Partnership Community Health Center, Inc. (PCHC) uses a sliding fee schedule based on the federal poverty guidelines established by the U.S. government.   PCHC cannot deny services based on a person’s inability to pay.

2022 Monthly Income Ranges for Federal Poverty Level (FPL) Calculation

Household Size

100% and below FPL

101 – 133% FPL

134 – 166% FPL

167-200% FPL

1

0 – 1,133

1,134 – 1,506

1,507 – 1,879

1,880 – 2,265

2

0 – 1,526

1,527 – 2,029

2,030 – 2,532

2,533 – 3,052

3

0 – 1,919

1,920 – 2,552

2,553 – 3,185

3,186 – 3,838

4

0 – 2,313

2,314- 3,076

3,077 – 3,839

3,840 – 4,625

5

0 – 2,706

2707 – 3,599

3,600 – 4,492

4,493 – 5,412

6

0 – 3,099

3,100 – 4,122

4,123 – 5,145

5,146 – 6,198

7

0 – 3,493

3,494 – 4,645

4,646 – 5,797

5,798 – 6,985

8

0 – 3,886

3,887 – 5,168

5,169 – 6,450

6,451- 7,772

For each additional person add: 0-393 394-523 524-652 653-787

100% Discount assessed to all charges with NOMINAL FEE requested

SLIDING FEES

Fee Tier (Circle One)

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

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.

Each year existing patients (and new patients) need to bring in proof of income (check stubs), picture ID, and current income tax forms.

Check stubs = 1 month | Tax returns = 1 year | Proof of no income = 3 months

 

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.