What You May Pay for Care
If you do not have insurance, we can tell you about how much your visit may cost. We may not know all the care you will need until we see you. The chart below shows what you may pay for different services. The amount depends on whether you can get a discount. Our staff can help you find out if you can get a discount.
| Service Type | Eligible for Discount | Not Eligible for Discount * | |
|---|---|---|---|
| Medical | $5 - $25 | $95 - $350 | |
| Behavioral Health | $5 - $25 | $150 - $200 | |
| Oral Health | $5 - $25 | $33 - $250 | |
| Dental - Maintenance (Cleaning, Flouride) | $15 - $35 | ||
| Dental - Procedures (Extractions, Fillings) | $15 - $35 | ||
| Dental - Advanced Services (Dentures, Crowns, etc.) | A separate estimate of costs will be provided prior to care delivery | ||
| Vision | $5 - $10 (+ Cost of Glasses) | ||
* Disclaimer: This estimate is based on what we know today. Your provider may find that you need more services during your visit. If that happens, your final bill may be different. If you have questions about your bill, call us at 567-825-1729 or visit hpwohio.org. Getting help with your bill will not affect the care you receive.
How We Decide if You Can Get a Discount
We look at how many people are in your family and how much money your family makes before taxes to see if you can get a discount. Your family may include parents, step-parents, a husband or wife, and children under age 18.
| Family Size | Money Your Family Makes Before Taxes | |||||
|---|---|---|---|---|---|---|
| A | B | C | D | E | No Discount | |
| 1 | $0 - $15,960 | $15,961 - $19,950 | $19,951 - $23,940 | $23,941 - $27,930 | $27,931 - $31,920 | $31,921 and above |
| 2 | $0 - $21,640 | $21,641 - $27,050 | $27,051 - $32,460 | $32,461 - $37,870 | $37,871 - $43,280 | $43,281 and above |
| 3 | $0 - $27,320 | $27,321 - $34,150 | $34,151 - $40,980 | $40,981 - $47,810 | $47,811 - $54,640 | $54,641 and above |
| 4 | $0 - $33,000 | $33,001 - $41,250 | $41,251 - $49,500 | $49,501 - $57,750 | $57,751 - $66,000 | $66,001 and above |
| 5 | $0 - $38,680 | $38,681 - $48,350 | $48,351 - $58,020 | $58,021 - $67,690 | $67,691 - $77,360 | $77,361 and above |
| 6 | $0 - $44,360 | $44,361 - $55,450 | $55,451 - $66,540 | $66,541 - $77,630 | $77,631 - $88,720 | $88,721 and above |
| 7 | $0 - $50,040 | $50,041 - $62,550 | $62,551 - $75,060 | $75,061 - $87,570 | $87,571 - $100,080 | $100,081 and above |
| 8 | $0 - $55,720 | $55,721 - $69,650 | $69,651 - $83,580 | $83,581 - $97,510 | $97,511 - $111,440 | $111,441 and above |
Proof of Income We Need
To get a discount, fill out a discount application. To keep your discount for more than 30 days, you must show proof of income. The table below shows the papers you can use to prove your income.
| Income Type | Documents to Bring |
|---|---|
| Wages/Tips | 2 Paystubs (must cover date of application) |
| Self-Employment | Prior year's taxes |
| Unemployment | 1 paystub (must be within same month as application) |
| Social Security/Disability | Award Letter (for the year the application is completed) |
| Pension/Retirement | Award Letter (for the year the application is completed) |
| Veterans Benefits | Current year's VA letter |
| Cash Assistance | Printout from JFS |
| Child Support | Printout from JFS |
Example: Maria's family has 4 people. Her family makes $38,000 a year. Looking at the chart, Maria qualifies for Level B. For a medical visit, she would pay $10.