We Are Here To Help You!
Our team is here to assist you in navigating payment for services provided. We offer customized payment plans, help with financial assistance applications, and PA Medicaid. Our number one goal is to work with you to develop successful payment arrangements on a schedule that meets your individual needs.
Learn more about the Insurance Plans accepted at River Valley Health & Dental or get help with the Health Insurance Marketplace.
Sliding Fee Scale Discount Program
Our sliding fee discount program is a schedule of discounts applied to our fee schedule, which adjusts fees based on a patient’s ability to pay. We will determine sliding fee eligibility based on your income and tax household size, then apply the appropriate sliding fee discount to all future visits. In addition, we will apply retroactive discounts to visits up to 14 calendar days prior to the date of your application. Eligibility is good for one year from the date of your application and you are required to re-apply to be eligible to continue to receive the discount. We send a renewal application to all active sliding fee scale program participants within 2 months of expiration to ensure there is no lapse in coverage of the sliding fee scale program discounts.
To APPLY ONLINE for the Sliding Fee Scale Discount Program
Susquehanna Community Health & Dental Clinic, Inc.
Dba River Valley Health & Dental Center
Effective 2/1/2024
Sliding Fee Scale Household Size & Annual Income Schedule
| Option A | Option B | Option C | Option D | Option F | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Patient Pays Slide Scale A | Patient Pays Slide Scale B | Patient Pays Slide Scale C | Patient Pays Slide Scale D | Patient Pays Full Fee |
||||||
| Household Size | ||||||||||
| 1 | $0 | $15,060 | $15,061 | $21,084 | $21,085 | $26,355 | $26,356 | $30,120 | $30,121 | and over |
| 2 | $0 | $20,440 | $20,441 | $28,616 | $28,617 | $35,770 | $35,771 | $40,880 | $40,881 | and over |
| 3 | $0 | $25,820 | $25,821 | $36,148 | $36,149 | $45,185 | $45,186 | $51,640 | $51,641 | and over |
| 4 | $0 | $31,200 | $31,201 | $43,680 | $43,681 | $54,600 | $54,601 | $62,400 | $62,401 | and over |
| 5 | $0 | $36,580 | $36,581 | $51,212 | $51,213 | $64,015 | $64,016 | $73,160 | $73,161 | and over |
| 6 | $0 | $41,960 | $41,961 | $58,744 | $58,745 | $73,430 | $73,431 | $83,920 | $83,921 | and over |
| 7 | $0 | $47,340 | $47,341 | $66,276 | $66,277 | $82,845 | $82,846 | $94,680 | $94,681 | and over |
| 8 | $0 | $52,720 | $52.721 | $73,808 | $73,809 | $92,260 | $92,261 | $105,440 | $105,441 | and over |
| Additional Amt > 8 | $5,380 | $5,380 | $7,532 | $7,532 | $9,415 | $9,415 | $10,760 | $10,760 | and over | |
| % of FPL | 100% or below | 101%-140% | 141%-175% | 176%-200% | above 200% | |||||
Sliding Fee Scale Payment Schedule by Service Line
| Patient Payment Responsibility | |||||
|---|---|---|---|---|---|
| Service Description | Slide Scale A | Slide Scale B | Slide Scale C | Slide Scale D | Full Fee |
| Chiropractic Services | $5.00 Nominal Fee | $15.00 | $20.00 | $25.00 | Patient Responsible for full fee associated with the visit |
| Dental Services | $15.00 Nominal Fee | 20% of charges | 40% of charges | 60% of charges | |
| Medical Services | $10.00 Nominal Fee | $20.00 | $40.00 | $60.00 | |
| Pharmacy Services | Drug Cost + $1.00 | Drug Cost + $5.00 | Drug Cost + $10.00 | Drug Cost + S15.00 | No Discount |
It is important to note that individuals seeking dental services will pay a percentage of total charges as outlined in the appropriate slide category. Some services are carved out from this discount percentage due to the cost of materials/lab fees, such as crowns. This pricing structure is available upon request. In addition, for pharmacy services patients will be responsible for the full cost of the drug plus a portion of the “fill fee”. These costs are available by speaking directly with the Pharmacist at River Valley Pharmacy. All patients that pay current balance due for that day’s visit at time-of-service will be offered a 25% prompt pay incentive. This incentive does not apply to proper balances.
Acceptable supporting documents for household earned and unearned income:
- One Full Month of Paystubs (Based on check date, all check stubs must be for a calendar month)
- Most Recently Filed Income Tax Return/W2’s
- Unemployment Compensation Determination Letter or Printout
- Annual Social Security Determination Letter or Printout
- Child Support Statement from Domestic Relations or Printout
- Letter from employer stating wages and hours worked each pay period
- Pension or Retirement Income
- Interest Income
- Self-Declaration Statement (Please see a member of Financial Services for Self-Declaration Statement)
All aforementioned supporting documents pertaining to your household earned and unearned income are required, along with the completed Sliding Fee Scale application, to be considered for sliding fee discount program.
If you will be returning your documents through the mail, please send them to:
River Valley Health & Dental
Attention: Financial Services
471 Hepburn Street
Williamsport, PA 17701
If you choose to drop them off, you may do so at: River Valley Health & Dental, 471 Hepburn Street, Williamsport, PA 17701
Please provide COPIES of all documents, as we do not mail them back to you.
You may be required to speak with a patient financial services representative to help with payment options, discount programs and other resources that you may not already know are available.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (570) 567-5400 Option #4,
then #1.