CURRENT POVERTY GUIDELINES

2019 SLIDING FEE SCALE

 

Gross Monthly Income

 

 

PATIENT TYPE

A B C D E
POVERTY LEVEL <100% 101 – 150% 151-175% 176-200% Private Pay
FAMILY SIZE

1

1041 1042-1561 1562-1821 1822-2082 2083+
2 1409 1410-2114 2115-2466 2467-2818 2819+
3 1778 1779-2666 2667-3111 3112-3555 3556+
4 2146 2147-3219 3220-3755 3756-4292 4293+
5 2514 2515-3771 3772-4400 4401-5028 5029+
6 2883 2884-4324 4325-5044 5045-5765 5766+
7 3251 3252-4876 4877-5689 5690-6502 6503+
8 3619 3620-5429 5430-6334 6335-7238 7239+
Payment $5.00 $15.00 $25.00 $35.00 Full

 

 

 

 

 

 

 

 

NOTE: FOR EACH ADDITIONAL FAMILY MEMBER, ADD: $4420

368 368 368 368

 

 

A:  Patient receives full discount, a nominal charge of $5.00 will be collected.

B:  Patient’s copayment will be $15.00 per visit

C:  Patient’s copayment will be $25.00 per visit

D:  Patient’s copayment will be $35.00 per visit

E:  PRIVATE PAY-NOT ELIGIBLE FOR DISCOUNT (Above 200% of Poverty)

Sliding fee patients who are given an order by a MHC provider for a lab/x-ray test prior to or immediately following an office visit will not be charged for that test since it is considered incidental to the office visit. However, any sliding fee patient coming in for other lab tests, x-rays or injections will be charged.

Medicare/PVT Insurance:       After MC/Insurance responds, apply fee schedule to those who qualify.

Patients without Insurance:   Patients with no insurance will be referred to appropriate agencies to obtain assistance.

NATIONAL POVERTY INCOME GUIDELINES

(Effective 3.1.19 RKS)

 

 

CURRENT POVERTY GUIDELINES

2019 DENTAL SLIDING FEE SCALE

 

Gross Monthly Income

PATIENT TYPE A B C D E
POVERTY LEVEL <100% 101 - 150% 151-175% 176-200% Private Pay
FAMILY SIZE

1

1041 1042-1561 1562-1821 1822-2082 2083+
2 1409 1410-2114 2115-2466 2467-2818 2819+
3 1778 1779-2666 2667-3111 3112-3555 3556+
4 2146 2147-3219 3220-3755 3756-4292 4293+
5 2514 2515-3771 3772-4400 4401-5028 5029+
6 2883 2884-4324 4325-5044 5045-5765 5766+
7 3251 3252-4876 4877-5689 5690-6502 6503+
8 3619 3620-5429 5430-6334 6335-7238 7239+
Discount 50% 40% 30%

NOTE: FOR EACH ADDITIONAL FAMILY MEMBER, ADD: $4420

368 368 368 368

 

  1. A) Patient receives full discount, a nominal charge will be collected. (See below)
  2. B) Patient is responsible for 50% of charges incurred.
  3. C) Patient is responsible for 60% of charges incurred.
  4. D) Patient is responsible for 70% of charges incurred.
  5. E) PRIVATE PAY-NOT ELIGIBLE FOR DISCOUNT (Above 200% of Poverty)

Nominal Charges for patients at or below 100% of poverty:

Preventive Services (includes cleaning, annual exam, bite wings and fluoride):                 $  35.00

Restorative Services (includes basic fillings/extractions):                                                    $  50.00

Major Procedures (root canals, crowns, bridges, dentures):                                                 $100.00*

*(Patient is responsible for 100% of dental lab fees from outside dental lab)

NATIONAL POVERTY INCOME GUIDELINES