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DIV. OF MATERNAL AND CHILD HEALTH SLIDING FEE SCALE MONTHLY GROSS INCOME FOR USE IN FAMILY PLANNING AND MCH CLINICS CABARRUS COUNTY HEALTH DEPARTMENT MATERNAL HEALTH PR~tiAM FEE SCALE - (GROSS INCOME) 100% OF FAMILY ZERO PAY TWENTY PERCENT FORTY PERCENT POVERTY SIZE PAY PAY SIXTY PERCENT EIGHTY PERCENT FULL PAY PAY PAY BEG1NS $581 1 $0 TO $581 $582 TO $726. 5727 TO $871 $872 TO 11016 $1017 TO $1161 $1162 $786 2 $0 TO 5786 5787 TO 5982 I983 TO $1179 11180 TO 11375 51376 TO $1571 $1572 5991 3 $0 TO $991 $992 TO $1239 $1240 TO $1486 51487 TO $1734 $1735 TO $1981 S1982 $1196 4 $0 TO $1196 $1197 TO $1495 11496 TO 11794 $1795 TO 52093 $2094 TO $2391 $2392 $1401 5 $0 TO 11401 $1402 TO $1751 $1752 TO $2101 $2102 TO $2451 $2452 TO $2801 $2802 $1606 6 $0 TO $1606 $1607 TO $2007 $2008 TO $2409 $2410 TO $2810 52811 TO' 13211 $3212 $1811 7 $0 TO $1811 $1812 TO $2264 $2265 TO $2716 $2717 TO $3169 $3170 TO $3621 $3622 $2016 8 $0 TO $2016 $2017 TO $2520 $2521 TO $3024 $3025 TO $3528 53529 TO $4031 $4032 52221 9 $0 TO $2221 $2222 TO $2776 $2777 TO 53331 53332 TO $3886 53887 TO' $4441 $4442 $2426 lO $0 TO $2426 $2427 TO $3032 $3033 TO $3639 $3640 TO $4245 $4246 TO 14851 $4852 $2631 11 $0 TO $2631 $2632 TO $3289 $3290 TO $3946 $3947 TO S4b04 $4605 TO $5261 $5262 $2836 12 $0 TO $2836 $2837 TO $3545 53546 TO $4254 $4255 TO $4963 $4964 TO $5671 $5672 INSTRUCTIONS: AFTER DETKEMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR AMOUNT NOTE: NO CHARGES MAY BE ASSESSED IF PATIENT IS MEDICAID ELIGIBLE. IF YEARLY SCALE. ANNUALIZED MONTHLY INCOME F1GUEES NAY NOT EQUAL THOSE ON ANNUAL DIV. OF MCH $/14/93 OF CHARGE ON APPROPRIATE SCHEDULE. INCOME IS KNOWN, USE ANNUAL SCALE DUE TO ROUNDING. Service ~0% pay 40% Pay 60% Pay 80% Pay Full Pay Complete (initial visit) $12.00 $24.00 $36.00 $48.00 $60.00 Revisit (subsequent visit) $12.00 $24.00 $36.00 $48.00 $60,00 Rhogam (for Rh negative pts.) $ '9.00 $18.00 $28.00 $37.00 $46.00 Non-Stress Fetal Test $12.00 $24.00 $35.00 $47.00 $59.00 Oral Glucose Tolerance Test $ 4.00 $ 8.00 $12.00 $16.00 $20.00 Eligibility will be determined, with each pregnancy. Income will be determined by declarartion of income by patient; however, verification can be requested at .the discretion of the eligibility specialist. Patients will be expected to pay according to the above fee scale. Patients on sliding fee scale who fail to pay during a pregnancy and return to the health department for care with a subsequent pregnancy will be referred to the program supervisor or nursing director prior to acceptance for care. Patients with hospital insurance will be ~eferred to private care. If the patient is unable to obtain medical care within Cabarrus County (i.e., lack of up-front funds, owes doctor for previous services, doctors' appointments filled) patient can receive care at the Cabarrus County Health Department. Insurance patients will be placed in the full category regardless of income. Insurance will be filed by health department. 06-17-91: Approved by Cabarrus County Board of Health and County commissioners, to be effecitve 07-01-91. 08-04-92: Approved by Cabarrus County Board of Health and County Commissioners 08-03-92.