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1400.02 2021 sliding fee schedule - fourthstreetclinic.org

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FOURTH STREET CLINIC SLIDING FEE SCHEDULE: Fourth Street Clinic provides homeless health care services on a sliding fee scale for eligible applicants based upon the HHS federal guidelines for those living at or below 200% of poverty level income as shown in the table below. Families or individuals with income above 200% of poverty level are not eligible for sliding fees discounts. ³ If family income is equal to or less than 200 % of poverty, patients must apply to qualify for the sliding fee discounts. ³ Families with incomes greater than 150% of poverty will be asked to provide verification of income as defined in the sliding fee discount policy and procedures. ³ If family income is greater than 200% of poverty level, or the patient is covered through an approved third-party insurer, services are billed at non-discounted contract rates for services other than Pharmacy. For Pharmacy and Pharmaceuticals, the fee is cost plus $1. ³ Fourth Street Clinic accepts Medicaid, Medicare, Primary Care Network (PCN) and Utah’s Children’s Health Insurance Program (CHIP). FSC 2021 Sliding Fee FEDERAL POVERTY LEVEL INCOME FOR THE STATE OF UTAH as of January 13, 2021 POVERTY GUIDELINE Applies to Medical, Dental, Lab, Behavioral Health (See Pharmacy and Pharmaceuticals schedule below) PERSONS IN FAMILY / HOUSEHOLD At or below 100% 125% 150% 175% 200% At or above 201 % Per Encounter Fee Fee per Encounter $0 Fee per Encounter $1 Fee per Encounter $2 Fee per Encounter $3 Fee per Encounter $4 Pay in Full 1 $ 12,880 $ 16,100 $ 19,320 $ 22,540 $ 25,760 $ 25,761 2 $ 17,420 $ 21,775 $ 26,130 $ 30,485 $ 34,840 $ 34,841 3 $ 21,960 $ 27,450 $ 32,940 $ 38,430 $ 43,920 $ 43,921 4 $ 26,500 $ 33,125 $ 39,750 $ 46,375 $ 53,000 $ 53,001 5 $ 31,040 $ 38,800 $ 46,560 $ 54,320 $ 62,080 $ 62,081 6 $ 35,580 $ 44,475 $ 53,370 $ 62,265 $ 71,160 $ 71,161 7 $ 40,120 $ 50,150 $ 60,180 $ 70,210 $ 80,240 $ 80,241 8 $ 44,660 $ 55,825 $ 66,990 $ 78,155 $ 89,320 $ 89,321 Household > 8 add $ 4,540 $ 5,675 $ 6,810 $ 7,945 $ 9,080 $ 9,081 *Based on 2021 Federal Poverty Guidelines. Aspe.hhs.gov/poverty-guidelines FSC 2021 Sliding Fee for Pharmacy FEDERAL POVERTY LEVEL INCOME FOR THE STATE OF UTAH as of January 13, 2021 POVERTY GUIDELINE Applies to Medical, Dental, Lab, Behavioral Health (See Pharmacy and Pharmaceuticals schedule below) PERSONS IN FAMILY / HOUSEHOLD At or below 100% 125% 150% 175% 200% At or above 201 % Per Encounter Fee Fee per Prescription $0 Fee per Prescription $1 Fee per Prescription $2 Fee per Prescription $3 Fee per Prescription $4 Pay in Full per Prescription 1 $ 12,880 $ 16,100 $ 19,320 $ 22,540 $ 25,760 $ 25,761 2 $ 17,420 $ 21,775 $ 26,130 $ 30,485 $ 34,840 $ 34,841 3 $ 21,960 $ 27,450 $ 32,940 $ 38,430 $ 43,920 $ 43,921 4 $ 26,500 $ 33,125 $ 39,750 $ 46,375 $ 53,000 $ 53,001 5 $ 31,040 $ 38,800 $ 46,560 $ 54,320 $ 62,080 $ 62,081 6 $ 35,580 $ 44,475 $ 53,370 $ 62,265 $ 71,160 $ 71,161 7 $ 40,120 $ 50,150 $ 60,180 $ 70,210 $ 80,240 $ 80,241 8 $ 44,660 $ 55,825 $ 66,990 $ 78,155 $ 89,320 $ 89,321 Household > 8 add $ 4,540 $ 5,675 $ 6,810 $ 7,945 $ 9,080 $ 9,081 *Based on 2021 Federal Poverty Guidelines. Aspe.hhs.gov/poverty-guidelines

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Page 1: 1400.02 2021 Sliding Fee Schedule - fourthstreetclinic.org

FOURTH STREET CLINIC SLIDING FEE SCHEDULE:

Fourth Street Clinic provides homeless health care services on a sliding fee scale for eligible

applicants based upon the HHS federal guidelines for those living at or below 200% of poverty level income as shown in the table below. Families or individuals with income above 200% of

poverty level are not eligible for sliding fees discounts. ³ If family income is equal to or less than 200 % of poverty, patients must apply to qualify for

the sliding fee discounts.

³ Families with incomes greater than 150% of poverty will be asked to provide verification of income as defined in the sliding fee discount policy and procedures.

³ If family income is greater than 200% of poverty level, or the patient is covered through an approved third-party insurer, services are billed at non-discounted contract rates for services other than Pharmacy. For Pharmacy and Pharmaceuticals, the fee is cost plus $1.

³ Fourth Street Clinic accepts Medicaid, Medicare, Primary Care Network (PCN) and Utah’s Children’s Health Insurance Program (CHIP).

FSC 2021 Sliding Fee FEDERAL POVERTY LEVEL INCOME FOR THE STATE OF UTAH as of January 13, 2021

POVERTY GUIDELINE Applies to Medical, Dental, Lab, Behavioral Health (See Pharmacy and Pharmaceuticals schedule below)

PERSONS IN FAMILY /

HOUSEHOLD

At or below 100% 125% 150% 175% 200% At or above

201 %

Per Encounter Fee Fee per Encounter $0

Fee per Encounter $1

Fee per Encounter $2

Fee per Encounter $3

Fee per Encounter $4 Pay in Full

1 $ 12,880 $ 16,100 $ 19,320 $ 22,540 $ 25,760 $ 25,761 2 $ 17,420 $ 21,775 $ 26,130 $ 30,485 $ 34,840 $ 34,841 3 $ 21,960 $ 27,450 $ 32,940 $ 38,430 $ 43,920 $ 43,921 4 $ 26,500 $ 33,125 $ 39,750 $ 46,375 $ 53,000 $ 53,001 5 $ 31,040 $ 38,800 $ 46,560 $ 54,320 $ 62,080 $ 62,081 6 $ 35,580 $ 44,475 $ 53,370 $ 62,265 $ 71,160 $ 71,161 7 $ 40,120 $ 50,150 $ 60,180 $ 70,210 $ 80,240 $ 80,241 8 $ 44,660 $ 55,825 $ 66,990 $ 78,155 $ 89,320 $ 89,321

Household > 8 add $ 4,540 $ 5,675 $ 6,810 $ 7,945 $ 9,080 $ 9,081

*Based on 2021 Federal Poverty Guidelines. Aspe.hhs.gov/poverty-guidelines

FSC 2021 Sliding Fee for Pharmacy FEDERAL POVERTY LEVEL INCOME FOR THE STATE OF UTAH as of January 13, 2021

POVERTY GUIDELINE Applies to Medical, Dental, Lab, Behavioral Health (See Pharmacy and Pharmaceuticals schedule below)

PERSONS IN FAMILY /

HOUSEHOLD

At or below 100% 125% 150% 175% 200% At or above 201 %

Per Encounter Fee

Fee per Prescription $0

Fee per Prescription $1

Fee per Prescription $2

Fee per Prescription $3

Fee per Prescription $4

Pay in Full per Prescription

1 $ 12,880 $ 16,100 $ 19,320 $ 22,540 $ 25,760 $ 25,761 2 $ 17,420 $ 21,775 $ 26,130 $ 30,485 $ 34,840 $ 34,841 3 $ 21,960 $ 27,450 $ 32,940 $ 38,430 $ 43,920 $ 43,921 4 $ 26,500 $ 33,125 $ 39,750 $ 46,375 $ 53,000 $ 53,001 5 $ 31,040 $ 38,800 $ 46,560 $ 54,320 $ 62,080 $ 62,081 6 $ 35,580 $ 44,475 $ 53,370 $ 62,265 $ 71,160 $ 71,161 7 $ 40,120 $ 50,150 $ 60,180 $ 70,210 $ 80,240 $ 80,241 8 $ 44,660 $ 55,825 $ 66,990 $ 78,155 $ 89,320 $ 89,321

Household > 8 add $ 4,540 $ 5,675 $ 6,810 $ 7,945 $ 9,080 $ 9,081

*Based on 2021 Federal Poverty Guidelines. Aspe.hhs.gov/poverty-guidelines

Page 2: 1400.02 2021 Sliding Fee Schedule - fourthstreetclinic.org

FOURTH STREET CLINIC TARIFA MOVIL:

La Clinica Fourth Street provee cuidados de salud a individuos indigentes y a quienes califiquen, guiandose por una tarifa movil, la cual se basa en las pautas establecidas por el Departamento de Salud y Servicios Humanos del gobierno federal para aquellos cuyos ingresos son 200 % o menores

del nivel de pobreza, el cual puede observarse en la tabla al final de la pagina.

Las familias o individuos cuyos ingresos sean mayores al 200% del indice de pobreza no califican para dichos descuentos.

Si el ingreso familiar es igual o menor que el 200 % del indice de pobreza , los pacientes deben aplicar para los descuentos de la tarifa movil. A las familias cuyos ingresos sean mayores al 150 % se les pedira que provean verificacion de dichos ingresos , tal como esta definido en la tarifa movil de descuentos. Si el ingreso familiar es mayor que el 200% del nivel de pobreza, o el paciente esta cubierto por un seguro medico, los servicios brindados seran cobrados a un precio sin descuento, excepto la farmacia.. Por la farmacia y medicamentos, el precio es el costo mas $1. La Clinica Fourth Street Clinic accepta Medicaid, Medicare, Primary Care Network (PCN) y Utah’s Children’s Health Insurance Program (CHIP).

FSC 2021 Tarifa Móvil

NIVEL DE POBREZA FEDERAL EN EL ESTADO DE UTAH establecido el 13 de Enero de 2021 INDICE DE POBREZA

Se aplica a servicios médicos, dentales, laboratorio y salud mental.

NUMERO DE PERSONAS EN LA

FLIA. / HOGAR

Al o por debajo del 100% 125% 150% 175% 200% Al o arriba del

201%

Cargo por visita Cargo por visita $0

Cargo por visita $1

Cargo por visita $2

Cargo por visita $3

Cargo por visita $4

Paga el costo completo

1 $ 12,880 $ 16,100 $ 19,320 $ 22,540 $ 25,760 $ 25,761 2 $ 17,420 $ 21,775 $ 26,130 $ 30,485 $ 34,840 $ 34,841 3 $ 21,960 $ 27,450 $ 32,940 $ 38,430 $ 43,920 $ 43,921 4 $ 26,500 $ 33,125 $ 39,750 $ 46,375 $ 53,000 $ 53,001 5 $ 31,040 $ 38,800 $ 46,560 $ 54,320 $ 62,080 $ 62,081 6 $ 35,580 $ 44,475 $ 53,370 $ 62,265 $ 71,160 $ 71,161 7 $ 40,120 $ 50,150 $ 60,180 $ 70,210 $ 80,240 $ 80,241 8 $ 44,660 $ 55,825 $ 66,990 $ 78,155 $ 89,320 $ 89,321

Hogar > 8 o mas $ 4,540 $ 5,675 $ 6,810 $ 7,945 $ 9,080 $ 9,081 *Basado en la Guía de Pobreza del gobierno federal para el 2021

FSC 2021 Tarifa Móvil NIVEL DE POBREZA FEDERAL EN EL ESTADO DE UTAH establecido el 13 de Enero de 2021

INDICE DE POBREZA Se aplica a la farmacia y medicamentos

NUMERO DE PERSONAS EN LA

FLIA. / HOGAR

Al o por debajo del 100% 125% 150% 175% 200% Al o arriba del

201%

Costo mensual por medicamento

Costo mensual por medicamento $0

Costo mensual por medicamento $1

Costo mensual por medicamento $2

Costo mensual por medicamento $3

Costo mensual por medicamento $4

Costo completo mas $1

1 $ 12,880 $ 16,100 $ 19,320 $ 22,540 $ 25,760 $ 25,761 2 $ 17,420 $ 21,775 $ 26,130 $ 30,485 $ 34,840 $ 34,841 3 $ 21,960 $ 27,450 $ 32,940 $ 38,430 $ 43,920 $ 43,921 4 $ 26,500 $ 33,125 $ 39,750 $ 46,375 $ 53,000 $ 53,001 5 $ 31,040 $ 38,800 $ 46,560 $ 54,320 $ 62,080 $ 62,081 6 $ 35,580 $ 44,475 $ 53,370 $ 62,265 $ 71,160 $ 71,161 7 $ 40,120 $ 50,150 $ 60,180 $ 70,210 $ 80,240 $ 80,241 8 $ 44,660 $ 55,825 $ 66,990 $ 78,155 $ 89,320 $ 89,321

Hogar con > 8 o mas $ 4,540 $ 5,675 $ 6,810 $ 7,945 $ 9,080 $ 9,081

*Basado en la Guía de Pobreza del gobierno federal para el 2021


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