Sliding Fee Scales Notice to patients: Community Health serves all patients regardless of income or insurance status. Discounts for pharmacy services provided by Community Health or one of the contracted pharmacies are offered on a sliding fee scale basis adjusted for family size and income. Front desk personnel can assist you in applying, or you may apply directly by calling the clinic and asking for the patient outreach coordinator. For information on how to cover the cost of health care, and create a plan that works for you, check payment options. Medical & Behavioral Health Sliding Fee Scale 100%Discount $10 Nominal Fee to be collected at time of Service 0-100% If your income falls between Family Size Federal Poverty Level 1 $0—$12,490 2 $0—$16,910 3 $0—$21,330 4 $0—$25,750 5 $0—$30,170 6 $0—$34,590 7 $0—$39,010 8 $0—$43,430 For each additional person add $4,420 75%Discount Greater of $20 nominal or 25% collected at time of service 101-135% If your income falls between Family Size Federal Poverty Level 1 $12,491—$16,862 2 $16,911—$22,829 3 $21,331—$28,796 4 $25,751—$34,763 5 $30,171—$40,730 6 $34,591—$46,697 7 $39,011—$52,664 8 $43,431—$58,631 For each additional person add $4,420 50%Discount Greater of $20 nominal or 50% collected at time of service 136-170% If your income falls between Family Size Federal Poverty Level 1 $16,863—$21,233 2 $22,830—$28,747 3 $28,797—$36,261 4 $34,764—$43,775 5 $40,731—$51,289 6 $46,698—$58,803 7 $52,665—$66,317 8 $58,632—$73,831 For each additional person add $4,420 25%Discount Greater of $20 nominal or 75% collected at time of service 171-200% If your income falls between Family Size Federal Poverty Level 1 $21,234—$24,980 2 $28,748—$33,820 3 $36,262—$42,660 4 $43,776—$51,500 5 $51,290—$60,340 6 $58,804—$69,180 7 $66,318—$78,020 8 $73,832—$86,860 For each additional person add $4,420 Medical & Behavioral Health Sliding Fee ApplicationPharmacy Sliding Fee Scale 100%Discount Acquisition cost + pharmacy dispensing fees + $2.50 admin fee 0-100% If your income falls between Family Size Federal Poverty Level 1 $0—$12,490 2 $0—$16,910 3 $0—$21,330 4 $0—$25,750 5 $0—$30,170 6 $0—$34,590 7 $0—$39,010 8 $0—$43,430 For each additional person add $4,420 75%Discount Acquisition cost + pharmacy dispensing fees + $5.00 admin fee 101-135% If your income falls between Family Size Federal Poverty Level 1 $12,491—$16,862 2 $16,911—$22,829 3 $21,331—$28,796 4 $25,751—$34,763 5 $30,171—$40,730 6 $34,591—$46,697 7 $39,011—$52,664 8 $43,431—$58,631 For each additional person add $4,420 50%Discount Acquisition cost + pharmacy dispensing fees + $7.50 admin fee 136-170% If your income falls between Family Size Federal Poverty Level 1 $16,863—$21,233 2 $22,830—$28,747 3 $28,797—$36,261 4 $34,764—$43,775 5 $40,731—$51,289 6 $46,698—$58,803 7 $52,665—$66,317 8 $58,632—$73,831 For each additional person add $4,420 25%Discount Acquisition cost + pharmacy dispensing fees + $10.00 admin fee 171-200% If your income falls between Family Size Federal Poverty Level 1 $21,234—$24,980 2 $28,748—$33,820 3 $36,262—$42,660 4 $43,776—$51,500 5 $51,290—$60,340 6 $58,804—$69,180 7 $66,318—$78,020 8 $73,832—$86,860 For each additional person add $4,420 Pharmacy Sliding Fee ApplicationDental Sliding Fee Scale 100%Discount $10 Nominal Fee collected at time of service. Lab fees additional cost to patient. 0-100% If your income falls between Family Size Federal Poverty Level 1 $0—$12,490 2 $0—$16,910 3 $0—$21,330 4 $0—$25,750 5 $0—$30,170 6 $0—$34,590 7 $0—$39,010 8 $0—$43,430 For each additional person add $4,420 75%Discount Greater of $25 nominal or 25% collected at time of service. Lab fees additional cost to patient. 101-135% If your income falls between Family Size Federal Poverty Level 1 $12,491—$16,862 2 $16,911—$22,829 3 $21,331—$28,796 4 $25,751—$34,763 5 $30,171—$40,730 6 $34,591—$46,697 7 $39,011—$52,664 8 $43,431—$58,631 For each additional person add $4,420 50%Discount Greater of $25 nominal or 50% collected at time of service. Lab fees additional cost to patient. 136-170% If your income falls between Family Size Federal Poverty Level 1 $16,863—$21,233 2 $22,830—$28,747 3 $28,797—$36,261 4 $34,764—$43,775 5 $40,731—$51,289 6 $46,698—$58,803 7 $52,665—$66,317 8 $58,632—$73,831 For each additional person add $4,420 25%Discount Greater of $25 nominal or 75% collected at time of service. Lab fees additional cost to patient 171-200% If your income falls between Family Size Federal Poverty Level 1 $21,234—$24,980 2 $28,748—$33,820 3 $36,262—$42,660 4 $43,776—$51,500 5 $51,290—$60,340 6 $58,804—$69,180 7 $66,318—$78,020 8 $73,832—$86,860 For each additional person add $4,420 Dental Sliding Fee ApplicationApplying for Sliding Fee When you come for your appointment to apply for sliding fee scales, please bring the following information with you: Birth Certificate Driver’s license with your picture on it or another photo ID showing your current address Proof of Residency (postmarked envelope, postcard or envelope, driver’s license issued within the last 6 months, utility bill, lease/rent receipt, property tax records) Proof of income including documentation for all wages earned (pay stubs for 4 consecutive pay periods or your tax return from the previous year), social security, worker’s comp, veteran’s benefits, military pay, child support/alimony, income from rent and interest/dividends from bank accounts, pensions and annuities. Proof of Medicaid denial (within the last six months). a Navigator can assist with VT Medicaid applications. Medical & Behavioral Health Sliding Fee Application Pharmacy Sliding Fee Application Dental Sliding Fee Application Payment Options
