CHAS Health Sliding Fee Discount Program & Good Faith Estimates
Whether or not you have insurance, CHAS Health may be able to reduce your costs through CHAS Health's Sliding Fee Discount Program. All patients are encouraged to complete an application. Eligibility is based on household size and income. Household size is the number of individuals inside or outside of the household, including the applicant, who is at least 50% dependent upon the family income being reported on the application.
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.
New Patients: When you visit CHAS Health, our staff will help you determine which sliding fee discount category you belong to. Please see the table below to learn more about our sliding fee discount categories.
To Apply for the Sliding Fee Discount Program you must:
- Make an appointment with a Patient Resources Coordinator (PRC) who will assist you in reviewing your insurance options.
- Fill out the CHAS Health’s Sliding Fee Discount Program Application.
- Give CHAS Health proof of your estimated current annual income:
- Pay stubs, recent tax return, unemployment statements, SSI letter, child support statements, letter from employer, L&I award letter, bank statement, or
- Signed Self-Declaration of Income
- Proof of income is required every year to continue to qualify for the Sliding Fee Discount Program. You are encouraged to fill out a new sliding fee application if your household size changes, or your monthly income changes by at least $150 and the change is expected to continue for at least two months.
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 - $14,580 | $14,580.01-$20,120.40 | $20,120.41-$25,515 | $25,515.01 - $29,160 | Above $29,160 |
| 2 | $0 - $19,720 | $19,720.01-$27,213.60 | $27,213.61 - $34,510 | $34,510.01 - $39,440 | Above $39,440 |
| 3 | $0 - $24,860 | $24,860.01-$34,306.80 | $34,306.81-$43,505 | $43,505.01-$49,720 | Above $49,720 |
| 4 | $0 - $30,000 | $30,000-$41,400 | $41,400.01-$52,500 | $52,500.01 - $60,000 | Above $60,000 |
| 5 | $0 - $35,140 | $35,140-$48,493.20 | $48,493.21-$61,495 | $61,495.01-$70,280 | Above $70,280 |
Sliding Fee Discount Program - Medical Services
| Sliding Fee Discount Category | Medical Services | Medical Services (Behavioral Health & Expanded Care Team*) | Spokane Urgent Care | Flu Immunization & Hepatitis A Vaccine |
|---|---|---|---|---|
| A | $20 | $0 | $50 | 100% Discount |
| B | $30 | $3 | $60 | 100% Discount |
| C | $50 | $6 | $75 | 100% Discount |
| D | $60 | $9 | $90 | 100% Discount |
| E | No Discount** | No Discount** | No Discount** | No Discount** |
* 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.
**No Discount - Contact CHAS Health for a Good Faith Estimate of charges. 509.444.8200
For Sliding Fee E (full fee) - Prices of common medical services
| Service | Code | Price Maximum* |
|---|---|---|
| Office visit, new patient | 99202-99205 | $435 |
| Office visit, established patient | 99212-99215 | $303 |
| Preventive annual health exam (18+ years old) | 99385-99387, 99395-99397 | $291 |
| Well-child exam (17 and younger, vaccinations not included) | 99381-99384, 99395-99397 | $240 |
| Behavioral health visit | 90791-90792, 90832-90837 | $311 |
| Clinical pharmacist, medication management | 99606-99607 | $73 |
| Registered nurse, chronic care management | 99487-99491 | $185 |
| Registered dietitian | 97802-97804 | $61 |
| Retinal scan | 92250 | $120 |
| IUD or Nexplanon insertion or removal (device billed through pharmacy) | 58300-58301, 11981-11983 | $535 |
| OB global package (prenatal care, vaginal delivery, postpartum care) | 59400-59430 | $4,687 |
*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 does not include the cost of vaccinations, tests, or other procedures that may be performed.
Services Outside of CHAS Health
CHAS Health’s Sliding Fee Discount Program can only apply to medical, pharmacy, dental, and behavioral health services provided at CHAS Health and Spokane Urgent Care. Inland Imaging, Quest Labs and Incyte Pathology offer a discount for patients that qualify for CHAS Health Sliding Fee Discount program when the services are ordered by a CHAS Health provider. All other services provided by outside specialists, labs, or radiology are not covered and Patient will be responsible for any and all charges.
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
| Service | Codes | Full Fee |
|---|---|---|
| Adult Dental Exam | D0150, D0210 | $259 |
| Periodic Oral Exam (POE) | D0120, D0274, D0220, D0230 (x2) | $224 |
| Limited Dental Exam (DX) | D0140, D0220, D0270 | $159 |
| Emergency Tooth Extraction (XA) | D0140, D0220, D7140 | $347 |
| Basic Cleaning with Fluoride | D1110, D1206 | $164 |
| Basic Cleaning without Fluoride | D1110 | $106 |
| Periodontal Maintenance | D4910 | $159 |
| Deep Cleaning (Peridontal Scaling) with Fluoride | D4341, D1206 | $357 |
| Deep Cleaning (Periodontal Scaling) without Fluoride | Full Fee price | $299 |
A personalized dental treatment plan with recommended services and costs will be provided to you after a dental exam.
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 & 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.
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 the resources available to you.
If you would like to receive a Good Faith Estimate customized for you, please call 509.444.8200 and ask to speak with a Patient Resources Coordinator for a Good Faith Estimate.
Important Notes: This Good Faith Estimate applies to uninsured patients who qualify for a sliding fee discount in categories A-D, and 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.
For uninsured patients in category E of the sliding fee scale above, the estimate above is limited to common services and a range of prices associated with those services. For an actual Good Faith Estimate, please contact CHAS Health at 509.444.8200 and request a Good Faith Estimate.
If the 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 at by calling CHAS Health Billing at 509.444.7880. Starting a dispute resolution process will not impact the quality of health services you receive at CHAS Health.