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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 $568 1 $0 to $568 $569 to $709 $710 to $851 $852 to $993 $994 to $1134 $1135 $766 2 $0 to $766 $767 to $957 $958 to $1149 $1150 to $1340 $1341 to $1531 $1532 $964 3 $0 to $964 $965 to $1205 $1206 to $1446 $1447 to $1687 $1688 to $1927 $1928 $1163 4 $0 to $1163 $1164 to $1453 $1454 to $1744 $1745 to $2034 $2035 to $2324 $2325 $1361 5 $0 to $1361 $1362 to $1701 $1702 to $2041 $2042 to $2381 $2382 to $2721 $2722 $1559 6 $0 to $1559 $1560 to $1949 $1950 to $2339 $2340 to $2729 $2730 to $3117 $3118 $1758 7 $0 to $1758 $1759 to $2197 $2198 to $2636 $2637 to $3076 $3077 to $3514 $3515 $1956 8 $0 to $1956 $1957 to $2445 $2446 to $2934 $2935 to $3423 $3424 to $3911 $3912 $2154 9 $0 to $2154 $2155 to $2693 $2694 to $3231 $3232 to $3770 $3771 to $4307 $4308 $2353 10 $0 to $2353 $2354 to $2941 $2942 to $3529 $3530 to $4117 $4118 to $4704 $4705 $2551 11 $0 to $2551 $2552 to $3189 $3190 to $3826 $3827 to $4464 $4465 to $5101 $5102 $2749 12 $0 to $2749 $2750 to $3436 $3437 to $4124 $4125 to $4811 $4812 to $5497 $5498 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 6/15/92 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. $ 5.00 $10.00 $15.00 $20.00 $25.00 $12.00 $24.00 $35.00 $47.00 $59.00 Complete (initial visit) Revisit (subsequent visit) Rhogam (for Rh negative patients) Non-Stress Fetal/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 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. Eligibility specialist will verify/document (using special form) that "patient is unable to receive care." Insurance patients will be placed in the full pay category regardless of income. Insurance will be filed by the health department.