Frequently asked questions about Dental Financial Assistance

DFA may be applied to certain necessary dental services provided at Kaiser Permanente facilities by KP dental clinicians. 

Note: Assistance for covering the cost of emergent and medically necessary hospital and non-hospital services, prescriptions (including dental prescriptions written by KP clinicans) and pharmacy supplies are covered under KP’s Medical Financial Assistance (MFA) program.

The DFA program does not provide financial assistance for:

  • Dental services that are not considered emergent or necessary as determined by a KP dental provider. 

  • The DFA policy applies only to services provided at Kaiser Permanente facilities by Kaiser Permanente dental clinicians. Even upon referral from a Kaiser Permanente dental clinician, all other services are not eligible for DFA.

Patients can apply for DFA prior to or up to 12 months after their care.

You’ll need the following information to apply:

  • Household size and income information for all adults in the household (see definitions in this FAQ)

  • Proof of income

Income verification is part of determining eligibility for dental financial assistance. Including proof-of-income documentation with your application will assist in confirming the accuracy of your income during the review process.

Patients who choose to verify their financial status by providing financial documentation may submit their most recent pay stubs or income tax return for the current tax year as proof of income. Kaiser Permanente will also accept additional proof-of-income documentation as outlined below.

The table lists the optional documents to submit according to your household income source(s).

Household income resource(s) Provide only one of the following per income source
Business, rental income 
 
  • Recent W-2, 1099 statement
  • Tax return
Employment income wages

 
  • Recent pay stubs
  • Recent W-2, 1099 statement
  • Tax return
Received pension, retirement, annuities income


 
  • Recent pay stubs
  • Pension/retirement disbursement statement
  • Recent W-2, 1099 statement
  • Tax return
Self-employed income


 
  • Recent pay stubs
  • Recent W-2, 1099 statement
  • Tax return
Social Security, Supplemental Security Income

 
  • Benefit verification letter from the Social Security Administration
  • Social Security statement
Unemployment benefits, disability income


 
  • Unemployment/disability benefits verification letter
  • Recent W-2, 1099 statement
  • Tax return
Veteran benefits income


 
  • VA benefits verification letter
  • Recent W-2, 1099 statement
  • Tax return
Government assistance (ex. Medicaid, TANF, SNAP, WIC or low income housing) 
  • Approval of eligibility letter
Interest or dividends income
 
  • Recent tax return
Spouse/child support payments received

 
  • Letter verifying monthly gross income received for child support or alimony

No household income

 
  • Written attestation or explanation

You might be asked to provide recent paystubs or tax returns. You can also send other income documents mentioned in the DFA program application. If you are approved for DFA, you’ll get a written notice and can choose to decline DFA or give income documents to ask for more help. Income documents given for DFA won’t be used to collect money.

You’re considered prequalified and will get DFA for all eligible services if you meet any of the following conditions:

  • Enrolled in a or likely eligible for a government health coverage program like Medicaid, Medicare Low Income Subsidy Program (LIS), or subsidized coverage from the Health Benefit Exchange.

  • Enrolled in a government public assistance program like Women, Infants and Children programs, Supplemental Nutrition and Assistance programs, low-income household energy assistance programs, or free/reduced cost lunch programs.

  • Living in low-income or subsidized housing

Income requirements apply to the members of the household.  

Household size is defined as: Patient’s family or household includes: 

  1. For persons 18 years of age and older - a spouse, domestic partner, and dependent children under 21 years of age, or any age if disabled, whether living at home or not.

    For persons 18 to 20 years of age, family members also include parent, caretaker relatives, and parents or caretaker relatives’ other dependent children under 21 years of age or any age if disabled. 

  2. For persons under 18 years of age - a parent, caretaker relatives, and other children under 21 years of age or any age if disabled.

Dental Financial Assistance award amounts are based on your household income as a percentage of the federal poverty guidelines:

Note: Assets are not considered income.

 

2025 Federal Poverty Guidelines

 

If your household family size is: 100% award for gross monthly household income at or below 200% FPG 75% award for gross monthly household income between 201% and 300% of FPG 50% award for gross monthly household income between 301% and 350% of FPG 25% award for gross monthly household income between 351% and 400% of FPG
1 Up to $2,608 $2,609 to $3,913 $3,914 to $4,565 $4,566 to $5,217
2 Up to $3,525 $3,526 to $5,288 $5,289 to $6,169 $6,170 $7,050
3 Up tp $4,442 $4,443 to $6,663 $6,664 to $7,733 $7,744 to $8,883
4 Up to $5,358 $5,359 to $8,038 $8,039 to $9,377 $9,378 to $10,717
5 Up to $6,275 $6,276 to $9,413  $9,414 to $10,981 $10,982 to $12,550
6 Up to $7,192 $7,193 to $10,788 $10,789 to $12,585 $12,586 to $14,383

Visit aspe.hhs.gov/poverty to find the guidelines for larger households.

Disclaimer

Past MFA award recipients aren't guaranteed future awards. Kaiser Permanente reserves the right to change the terms and conditions of the MFA program at any time. An MFA award is not a covered benefit and does not change the services covered or cost-sharing owed under your plan.

A patient who meets eligibility requirements will get a sliding scale discount on their costs for eligible KP dental services. The DFA discount is based on where the patient’s household income falls within the Federal Poverty Level (FPL) guidelines:

Federal Poverty Guidelines Percentages Financial Assistance Discount
From To  
0%  200% 100% Discount (Full)
201%  300% 75% Discount (Partial)
301% 350% 50% Discount (Partial)
351% 400% 25% Discount (Partial)

If a patient is approved for partial DFA, the remaining balance is required to be paid in full or the patient has an option to set up an interest-free payment plan.

The DFA eligibility period starts from the approval date in the award letter and lasts up to 180 days for eligible follow-up services.

If you experience a change in household income, you’ll be asked to reapply to the DFA program.

If your application was recently denied or you believe you qualify for a larger award, you can appeal the decision.

Start an appeal application by mailing or faxing financial documentation to the address or fax number listed near the bottom. 

You will need to provide:

  • The reason why you’re appealing (job loss, for example) 

  • Current financial documentation of your total gross household income to support your appeal (refer to the table shown in the “What information will I need to apply” section above for the required documentation of your income)

You will not be refunded for any payments you make before an appeal is approved.

You have 30 days to file an appeal. After 30 days, you will be asked to submit a new application.

To appeal for a larger award, you may appeal at any time before the award end date. 

If you didn’t provide the requested financial documentation or if your income changed, you can submit additional documentation. See the “What information will I need to apply” section above for the required income documentation.

To submit your appeal via fax or mail, complete and return the Appeal Request form included with your award letter along with supporting documentation.

To submit your appeal letter and documentation, please fax or mail using the contact information below:

Kaiser Permanente​
Attention: Financial Counselors​
500 NE Multnomah St.​
Portland, OR 97232

Or by fax: 1-877-829-3547​

Send copies of official documents; originals are not required.

Write the following information on the first page of your proof of income:

  • First and last name

  • Medical record number (if any)

  • Home address

  • Date of birth

Once we receive the requested documentation, we’ll send you a letter regarding the decision on your appeal within 30 days. If you file an appeal without including any additional information with your request, we’ll automatically deny your appeal. All appeal decisions are final.