fees we provide.

If you find that you are unable to pay for your care we want to help. There are multiple options available to help you. Please contact our billing office if you would like to find out more. You will not be refused care based upon your ability to pay for services.

*Due to the high cost of supplies, patients will be required to pre-pay their portion before being allowed to schedule Dental Restorative Services. All other services are available without the pre-payment requirement. 

 

Sliding Fee Discount Groups (based on family size and household income)

 

Family
Size
Group 1
100% & Below
Group 2
101% – 133%
Group 3
134% – 150%
Group 4
151% – 175%
Group 5
176% – 200%
Group 6
201% & Above
1 0$ – $12,060 $12,061 – $16,040 $16,041 – $18,090 $18,091 – $21,105 $21,106 – $24,120 $24,121 – +
2 $0 – $16,240 $16,241 – $21,599 $21,600 – $24,360 $24,361 – $28,420 $28,421 – $32,480 $32,481 – +
3 $0 – $20,420 $20,421 – $27,159 $27,160 – $30,630 $30,631 – $35,735 $35,736 – $40,840 $40,841 – +
4 $0 – $24,600 $24,601 – $32,718 $32,719 – $36,900 $36,901 – $43,050 $43,051 – $49,200 $49,201 – +
5 $0 – $28,780 $28,781 – $38,277 $38,278 – $43,170 $43,171 – $50,365 $50,366 – $57,560 $57,561 – +
6 $0 – $32,960 $32,961 – $43,837 $43,838 – $49,440 $49,441 – $57,680 $57,681 – $65,920 $65,921 – +
7 $0 – $37,140 $37,141 – $49,396 $49,397 – $55,710 $55,711 – $64,995 $64,996 – $74,280 $74,281 – +
8 $0 – $41,320 $41,321 – $54,956 $54,957 – $61,980 $61,981 – $72,310 $72,311 – $82,640 $82,641 – +
9 $0 – $45,500 $45,501 – $60, 515 $60,516 – $68,250 $68,251 – $79,625 $79,626 – $91,000 $91,001 – +
10 $0 – $49,680 $49,681 – $66,074 $66,075 – $74,520 $74,521 – $86,940 $86,941 – $99,360 $99,361 – +

Nominal Fee Schedule

Group 1 Group 2 Group 3 Group 4 Group 5 Group 6
0 - 100% FPL 101% - 133% FPL 134% - 150% FPL 151% - 175% FPL 176% - 200% FPL 200% & Above
Index
*see below
Nominal Fee Supply Cost Nominal Fee Supply Cost Nominal Fee Supply Cost Nominal Fee Supply Cost Nominal Fee Supply Cost Full Fee
1 $25 NA $30 NA $40 NA $50 NA $60 NA Full Fee
2 $25 80% Discount 50% Discount 45% Discount 40% Discount 35% Discount Full Fee
3 $15 NA $20 NA $30 NA $40 NA $50 NA Full Fee
4 $0 $5 $5 $5 $10 $5 $15 $5 $20 $5 Full Fee
5 $0 50% Discount 45% Discount 40% Discount 35% Discount 30% Discount Full Fee
6 $2 NA $4 NA $6 NA $8 NA $10 NA Full Fee
7 For dental fees and discounts please refer to the Heritage Health Dental Fee and Discount Schedule

*Nominal Fee Schedule Services Index

  1. Medical & Behavioral Health Office Visits

  2. Medical Procedures

  3. Radiology Services (in-house)

  4. Laboratory Services (in-house)

  5. Medical Supplies

  6. Shared Medical Appointments

  7. Dental Services

    • Preventative/Emergency Services
    • Preventative/Emergency Services
    • Dental Products

Trouble viewing pricing tables?

View or download Sliding Fee Documentation here.