Sliding Fee Scale Policy for Self-Pay Patients

 

  1. The Sliding Fee Scale is a discount program for self-pay patients at Community Dental Care based on the Federal Poverty Guidelines for family income and size. By following established income guidelines, patients will be treated in a fair and consistent manner.
     
  2. Before a patient may apply for sliding scale, he/she must first apply for Medical Assistance. The patient will be refunded this fee if he/she is subsequently enrolled in one of the state’s public programs and the claim is paid retroactively by the state.
     
  3. If a patient’s Medical Assistance application is rejected, then the patient may fill out a Community Dental Care application for sliding scale. The patient must also supply, in any combination, the following documentation verifying identity and income. This includes:
    • Pay stubs (most recent two periods) from everyone in household who works
    • Federal tax returns for the prior year
    • Alternate financial documentation (e.g. Social Security Explanation of Benefits, Unemployment Benefits, etc.) if the patient doesn’t receive a paycheck.
    • A signed letter from the patient stating that he/she is without any form of household income and explaining how living expenses are met.
  4. Any change in family size or income as well as change in contact information must be reported to the Financial Coordinator. Income verification updates will occur annually on the date of application.
     
  5. For patients at or above 101% of the Federal Poverty Guidelines, all fees follow the sliding scale and patients are expected to pay on the day of service, which is the standard clinic practice for patient charges and co-pays at Community Dental Care.

Supplemental mini-grants for charity dentistry may be available for emergency patients and patients at less than 120% poverty level, depending on funding and at the clinic’s discretion.

American Dental Association logo logo logo