Poverty Guidelines

Monroe Health Center’s current poverty guidelines

Monroe County Health Center 2020 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

 1063 1064-1595 1596-1861 1862-2127 2128+

2

 1437 1438-2155 2156-2514 2515-2873 2874+

3

 1810 1811-2715 2716-3168 3169-3620 3621+

4

 2183 2184-3275 3276-3821 3822-4367 4368+

5

 2557 2558-3835 3836-4474 4475-5113 5114+

6

 2930 2931-4395 4396-5128 5129-5860 5861+

7

 3303 3304-4955 4956-5781 5782-6607 6608+

8

 3677 3678-5515 5516-6434 6435-7353 7354+

Payment

 $5.00 $15.00 $25.00 $35.00 Full

 

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.

Monroe County Health Center 2020 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

 1063 1064-1595 1596-1861 1862-2127 2128+

2

 1437 1438-2155 2156-2514 2515-2873 2874+

3

 1810 1811-2715 2716-3168 3169-3620 3621+

4

 2183 2184-3275 3276-3821 3822-4367 4368+

5

 2557 2558-3835 3836-4474 4475-5113 5114+

6

 2930 2931-4395 4396-5128 5129-5860 5861+

7

 3303 3304-4955 4956-5781 5782-6607 6608+

8

 3677 3678-5515 5516-6434 6435-7353 7354+

Discount

 50% 40% 30%

 

NOTE: FOR EACH ADDITIONAL FAMILY MEMBER, ADD: $4480

373 373 373 373

A) Patient receives full discount, a nominal charge will be collected. (See below)

B) Patient is responsible for 50% of charges incurred.

C) Patient is responsible for 60% of charges incurred.

D) Patient is responsible for 70% of charges incurred.

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)