CHAS Health Sliding Fee Discount Program & Good Faith Estimates
CHAS Health may be able to lower the cost of your care through our Sliding Fee Discount Program. All patients are encouraged to apply for the Sliding Fee Discount Program – even if you have insurance. Eligibility is based on household size and income of all adult household members. Household size includes everyone who depends on the household’s income for at least half of their living expenses.
How much you will pay will depend on your income. We offer discounts off our regular charges based on a person’s income and the number of people in their household.
To Apply for the Sliding Fee Discount Program you must:
- Complete CHAS Health’s Sliding Fee Discount Program Application
- Give CHAS Health proof of your estimated current annual income. These documents may include:
- Pay stubs,
- A recent tax return, or
- Benefit letters (social security, unemployment, etc.)
- If you cannot bring these documents, you may complete the Self Declaration of Income.
- To keep your CHAS Health Sliding Fee Discount, you must renew it every year. Each year, you need to submit a new application and provide proof of income.
- Submit a new application if your household size changes or your monthly income changes by $150 or more for at least two months.
Services Outside of CHAS Health
CHAS Health’s Sliding Fee Discount Program applies only to services provided at CHAS Health and Spokane Urgent Care. Patients who qualify may also receive discounts for labs and imaging services provided by Inland Imaging, Quest Labs, Labcorp, and Incyte Pathology when ordered by a CHAS Health provider. All other services from outside specialists, labs, or radiology are not covered, and patients are responsible for all charges.
Sliding Fee Discount Category
| Household Size | A 0-100% FPL | B >100%-138% FPL | C >138%-175% FPL | D >175%-200% FPL | E >200% FPL |
|---|---|---|---|---|---|
| 1 | $0 -$15,960 | $15,960.01 - $22,024.80 | $22,024.81 - $27,930.00 | $27,930.01 - $31,920 | ≥ $31,920.01 |
| 2 | $0 - $21,640 | $21,640.01 - $29,863.20 | $29,863.21 - $37,870.00 | $37,870.01 - $43,280 | ≥ $43,280.01 |
| 3 | $0 - $27,320 | $27,320.01 - $37,701.60 | $37,701.61 - $47,810.00 | $47,810.01 - $54,640 | ≥ $54,640.01 |
| 4 | $0 - $33,000 | $33,000.01 - $45,540 | $45,540.01 - $57,750 | $57,750.01 - $66,000 | ≥ $66,000.01 |
| 5 | $0 - $38,680 | $38,680.01 - $53,378.40 | $53,378.41 - $67,690.00 | $67,690.01 - $77,360 | ≥ $77,360.01 |
| 6 | $0 - $44,360 | $44,360.01 - $61,216.80 | $61,216.81 - $77,630 | $77,630.01 - $88.720 | ≥ $88.720.01 |
Sliding Fee Discount Program - Medical Services
| Sliding Fee Discount Category | Medical Services | Medical Services (Behavioral Health & Expanded Care Team*) | Flu & COVID Immunizations |
|---|---|---|---|
| A | $20 | $0 | 100% Discount |
| B | $30 | $3 | 100% Discount |
| C | $50 | $6 | 100% Discount |
| D | $60 | $9 | 100% Discount |
| E | No Discount – Contact CHAS Health for a Good Faith Estimate of charges 509.444.8200 | ||
* Behavioral health sliding fee applies to visits with Behavioral Health providers including substance abuse. Expanded Care Team scale includes: Clinical Pharmacists, Registered Dieticians, Registered Nurse, Chronic Care Management and Collaborative Care Management programs, and Pathways to Wellness program visits.
For Sliding Fee E (full fee) - Prices of common medical services
Listed below are the prices of common medical services. Actual prices may be less than maximum price but will not exceed the maximum for the codes listed. The prices listed are for the visit itself, and do not include the cost of vaccinations, tests, or other procedures that may be performed.
| Service | Code | Price Maximum* |
|---|---|---|
| Office visit, new patient | 99202-99205 | $457 |
| Office visit, established patient | 99212-99215 | $326 |
| Preventive annual health exam (18+ years old) | 99385-99387, 99395-99397 | $306 |
| Well-child exam (17 and younger, vaccinations not included) | 99381-99384, 99395-99397 | $223 |
| Behavioral health visit | 90791-90792, 90832-90837 | $327 |
| Clinical pharmacist, medication management | 99606-99607 | $89 |
| Registered nurse, chronic care management | 99487-99491 | $194 |
| Registered dietitian | 97802-97804 | $64 |
| Retinal scan | 92250 | $126 |
| IUD or Nexplanon insertion or removal (device billed through pharmacy) | 58300-58301, 11981-11983 | $568 |
| OB global package (prenatal care, vaginal delivery, postpartum care) | 59400-59430 | $4,687 |
Dental Services
| Sliding Fee Discount Category |
Level 1 Basic Dental Services |
Level 2 Restorative and Peridontal Services |
Level 3 Crowns, Inlays, and Onlays |
|---|---|---|---|
| A | $35 per visit | $35 per visit | $100 for first unit $65 lab fee for each additional unit |
| B | $45 per visit | $75 per visit | $395 per unit |
| C | $60 per visit | $100 per visit | $540 per unit |
| D | $75 per visit | $150 per visit | $755 per unit |
| E | 100% (Full Fee) | 100% (Full Fee) | 100% of Professional Fee and Lab Fee |
Prices of Common Dental Services
A personalized dental treatment plan with recommended services and costs will be provided to you after a dental exam. The table below lists the prices of some common dental services. Prices may vary based on actual services provided.
| Service | Codes | Full Fee |
|---|---|---|
| Adult Dental Exam | D0150, D0210 | $276 |
| Periodic Oral Exam (POE) | D0120, D0274, D0220, D0230 (x2) | $246 |
| Limited Dental Exam (DX) | D0140, D0220, D0270 | $169 |
| Emergency Tooth Extraction (XA) | D0140, D0220, D7140 | $369 |
| Basic Cleaning with Fluoride | D1110, D1206 | $175 |
| Basic Cleaning without Fluoride | D1110 | $114 |
| Deep Cleaning (Periodontal Scaling) with Fluoride | D4341, D1206 | $376 |
| Deep Cleaning (Periodontal Scaling) without Fluoride | D4341 | $315 |
Pharmacy Services
| Sliding Fee Discount Category | Pharmacy Medications (Cost of the medication + dispensing fee) | Select Pharmacy Supplies** (Cost of the equipment + dispensing fee) | Pharmacy (Bicillin, Prolia & IUD medication only) |
|---|---|---|---|
| A | Cost of the medication + $0 | $0 | $0 |
| B | Cost of the medication + $3 | $0 + $3 | $0 |
| C | Cost of the medication + $6 | $0 + $6 | $0 |
| D | Cost of the medication + $9 | $0 + $9 | $0 |
| E >200% to 400% FPL | Cost of the medication + $23 | Cost of the equipment + $23 | Cost |
| Full Fee (Over 400% FPL) | No Discount (Usual and Customary Fee* + $23) | No Discount (Usual and Customary Fee* + $23) | No Discount (Usual and Customary Fee*) |
*Usual and Customary fee is the average wholesale price paid at a retail pharmacy.
**Please ask your CHAS Health pharmacy for a current list of supplies covered under the Select Pharmacy Supplies sliding fee scales.
Important Notes: This Good Faith Estimate is based on our understanding of your needs as of today. While caring for you, our providers may recommend additional services that are not listed here. Your actual charges may vary from this estimate. This estimate is not a contract and does not require you to get services from CHAS Health. If your actual charges are more than $400 above this estimate, you can initiate a provider-patient dispute resolution process. You can learn how to start this process by calling CHAS Billing at 509.444.7880. Starting a dispute resolution process will not impact the quality of health services you receive at CHAS Health.
CHAS Health will not deny services based on a patient’s inability to pay, even if that means reducing or waiving costs (if applicable). Contact a CHAS Health Patient Resources Coordinator at 509.444.8200 to learn about resources available to you.