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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 FULL PAY POVERTY SIZE PAY PAY PAY PAY BEGINS $581 1 $0 to $581 $582 to $726 $727 to $871 $872 to $1016 $1017 to $1161 $1162 $786 2 $0 to $786 $787 to $982 $983 to $1179 $1180 to $1375 $1376 to $1571 $1572 $991 3 $0 to $991 $992 to $1239 $1240 to $1486 $1487 to $1734 $1735 to $1981 $1982 $1196 4 $0 to $1196 $1197 to $1495 $1496 to $1794 $1795 to $2093 $2094 to $2391 $2392 $1401 5 $0 to $1401 $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 $2811 to $3211 $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 $3529 to $4031 $4032 $2221 9 $0 to $2221 $2222 to $2776 $2777 to $3331 $3332 to $3886 $3887 to $4441 $4442 $2426 10 $0 to $2426 $2427 to $3032 $3033 to $3639 $3640 to $4245 $4246 to $4851 $4852 $2631 11 $0 to $2631 $2632 to $3289 $3290 to $3946 $3947 to $4604 $4605 to $5261 $5262 $2836 12 $0 to $2836 $2837 to $3545 $3546 to $4254 $4255 to $4963 $4964 to $5671 $5672 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. DIV. OF MCH 5/14/93 AFTER DETERMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR AMOUNT OF CHARGE ON APPROPRIATE SCHEDULE. 20% Pay 40% Pay 60% Pay 80% Pay Full Pay $12.00 $24.00 $36.00 $48.00 $60.00 $12.00 $24.00 $36.00 $48.00 $60.00 $ 9.00 $18.00 $28.00 $37.00 $46.00 $12.00 $24.00 $35.00 $47.00 $59.00 $ 4.00 $ 8.OO $12.00 $16.00 $20.00 Complete (initial visit) Revisit (subsequent visit) Rhogam (for Rh negative patients) Non-Stress Fetal/Test Oral Glucose Tolerance Test Eligibility will be determined with each pregnancy. Income will be determined by declaration 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 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.