www.sawtoothmountainclinic.org 513 5th Ave. W., Grand Marais, MN 55604, Phone: 218-387-2330 Fax: 218-387-1278 Sandy L Stover, MD; Paul E Terrill, MD; Jennifer L Delfs, MD; Michael R Sampson, MD; Milan C Schmidt, MD; Kurt Farchmin, MD; Lisa M Zallar, CNP Service Mission of Sawtooth Mountain Clinic: To provide access to high quality, comprehensive, primary healthcare in Cook County to all users, regardless of financial ability to pay for services. Sliding Fee Scale Application The sliding fee scale program is income based – offered by the U.S. Department of Health & Human Services, :330 federal grant funding – available to all – regardless of existing insurance coverage. Your provider may not know program details. Please contact Steve Fleace, 387-2330, Ext. 113. steve@sawtoothmountainclinic.org; or Erin Watson, ext. 153, erin@sawtoothmountainclinic.org. A. Sliding Fee Scale Program. 1. This program is available to patients of the Sawtooth Mountain Clinic, and is dependent on the annual renewal of the federal grant. 2. This program covers medical outpatient services received at the Sawtooth Mountain Clinic and the lab, physical therapy, and x-ray departments of the Cook County North Shore Hospital. It does not cover charges if you are hospitalized or are seen in the hospital’s emergency room. 3. The patient will pay a small fee of $5.00 or $10.00 per visit or prescription. 4. All patients must reapply for the program yearly. Eligibility for the previous year ends on May 1 and a new application must be filed if the patient wishes to continue participation. B. Eligibility: Income must be within federal guidelines for family size (see attached chart). You may have other insurance and still be eligible. C. 1. 2. 3. Instructions for Application: Obtain application form from receptionist at the clinic. Read sliding scale program description and complete the application form. Attach proof of income to application. Examples of proof of income: Photocopy of W-2 form, front two pages of federal income tax return, social security check, pay stubs, or unemployment letter. Program Benefits 1. Clinic Services: Coverage: Most medical services obtained at the Sawtooth Mountain Clinic are covered. SMC reserves all rights to review what will be eligible for sliding scale discount. Billing: The Sawtooth Mountain Clinic will submit a claim to any insurance company for which you provide membership information. After insurance has processed, the remainder of the charges are adjusted. You will be billed only for the percentage you owe. 2. Other Services: Special order needs, certain travel immunizations, or birth control devices will be reviewed on an individual basis. 3. Hospital Services: Patient must notify the North Shore Hospital that he/she is a participant in the sliding scale program. Coverage: The sliding fee scale will only cover charges from North Shore Hospital if they were ordered by Sawtooth Mountain Clinic providers. The following services, if ordered by Sawtooth Mountain Clinic, will be covered: a. Outpatient laboratory tests, b. Outpatient x-ray and diagnostic tests, c. Outpatient physical and occupational therapy with services of $1000 maximum per calendar year. Does not cover post op physical therapy or post specialist consultation physical therapy orders. For questions about physical therapy coverage, call Steve Fleace, 387-2330 ext. 113; or Erin Watson, 387-2330 ext. 153 Our program does not cover cardiac rehab, supplies, IV therapy, in-patient/observation at the hospital, Care Center charges or prescriptions while in the Care Center. Billing: The hospital will submit a claim to your insurance company. You are responsible to let the hospital know you are on sliding scale. The hospital will then bill the clinic directly for your charges. The clinic will adjust the bill and send you a statement for the percentage you owe. 4. Medicine and Drugs: Coverage: Only prescriptions written by a Sawtooth Mountain Clinic Provider and obtained at the Arrowhead Pharmacy or Grand Marais Pharmacy in Grand Marais will be covered. (**Patient shall pay 5% at Level A, 25% at Level B, 50% at Level C, and 75% at Level D, for pharmacy coverage.) Prescriptions are not covered if they are written for items available over-the-counter, with the exception of diabetic supplies – these are covered with a written prescription (yearly) from one of Sawtooth Mountain Clinic’s providers. Prescriptions written for use as an in-patient at the North Shore Hospital or Care Center will not be covered. 5. Dental Care for patients of SMC: Coverage: The sliding scale will cover up to $1,000 annually per patient for services provided by Drs. Hedstrom and Lindquist’s office, Grand Marais Family Dentistry. The dentist can request additional coverage from the clinic for special situations that are medically necessary. Dental Insurance: If you have dental insurance, the dentist office will submit a claim to your insurance carrier and then bill the clinic directly for the remaining charges. The clinic will send you a statement for the percentage you are responsible for. 6. Counseling and Support Referrals for patients of SMC: Sliding scale will provide up to 15 visits per year with counseling and support providers in our community. Currently participating are Linda Vanden Brook, MA, LMFT, at 4 Directions; Wayne Arnzen, MA, LP; Kelly Senty, M.A., at Steps of Change; Sherri Moe, MS; and the Human Development Center. Please tell your counseling provider that you are on Sawtooth Mountain Clinic’s sliding scale program at time of registration or at your appointment. Billing: Your counseling provider may bill you. If you receive a bill, bring it to Steve Fleace at the Sawtooth Mountain Clinic. 7. Vision Care for patients of SMC: The sliding scale will cover basic vision exams up to twice per year as necessary. Exams must be performed by St Luke’s Ophthalmology Associates located at the Cook County North Shore Hospital and Care Center. Sliding scale will not cover glasses or contacts. St Luke’s will submit a claim to your insurance company. You are responsible to let St Luke’s know that you are on sliding scale. St Luke’s will then bill the clinic directly for your charges. The clinic will adjust the bill and send you a statement for the percentage you owe. 8. Referrals: Consultations: The sliding scale will cover an initial outpatient consultation, when the referral is made by a Sawtooth Mountain Clinic Provider. Billing: Please notify your specialist’s office, at the time you register, that you wish to have them file your insurance claim for you. The specialist will bill you. You must then bring your bill to the Sawtooth Mountain Clinic. We will adjust consultation fees based on sliding scale eligibility. The specific services authorized are covered by the sliding scale, but if you seek continued care at the specialist, it will not be covered, even if for the condition originally treated. If the specialist hospitalizes you, please remember that the sliding fee scale covers no inpatient costs. Chiropractic Care for patients of SMC, with referral: Sawtooth Mountain Clinic Providers may refer you for complimentary medical services available in Cook County. The sliding fee scale program will cover services up to $500.00/calendar year. A referral slip from a Sawtooth Mountain Clinic Provider must be given to the Chiropractor (Malin Aseby-Gesch, D.C. or Loren Stoner, D.C.) to be eligible for this benefit. SMC does not cover x-rays ordered by the Chiropractor. Hearing Aid Assistance for SMC patients, with referral: Sawtooth Mountain Clinic Providers may refer you for assistance of up to $1,000.00/calendar year for the purchase of hearing aids when arranged through hearing providers visiting SMC. Hearing assistance will be reviewed on a case by case basis and must be pre-approved. Physical Therapy for SMC patients, with referral: In addition to physical therapy through the Cook County North Shore Hospital referenced above, Sawtooth Mountain Clinic Providers may refer you for physical therapy services to Becky Stoner P.T. at the Grand Marais Wellness Center. The sliding fee scale program will cover up to $1,000.00/calendar year. A referral slip from a SMC Provider must be given to the physical therapist to be eligible for this benefit. SMC does not cover x-rays ordered by the physical therapist. Acupuncture, Acupressure, Homeopathic, Healing Touch, Massage and Art Therapy for SMC patients, with referral: Sawtooth Mountain Clinic Providers may refer you for services up to $500.00/calendar year per provider type. A referral slip from a Sawtooth Mountain Clinic Provider must be given to the provider to be eligible for these benefits. Eligible providers include Mona Abdel-Rahman L.Ac. at Crescent Moon Acupuncture LLC; Jessi Nicholson L.Ac.M.O.M. at Quiet Waters Acupuncture and Herbal Medicine; Debi LaMusga H.T.P. at Anahata Healing Touch; Christal Stone Kelahan MT at Therapy by the Lake; Laurie J. Senty BCTMB at Shiatsu Therapy and Therapeutic Massage; Trish Francis C.M.T. at Well Springs Therapy; Carol Einwalter NBCMT LMT and staff at WatersMeet Wellness Center; Margy Nelson C.M.T. Homeopath; Natalie Sobanja MT; Suzabelle Janicek ATR MFA MA; and Pamela Faye, RN, CHTP, Healing Touch and Massage Therapy. 9. Lab & x-ray: Lab charges from Medtox will be covered for pathology. X-ray charges from Consulting Radiologists will be covered for x-ray interpretations. MRI mobile unit (available at North Shore Hospital) x-ray charges will be covered one time/calendar year. The Providers at Sawtooth Mountain Clinic must authorize these outpatient services. If you receive a bill, please bring it to Steve Fleace or Erin Watson at the SMC. 10. Other Area Services: Cook County North Shore Hospital has a Community Care program available for qualified patients. Call 387-3040 for more information. Oral Health Task Force has a sliding fee program for children’s additional dental care. Call the Grand Marais Family Dentistry at 387-2774 to inquire about this program. Please keep these instructions for future use. Slide/2015 appl 10/2015 This program is made available through the U.S. Department of Health and Human Services, Community Health Centers, section :330 grant funding. Sawtooth Mountain Clinic is a 501©(3) not-for-profit organization. Sawtooth Mountain Clinic, Inc. Sliding Scale Statement of Financial Position OFFICE USE _______% _______ ___________________ _______ Applicant’s Name______________________________ Date of Birth Spouse’s Name ________________________________ Date of Birth ___________________ Mailing Address__________________________________________________________________ Home Telephone_______________________________ Work Telephone (Spouse)_______________________ Work Telephone__________________ Family Dependents (living at home): First Name Birth Date Last Name if Different ________________________ ________________________ ________________________ __________________ (Attach separate sheet if more space is needed.) Insurance Co. Name Do you plan to apply for Medical Assistance? ________ Social Security Number _____________________ Group #. Policy # _________________ Earned Income $___________________ /year. Social Security/Pensions $________________ Unemployment Income $_____________Self employed adjusted gross income $___________ Interest Income $____________________ TOTAL: $______________________________ Type of Income verification: _________________ PLEASE CHECK OR CIRCLE ONE THAT APPLIES: RACE: Hispanic or Latino Asian Caucasian American Indian or Alaskan Native Black or African American Native Hawaiian Pacific Islander ETHNICITY: Hispanic or Non-Hispanic VETERAN: More than one race Yes No I hereby acknowledge that I have read these instructions. Sawtooth Mountain Clinic and Cook County North Shore Hospital may share my income information to determine program availability. I understand that the Sawtooth Mountain Clinic’s sliding scale of assistance for low-income residents is a defined program with service and payment limits. The Clinic will not be responsible for bills which I may incur outside of the specified limits. I hereby swear that the above information is correct as stated. Falsifying this information is a crime punishable by law. _____________________________________ Signature _____________________________________ Spouse’s name/signature if applicable ________________________________ Date Income Eligibility 2015-2016 Family size 1 2 3 4 5 6 7 8 Level APatient pays 5% of charge 0-11,770 0-15,930 0-20,090 0-24,250 0-28,410 0-32,570 0-36,730 0-40,890 Level B-Patient pays Level C-Patient pays 10% of charge 15% of charge 11,771-15,693 15,931-21,240 20,091-26,787 24,251-32,333 28,411-37,880 32,571-43,427 36,731-48,973 40,891-54,520 15,694-19,617 21,241-26,550 26,788-33,483 32,334-40,417 37,881-47,350 43,428-54,283 48,974-61,217 54,521-68,150 Level D-Patient pays 20% of charge Patient pays 100% of charge 19,618-23,540 26,551-31,860 33,484-40,180 40,418-48,500 47,351-56,820 54,284-65,140 61,218-73,460 68,151-81,780 23,541+ 31,861+ 40,181+ 48,501+ 56,821+ 65,141+ 73,461+ 81,781+ (**Patient shall pay 5% at Level A, 25% at Level B, 50% at Level C, and 75% at Level D, for pharmacy coverage.)