Service Locations/Phone NumbersAspen ...................................................... 970.920.5555Craig .........................................................970.824.6541Eagle ........................................................970.328.6969Frisco ....................................................... 970.668.3478Glenwood Springs ............................. 970.945.2583Granby ..................................................... 970.887.2179Grand Junction ....................................970.241.6023Meeker .................................................... 970.878.5112Rangely .................................................... 970.675.8411Rifle .......................................................... 970.625.3582Steamboat Springs ............................. 970.879.2141Vail ............................................................ 970.476.0930Walden ................................................... 970.723.0055

Billing Department ...............................888.320.5218

www.MindSpringsHealth.org

Nov 2015

Mind Springs Health is pleased to offer a greatly enhanced sliding-scale fee discount for Behavioral Health mental health and substance abuse services.

Sliding-scale fee discounts are available to clients who are within 300% or less of the Federal Poverty Guidelines, are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay based on their financial situation. Fees are a per session co-pay.

Financial assistance is available to client’s experiencing a financial hardship on a case by case basis. Please speak with our front desk staff for information.

VisionWe envision health and wellness in our communities.

MissionIt is our mission to provide access to quality mental health and substance abuse services, enhancing recovery and resilience in individuals, families and communities.

Values» Strength created through local partnerships,

with collaboration & education» Integrity and accountability in all we do» Outcomes driven» Responsible financial stewardship» Leadership in physical and behavioral health

care integration» Culture of trauma-informed care» Focus on exceptional customer service

FINANCIAL ASSISTANCEMind Springs Health is committed to reducing

financial barriers to treatment for those members of our community who are in need of financial assistance for mental health and

substance abuse services.

24-HOUR CRISIS LINE

888.207.4004

MSprings_Financial Assistance_broch_Update9-15.indd 1 11/9/15 12:19 PM

Service ExclusionsDriving Under the Influence (DUI) classes, Detoxification, and court ordered substance abuse services are excluded from sliding-scale fee discounts.

How much are co-pays?Once the ability to pay is established, the cost per service can range from $0 to full fee per service. Cost is based on a percentage of Mind Springs Health full fee and subject to periodic revisions.

Sliding-scale Fee Discount Rating ________________________

Fees are subject to change under periodic reviews. Fees vary based on duration and provider credentials. Please review with a Business Services Associate.

Payment Requirements» Payment is expected at the time of service.» Accepted payment types: cash, check, VISA, MasterCard or Discover.» If payment cannot be made at the time of service, appointment will be rescheduled for a time when payment

can be made.» Statements are mailed out monthly if a balance is owed.

No Show/Cancellation PolicyAll appointments cancelled less than 24 hours before the appointment start time will be considered a no-show. Two consecutive no-show appointments or 3 no-shows within a 90-day period may result in discontinuation of scheduled appointments. If scheduled appointments are discontinued, services may be available through drop-in treatment. Services remain subject to co-pay.

How do I Qualify?» Must be uninsured or under insured» Not enrolled in Medicaid or other

publically funded program» Within 300% of the

Federal Poverty Guidelines

The sliding-scale fee discount is based on number of people in household and household income. Acceptable sources of income are as follows:

Acceptable Proof of Income» Most recent paychecks for all household

members. If not available, a letter from the employer addressed to “Whom It May Concern” indicating annual gross income from employment.

» Last 60 days (2 months’ worth) of bank statements.

» Colorado Indigent Care Program or equivalent designated community partner

Reassessment is required if the number of household members or household income changes. If client obtains health insurance or other funding source the information must be provided to the office staff, who will determine continued eligibility for the reduced fee.

Continued EligibilityProof of income is good for one year. To remain eligible, proof of income must be provided every 12 months. Should proof of income not be provided by the next scheduled appointment charges will be full fee.

Therapy Full Fee Unlicensed LicensedEvaluation $165 – $260 $ $

Individual $70 – $165 $ $

Family $105 – $250 $ $

Group $35 – $60 $ $

Psychiatry Full Fee APN MDEvaluation $285 – $320 $ $

Individual $115 – $265 $ $

Medication Management $60 – $250 $ $

• Wages/Tips/Salary• Trust Fund Income• SSI• SSDI• Savings/Retirement• Self Employment (including bank statements)

• Unemployment• Cash Gifts• Alimony• Rental Income• Worker’s

Compensation

MSprings_Financial Assistance_broch_Update9-15.indd 2 11/9/15 12:19 PM

Client

Resp.

Discount

Rating

FPL Family

Size

1 0 5,939 0 5,939 5,940 11,880 11,881 17,820 17,821 23,760 23,761 29,700 29,701 35,640

2 0 8,009 0 8,009 8,010 16,020 16,021 24,030 24,031 32,040 32,041 40,050 40,051 48,060

3 0 10,079 0 10,079 10,080 20,160 20,161 30,240 30,241 40,320 40,321 50,400 50,401 60,480

4 0 12,149 0 12,149 12,150 24,300 24,301 36,450 36,451 48,600 48,601 60,750 60,751 72,900

5 0 14,219 0 14,219 14,220 28,440 28,441 42,660 42,661 56,880 56,881 71,100 71,101 85,320

6 0 16,289 0 16,289 16,290 32,580 32,581 48,870 48,871 65,160 65,161 81,450 81,451 97,740

7 0 18,364 0 18,364 18,365 36,730 36,731 55,095 55,096 73,460 73,461 91,825 91,826 110,190

8 0 20,444 0 20,444 20,445 40,890 40,891 61,335 61,336 81,780 81,781 102,225 102,226 122,670

CICP

Crosswalk

Mind Springs Health

Sliding Scale Rating - Effective March 1, 2016

Annual Income Range / Percentage Federal Poverty Level

0% 1% 5% 10% 25% 40% 50%

50%

Z A B C D E F

100% 99% 95% 90% 75% 60%

Note: For each additional person, add $4,160 to annual income. Derived from federal poverty guidelines. Z = Homeless

251 - 300%

Z N A, B, C D, E, F G, H I N/A

0 - 50% 0 - 50% 51 - 100% 101 - 150 % 151 - 200% 201 - 250%

Client Financial Responsibility Policy and Procedures Mind Springs, Inc.

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Client Financial Responsibility Policy and Procedures Mind Springs, Inc.

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Client Financial Responsibility Policy and Procedures Mind Springs, Inc.

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Client Financial Responsibility Policy and Procedures Mind Springs, Inc.

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Client Financial Responsibility Policy and Procedures Mind Springs, Inc.

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Client Financial Responsibility Policy and Procedures Mind Springs, Inc.

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Fee Adjustment Application Client Name: ___________________________________________________ HEAD OF HOUSEHOLD: Name Date of Birth Social Security # Employer: Annual Gross Income: $ # of People Supported by this income I am currently unemployed Date of last paycheck I do, do not qualify for Unemployment Benefits ADDITIONAL EMPLOYED PERSON(S) IN HOUSEHOLD: Name Date of Birth Social Security # Employer: Annual Gross Income: $ Currently unemployed Date of last paycheck Does, does not qualify for Unemployment Benefits Fee Increase: I am able to pay more for my services than the established rating scale. Increase fee to Plan Fee Reduction: I am requesting financial assistance with Mind Springs Health established sliding fee scale Back balance on my account due to insurance deductibles or co-pays I am experiencing the following hardships: Change in employment: Previous wages $ Current wages $ Catastrophic medical expenses amount owed $ Unexpected expenses which may hinder my earning ability: Change in household Divorce Separation Death of wage earner Loss of child support Additional family members Increased Transportation Cost Increased Housing Cost Increased Utility Costs I hereby certify that the information listed herein is correct to the best of my knowledge and give Mind Springs Health permission to verify any information listed. Client or Authorized Person’s Printed Name Signature Date

For Msprings Staff Use Only: It is clinically necessary for this person to continue to receive treatment at a reduced fee Program Director Date Ability-to-pay reduced from UBP Plan to UBP Plan Begin Date End Date (Note – Z rating is for homeless clients only) Business Services Assistant Date submitted to PD A one time debt relief write off is approved $ MHC Revenue Cycle Supervisor