Sliding Fee Scale FQHC

 

SIU Center for Family Medicine

2018 SLIDING FEE SCALE for FINANCIAL ASSISTANCE

All patients who do not have coverage for medical or dental insurance are eligible for financial assistance based on their income. To see if you qualify all patients are asked to call the office and speak to our the financial counselors to determine what documents to bring or stop at any of our clinics. 

 

Federal Poverty Level (FPL)

FAMILY SIZE --
Members in Household

2018
FPL

100% or Less
FQHC Level
0

101%-138%
FQHC Level
1

139%-150%
FQHC Level
2

151%-175%
FQHC Level
3

176%-200%
FQHC Level
4

Annual income displayed is highest possible in each category in order to qualify

1

$12,140

$12,140

$16,753

$18,210

$21,245

$24,280

2

$16,460

$16,460

$22,715

$24,690

$28,805

$32,920

3

$20,780

$20,780

$28,676

$31,170

$36,365

$41,560

4

$25,100

$25,100

$34,638

$37,650

$43,925

$50,200

5

$29,420

$29,420

$40,600

$44,130

$51,485

$58,840

6

$33,740

$33,740

$46,561

$50,610

$59,045

$67,480

7

$38,060

$38,060

$52,523

$57,090

$66,605

$76,120

8

$42,380

$42,380

$58,484

$63,570

$74,165

$84,760

Each add'l family member
> 8

$4,320

$4,320

$5,962

$6,480

$7,560

$8,640


 

Sliding Fee Scale

 Nominal Charge

Level 1

Level 2

Level 3

Level 4

MEDICAL/BEHAVIORAL

 

$5

$10

$15

$20

$25

DENTAL

 

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