Sliding Scale Fee
Harbor Care Health and Wellness Center Sliding Scale
|
HCHWC Medical Fee Scale |
0-100% Poverty |
101-138% Poverty |
139-185% Poverty |
186-200% Poverty |
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Category A |
Category B |
Category C |
Category D |
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|
Income up to: |
Income From: |
To: |
Income From: |
To: |
Income From: |
To: |
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|
Annual |
$13,590 |
$13,591 |
$18,754 |
$18,755 |
$25,142 |
$25,143 |
$27,180 |
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|
Annual |
$18,310 |
$18,311 |
$25,268 |
$25,269 |
$33,874 |
$33,875 |
$36,620 |
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|
Annual |
$23,030 |
$23,030 |
$31,781 |
$31,782 |
$42,606 |
$42,607 |
$46,060 |
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|
Annual |
$27,750 |
$27,751 |
$38,295 |
$38,296 |
$51,338 |
$51,339 |
$55,500 |
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|
Annual |
$32,470 |
$32,471 |
$44,809 |
$44,810 |
$60,070 |
$60,071 |
$64,940 |
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|
Annual |
$37,190 |
$37,191 |
$51,322 |
$51,323 |
$68,802 |
$68,803 |
$74,380 |
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|
Copay Per Visit |
$10.00 |
$15.00 |
$20.00 |
$25.00 |
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*For families/household with more than 6 persons, add $4,720 for each additional person* |
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Harbor Care Health and Wellness Center Pharmacy Sliding Scale
|
HCHWC Pharmacy Fee Scale |
0-100% Poverty |
101-138% Poverty |
139-185% Poverty |
186-200% Poverty |
|
Category A |
Category B |
Category C |
Category D |
|
|
Generics |
Acquisition Cost + $3.00 Dispensing Fee |
Acquisition Cost + $4.00 Dispensing Fee |
Acquisition Cost + $5.00 Dispensing Fee |
Acquisition Cost + $6.00 Dispensing Fee |
|
Brand |
Acquisition Cost + $3.00 Dispensing Fee |
Acquisition Cost + $4.00 Dispensing Fee |
Acquisition Cost + $5.00 Dispensing Fee |
Acquisition Cost + $6.00 Dispensing Fee |
|
Controls |
Acquisition Cost + $3.00 Dispensing Fee |
Acquisition Cost + $4.00 Dispensing Fee |
Acquisition Cost + $5.00 Dispensing Fee |
Acquisition Cost + $6.00 Dispensing Fee |
Harbor Care Health and Wellness Center Dental Sliding Scale
|
HCHWC Dental Fee Scale |
0-100% |
101-138% |
139-185% |
186-200% |
|
Category A |
Category B |
Category C |
Category D |
|
|
Category 1 – Preventive Care |
$50.00* Per Visit |
40% Discount 60% Patient Portion |
30% Discount 70% Patient Portion |
20% Discount 80% Patient Portion |
|
Category 2 – Optional Care (Prices Will Vary & Lab Fees Apply) |
$65.00* Per Visit |
40% Discount 60% Patient Portion |
30% Discount 70% Patient Portion |
20% Discount 80% Patient Portion |
|
Category 3- Complex Care |
$85.00* Per Visit |
40% Discount 60% Patient Portion |
30% Discount 70% Patient Portion |
20% Discount 80% Patient Portion |
Harbor Care Health and Wellness Sliding Fee Discount Program Frequently Asked Questions
+ How can the Harbor Care Health and Wellness Sliding Fee Discount Program help me?
Harbor Care Health and Wellness Center can reduce your cost of healthcare through our Sliding Fee Discount Program. This program is designed to offset a portion of your out-of-pocket expenses for selected healthcare services.
The Sliding Fee Discount Program is a Federal grant that allows our healthcare facility to reduce or “slide” the fees of healthcare services for patients that reside at or below 200% of Federal Poverty Guideline.
+ Who is eligible for the Sliding Fee Discount Program?
Patients who have no insurance or insurance that does not cover all healthcare expenses and who reside at or below 200% of the Federal Poverty Guideline.
+ How is eligibility determined?
• The income of the patient or patient’s family • How many people are in the patient’s household
+ How does a patient apply?
Provide one of the documents below as proof of income. This income documentation will need to be reviewed and updated annually.
+ Who pays for the services that are discounted?
Our Federal grant pays for the remainder of the balance for patients that qualify for Sliding Fee Discount Program.
+ Does the patient have to be a U.S. Citizen to apply for the program?
No.
+ What if the patient has no income at all?
They can still apply. We need a brief signed note from the person or facility covering the patient’s cost of living.
+ If the patient has insurance with deductible, co-insurance and/or copayment, can they still apply for the program?
Yes. If the patient qualifies for the program, the grant will cover a portion or all their out-of-pocket expense.
+ Required documentation
To see if you qualify for our Sliding Fee Discount Program, please bring in one of the follow documents:
• Copies of one month of employment pay stubs
• Copy of an Agency Letter indicating income level (SSA, VA, Social Services Agency or Employment Securities Commission)
• Copy of Federal tax return (W-2 only is not acceptable)
• Dated letter from employer stating amount of cash payment (does not need to be notarized)
• Dated letter from homeless shelter (contact shelter for verification of continued residency)
• Dated letter from head of hold and/or family member where patient resides.
We would be happy to schedule time with one of our representatives to assist you further. Please bring a copy of these documents with you, along with identification for your meeting with our representative.