Sliding Fee Discount Program

SEMO Health Network (SEMOHN) provides comprehensive medical and dental care to all patients regardless of their ability to pay.  To ensure the care is affordable for all patients, SEMOHN offers a sliding fee discount program.  Any patient, whether insured or uninsured, may apply for the sliding fee discount program as outlined by the U.S. Department of Health & Human Services.  The program allows a patient to receive a discount on services based on their family size and annual income compared to the Federal Poverty Guidelines.

In order to qualify for the sliding fee discount program, patients must complete the sliding fee discount program application paperwork and provide the appropriate proof of income. Patients cannot be seen on the sliding fee discount program until they have completed their sliding fee paperwork and have been approved by a SEMOHN employee. Enrollment must be renewed annually.

Acceptable proofs of income are as follows:

  1. Most recent tax return – PREFERRED
  2. Most recent W-2 or 1099
  3. Most recent check stub for patient’s working full-time (40 hours a week)
  4. Last three consecutive check stubs for patients working part-time (less than 40 hours a week) or seasonally
  5. Statement from employer
  6. Most recent unemployment check stub or benefits letter
  7. Pension, retirement, disability, or social security award letter Temporary Assistance to Needy Families Letter from Division of Family Services
  8. Court order settlements (example: child support)
  9. Any other written verifiable income statement – self-employment income needs to be verified by accounting records from the business.

 

Proof of income includes all persons living in the household.  Any household members determined to potentially qualify for Medicaid coverage are strongly encouraged to apply for Medicaid. Our staff is available to assist you with this process.  If the necessary paperwork is not provided, the appointment can either be rescheduled or standard charges will apply.

Below are charts detailing the net amount owed for Medical and Dental Services after the Sliding Fee Discount has been applied.

Medical and Behavioral Health Sliding Fee Discount Schedule

With Office Visit

Lab Visit Only
Slide A

$30 + $15 if Lab Work Needed

$15
Slide B

$40 + $20 if Lab Work Needed

$20
Slide C

$50 + $25 if Lab Work Needed

$25
Slide D

$60 + $30 if Lab Work Needed

$30
Slide E

$70 + $35 if Lab Work Needed

$35
Slide F

No discount available
NOTE: SEMOHN will make reasonable efforts to secure payment form patients for services rendered while ensuring that no patient denied services based on inability to pay. As a means of reducing barriers to care, payment plan options are available. We will work with patients to set terms for payments that are reasonable based on their annual income.

Dental Sliding Fee Discount Schedule

A

 B C D E

F

Fee Per Service:
Dental Exam

$20

 $25 $30 $35

$40

No Discount Available
Basic Cleaning

$20

 $25 $30 $35

$40

Fee Per Procedure:
Dental X-Ray

$10

 $12 $14 $16

$18
Fillings:
1 Surface

$60

 $70 $80 $90

$100
2 Surfaces

$90

 $100 $110 $120

$130
3 Surfaces

$120

 $130 $140 $150

$160
4 or more Surfaces

$150

 $160 $170 $180

$190
Dental Procedures:
Level 1

$20

 $25 $30 $35

$40
Level 2

$60

 $70 $180 $90

$100
Level 3

$100

 $110 $120 $130

$140
Level 4

$200

 $220 $240 $260

$280
Level 5

$300

 $350 $400 $450

$500
Level 6

$400

 $450 $500 $550

$600
Level 7

$500

 $600 $700 $800

$900
Level 8

$600

 $700 $800 $900

$1,000

Level 1 Procedures

Sealant

Basic Replacement or Repair

Primary Extraction

Level 2 Procedures

Intermediate Cleaning

Intermediate Replacement or Repair

Simple Extraction

Pulpotomy – Primary Root Canal

Level 3 Procedures

Complex Cleaning

Surgical Extraction

Stainless Steel Crown

Level 4 Procedures

Denture Reline

Bilateral Space Maintainer

Impacted Extraction

Level 5 Procedures

Flipper Partial

Anterior Root Canal

 

Level 6 Procedures

Pre-Molar Root Canal

Metal Partials

 

 

Level 7 Procedures

Porcelain Crown

Molar Root Canal

Resin Partials

Level 8 Procedures

Flex Base Partials

Complete Upper or Lower Dentures

 
NOTE: SEMOHN will make reasonable efforts to secure payment form patients for services rendered while ensuring that no patient denied services based on inability to pay. As a means of reducing barriers to care, payment plan options are available. We will work with patients to set terms for payments that are reasonable based on their annual income.