Important! How the Affordable Care Program works

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1 Important! How the Affordable Care Program works What is the Affordable Care Program? The Program allows us to offer patients a sliding fee scale, depending on household income. You share the costs of your care and must pay a visit fee at each visit. You may also have to pay for certain medical supplies, equipment, and vaccines. This is a Federally Funded Program and federal poverty guidelines set limits on household income and dependents. This program is NOT health insurance and does not fulfill the federal requirement to have health insurance. We can help you identify health insurance options through MaineCare or the Federal Health Insurance Marketplace. Which services are covered and which are not? Only the healthcare visits you make to us are covered. This includes visits to your primary provider, mental health counselor, physical therapy, specialty care, or preventive dental care. The program also allows discounts for medicines from our pharmacy. The program does NOT cover visits to the hospital or other offices. The program does NOT cover certain lab work, tests, or x-rays that must be sent to outside providers, such as Spectrum or Dahl Chase. Those providers will bill you for their work. We may be able to help you get outside services at lower cost. Be sure to ask. What if I am referred to another place for care? When you get care outside of PCHC, you must ask the outside care provider if they have a sliding fee scale. The Affordable Care Program does not cover care providers outside Penobscot Community Health Care. What about costs? The visit fee is the amount you must pay at the time of each visit to us. Remember, this program does not offer free service. It offers discounts. We will explain the fees for care when you are accepted for the program. Visit fees are on a sliding fee scale, depending on your income. You must pay your visit fee at the time of each visit. How do I apply and get started with the program? Visits will be at full price until your application is received and approved. Apply at or before the first visit when you are unable to pay. This may be when you are a new patient or when you face hard times, such as losing a job. Don t wait to apply! We cannot offer discounts for services you got weeks or months before getting on the program. When you apply, you must send us the paperwork within 30 days. If you are unable meet this requirement, you must ask for an extension or reapply for the program. When you apply at a medical visit and are accepted to the program, the bill for that visit may be reduced. We will send you a letter to let you know.

2 Affordable Care Program (ACP) Application New or Renew Please fill in all the spaces. If you do not have an employer or insurance, write none. Name: Date of Birth: Social Security: Marital Status: Mailing Address: Where you live, if different from mailing address Contact Phone: Employer If you have insurance, write the name here: How to apply for the program Giving Proof of Income Applicants must provide: Last year s income tax return with all W-2 s, schedules and attachments. If you are claimed as a dependent on someone else s tax return, submit that taxpayer s return. o I filed taxes for last year: Yes No o I plan to file taxes for this year: Yes No o I was claimed by someone else as a tax dependent for last year: Yes No o I will be claimed by someone else as a tax dependent for this year: Yes No The last 3 months of current pay check stubs or a list of 3 months gross income on employer s letterhead signed by the employer. Most recent social security, disability, or pension statement. All required forms and documents must be submitted within 30 days of this application. This program requires a visit fee at the time of each visit. It is not free care. I understand that I will be required to fill out an IRS 4506-T form so that PCHC may request a tax transcript or verify my filing status. This is required even if you do not file taxes. I understand that if I get medicine from a drug company program, I allow that company to review my medical record and application to check on this medicine for audit purposes. I certify that all my answers are correct and complete as far as I know. I will tell PCHC about any changes in my health insurance or family income. I understand that if I misrepresent or give false information, I will be disqualified from the program. I understand that this program is NOT health insurance and does NOT fulfill the federal requirement to have health insurance. Patient Signature Date O & E Specialist Date

3 Listing Members of Your Household: If you filed taxes, please provide income information for yourself, your spouse, and any dependent you claimed on your taxes. If you are claimed as a dependent by someone else, please provide income for the person who claims you and anyone else listed on their tax return. If you do not file taxes and are not claimed as a dependent by anyone else, please provide income information for yourself, your spouse and any other person(s) who contribute to your support. First/Last Name Date of Birth Relation to you 1. (Self, spouse, child, parent, etc.) Gross income (before deductions) Income source (Job, Social Security, SSI, Tanf, etc.) We re here to help. Call us with questions. weekdays between 8 am and 5 pm. PCHC s Outreach & Enrollment Specialist team can help you with the application process. We can also help you find health insurance options through MaineCare or through the Federal Health Insurance Marketplace.

4 Affordable Care Application Worksheet Thank you for requesting an Affordable Care Application at Penobscot Community Health Care (PCHC). Your application must be complete, with all the members of your household included. Proof of income for all household members must also be provided. Please complete the worksheet below to see what we will need from you. **Please provide copies of income statements as noted below, originals will not be returned. IF ANYONE IS. Earning Wages from an employer Self Employed or Receiving Rental Income Unemployed Receiving Unemployment Benefits Receiving Workers Compensation Benefits Receiving Short/Long Term Disability Benefits Receiving Social Security or Disability Income (SSI/SSDI) Using savings or investments to pay expenses Retired and receiving retirement benefits Receiving Alimony or Child Support Receiving any form of Public Assistance (TANF, Food Stamps, General Assistance, etc ) Receiving assistance from family/friends Full-time Student receiving student loans Amount/ Frequency YOU MUST PROVIDE COPIES OF Most recent pay stubs from each job showing last 3 months or last 12 months gross income. Last year s tax return and all supporting schedules. Last 3 months rental receipts to show gross rental income. Unemployment benefit letter or Weekly Claims report showing current gross income. To request a letter, call or go to https://gateway.maine.gov/dol/webinq/. Workers Compensation benefits award letter showing gross distribution. Most recent pay stubs showing gross income for disability benefits for the last three months. Current year award letter. You can request a copy of your benefit award letter by calling The last three months bank statements showing withdrawals to pay expenses. Benefit letter or statement (if 401K, IRA, etc ) showing gross amount distributed. Record of payments received or copy of the court order. Benefit determination letter. Letter explaining the support you are receiving, signed by the person providing the support Copy of your FAFSA Please complete IRS form 4506t and include a copy of your most recent federal tax filing. MaineCare & Maine Breast and Cervical Health applications are available and you are encouraged to apply.

5 STATEMENT OF SUPPORT Patient Name: «PatientName» Patient Date of Birth: «Birthdate» Do any of these apply to you?? I don t pay rent or someone helps me with rent. I am living with I don t pay for my daily living expenses. I get help from This person will claim me as a tax dependent I am homeless and staying in a shelter or transitional housing. We will need a signed statement from a staff person. Statement of support: Patient Signature: Supporter Signature: Date: Date:

6 Patient Information Form Name: Date of Birth: Social Security Number: - - Address: Person(s) to notify in case of emergency: Phone: Phone: PCHC requires this information to receive the federal funding needed to support its mission of providing quality, affordable healthcare to all. The information you give is kept confidential (private). Primary language: (check one) English French Spanish Other Race: White/Caucasian American Indian/Alaska Native Asian Native Hawaiian African American Other Pacific Islander More than one race Other Hispanic/Latino: Yes No Number of people living in your household? Housing status: Not homeless Homeless Public housing Transitional If Homeless, where do you stay? Shelter Doubled Up Street Other Agricultural worker: Yes No If yes, which one: Migrant Seasonal Military Veteran: Yes No Household income range: $0-$10,000 $35,001-$40,000 $65,001-$70,000 $10,001-$15,000 $40,001-$45,000 $70,001-$75,000 $15,001-$20,000 $45,001-$50,000 $75,001-$80,000 $20,001-$25,000 $50,001-$55,000 $80,001-$85,000 $25,001-$30,000 $55,001-$60,000 $85,001-$90,000 $30,001-$35,000 $60,001-$65,000 > $90,001 RESPONSIBLE PARTY INFORMATION Does the patient have an agent or legal guardian who makes decisions on their behalf? Yes No If yes, Name of Person(s) Responsible for Patient: Relation (Parent, Spouse, etc.): Phone: *If the patient is over 18 years old, please provide an Advance Directive, such as a Healthcare Power of Attorney.

7 Affordable Care Program Fee Schedule Program Level Visit Fee Table SERVICE Level 1 Level 2 Level 3 Level 4 Level 5 Primary Care $12 $35 $45 $55 $65 PCHC Lab Testing & Radiology (X-ray) $12 $25 $35 $45 $55 Specialty $35 $45 $55 $65 $75 Preventive Dental $35 $45 $55 $65 $75 Restorative / Other Dental $35 35% 25% 15% 5% Pharmacy Primary Care includes: Pediatrics, Geriatrics, Counseling, OMT, Gynecology, Nutrition/Diabetes Education, and Psychiatry. Specialty includes: Dermatology, Podiatry, PT, Speech, Audiology, and Wound Care. Preventive Dental includes: Hygiene, Cleanings, Exams, and Radiology. Restorative/Other Dental includes: Fillings, Non-Surgical Simple Extractions, Palliative Care (temporary relief of pain), and LIMITED orthodontics. ** Certain medical supplies, equipment, and vaccines may not be covered by the Affordable Care Program, including but not limited to hearing aids, dental implants, root canals, dentures (complete or partial), and surgical extractions.

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