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WOMEN'S HEALTH SECTION SLIDING FEE SCALE MONTHLY GROSS INCOME FOR USE IN FAMILY PLANNING AND MCH PROGRAMS CABARRUS COUNTY HEALTH DEPARTMENT MATERNAL HEALTH PROGRAM FEE SCALE - (GROSS INCOME) 100% OF FAMILY ZERO PAY TWENTY PERCENT FORTY PERCENT SIXTY PERCENT EIGHTY PERCENT POVERTY SIZE PAY PAY PAY PAY $613 1 $0 to $613 $614 to $767 $768 to $920 $921 to $1073 $1074 to $1226 $820 2 $0 to $820 $821 to $1025 $1026 to $1230 $1231 to $1435 $1436 to $1639 $1027 3 $0 to $1027 $1028 to $1283 $1284 to $1540 $1541 to $1797 $1798 to $2052 $1233 4 $0 to $1233 $1234 to $1542 $1543 to $1850 $1851 to $2158 $2159 to $2466 $1440 5 $0 to $1440 $1441 to $1800 $1801 to $2160 $2161 to $2520 $2521 to $2879 $1647 6 $0 to $1647 $1648 to $2058 $2059 to $2470 $2471 to $2882 $2883 to $3292 $1853 7 $0 to $1853 $1854 to $2317 $2318 to $2780 $2781 to $3243 $3244 to $3706 $2060 8 $0 to $2060 $2061 to $2575 $2576 to $3090 $3091 to $3605 $3606 to $4119 $2267 9 $0 to $2267 $2268 to $2833 $2834 to $3400 $3401 to $3967 $3968 to $4532 $2473 10 $0 to $2473 $2474 to $3092 $3093 to $3710 $3711 to $4328 $4329 to $4946 $2680 11 $0 to $2680 $2681 to $3350 $3351 to $4020 $4021 to $4690 $4691 to $5359 $2887 12 $0 to $2887 $2888 to $3608 $3609 to $4330 $4331 to $5052 $5053 to $5772 FULL PAY BEGINS. $1227 $164o $2053 $2467 $2880 $3293 $3707 $4120 $4533 $4947 $5360 $5773 INSTRUCTIONS: NOTE: NO CHARGES MAY BE ASSESSED IF PATIENT IS MEDICAID ELIGIBLE. IF YEARLY INCOME IS KNOWN, USE ANNUAL SCALE. ANNUALIZED MONTHLY INCOME FIGURES MAY NOT EQUAL THOSE ON ANNUAL SCALE DUE TO ROUNDING. AFTER DETERMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR AMOUNT OF CHARGE ON APPROPRIATE SCHEDULE. DIV. OF MCH 6/10/94 SERVICE 20% Pay 40% Pay 60% Pay 80% Pay Complete (initial visit) $15.84 $31.68 $47.52 $63.36 Revisit (subsequent visit) $15.84 $31.68 $47.52 $63.36 Rhogam (for Rh negative patients) $ 9.28 $18.55 $27.53 $37.10 Non-Stress Fetal Test $12.00 $24.00 $35.00 $47.00 Oral Glucose Tolerance Test $ 4.00 $ 8.00 $12.00 $16.00 Eligibility will be determined with each pregnancy. Income will be determined by declaration of income by patient; however, verification Full Pay $79.20 $79.20 $46.38 $59.00 $20.00 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 and excessive income 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' appointments filled) patient can receive care at the Cabarrus County Health Department. Insurance patients will be placed in the full pay category regardless of income. Insurance will be filed by the health department.