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FAMILY PLANNING FEE SCALE
<br />
<br /> 125%'to 200% FederaY Poverty
<br />
<br /> Patient Fee Category -- Annual Gross Income
<br />
<br /> 150% ' SSBG*
<br />Family Reference (Title XX) 20Z 40% 60Z 80% .. Full
<br />Size Figure Eligibility paM Pa~ '~ay Pay Pay
<br />I $ 8,655 $0-$ 7,212 $ 7,213- 8,294 $ 8,295- 9,376 $ 9,377-10,488 $10,459-11,539 $11,540
<br />2 $11,595 $0-$ 9,662 $ 9,663-1i,112 $11,113-12,56I $12,562-14,010 $14,011-1S,459 $15,460
<br />3 $14,535 $0-$12,112 $12,113-I3,929 $13,930-15,746 $15,747-17,563 $17,564-19,379 $19,380
<br />4 $17,475 $0-$14,562 $14,563-16,747 $16,748-18,931 $18,932-21,115 $21,116-23,299 $23,300
<br />5 $20,415 $0-$17,012 $17,013-19,564 $19,565-22,116 $22,117-24,668 $24,669-27,219 $27,220
<br />6 $23,355 $O-$19,462 $19,463-22,382 $22,383-25,301 $25,302-28,220 $28,221-31,139 $31,140
<br />7 $26,295 $0-$21,912 $21,913-25,199 $25,200-28,686 $28,487-31,773 $31,774-35,059 $35,060
<br />8 $29,~35 $0-$24,362 $24,363-28,017 $28,018-31,671 $31,672-35,325 $35,326-38,979 $38,980
<br />9 $32,L75 $0~$26,812 $26,813-30,834 $30,835-34,856 $34,857-38,878 $38,879-42,899 $42,900
<br />10 $3§,115 $0-$29,262 $29,263-33,652 $33,653-38,041 $38,042-42,430 $42,431-46,819 $46,820
<br /> + 2,940 + 2,450 + 3,920
<br />
<br /> Complete Physical (Initial or Annual): $15.37 $30.74 $46.12 S61.49 $76.86
<br /> Extended ReVisit (Revisit with Pelvic):' $ 5.75 '"' $11.50 $17.25 $23.00 $28.75.
<br /> Limited Revisit (Revisit without Pelvic): $ 3.25 $ 6.25 $ 9.25 $12.50 $15.50
<br /> Natural Family. Planning (NPP) Services $ 8.00 $16.00 $24.00 $32.00 $40.00
<br /> .Natural Family Planning Services are those provided by a.certified NF~ Case Manager which are necessary to teach
<br /> ezfective method usage--a typical "package" would include i~itial counseling and as many as thre~ return sessions
<br /> spread over the next two to three months, as well as necessary NFP supplies (i.e., thermometers, charts, etc.)
<br /> Additional charges may be assessed (at the discretion.of the case manager) for subsequent visits that exceed those
<br /> neede~ to establish basic. NFP p~oficiency. Do not bill Medicaid or Title XX for NFP. Note: Complete Physical's
<br /> (Initials er Annuals) provided to 5FfP patients may be reimbursable.
<br /> *Social Services Block Grant--Patients whose income falls into (or below) this range are not to be charged a fee. The
<br /> ~ Service package is not covered by existing reimbursement agreements--do not bill Title XX for NFP services. If
<br /> patient is eligible for Medicaid reimbursement, Medicaid should be billed instead.
<br /> 5/88 Family Planning Branch (To be effective 07/01/88.)
<br /> 06-06£88: Approved by the Cabarrus County Board of Health to be effective 07-01-88.
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