Good Faith Estimate
Health care providers are required to give patients who don't have insurance an estimate of the cost for services. It is difficult to know exactly what type of care you will receive during your visit. The chart below shows the average cost associated with different kinds of care a patient may receive from Health Partners of Western Ohio, based on their eligibility for our Fee Discount Program. When you visit Health Partners of Western Ohio, our staff will help you determine your eligibility for our Fee Discount Program. More information on our Fee Discount Program is included on the next page.
| 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 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. We do not have information about the cost of services or products that you may need to obtain outside of our facility. Your actual charges may vary from this estimate. This estimate is not a contract and does not require you to get services from Health Partners of Western Ohio. 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 at hpwohio.org or by calling our billing department at 567-825-1729. Starting a dispute resolution process will not reduce the quality of health services you receive at Health Partners of Western Ohio.
How Health Partners of Western Ohio Determines Fee Discount Eligibility
A patient's Fee Discount eligibility is based on the number of people in their family and their total family income. Family is defined as mother, step-mother, father, step-father, spouse (legally married) and dependent children under the age of 18. The table below can be used to determine your eligibility.
| Family Size | Total Family Income (Gross) | |||||
|---|---|---|---|---|---|---|
| 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 |
Required Proof of Income
Discounts are applied once eligibility is determined, upon completion of a discount application. Continued discounts beyond 30 days require proof of income. Acceptable documents for proof of income are listed in the table below.
| Income Type | Proof of Income Required |
|---|---|
| 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: A patient comes in for a medical visit, has 4 people in their household, and their total income is counted as $38,000. Using the first table above, they are in SFS level B. According to SFS level B in Table 1, the patient wil pay $10 for each medical visit.