Valley Family Health Care Locatjons: Payetue Medical Ontario Dental - - PowerPoint PPT Presentation

Valley Family Health Care ofgers discounted services based on the size of the patjent’s household and income. The Sliding Fee Scale is determined by calculatjng the family’s gross monthly income and the number of people supported in the household. In order to qualify for the sliding fee, the patjent must fjll out an applicatjon and provide proof of current or annual income. Proof of income can be one of the following:

• Pay stub
• Bank Statement (showing deposits)
• Unemployment/Employment verifjcatjon statement from the state

Employment offjce

• Taxes (last year’s)
• Social Security or Disability print out from Medicare
• Letuers from the patjent’s employer

*VFHC Stafg will verify proof of income once received. The patjent will have to update income informatjon every year. Insured patjents that qualify for the sliding fee may receive the discount. First, the patjent’s insurance plans are billed. Based on the amount of the insurance payment, deductjble, pre-existjng conditjons, covered services, etc. the patjent may get a sliding fee adjustment. Patjents may receive a discount of 25%, 50%, or 75% for medical and behavioral health services and 25%, 40%, or 50%, for dental services based on income and number of people supported in the household. For patjents 100% or below the Federal Poverty Level, a nominal charged is applied.

Dental Nominal Charges:

Dental Treatment Procedures:

Please request nominal charge list from a VFHC Dental Receptjonist.

Dental Full or Limited Exam $20 Dental Hygiene Appointment $20 Dental Full Exam with X-Rays $45

Medical, Behavioral Health, etc. Nominal Charges:

Visits $20 Labs In—House $10 Procedures (See Front Desk for List) $75 Immunizatjon Administratjon $7

Payetue Medical 1441 NE 10th Ave Payetue, ID 208-642-9376 Payetue Dental 1501 NE 10th Ave Payetue, ID 208-642-9379 New Plymouth Medical 300 N Plymouth New Plymouth, ID 208-278-3335 Emmetu Medical 207 E 12th St Emmetu, ID 208-365-1065 Ontario Medical 2327 SW 4th Ave Ontario, OR 541-889-0052 Ontario Dental 2327 SW 4th Ave Ontario, OR 541-889-0052 Nyssa Medical 17 S 3rd St Nyssa, ID 541-372-5738 Nyssa Dental 17th N 6th St Nyssa, ID 541-372-2606 Vale Medical

789 Washington W

Vale, ID 541-473-2101 Treasure Valley Pediatric Clinic 1219 SW 4th Ave, Suite 1 Ontario, OR 541-889-2668

Valley Family Health Care Locatjons:

vfic.org

Follow us on Facebook @VFHC1

Note: No patjent shall be denied service due to an individual’s inability to pay.

Sliding Fee Scale Based on Federal Register 2018– Poverty Income Guidelines

Sliding Fee Discount

Code 0: Nominal Charges Visits $20 Labs In—House $10 Procedures (See Front Desk for List) $75 Immunizatjon Administratjon $7 Code 25: Patjents pay 25% of fee* Code 50: Patjents pay 50% of fee* Code 75: Patjents pay 75% of fee* Code 100: Patjents are ineligible for discounts; Pay 100% of fee

Sliding Fee Discount Classes Income Measure % of Federal Poverty Income Guidelines Family Size

Code 0 Code 25 Code 50 Code 75 Code 100

Up to 100.00% 100.01% - 149.99% 150.00% - 174.99% 175.00% - 200.00% 200.01% + 1 Annual $0 —

$ 12,140 $ 12,141 — $ 18,209 $ 18,210 — $ 21,244 $ 21,245 — $ 24,280 $ 24,281 +

Monthly $0 —

$ 1,012 $ 1,013 — $ 1,517 $ 1,518 — $ 1,770 $ 1,771 — $ 2,023 $ 2,024 +

2 Annual $0 —

$ 16,460 $ 16,461 — $ 24,688 $ 24,689 — $ 28,803 $ 28,804 — $ 32,920 $ 32,921 +

Monthly $0 —

$ 1,372 $ 1,373 — $ 2,057 $ 2,058 — $ 2,400 $ 2,401 — $ 2,743 $ 2,744 +

3 Annual $0 —

$ 20,780 $ 20,781 — $ 31,168 $ 31,169 — $ 36,363 $ 36,364 — $ 41,560 $ 41,561 +

Monthly $0 —

$ 1,732 $ 1,733 — $ 2,597 $ 2,598 — $ 3,030 $ 3,031 — $ 3,463 $ 3,464 +

4 Annual $0 —

$ 25,100 $ 25,102 — $ 37,647 $ 37,648 — $ 43,922 $ 43,923 — $ 50,200 $ 50,201 +

Monthly $0 —

$ 2,092 $ 2,093 — $ 3,137 $ 3,138 — $ 3,660 $ 3,661 — $ 4,183 $ 4,184 +

5 Annual $0 —

$ 29,420 $ 29,421 — $ 44,127 $ 44,128 — $ 51,482 $ 51,483 — $ 58,840 $ 58,841 +

Monthly $0 —

$ 2,452 $ 2,453 — $ 3,677 $ 3,678 — $ 4,290 $ 4,291 — $ 4,903 $ 4,904 +

6 Annual $0 —

$ 33,740 $ 33,741 — $ 50,607 $ 50,608 — $ 59,042 $ 59,043 — $ 67,480 $ 67,481 +

Monthly $0 —

$ 2,812 $ 2,813 — $ 4,217 $ 4,218 — $ 4,920 $ 4,921 — $ 5,623 $ 5,624 +

7 Annual $0 —

$ 38,060 $ 38,061 — $ 57,086 $ 57,087 — $ 66,601 $ 66,602 — $ 76,120 $ 76,121 +

Monthly $0 —

$ 3,172 $ 3,173 — $ 4,757 $ 4,758 — $ 5,550 $ 5,551 — $ 6,343 $ 6,344 +

8 Annual $0 —

$ 42,380 $ 42,381 — $ 63,566 $ 63,567 — $ 74,161 $ 74,162 — $ 84,760 $ 84,761 +

Monthly $0 —

$ 3,532 $ 3,533 — $ 5,297 $ 5,298 — $ 6,180 $ 6,181 — $ 7,063 $ 7,064 +

*Each additjonal family member + $4,320 Annual/ + $4,320 Annual/ + $4,320 Annual/ + $4,320 Annual/ + $4,320 Annual/ + $360 Monthly + $360 Monthly + $360 Monthly + $360 Monthly + $360 Monthly * But not less than the nominal charge

Note: No patjent shall be denied service due to an individual’s inability to pay.

Medical & Behavioral Health

Sliding Fee Scale Based on Federal Register 2018– Poverty Income Guidelines

Sliding Fee Discount

Code 0: Nominal Charges Dental Full or Limited Exam $20 Dental Hygiene Appointment $20 Dental Full Exam with X-Rays $45 Dental Treatment Procedures:

Please request nominal fee list from Receptjonist

Code 50: Patjents pay 50% of fee* Code 60: Patjents pay 60% of fee* Code 75: Patjents pay 75% of fee* Code 100: Patjents are ineligible for discounts; Pay 100% of fee

Sliding Fee Discount Classes Income Measure % of Federal Poverty Income Guidelines Family Size

Code 0 Code 50 Code 60 Code 75 Code 100 Up to 100.00% 100.01% - 149.99% 150.00% - 174.99% 175.00% - 200.00% 200.01% + 1 Annual $0 —

$ 12,140 $ 12,141 — $ 18,209 $ 18,210 — $ 21,244 $ 21,245 — $ 24,280 $ 24,281 +

Monthly $0 —

$ 1,012 $ 1,013 — $ 1,517 $ 1,518 — $ 1,770 $ 1,771 — $ 2,023 $ 2,024 +

2 Annual $0 —

$ 16,460 $ 16,461 — $ 24,688 $ 24,689 — $ 28,803 $ 28,804 — $ 32,920 $ 32,921 +

Monthly $0 —

$ 1,372 $ 1,373 — $ 2,057 $ 2,058 — $ 2,400 $ 2,401 — $ 2,743 $ 2,744 +

3 Annual $0 —

$ 20,780 $ 20,781 — $ 31,168 $ 31,169 — $ 36,363 $ 36,364 — $ 41,560 $ 41,561 +

Monthly $0 —

$ 1,732 $ 1,733 — $ 2,597 $ 2,598 — $ 3,030 $ 3,031 — $ 3,463 $ 3,464 +

4 Annual $0 —

$ 25,100 $ 25,102 — $ 37,647 $ 37,648 — $ 43,922 $ 43,923 — $ 50,200 $ 50,201 +

Monthly $0 —

$ 2,092 $ 2,093 — $ 3,137 $ 3,138 — $ 3,660 $ 3,661 — $ 4,183 $ 4,184 +

5 Annual $0 —

$ 29,420 $ 29,421 — $ 44,127 $ 44,128 — $ 51,482 $ 51,483 — $ 58,840 $ 58,841 +

Monthly $0 —

$ 2,452 $ 2,453 — $ 3,677 $ 3,678 — $ 4,290 $ 4,291 — $ 4,903 $ 4,904 +

6 Annual $0 —

$ 33,740 $ 33,741 — $ 50,607 $ 50,608 — $ 59,042 $ 59,043 — $ 67,480 $ 67,481 +

Monthly $0 —

$ 2,812 $ 2,813 — $ 4,217 $ 4,218 — $ 4,920 $ 4,921 — $ 5,623 $ 5,624 +

7 Annual $0 —

$ 38,060 $ 38,061 — $ 57,086 $ 57,087 — $ 66,601 $ 66,602 — $ 76,120 $ 76,121 +

Monthly $0 —

$ 3,172 $ 3,173 — $ 4,757 $ 4,758 — $ 5,550 $ 5,551 — $ 6,343 $ 6,344 +

8 Annual $0 —

$ 42,380 $ 42,381 — $ 63,566 $ 63,567 — $ 74,161 $ 74,162 — $ 84,760 $ 84,761 +

Monthly $0 —

$ 3,532 $ 3,533 — $ 5,297 $ 5,298 — $ 6,180 $ 6,181 — $ 7,063 $ 7,064 +

*Each additjonal family member + $4,320 Annual/ + $4,320 Annual/ + $4,320 Annual/ + $4,320 Annual/ + $4,320 Annual/ + $360 Monthly + $360 Monthly + $360 Monthly + $360 Monthly + $360 Monthly

Dental

* But not less than the nominal charge

Note: No patjent shall be denied service due to an individual’s inability to pay.