SpectraPlan Eligibility 2025

Family Size & Income
Family Size*
Income for Family Size 1
Income for Family Size 2
Income for Family Size 3
Income for Family Size 4
Income for Family Size 5
Income for Family Size 6
Income for Family Size 7
Income for Family Size 8
Income for Family Size 9
Income for Family Size 10
Below is a chart reflecting our 2025 SpectraPlan Discount Program eligibility (please note that you do not have to do anything with this chart, it is only for reference):
Spectra Health offers a sliding fee discount program, known as the SpectraPlan. The SpectraPlan can assist with the cost of care for services at Spectra Health. All discounts are subject to a Nominal Fee.

This form is used for potential eligibility for the DISCOUNT PROGRAM at Spectra Health and refusing is declining ANY possible discount on future services.
Please check ONLY ONE box below:*

I WANT to apply for the SpectraPlan. I WANT to be contacted by Spectra Health staff to discuss completing a full SpectraPlan application and providing income verification.I DO NOT want to apply for the SpectraPlan. I do not want/need any discount on future services I receive at Spectra Health. I understand I can apply for the SpectraPlan at any time in the future if needed.Common reasons for not participating in the SpectraPlan are:• A third-party agency is responsible for patient payment.• You are not eligible to participate due to income.• You are not interested in participating.

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Date*

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If eligibility is indicated above, please note a full application and income verification is required to determine approval, Spectra Health Social Service Department would be pleased to assist with the full SpectraPlan application process. Please schedule an appointment with registration or call 701-757-2100 for further assistance.

Please note the SpectraPlan discount program can NOT be applied to reduce any monthly Medicaid recipient liability for those patients for whom this
applies.
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