Sliding Fee – Good Faith Estimate

Heritage Health Good Faith Estimate

This Good Faith Estimate shows the cost of items and services that are reasonably expected for your healthcare needs for an item of service at Dirne Health Centers, Inc. (also known as “Heritage Health”). This estimate is based on our understanding of your needs today.  While caring for you, our providers may recommend additional services not listed here, or unknown or unexpected costs may arise during your service. Because of this, your final charges may differ from the estimate set forth in this document. Payment for services will depend on your income.  Heritage Health offers fee discounts based on your income and the number of people in your household.  Heritage Health staff will help you determine which payment group you belong to.  

Please see “How Heritage Health Determines Your Payment Group” for more information.   

 

Disclaimer: 

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Sliding Fee Program:

It is the mission of Heritage Health to provide affordable medical, dental and mental health services for the community without regard to a person’s ability to pay. Patients will have the opportunity to discuss their payment options at the time of check-in at the health center or afterward with one of our financial consultants.

Insurance:


Heritage Health accepts a wide range of medical and dental insurances. Patients with insurance plan(s) are expected to pay the co-payment amount that has been established by their insurance company at the time of service. Heritage Health will bill a patient’s insurance for all services; patients may be responsible for additional expenses not covered by their insurance company. Patients may also be eligible for our sliding fee discount that can be applied to the outstanding balance as long as doing so is not prohibited by our contract with the insurance carrier. We will make every attempt to help patients understand the coverage, charges, and discounts available to them.

Sliding Fee Discount:


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:

30 Days of Paystubs

Official Documentation of Child Support

Official Documentation of Alimony

Notarized Letter from the Patients Employer in the case of Contract Work

Official Unemployment Documentation

State Aid Approval Letter (must include amount of income)

Social Security Benefit Form

Please provide these documents at the time of your appointment as we will be unable to apply any discounts without proper documentation. 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 on 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. Please contact us if you have any questions.

Sliding Fee Discount Groups for Medical + Psychiatric Services

Based on family size and household income
Fam. SizeGroup 1
0-100%
Group 2
101-133%
Group 3
134-150%
Group 4
151-175%
Group 5
176-199%
Group 6
>200% +
1$0 - 13,590.00$13,590.01 - 18,074.40$18,074.41 - 20,385.00$20,385.01 - 23,782.50$23,782.51 - 27,179.99$27,044 +
2$0 - 18,310.00$18,310.01 - 24,352.30$24,352.31 - 27,465.00$27,465.01 - 32,042.50$32,042.51 - 36,619.99$36,436 +
3$0 - 23,030.00$23,030.01 - 30,629.90$30,629.91 - 34,545.00$34,545.01 - 40,302.50$40,302.51 - 46,059.99$45,829 +
4$0 - 27,750.00$27,750.01 - 36,907.50$36,907.51 - 41,625.00$41,625.01 - 48,562.50$48,562.51 - 55,499.99$55,222 +
5$0 - 32,470.00$32,470.01 - 43,185.10$43,185.11 - 48,705.00$48,705.01 - 56,822.50$56,822.51 - 64,939.99$64,615 +
6$0 - 37,190.00$37,190.01 - 49,462.70$49,462.71 - 55,785.00$55,785.01 - 65,082.50$65,082.51 - 74,379.99$74,088 +
7$0 - 41,910.00$41,910.01 - 55,740.30$55,740.31 - 62,865.00$62,865.01 - 73,342.50$73,342.51 - 83,819.99$83,400 +
8$0 - 46,630.00$46,630.01 - 62,017.90$62,017.91 - 69,945.00$69,945.01 - 81,602.50$81,602.51 - 93,259.99$92,793 +

Nominal Fee Schedule

See below for index
Level A | 0% - 100%Level B | 133% Level C | 150% Level D | 175% Level E | 200% Over 200%
Group 1Group 2Group 3 Group 4 Group 5 Group 6
1$25$35$45$55$65Full Fee
2Flat Fees for test & procedure graduated for each Discount Level (see the schedule of fees). Full Fee
3100% Discount 50% Discount 40% Discount 30% Discount 20% Discount Full Fee
4$2 $4$6$8$10Full Fee
5Flat Fees for procedure graduated for each Discount Level (Heritage Health Dental Fee + Discount Schedule).Full Fee
6$15$20$25$30$40Full Fee
7$25$35$45$55$65Full Fee
8$5$6$7$8$9Full Fee
9$45$50$55$60$65Full Fee
10Lesser of the copayment or the flat fee based on the Discount Level and service rendered. Full Fee
11Lesser of the outstanding deductible or the flat fee based on the Discount Level and service rendered.Full Fee

*Nominal Fee Schedule Services Index

  1. Medical, MAT, or Psychiatric Visits


  2. Medical Test/Procedure(s)


  3.  Laboratory Tests | LabCorp


  4. Shared Medical Appointments


  5. Dental Visits

    Preventative/Emergent Services, Restorative Services, Dental Products


  6. Counseling/Dietitian Visits


  7. Pain Management


  8.  Medication Assistance Program (MAP) | Group Therapy (FSS)


  9. Restored Paths (in-scope services only)


  10. Co-Payments


  11. Deductibles

View or download Sliding Fee Application here.