AG 1992 08 03 - Laserfiche WebLink

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DIV. OF MATERNAL AA~3 CHILD HF_ALTH SLIDING FEE SCALE MONThlY GROSS INCOME FOR USE IN FAMILY PLARNING AND MCH CLINICS 100% OF FAMILY ZERO PAY TWENTY PERCENT FORTY PERCENT POVERTY S I ZE PAY PAY CABARRUS COUNTY ItEALTH DEPARTMENT MATERNAL HEALTH PROGRAM FEE SCALE - (GROSS INCOME) SIXTY PERCF-NT EIGHTY PERCENT FULL PAY PAY PAY BEGINS $568 1 $0 TO $568 $569 TO $709 $710 TO $851 $766 2 $0 TO $766 $767 TO $957 $958 TO $1149 $964 3 $0 TO $964 $965 TO $1205 $1206 TO $1446 $1163 4 $0 TO $1163 $1164 TO $1453 $1454 TO $1744 $1361 5 $0 TO $1361 $1362 TO $1701 $1702 TO $2041 $1559 6 $0 TO $1559 $1560 TO $1949 $1950 TO $2339 $1758 7 $0 TO $1758 $1759 TO $219] $2198 TO $2636 $1956 8 $0 TO $1956 $1957 TO $2445 $2446 TO $2934 $2154 9 $0 TO $2154 $2155 TO $2693 $2694 TO $3231 $2353 10 $0 TO $2353 $2354 TO $2941 $2942 TO $3529 $2551 I! $0 TO $2551 $2552 TO $3189 $3190 TO $3826 $2749 12 $0 TO $2749 $2750 TO $3436 $3437 TO $4124 ;852 TO $993 $994 TO 11134 $1135 ;1150 TO $1340 $1341 TO $1531 $1532 1447 TO $16B7 $1688 TO $1927 $1928 ;1745 TO $2034 $2035 TO $2324 $2325 ;2042 TO $2381 $2382 'TO $2721 $2722 ;2340 TO $2729 $7730 TO $3117 $3118 ;2637 TO $3076 $3077 TO $3514 $3515 ;2935 TO $3423 $3424 TO $3911 $3912 ;3232 TO $3770 $3771 TO $4307 $4308 ~3530 TO $4117 $411B TO $4704 $4705 ;3827 TO $4464 $4465 TO $5101 $5102 ~4125 TO $4811 $4812 TO $5497 $5498 INSTRUCTIONS: AFTER DETERMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR NOTE: NO CMARGE$ MAY BE ASSESSED IF PATIENT IS MEDICAID ELIGIBLE. IF SCAL~. ANNUALIZED MONTHLY INCOME FI~JRES MAY NOT EQUAL THOSE ON DIV. OF MCH ~/~s/92 207, C~nplete (ini~] visit) $12.00 Revisit (subsequent visit) $12.00 Rhogsm (for Ph negative patients) $ 5.00 Non-Stress Fetal Test $12.00 Eligibility w~11 be determined with each pregnar~. 40% PAY $24.00 $24.00 $10.00 $24.00 AMOUNT OF CHARGE ON APPROPRIATE Y~Y INCOME IS k~IOWN, IISE ~ S~ DUE ~ ROU~ING. ~% PAY ~% PAY ~ PAY $~.~ ~.~ $~.~ $15.~ $20.~ $25.~ $35.~ ~7.~ Incoma will be determined by de~]_~r'ation of inccem by patient; however, verification can be requested at the discretion of the eligibility speed,list. Patients will be expected to pay aacording to the above fee scale. Patients on sliding fee snm)-, who fall to pay during a pregnancy and return to the b~mlth department for care with a subsequent pregnancy wi. 1_.] be referred to the pro~n supervisor or uursing director prior to acceptance for ~mre. Patients with hospital insurance will be referred 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' appoinlm~nts filled) patient can receive care at the Cabarrus Gounty H~lth Department. Eligibility spe:!~list will verify/dcc~m~nt (using special form) that "pati~mt is unable to receive care." Insuranc~ patients wi~ be placed in the full pay category regardless of inccme. Insurance wi]] be filed by the Health department. 6-17-91: Approved by Cabarrus County Board of lt~lth ar~ County C~,,,isstonsers, to be effective 7-1-91. ."