Sliding Fee Scale Program

What is the Sliding Fee Scale Program?

The Sliding Fee Scale Program is in place to meet the needs of the uninsured or under insured patients, providing reduced costs on most services for those who qualify, based on annual household income. No one will be denied access to services at MMHC, as services are offered regardless of insurance status or ability to pay.

How do I qualify?

To qualify for the program, you must show proof of gross annual income for all immediate family members living in your household. Gross income is ALL income from ALL sources before taxes. Applicants should provide a copy of any of the accepted income verification materials listed.

Documentation

To qualify, you MUST provide documentation to support need within 10 days of your appointment. MMHC requires the following documentation:

  • Recent Federal Tax Return
  • IRS Form W-2 or 1099's
  • Pay stubs for one month
  • Social Security Award Letter
  • Pension Benefit Confirmation Letter
  • Unemployment Insurance Award Letter

Sliding Fee Scale

The following table is used to determine patient eligibility and calculate payment responsibility based on Federal Poverty Levels for 2021.

For each additional person, add $4,540.

FQHC Sliding Scale-2

Income includes: Earnings, unemployment compensation, worker's compensation, Social Security, Supplemental Security Income, public assistance, veterans' payments, survivor benefits, pension or retirement income, interest, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household and other miscellaneous sources.

Services not included in the Sliding Scale Fee Program: Lab costs, radiology costs, offsite services, such as hospital services or services performed at Margaret Mary Health


How to Apply

Complete the Sliding Fee Scale Application and send it, along with supporting documentation, to:

Margaret Mary Health Center
11137 U.S. 52
Brookville, IN 47012