Sliding Fee Program

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 their 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

Official Unemployment Documentation

State Aid Approval Letter (must include amount of income)

Social Security Benefit Form

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

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 (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 – $12,140 $12,141 – $16,146 $16,147 – $18,210 $18,211 – $21,245 $21,245 – $24,280 $24,281 +
2 $0 – $16,460 $16,461 – $21,891 $21,892 -$24,690 $24,691 – $28,805 $28,805 – $32,920 $32,921 +
3 $0 – $20,780 $20,781 – $27,637 $27,638 – $31,170 $31,171 – $36,365 $36,366 – $41,560 $40,561 +
4 $0 – $25,100 $25,101 – $33,383 $33,384 – $37,650 $37,651 – $43,925 $43,926 – $50,200 $50,201 +
5 $0 – $29,420 $29,421 – $39,129 $39,130 – $44,130 $44,131 – $51,485 $51,486 – $58,840 $58,841 +
6 $0 – $33,740 $33,741 – $44,874 $44,875 – $50,610 $50,611 – $59,045 $59,046 – $67,480 $67,481 +
7 $0 – $38,060 $38,061 – $50,620 $50,621 – $57,090 $57,091 – $66,605 $66,606 – $76,120 $76,121 +
8 $0 – $42,380 $42,381 – $56,365 $56,366 – $63,570 $63,571 – $74,165 $74,166 – $84,760 $84,761 +
9 $0 – $46,700 $46,701 – $62,111 $62,112 – $70,050 $70,051 – $81,725 $81,726 – $93,400 $93,401 +
10 $0 – $51,020 $51,021 – $67,857 $67,858 – $76,530 $76,531 – $89,285 $89,286 – $102,040 $102,041 +

Nominal Fee Schedule

Group 1 Group 2 Group 3 Group 4 Group 5 Group 6
Index
*see below
1 $25 $35 $45 $55 $65 $80
2 Flat Fees for test & procedure graduated for each Discount Level (see schedule of fees)
3 $2 $4 $6 $8 $10 $79
4 Flat Fees for procedure graduated for each Discount Level (Heritage Health Dental fee and discount schedule)
5 $15 $20 $25 $30 $40 $60
6 $25 $35 $45 $55 $65 $80
7 $50 $75 $75 $75 $75 $100
8 $10 $10 $10 $10 $10 $10
9 Lesser of the copayment or the flat fee based on the Discount Level and service rendered
10 Lesser of the outstanding deductible or the flat fee based on the Discount Level and service rendered

*Nominal Fee Schedule Services Index

  1. Medical or Psychiatric Visits

  2. Medical Test/Procedure(s)

  3. Shared Medical Appointments

  4. Dental Visits

  5. Counseling Visits

  6. Pain Management

  7. Medication Assisted Therapy (MAT)

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

  9. Copayments

  10. Deductibles

View or download Sliding Fee Documentation here.