Sliding Fee Scale

Whether or not you have insurance, Partnership Community Health Center may be able to reduce your costs through our Sliding Fee Discount Program. All patients are encouraged to complete an application. Eligibility is based on household size and income.

Our Sliding Fee Scale is updated yearly. Each year, patients need to bring in proof of income (check stubs, tax forms, etc.) and a picture ID.

  • You have 30 days since your last visit to submit proof of income; BUT, if you need a referral to see a specialist, you may need to submit proof of income within 5 days.
  • Below are examples of acceptable documents you can provide.
    • One month’s worth of consecutive paystubs, starting with the most current and going back 30 days. Paystubs need to be supplied for all working household members.
    • A copy of last year’s taxes.
    • If you receive child support, social security, or unemployment, please bring in the award letter from the state which indicates the income, or a benefit statement.
    • If you are living with someone who is providing you with financial support, you will be asked to have them fill out and sign a letter of support stating this.

 

2024 Monthly Income Ranges for Federal Poverty Level (FPL) Calculation

Household Size

100% and below FPL

(Nominal Fee)

101 – 133% FPL

(Tier 1)

134 – 166% FPL

(Tier 2)

167-200% FPL

(Tier 3)

1

$0 – 1,255

1,256 – 1,669

1,670 – 2,083

2,084 – 2,510

2

$0 – 1,703

1,704 – 2,265

2,266 – 2,828

2,829 – 3,407

3

$0 – 2,152

2,153 – 2,862

2,863 – 3,572

3,573 – 4,303

4

$0 – 2,600

2,601- 3,458

3,459 – 4,316

4,317 – 5,200

5

$0 – 3,048

3,049 – 4,054

4,055 – 5,060

5,061 – 6,097

6

$0 – 3,497

3,498 – 4,651

4,652 – 5,804

5,805 – 6,993

7

$0 – 3,945

3,946 – 5,247

5,248 – 6,549

6,550 – 7,890

8

$0 – 4,393

4,394 – 5,843

5,844 – 7,293

7,294- 8,787

For each additional person add: $0-448 $449-596 $597-744 $745-897

Fee Tier

Nominal Fee

Sliding Fee Tier 1

Sliding Fee Tier 2

Sliding Fee Tier 3

Flat Fee Exam

$20 * No more than $20 will be requested for a single date of service

$30.00

$50.00

$80.00

Fee For Non-Exam Services/Procedures

30%

40%

50%

Charges and Calculated Sliding Fee for Non-Exam services will vary based on the procedure or additional services being performed. If you qualify for reduced cost services, Partnership Community Health Center (PCHC) will notify you prior to your appointment with an estimated cost. The estimated cost is subject to change based on services done at your appointment. Payment is due at the time of your appointment.

Our Sliding Fee Discount Program can only apply to medical, dental, and behavioral health services
provided at Partnership Community Health Center. Certain medical services, such as Mirena and Nexplanon insertion, and dental services, such as lab fees for dentures, are not eligible for our sliding fee discount.

Good Faith Estimate

As of January 2022, patients who don’t have insurance (or who are receiving services not covered by their insurance or are out of their insurance plan’s network) are entitled to receive an estimate for the cost of their upcoming appointment.

Referred to as a Good Faith Estimate, it will include the total expected cost of any non-emergency items or services. This includes any related costs on medical, dental, or behavioral health services provided.

Patients will receive the Good Faith Estimate in writing at least 1 business day prior to the service or item if it is scheduled at least 3 days out.

If you receive a bill that is at least $400 more than the Good Faith Estimate, you can dispute the bill.

For questions or more information about your right to a Good Faith Estimate, visit: www.cms.gov/nosurprises or call 1-800-985-3059.

If you are interested in learning more about your health insurance coverage options, please contact our Outreach and Enrollment Department at (920) 882-6420.

Estimado de Buena Fe

A partir de enero del 2022, los pacientes que no tienen aseguranza (o que reciben servicios no cubiertos por su aseguranza o están fuera de la red de su plan de aseguranza) tienen derecho a recibir un estimado del costo de su próxima cita.

Conocido como Estimado de Buena Fe, incluirá el costo total anticipado de cualquier artículo o servicio que no sea de emergencia. Esto incluye cualquier costo relacionado con los servicios médicos, dentales o de salud mental proporcionados.

Los pacientes recibirán el Estimado de Buena Fe por escrito al menos 1 día laboral antes del servicio o artículo si está programado por al menos 3 días de anticipado.

Si recibe una factura que es al menos $400 más que el Estimado de Buena Fe, puede cuestionar la factura.

Para preguntas o más información sobre su derecho a un Estimado de Buena Fe, visite: www.cms.gov/nosurprises o llame al 1-800-985-3059.

Si está interesado en obtener más información sobre sus opciones de seguro médico, llame a nuestro departamento de inscripciones al (920) 882-6420.