Ill. Admin. Code tit. 77, pt. 635, app B

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Current through Register Vol. 48, No. 49, December 6, 2024

Appendix B - A Guide to Cost Analysis Developing Cost Based Fees and Sliding Fee Scale

Illinois Department of Public Health

A Guide to Cost Analysis

Developing Cost Based Fees

and

Sliding Fee Scale

Revised 11/89

A. B.A.

TABLE OF CONTENTS

INTRODUCTION.............................................................................................................................

APPROACH......................................................................................................................................

FUNCTIONAL AREAS.....................................................................................................................

DETERMINATION OF COST PER PROCEDURE............................................................................

PREPARE A COST OF SERVICE/FEE DETERMINATION

WORKSHEET FOR EACH COST CENTER..........................................................................

EXPENSE ALLOCATIONS FOR THE BCRR...................................................................................

RELATIVE VALUES........................................................................................................................

OPTIONAL REVENUE ANALYSIS.................................................................................................

CALCULATING THE SCHEDULE OF DISCOUNTS.......................................................................

DEVELOPMENT OF A SLIDING FEE SCALE.................................................................................

ATTACHMENTS

ATTACHMENT A:SAMPLES OF ADMINISTRATIVE COSTS......................................................

ATTACHMENT B:MEDICAL COST CENTER WORKSHEET.......................................................

ATTACHMENT C:LABORATORY COST CENTER WORKSHEET..............................................

ATTACHMENT D:PHARMACY COST CENTER WORKSHEET..................................................

ATTACHMENT E:EDUCATION/COUNSELING COST CENTER WORKSHEET.........................

ATTACHMENT F:POVERTY INCOME GUIDELINES - CLIENT FEE DISCOUNT CATEGORIES

ATTACHMENT G:SLIDING FEE SCALE......................................................................................

LIST OF EXAMPLES

ALLOCATION OF MONIES FOR BCRR.........................................................................................

COMPLETED BCRR FROM ABOVE ALLOCATIONS....................................................................

DETERMINATION OF COST PER PROCEDURE............................................................................

FEE DETERMINATION WORKSHEETS.........................................................................................

Medical...........................................................................................................

Laboratory......................................................................................................

Pharmacy........................................................................................................

Education and Counseling..............................................................................

POVERTY INCOME GUIDELINES - CLIENT FEE DISCOUNT CATEGORIES.............................

SAMPLE SLIDING FEE SCALE.......................................................................................................

COST BASED FEES

INTRODUCTION

Federal regulations require that each family planning project have a schedule of fees for the services it provides. You must develop realistic fees which reflect the cost of operation, yet are competitive to the local market. There must be a corresponding schedule of discounts which will be used by individuals based on their ability to pay.

It is now necessary for family planning providers to concentrate on management plans which will provide them with the information to develop, implement and analyze their efficiency, thus controlling costs. Only agencies with a sound financial management plan will remain financially viable.

The object of this manual is to help you determine the cost of providing services and setting the fees to be charged using Bureau of Community Health Services Common Reporting Requirements (BCRR) data with some modifications and utilization data provided by your CVR's.

Costs will come from using the financial information you reported in the various cost centers of your BCRR, Table 6, Column g. We would suggest completing the expense allocations pages to check the accuracy of your allocations on the BCRR and to insure accurate fees.

Utilization figures must be collected over the same period as the reported costs. Specific procedure data, not encounter data, must be used, since the purpose is to derive a cost per procedure. An actual count of your procedures over a specific time period may be obtained from your population profile as reported from your CVR's or you may use a daily log of clinic activity.

APPROACH

Rates charged for each service should reflect both direct and indirect costs. Direct costs include expenses associated with providing patient care (i.e., physician, nursing, supplies, etc.) plus an amount of overhead or indirect costs which are expended to support direct patient care (i.e., administration, housekeeping, rent, etc.). In order to arrive at a true cost you must include the value of donated goods and services. You have allocated your overhead or indirect costs to the various cost centers on Table 6, worksheets A and B (administration, facility costs and fringe benefits) so that the amount on Table 6, column g in each cost center represents your total costs. Examples of administrative and facility costs are Attachment A.

There are seven steps in the development of cost based fee:

1. Identify the functional cost centers.

2. Identify services provided in each cost center.

3. Collect utilization data on services provided.

4. Collect direct cost data for each functional cost center.

5. Allocate overhead costs to functional cost centers.

6. Determine total units of service provided.

7. Determine cost of each service.

FUNCTIONAL AREAS

The health care functional areas within a family planning program represent a separation of functions within the program. A typical family planning program will provide services within four functional areas:

A. MEDICAL (CLINIC) OPERATIONS

Medical services delivered in providing a family planning method of a patient, and the diagnosis and treatment of related problems; excludes x-ray, laboratory and pharmacy services.

B. LABORATORY

Laboratory services provided by the family planning program including specimen collection and preparation for referral to outside laboratories.

C. PHARMACY

Services provided in the dispensing of contraceptives and medications to the family planning patient.

D. HEALTH EDUCATION/COUNSELING

Services provided to the client or prospective client for family planning related problem resolution or information. Includes tubal ligation counseling, fertility awareness and similar services.

DETERMINATION OF COST PER PROCEDURE

The purpose of this step is to distribute health care costs to particular procedures to derive the unit cost of each procedure. The cost per procedure should be computed for all procedures. The cost per procedure information is useful for managers in establishing charges and for analyzing the benefit of continuing to provide specific services. There may be some cases in which the cost per procedure requires a charge so far above the competitive rate (what other providers in the area would charge for that service) that the charge is prohibitive. This should be a signal to management that steps must be taken to lower costs in the future or consideration should be given to phasing out that service and making alternative arrangements.

In order to determine the cost you must define the specific procedures performed in each cost center and determine how many times or frequency the procedure is performed. We have assigned relative values to procedures.

Prepare a Cost of Service/Fee Determination Worksheet for each cost center. See Attachment B, C, D and E.

MEDICAL COST CENTER
Attachment B
1.	Column A	-	List procedure
2.	Column B	-	List Service Utilization/Frequency of Procedure.
3.	Column C	-	List Relative Value for Procedure.
4.	Column D	-	Column B X Column C. Total Column D.
5.	Column E	-	Cost center amount from BCRR Table 6, Column G, line 1.
6.	Column F	-	Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item.
7.	Column G	-	The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service.
8.	Column H	-	Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
9.	Column I	-	Adjusted cost equal's cost/service in Column G times Column H, cost of living allowance (COLA) % plus 100%.
Example:
$10.00 X 105% = $10.50
10.	Column J	-	The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.
LABORATORY COST CENTER
Attachment C
1.	Column A	-	List lab services provided.
2.	Column B	-	List Service Utilization/Frequency of Procedure.
3.	Column C	-	List Relative Value for Procedure.
4.	Column D	Column B X Column C. Total Column D.
5.	Column E	-	Cost center amount from BCRR Table 6, Column G, line 2, minus the cost of PURCHASED OUTSIDE LABORATORY TESTS equals adjusted total cost/cost center. OUTSIDE LABORATORY TESTS ARE THOSE TESTS NOT PERFORMED BY THE AGENCY. This does not include collection of specimens.
6.	Column F	-	Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit.
7.	Column G	-	Adjusted cost/service equals the dollar amount in Column F times each relative value of Column C. This amount represents the cost for each specific service. Column F X Column C.
8.	Column H	-	Enter the per unit purchase expense of OUTSIDE LABORATORY TESTS on the appropriate line or lines. This additional purchase expense applies only to designated tests. For nondesignated test, Column H equals ZERO.
9.	Column I	-	Total base cost equals adjusted cost/service plus per unit purchase expenses. Column G + Column H.
10.	Column J	-	Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
11.	Column K	-	Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA) % plus 100%.
Example:
$4.60 X 105% = $4.83
12.	Column L	-	The full fee to be charged and should approximate Column K. Cor convenience round up to nearest dollar.
PHARMACY COST CENTER
Attachment D
1.	Column A	-	List pharmaceuticals provided.
2.	Column B	-	List Service Utilization.
3.	Column C	-	List Relative Value for Pharmaceuticals.
4.	Column D	-	Column B X Column C. Total Column D.
5.	Column E	-	Cost center amount from BCRR Table 6, Column G, line 4, minus the cost of consumed pharmaceuticals equals adjusted total cost/cost center.
6.	Column F	-	Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit.
7.	Column G	-	Adjusted cost/service equals the dollar amount in Column F, times each relative value of Column C. This amount represents the cost for each specific service. Column F x Column C.
8.	Column H	-	Equals the purchase expense per pharmaceutical unit. To arrive at an average per unit purchase expense, for Attachment D, Column H, when several brands of a pharmaceutical are purchased at different prices you will divide the total dollar value of those pharmaceuticals consumed during that period by the total number of units of those pharmaceuticals consumed during the same reporting period.
9.	Column I	-	Total base cost equals adjusted cost/service plus per unit purchase expense. Column G + Column H.
10.	Column J	-	Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
11.	Column K	-	Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA) % plus 100%.
Example:
$4.60 X 105% = $4.83
12.	Column L	-	The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.
EDUCATION/COUNSELING COST CENTER
Attachment E
1.	Column A	-	List procedure.
2.	Column B	-	List Service Utilization/Frequency of Procedure.
3.	Column C	-	List Relative Value for Procedure.
4.	Column D	-	Column B X Column C. Total Column D.
5.	Column E	-	Cost center amount from BCRR, Table 6, Column G, line 7.
6.	Column F	-	Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item.
7.	Column G	-	The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service.
8.	Column H	-	Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
9.	Column I	-	Adjusted cost equals cost/service in Column G times Column H, cost of living allowance (COLA)% plus 100%.
Example:
$10.00 X 105% = $10.50
10.	Column J	The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.
MEDICAL COST CENTER
CLIENT EXAMINATION DIRECT EXPENSES SALARIES AND WAGES (Include only those staff who perform or assist in performing client examinations.)
1.	Physician	1.	$	.00
2.	Physician Assistants	2.	$	.00
3.	Nurse Practitioners	3.	$	.00
4.	Nurse Midwives	4.	$	.00
5.	Other Nurses	5.	$	.00
MEDICAL SUPPORT
6.	Medical Appointment Secretary	6.	$	.00 _________
7.	Portion of Client Records Clerk	7.	$	.00
8.	Total Salaries	8.	$	.00
Total on line 8 is equal to BCRR Table 6, worksheet A, column E, line 1.
OTHER CLIENT EXAMINATION EXPENSES
9.	Contractual Examiners Fees	9.	$	.00
10.	Client Examination Equipment Lease or Rental	10.	$	.00
11.	Client Examination Equipment Depreciation	11.	$	.00
12.	Client Examination Equipment Depreciation Expense	12.	$	.00
13.	Client Examination Supplies Expense	13.	$	.00
14.	Client Examination Staff Travel Expense	14.	$	.00
15.	Malpractice Insurance	15.	$	.00
16.	Other Client Examination Expenses	16.	$	.00
17.	Total Other Client Examination Expenses	17.	$	.00
(Sum of lines 9 through 16) Total on line 17 is equal to BCRR Table 6, worksheet A, Column I, line 1.
DONATED MEDICAL EXPENSES
18.	Value of Physician's Donated Time	18.	$	.00
19.	Value of Nurse Midwife/N.P.'s Donated Time	19.	$	.00
20.	Value of R.N.'s Donated Time	20.	$	.00
21.	Value of LPN's Donated Time	21.	$	.00
22.	Value of other Donated Medical Expenses	22.	$	.00
23.	Total Donated Services and Materials	23.	$	.00
(Sum of lines 18 through 22) Total on line 23 is equal to BCRR Table 6, worksheet A, Column j, line 1.
PATIENT EXAM INDIRECT COSTS
24.	Medical Fringe Benefits	24.	$	.00
(Worksheet A - Column g, line 1)
25.	Medical Facility Costs	25.	$	.00
(Worksheet B - Column d, line 1)
26.	Administrative Costs	26.	$	.00
(Worksheet B - Column g, line 1)
To arrive at the total medical costs you will add salary and wages (8), other costs (17) and donated services and materials (23) to the fringe benefits (24), facility costs (25) and administrative costs (26).
27.	Total Medical Costs	27.	$	.00
This total equals BCRR Table 6, Column g, line 1.
LABORATORY COST CENTER
LABORATORY SERVICES DIRECT EXPENSES
28.	Salaries and Wages (include only those staff who
perform tests, assist in tests or prepare specimens)	28.	$	.00
29.	Total	29.	$	.00
Total on line 29 is equal to BCRR Table 6, worksheet A, Column E, line 2.
OTHER LABORATORY EXPENSES
30.	Laboratory Equipment Lease or Rental Expense	30.	$	.00
31.	Laboratory Equipment Depreciation Expense Laboratory Equipment Maintenance and Repair	31.	$	.00
32.	Expense	32.	$	.00
33.	Laboratory Supplies Expense	33.	$	.00
34.	Purchased Outside Laboratory Services Expense	34.	$	.00
35.	Other Laboratory Expenses	35.	$	.00
36.	Total Other Laboratory Services Direct Expenses	36.	$	.00
(Sum of lines 30 through 35) Total on line 36 is equal to BCRR Table 6, worksheet A, Column I, line 2.
DONATED LABORATORY EXPENSES
37.	Value of Lab Technician's Donated Time	37.	$	.00
38.	Value of Donated Lab Supplies	38.	$	.00
39.	Value of Donated Lab Tests	39.	$	.00
40.	Value of other Donated Lab Expenses	40.	$	.00
41.	Total Donated Laboratory Services and Materials	41.	$	.00
(Sum of lines 37 through 40) Total on line 41 is equal to BCRR Table 6, worksheet A, Column j, line 2.
LABORATORY SERVICES INDIRECT EXPENSES
42.	Laboratory Fringe Benefits	42.	$	.00
(Worksheet A - Column g, line 2)
43.	Laboratory Facility Costs	43.	$	.00
(Worksheet B - Column d, line 2)
44.	Laboratory Administration Costs	44.	$	.00
(Worksheet B - Column g, line 2)
To arrive at the total laboratory expenses you will add salary and wages (29), other costs (36) and donated services and materials (41) to the fringe benefits (42), facility costs (43) and administrative costs (44).
45.	Total Laboratory Costs	45.	$	.00
This total equals BCRR Table 6, Column g, line 2.
OUTSIDE LABORATORY TESTS:
Any laboratory test completed by an outside incorporated entity. An invoice and payment to the entity for services must exist. If you have "purchased outside laboratory fees" which will be included in total laboratory expenses for you BCRR information, you must now subtract the dollar amount of those purchases from your BCRR total on Table 6, Column G, line 2 to arrive at the dollar amount to be used in your total adjusted cost/center of Attachment C, Column E. You WILL NOT use the amount from you BCRR Table 6, Column G, line 2 for this amount.

			OUTSIDE LABORATORY COST AREA
Type of Supply			Your Cost/Unit x Number Used = Total Expense*
	46.	VDRL/RPR		$	x	$	.00
	47.	Pap Smear		$	x	47.	$	.00
	48.	Gonorrhea Culture		$	x	48.	$	.00
	49.	Miscellaneous Culture		$	x	49.	$	.00
	50.	Sickle Cell		$	x	50.	$	.00
	51.	PP Blood Glucose		$	x	51.	$	.00
	52.	Cholesterol Level		$	x	52.	$	.00
	53.	SMA 12		$	x	53.	$	.00
	54.	Colposcopy		$	x	54.	$	.00
	55.	Colposcopy and Biopsy		$	x	55.	$	.00
	56.	Chlamydia		$	x	56.	$	.00
	57.	Total Outside Laboratory Fees		57.	$	.00
	*Round to the nearest dollar amount.
	58.	Adjusted total cost/center:		58.	$	.00
	Line 45, subtract Line 67, equals amount on Line 58. This is the amount to be used in the Adjusted Total Cost/Center, Attachment C, Column E.
	PHARMACY COST CENTER
Supplies Consumed During Reporting Period:
Type of Supply				Your Cost/Unit x Number Used = Total Expense*
	59.	Oral Contraceptives		x	59.	$	.00
	60.	Cream		x	60.	$	.00
	61.	Jelly		x	61.	$	.00
	62.	Suppository (each)		x	62.	$	.00
	63.	Foam		x	63.	$	.00
	64.	Diaphragm		x	64.	$	.00
	65.	IUD		x	65.	$	.00
	66.	Basal T & C		x	66.	$	.00
	67.	Sponges (each)		x	67.	$	.00
	68.	Condoms (each)		x	68.	$	.00
	69.	Meds/Vag. Inf.		x	69.	$	.00
	70.	Meds/Std Rx		x	70.	$	.00
	71.	Contraceptive Film		x	71.	$	.00
*The number used for each type of supply will come from your inventory sheets.
	72.	Total (Sum of lines 59 through 71)		72.	$	.00
PROVISION OF CONTGRACEPTIVE DRUGS/SUPPLIES DIRECT EXPENSES
	73.	Salaries and Wages for Staff Who Dispense or
	Assist in Providing Contraceptive Drugs and Supplies			73.	$	.00
	74.	Total		74.	$	.00
	Total on line 74 is equal to BCRR Table 6, worksheet A, Column E, line 4.
OTHER PHARMACY EXPENSES
	75.	Provision of Drugs and Supplies Equipment
	Lease or Rental Expense		75.	$	.00
	76.	Provision of Drugs and Supplies Depreciation Expense			76.	$	.00
	77.	Provision of Drugs and Supplies Equipment Maintenance and Repair Expense			77.	$	.00
	78.	Dispensing Supplies Expense		78.	$	.00
	79.	Other Pharmacy Expenses		79.	$	.00
	80.	Total (Sum of lines 75 through 79)		80.	$	.00
	81.	Total All Pharmacy Expenses		81.	$	.00
	(Sum of lines 72 and 80) Total on line 81 is equal to BCRR Table 6, worksheet A, Column I, line 4.
DONATED PHARMACY EXPENSES
	82.	Value of Pharmacists' Donated Time			82.	$	.00
	83.	Value of Donated Pharmacy Supplies			83.	$	.00
	84.	Value of Donated Contraceptive Supplies			84.	$	.00
	85.	Value of Other Donated Pharmacy Expenses			85.	$	.00
	86.	Total Donated Pharmacy Services and Materials			86.	$	.00
	(Sum of lines 82 through 85) Total on line 86 is equal to BCRR Table 6, worksheet A, Column j, line 4.
PHARMACY SERVICES INDIRECT EXPENSES
	87.	Pharmacy Fringe Benefits			87.	$	.00
	(Worksheet A - Column g, line 4)
	88.	Pharmacy Facility Costs		88.	$	.00
	(Worksheet B - Column d, line 4)
	89.	Pharmacy Administration Costs			89.	$	.00
	(Worksheet B - Column g, line 4)
To arrive at the total Pharmacy costs you will add salary and wages (74), other costs (81) and donated services and materials (86) to fringe benefits (87), facility costs (88) and administrative costs (89).
	90	Total Pharmacy Costs			90.	$	.00
	This total equals BCRR Table 6, Column g, line 4.
	91.	Adjusted total cost center			91.	$	.00
To arrive at the total adjusted cost/center you must subtract the dollar amount of consumed contraceptives, drugs/supplies, from you BCRR total on Table 6, Column G, line 4, which is the amount on Line 90, minus line 72, equals the amount on line 91. This is the amount to be used in the adjusted Total cost/center, Attachment D, Column E.
	COUNSELING AND EDUCATION COST CENTER
FAMILY PLANNING COUNSELING AND EDUCATIONAL DIRECT EXPENSES
	92.	Salaries and Wages, Family Planning			92.	$	.00
	Counselors, Educators and Assistants
	93.	Portion of Client Records Clerk			93.	$	.00
	94.	Total			94.	$	.00
	Total on line 94 is equal to BCRR Table t, worksheet A, Column E, line 7.
OTHER COUNSELING AND EDUCATION EXPENSES
	95.	Counseling and Educational Services			95.	$	.00
	Staff Travel Expense
	96.	Counseling and Educational Services			96.	$	.00
	Equipment Rental
	97.	Counseling Expense or Lease Expense and			97.	$	.00
	Educational Services Equipment Depreciation
	98.	Counseling and Educational Services Equipment			98.	$	.00
	Repair and Maintenance Expense
	99.	Counseling and Educational Supplies Expense			99.	$	.00
	100.	Other Counseling and Educational Expense			100.	$	.00
	101.	Total Family Planning Counseling and Educational Services Direct Expenses			101.	$	.00
	Total on line 101 is equal to BCRR Table 6, worksheet A, Column I, line 7.
DONATED EDUCATION AND COUNSELING EXPENSES
	102.	Value of Counselors Donated Time			102.	$	.00
	103.	Value of Other Donated Counseling and Educational Services Expenses			103.	$	.00
	104.	Total Donated Counseling and Educational Services Expenses			104.	$	.00
	(Sum of lines 102 and 103) Total on line 104 is equal to BCRR Table 6, worksheet A, Column j, line 7.
COUNSELING AND EDUCATIONAL INDIRECT EXPENSES
	105.	Counseling and Education Fringe Benefits			105.	$	.00
	(Worksheet A - Column g, line 7)
	106.	Counseling and Education Facility Costs			106.	$	.00
	(Worksheet B - Column d, line 7)
	107.	Counseling and Education Administration Costs			107.	$	.00
	(Worksheet B - Column g, line 7)
To arrive at the total Counseling and Education costs you will add salary and wages (92), other costs (101) and Donated Counseling and Educational Services (104) to fringe benefits (105), facility costs (106) and administrative costs (107).
	108.	Total Counseling and Education Costs				108.	$	.00
	This total equals BCRR Table 6, Column g, line 7.

FAMILY PLANNING CLIENT VISIT RELATIVE VALUES
SERVICES	RVS
MEDICAL SERVICES VISITS
Minimal Service	11.00
Brief/Intermediate Exam	18.00
Extended Exam	30.00
Insertion of IUD	30.00
Diaphragm Fit	15.00
Sonography/lost IUD	30.00
X-ray/lost IUD	24.00
LAB PROCEDURES
Hematocrit/Hemoglobin	3.00
U/A Dip Stick	4.00
Pregnancy Test	10.00
VDRL/RPR	6.00
Pap Smear	8.00
Gonorrhea Culture	6.00
Bacterial Smear/Wet Mount	5.00
Miscellaneous Culture	6.00
Sickle Cell	5.00
P.P. Blood Glucose	6.00
Triglycerides	6.00
SMA 12	16.00
Colposcopy	30.00
Colposcopy with Biopsy	40.00
Chlamydia	7.00
Miscellaneous Culture	3.00
Sickle Cell	4.00
P.P. Blood Glucose	10.00
Triglycerides	6.00
SMA 12	8.00
Colposcopy	6.00
Colposcopy with Biopsy	5.00
Chlamydia	6.00
CONTRACEPTIVE DRUGS/SUPPLIES
Orals	1.20
Creams	2.65
Jellies	2.65
Suppositories (each)	.15
Foams	3.00
Diaphragm	4.00
Basal T & C	10.00
IUD	50.00
Sponges (each)	1.50
Condoms (each)	.22
Meds/Vag. Inf.	5.00
Meds/STD	5.00
Contraceptive Film	2.00
EDUCATION AND COUNSELING
In-depth/1 hour	11.00
15 min. to 1 Hour	7.00
Revised
11/89

CALCULATING THE SCHEDULE OF DISCOUNTS
1.	Determine the number of payment categories.
		Example:	For the purpose of this manual, we will use a six step schedule.
2.	The income levels for the zero pay category will be the poverty levels published annually in the Federal Register. (See Attachment F)
		Example:	The poverty level for a one person family is $5,980; for a two person family the poverty level is $8,020, etc.
3.	The income levels for the full fee will be 250% of the poverty level plus $1.00.
		Example:	For Family Size of 1, 100% pay = $5,980 x 2.5 = t$14,950 + $1 or $14,951
4.	To determine the income levels between 0% pay and 250% pay, use the following formula:
		The 250% income level minus the poverty level, divided by the number of payment categories, minus 2.
		The result of this computation is the dollar range for each step.
		Example:	Family Size 1 - $14,950 (full fee > 250%) minus $5,980 (0%) = $8,970 divided by 4 (6 steps-2 steps) = $2,242.50 step interval.
5.	The lower limit of each step is $1 more than the upper limit of the preceding step.
		Example:	Family Size 1, upper limit of 0% pay is $5,980, lower limit of the next category (20%) is $5,981.
6.	The upper level for each step is computed by adding the dollar interval computed in Step 4 to the upper limit of the preceding step.
		Example:	Family Size 1 - upper limit of 0% pay is $5,980; upper limit of the next category is $5,981 + $2,243 or $8,224. See Attachment F.

DEVELOPMENT OF A SLIDING FEE SCALE

Federal regulations require that we provide family planning services on a sliding fee scale to allow persons to receive services regardless of their income level and subsequent ability to pay. Client or family income level is the determining factor for what level or percentage of the full fee a client will be charged.

A fee system must be developed and reevaluated at least annually after completing a cost analysis. The sliding fee scale will be based on the most current Federal Poverty Income Guidelines (See Attachment F). All clients must update their financial status every 12 months.

A sliding fee scale must be simple to be useful. Any fee scale which is over burdensome to the cashier or person computing the fee loses its value as the time required to compute the fee increases. Fees must be reasonable, related to cost and not provide a barrier to care. In selecting the client fee discount categories, it is important to remember that too few categories may either classify many clients at the lower end, reducing income, or at the upper end, discouraging clients to seek care because of the cost, thereby also reducing income. Too many categories may be difficult to implement and administer. For the purpose of this manual, we will use a six step sliding fee scale. See Attachment G.

Attachment A
EXAMPLES OF ADMINISTRATIVE COSTS
1.	Project Director
2.	Administrative Secretary and Receptionist
3.	Bookkeeper
4.	Administrative supplies
5.	Administrative staff travel and per diem
6.	Vehicle rental or lease expense
7.	Auditing and accounting
8.	Legal fees
9.	Consultants expense
10.	Dues and subscriptions
11.	Advertising
12.	Postage
13.	Printing
14.	Purchased staff training
15.	Fidelity bonding
16.	Photo copy
17.	Equipment depreciation
EXAMPLES OF FACILITY COSTS
1.	Custodian or Janitorial Contractual Services
2.	Building rental
3.	Building depreciation
4.	Building and contents insurance
5.	Building maintenance and repair
6.	Security
7.	Utilities
8.	Telephone
9.	Janitorial supplies

Attachment B

COST OF SERVICE/FEE DETERMINATION WORKSHEET

MEDICAL COST CENTER

(A)

SERVICE/PROCEDURE

(B)

SERVICE UTILIZATION (FREQUENCY)

(C)

RVS VALUE

(D)

TOTAL SERVICE UNITS

(E)

TOTAL COST/ COST/CENTER

(F)

AVERAGE COST/SERVICE UNIT

(G)

COST/ SERVICE

(H)

COST OF LIVING ALLOWANCE

(I)

ADJUSTED

COST

(J)

FEE

Minimal Service

11.00

////////////////////////////

Brief/Intermediate Exam

18.00

////////////////////////////

Extended Exam

30.00

////////////////////////////

IUD Insertion

30.00

////////////////////////////

Diaphragm Fit

15.00

////////////////////////////

Sonography/lost IUD

30.00

////////////////////////////

X-ray/lost IUD

24.00

////////////////////////////

TOTAL

//////////////////////////

////////////////

//////////////////////////////

///////////////////

/////////////////////////////////

/////////////////////////

///////////////////////////////////

NOTES

D = B x C

G = F x C

REVISED

03-NOV-89

Total Column D

M = Cost of Living Allowance (COLA)

E = Column G, line 1 of BCRR Table 6

I = G x (COLA % + 100%)

F = Column E / Column D Total

J = Fee

Attachment C

COST OF SERVICE/FEE DETERMINATION WORKSHEET

LABORATORY COST CENTER

(A)

SERVICE/PROCEDURE

(B)

SERVICE UTILIZATION (FREQUENCY)

(C)

RVS VALUE

(D)

TOTAL SERVICE UNITS

(E)

ADJUSTED TOTAL COST/ COST/CENTER

(F)

AVERAGE COST/SERVICE UNIT

(G)

COST/SERVICE ADJUSTED

(H)

PER UNIT PURCHASE EXPENSE

(I)

TOTAL BASE COST

(J)

COST OF LIVING ALLLOWANCE

(K)

ADJUSTED COST

(L)

FEE

HGB/HCT

3.00

//////////////////////////

Urinalysis

4.00

///////////////////////////

Pregnancy Test

10.00

////////////////////////////

VDRL/RPR

6.00

///////////////////////////

Pap Smear

8.00

///////////////////////////

Gonorrhea Culture

6.00

///////////////////////////

Miscellaneous Culture

6.00

//////////////////////////

Bacterial Smear/Wet Mount

5.00

//////////////////////////

Sickle Cell

5.00

//////////////////////////

P.P. Blood Glucose

6.00

//////////////////////////

Cholesterol Level

6.00

//////////////////////////

SMA - 12

16.00

//////////////////////////

Colposcopy

30.00

//////////////////////////

Colposcopy and Biopsy

40.00

//////////////////////////

Chlamydia

7.00

//////////////////////////

TOTAL

/////////////////////////

////////////////

////////////////////////

///////////////////

/////////////////////////

//////////////////

////////////////////

////////////////

/////////////////

NOTES:

D = B x C

H = Actual Per Unit Purchase Expense From Outside Laboratory

REVISED

03-NOV-89

Total Column D

I = Total Cost G + H

E = Column G, line 2 of BCRR Table 6,

J = Cost of Living Allowance (COLA)

Minus the Cost of Purchased Outside Laboratory Tests

K = I x (COLA % + 100%)

F = Column E / Column D Total

10.

L = Fee

G = F x C

Attachment D

COST OF SERVICE/FEE DETERMINATION WORKSHEET

PHARMACY

COST CENTER

(A)a

SERVICE/PROCEDURE

(B)

SERVICE UTILIZATION (FREQUENCY)

(C)

RVS VALUE

(D)

TOTAL SERVICE UNITS

(E)

ADJUSTED TOTAL COST/ COST/CENTER

(F)

AVERAGE COST/SERVICE UNIT

(G)

COST/ SERVICE ADJUSTED

(H)

PER UNIT PURCHASE EXPENSE

(I)

TOTAL BASE COST

(J)

COST OF LIVING ALLOWANCE

(K)

ADJUSTED COST

(L)

FEE

Orals

1.20

//////////////////////

Creams

2.65

//////////////////////

Jellies

2.65

///////////////////////

Suppositories (each)

0.15

///////////////////////

Foams

3.00

///////////////////////

Diaphragms

4.00

///////////////////////

IUDS

50.00

///////////////////////

Basal T & C

10.00

///////////////////////

Sponges (each)

1.50

///////////////////////

Condoms (each)

0.22

///////////////////////

Meds/Vag Inf

5.00

///////////////////////

Meds/STD

5.00

///////////////////////

Contraceptive Film

2.00

///////////////////////

TOTAL

/////////////////////////

//////////////

////////////////////////

//////////////////////

////////////////////

////////////////

/////////////////////

////////////////////

//////////////////////

NOTES:

D = B x C

H = Actual Per Unit Purchase Expense

REVISED

03-NOV-89

Total Column D

I = G + H

E = Column G, line 4 of BCRR Table 6

J = Cost of Living Allowance (COLA)

Minus the Cost of Consumed Pharmaceuticals

K x (COLA % + 100%)

F = Column E / Column D Total

10.

L = Fee

G = F x C

Attachment E

COST OF SERVICE/FEE DETERMINATION WORKSHEET

EDUCATION/COUNSELING COST CENTER

(A)

SERVIC/PROCEDURE

(B)

SERVICE UTILIZATION (FREQUENCY)

(C)

RVS VLAUE

(D)

TOTAL SERVICE UNITS

(E)

TOTAL COST/ COST/CENTER

(F)

AVERAGE COST/SERVICE UNIT

(G)

COST/ SERVICE

(H)

COST OF LIVING ALLOWANCE

(I)

ADJUSTED COST

(J)

FEE

Indepth 1 Hour

11.00

///////////////////

Counseling/15 Min to 1 Hr

7.00

///////////////////

TOTAL

////////////////////

///////////////

////////////////////

//////////////

//////////////////

/////////////////

//////////////

NOTES:

D = B x C

G = F x C

REVISED

03-NOV-89

Total Column D

H = Cost of Living Allowance (COLA)

E = Column G, line 7 of BCRR Table 6

I = G x (COLA % + 100%)

F = Column E / Column D Total

J = Fee

Attachment F

EXAMPLE

POVERTY INCOME GUIDELINES

CLIENT FEE DISCOUNT CATEGORIES

03/08/89

Family Planning Services

1989 Revised Guidelines as published in Federal Register, 2/16/89, Vol. 54, No. 31

FAMILY SIZE		0%				20%			40%			60%			80%			100%
FAMILY SIZE		A	B		C	D	E	F	G	H	I	J		K
1		0	-	5980		5981	-	8224	8225	-	10467	10468	-	12711	12712	-	14950	14951
2		0	-	8020		8021	-	11029	11030	-	14037	14038	-	17046	17047	-	20050	20051
3		0	-	10060		10061	-	13834	13835	-	17607	17608	-	21381	21382	-	25150	25151
4		0	-	12100		12101	-	16639	16640	-	21177	21178	-	25716	25717	-	30250	30251
5		0	-	14140		14141	-	19444	19445	-	24747	24748	-	30051	30052	-	35350	35351
6		0	-	16180		16181	-	22249	22250	-	28317	28318	-	34386	34387	-	40450	40451
7		0	-	18220		18221	-	25054	25055	-	31887	31888	-	38721	38722	-	45550	45551
8		0	-	20260		20261	-	27859	27860	-	35457	35458	-	43056	43057	-	50650	50651
*	FOR FAMILY UNITS WITH MORE THAN 8 MEMBERS, FOR EACH ADDITIONAL MEMBER AND ADD TO COLUMN B; $2,040
**	POVERTY LEVEL				$5,980
B	=	Family size = 1 = Poverty Level
B	=	All other Family size = Previous Family size Poverty Level plus $2,040
C	=	(B + 1)
D		(J - B) / 4 + C
E		(D + 1)
F	=	(J-B) / 4 + E
G	=	(F + 1)
H	=	(J-B) / 4 + G
I	=	(H + 1)
J	=	(B x 2.5)
K	=	(J + 1)

Attachment G

SLIDING FEE SCALE

**********************************************************************************************************

SERVICE/PROCEDURES (a)	COST/ SERVICES	FEE	0%	20%	40%	60%	80%	100%
Minimal Services	________	________	________	________	________	________	________	________
Brief/Intermediate Exam	________	________	________	________	________	________	________	________
Extended Exam	________	________	________	________	________	________	________	________
IUD Insertion	________	________	________	________	________	________	________	________
Diaphragm Fit	________	________	________	________	________	________	________	________
Sonography/lost IUD	________	________	________	________	________	________	________	________
X-ray/lost IUD	________	________	________	________	________	________	________	________
HCT/HBG	________	________	________	________	________	________	________	________
Urinalysis	________	________	________	________	________	________	________	________
Pregnancy Test	________	________	________	________	________	________	________	________
VDRL/RPR	________	________	________	________	________	________	________	________
Pap Smear	________	________	________	________	________	________	________	________
Gonorrhea Culture	________	________	________	________	________	________	________	________
Miscellaneous Culture	________	________	________	________	________	________	________	________
Bacterial Smear/Wet Mount	________	________	________	________	________	________	________	________
Sickle Cell	________	________	________	________	________	________	________	________
PP Blood Glucose	________	________	________	________	________	________	________	________
Cholesterol Level	________	________	________	________	________	________	________	________
SMA-12	________	________	________	________	________	________	________	________
Colposcopy	________	________	________	________	________	________	________	________
Colposcopy and Biopsy	________	________	________	________	________	________	________	________
Chlamydia	________	________	________	________	________	________	________	________
Orals	________	________	________	________	________	________	________	________
Creams	________	________	________	________	________	________	________	________
Jellies	________	________	________	________	________	________	________	________
Suppositories (each)	________	________	________	________	________	________	________	________
Foams	________	________	________	________	________	________	________	________
Diaphragms	________	________	________	________	________	________	________	________
IUDS	________	________	________	________	________	________	________	________
Basal T & C	________	________	________	________	________	________	________	________
Sponges (each)	________	________	________	________	________	________	________	________
Condoms (each)	________	________	________	________	________	________	________	________
Meds/Vag Inf	________	________	________	________	________	________	________	________
Meds/STD	________	________	________	________	________	________	________	________
Contraceptive Film	________	________	________	________	________	________	________	________
In-depth 1 Hour	________	________	________	________	________	________	________	________
Counseling/15 Min. to 1 Hr.	________	________	________	________	________	________	________	________

**********************************************************************************************************

ALLOCATION OF MONIES FOR BCRR
SALARIES			EQUIPMENT DEPRECIATION
0.5	OB/GYN Physician	50,000	Medical	800
0.2	OB/GYN Nurse Practitioners	52,000	Laboratory	200
1.5	RN's	24,000	Patient Records	100
0.5	RN (Pharmacy)	8,000	Administration	900
0.2	LPN's	22,000
0.5	Medical Appt. Secy.	5,750
0.5	Client Records Clerk	5,750	INSURANCE
1.0	Health Educator	16,000
0.5	Laboratory Technician	7,000	Medical Malpractice	5,000
1.0	Project Director	20,000	Fidelity Bonding	100
1.0	Admin. Secy./Recept.	12,000	Facility (fire, flood)	1,000
1.0	Bookkeeper	12,000
0.2	Custodian	1,600
			RENT	12,000
			UTILITIES	1,800
			TELEPHONE	740
FRINGE BENEFITS		27,300	PHOTO COPY	560
			POSTAGE	375
			ADMIN. TRAVEL	200
CONSULTANT & CONTRACT SERVICES
Nurse Practitioner		17,000	SQUARE FOOTAGE
Outside Laboratory		19,792
Account's Fee		800	Medical	1,600 sq'
Attorney's Fee		100	Laboratory	200
Security		2,000	Other Health	300
			Administration	400
				2,500 sq'
SUPPLIES
Medical		10,000
Laboratory		3,000
Health Education		500
Pharmacy		1,000
Patient Records		200
Administration		500
Housekeeping		100
DONATED MATERIALS
Volunteer R.N.'s		6,000
GC's done by State lab		1,200
Contraceptives from closing clinic		2,400
Volunteer Counselor		400
Administrator's time		700
Rent at 2^nd site		1,200

MEDICAL COST CENTER
CLIENT EXAMINATION DIRECT EXPENSES
SALARIES AND WAGES (Include only those staff who perform or assist in performing client examinations.)
	1. Physician								1.			$		50,000.00
	2. Physician Assistants								2.			$		.00
	3. Nurse Practitioners								3.			$		52,000.00
	4. Nurse Midwives								4.			$		.00
	5. Other Nurses								5.			$		46,000.00
Medical Support
	6. Medical Appointment Secretary								6.			$		5,750.00
	7. Portion of Client Records Clerk								7.			$		4,600.00
	8. Total Salaries								8.			$		158,350.00
	Total on line 8 is equal to BCRR Table 6, worksheet A, Column E, line 1.
OTHER CLIENT EXAMINATION EXPENSES
	9. Contractual Examiners Fee								9.			$		17,000.00
	10. Client Examination Equipment Lease or Rental								10.			$		.00
	11. Client Examination Equipment Depreciation Expense								11.			$		800.00
	12. Client Examination Equipment Repair & Maintenance								12.			$		.00
	13. Client Examination Supplies Expense								13.			$		10,000.00
	14. Client Examination Staff Travel Expense								14.			$		.00
	15. Malpractice Insurance								15.			$		5,000.00
	16. Other Client Examination Expenses								16.			$		240.00
	17. Total Other Client Examination Expenses								17.			$		33,040.00
	(Sum of lines 9 through 16) Total on line 17 is equal to BCRR Table 6, worksheet A, Column I, line 1.
DONATED MEDICAL EXPENSES
	18. Value of Physician's Donated Time								18.			$		.00
	19. Value of Nurse Midwife/N.P.'s Donated Time								19.			$		.00
	20. Value of R.N.'s Donated Time								20.			$		6,000.00
	21. Value of LPN's Donated Time								21.			$		.00
	22. Value of other Donated Medical Expenses								22.			$		.00
	23. Total Donated Services and Materials								23.			$		6,000.00
	(Sum of lines 18 through 22)
	Total on line 23 is equal to BCRR Table 6, worksheet A, Column j, line 1.
PATIENT EXAM INDIRECT COSTS
	24. Medical Fringe Benefits (Worksheet A - Column g, line 1)								24.			$		18,291.00
	25. Medical Facility Costs (Worksheet B - Column d, line 1)								25.			$		11,984.00
	26. Administrative Costs (Worksheet B - Column g, line 1)								26.			$		37,724.00
To arrive at the total medical costs you will add salary and wages (8), other costs (17) and donated services and materials (23) to the fringe benefits (24), facility costs (25) and administrative costs (26).
	27. Total Medical Costs								27.			$		265,389.00
	This total equals BCRR Table 6, Column g, line 1.
LABORATORY COST CENTER
LABORATORY SERVICES DIRECT EXPENSES
	28. Salaries and Wages (include only those staff who perform tests, assist in tests or prepare specimens)								28.			$		7,000.00
	29. Total								29.			$		7,000.00
	Total on line 29 is equal to BCRR Table 6, worksheet A, Column E, line 2.
OTHER LABORATORY EXPENSES
	30. Laboratory Equipment Lease or Rental Expense								30.			$		.00
	31. Laboratory Equipment Depreciation Expense								31.			$		200.00
	32. Laboratory Equipment Maintenance and Repair Expense								32.			$		.00
	33. Laboratory Supplies Expense								33.			$		3,000.00
	34. Purchased Outside Laboratory Services Expense See page 35.								34.			$		19,792.00
	35. Other Laboratory Expenses								35.			$		.00
	36. Total Other Laboratory Services Expenses								36.			$		22,992.00
	(Sum of lines 30 through 35)
	Total on line 36 is equal to BCRR Table 6, worksheet A, Column I, line 2.
DONATED LABORATORY EXPENSES
	37. Value of Lab Technician's Donated Time								37.			$		.00
	38. Value of Donated Lab Supplies								38.			$		.00
	39. Value of Donated Lab Tests								39.			$		1,200.00
	40. Value of other Donated Lab Expenses								40.			$		.00
	41. Total Donated Laboratory Services and Materials								41.			$		1,200.00
	(Sum of lines 37 through 40)
	Total on line 41 is equal to BCRR Table 6, worksheet A, Column j, line 2.
LABORATORY SERVICES INDIRECT EXPENSES
	42. Laboratory Fringe Benefits (Worksheet A - Column g, line 2)								42.			$		819.00
	43. Laboratory Facility Costs (Worksheet B - Column d, line 2)								43.			$		1,598.00
	44. Laboratory Administration Cost (Worksheet B - Column g, line 2)								44.			$		5,716.00
To arrive at the total laboratory expenses you will add salary and wages (29), other costs (36) and donated services and materials (41) to the fringe benefits (42), facility costs (43) and administrative costs (44).
	45. Total Laboratory Costs								45.			$		39,325.00
	This total equals BCRR Table 6, Column g, line 2.
OUTSIDE LABORATORY TESTS:
Any laboratory test completed by an outside incorporated entity. An invoice and payment to the entity for services must exist.
If you have "purchased outside laboratory fees" which will be included in total laboratory expenses for your BCRR information, you must now subtract the dollar amount of those purchases from your BCRR total on Table 6, Column G, line 2 to arrive at the dollar amount to be used in your total adjusted cost/center of Attachment C, Column E. You WILL NOT use the amount from your BCRR Table 6, Column G, line 2 for this amount.
OUTSIDE LABORATORY COST AREA
Type of Supply		Your Cost/Unit		x	Number Used		=			Total Expense*
	46. VDRL/RPR	4.00		x	8		46.			$			32.00
	47. Pap Smear	3.50		x	4,000		47.			$			14,000.00
	48. Gonorrhea Culture	6.50		x	8		48.			$			52.00
	49. Miscellaneous Culture	18.00		x	40		49.			$			720.00
	50. Sickle Cell	5.00		x	100		50.			$			500.00
	51. P.P. Blood Glucose	4.50		x	20		51.			$			90.00
	52. Cholesterol Level	4.00		x	10		52.			$			40.00
	53. SMA 12	6.75		x	10		53.			$			68.00
	54. Colposcopy	40.00		x	4		54.			$			160.00
	55. Colposcopy and Biopsy		50.00	x	1		55.			$			50.00
	56. Chlamydia		8.00	x	510		56.			$			4,080.00
	57. Total Outside Laboratory Fees						57.			$			19,792.00
	58. Adjusted Total Cost Center:						58.			$			19,533.00
	Line 45, subtract Line 57
*Round to the nearest dollar amount. equals amount on Line 58.
This is the amount to be used in the Adjusted Total
Cost/Center, Attachment C, Column E
PHARMACY COST CENTER
Supplies Consumed During Reporting Period:
Type of Supply			Your Cost/Unit	x	Number Used		=			Total Expense**
	59. Oral Contraceptives		.70	x	58,500		59.			$			40,950.00
	60. Cream		1.00	x	54		60.			$			54.00
	61. Jelly		1.00	x	50		61.			$			50.00
	62. Suppository (each)		.20	x	5		62.			$			1.00
	63. Foam		.90	x	2,304		63.			$			2,074.00
	64. Diaphragm		3.00	x	124		64.			$			372.00
	65. IUD		36.00	x	24		65.			$			864.00
	66. Basal T & C		16.50	x	2		66.			$			33.00
	69. Meds/Vag. Inf.		4.70	x	540		69.			$			2,538.00
	70. Meds/STD Rx		4.70	x	539		70.			$			2,533.00
	71. Contraceptive Film		3.00	x	10		71.			$			30.00
	72. Total (Sum of lines 59 through 71)					72.		$			50,500.00
* The number used for each type of supply will come from your inventory sheets. ** Round to the nearest dollar amount
PROVISION OF CONTRACEPTIVE DRUGS/SUPPLIES DIRECT EXPENSES
	73. Salaries and Wages for Staff Who Dispense or Assist in Providing Contraceptive Drugs and Supplies					73.		$			8,000.00
	74. Total					74.		$			8,000.00
	Total on line 74 is equal to BCRR Table 6, worksheet A, Column E, line 4.
OTHER PHARMACY EXPENSES
	75. Provision of Drugs and Supplies Equipment Lease or Rental Expense					75.		$			.00
	76. Provision of Drugs and Supplies Depreciation Expense					76.		$			.00
	77. Provision of Drugs and Supplies Equipment Maintenance and Repair Expense					77.		$			.00
	78. Dispensing Supplies Expense					78.		$			.00
	79. Other Pharmacy Expenses					79.		$			.00
	80. Total (Sums of lines 75 through 79)					80.		$			-0- .00
	81. Total All Pharmacy Expenses					81.		$			50,500.00
	(Sum of lines 72 and 80)
	Total on line 81 is equal to BCRR Table 6, worksheet A, Column I, line 4.
DONATED PHARMACY EXPENSES
	82. Value of Pharmacists' Donated Time					82.		$			.00
	83. Value of Donated Pharmacy Supplies					83.		$			.00
	84. Value of Donated Contraceptive Supplies					84.		$			2,400.00
	85. Value of Other Donated Pharmacy Expenses					85.		$			.00
	86. Total Donated Pharmacy Services and Materials					86.		$			2,400.00
	(Sum of lines 82 through 85),
	Total on line 86 is equal to BCRR Table 6, worksheet A, Column j, line 4.
PHARMACY SERVICES INDIRECT EXPENSES
	87. Pharmacy Fringe Benefits (Worksheet A - Column g, line 4)					87.		$			819.00
	88. Pharmacy Facility Costs (Worksheet B - Column d, line 4)					88.		$			1,198.00
	89. Pharmacy Administration Cost (Worksheet B - Column g, line 4)					89.		$			10,288.00
To arrive at the total Pharmacy cost you will add salary and wages (74), other costs (81) and donated services and materials (86) to fringe benefits (87), facility costs (88) and administrative costs (89).
	90. Total Pharmacy Cost This total equals BCRR Table 6, Column g, line 4.					90.		$			73,205.00
	91. Adjusted total costs center					91.		$			22,705.00
To arrive at the total adjusted cost/center you must subtract the dollar amount of consumed contraceptives, drugs/supplies from your BCRR total on Table 6, Column G, line 4, which is the amount on line 90, minus line 72, equals the amount on line 91. This is the amount to be used in the adjusted total cost/center, Attachment D, Column E.
COUNSELING AND EDUCATION COST CENTER
FAMILY PLANNING COUNSELING AND EDUCATIONAL DIRECT EXPENSES
	92. Salaries and Wages, Family Planning Counselors, Educators and Assistants					92.		$			16,000.00
	93. Portion of Client Records Clerk					93.		$			1,150.00
	94. Total					94.		$			17,150.00
	Total on line 94 is equal to BCRR Table 6, worksheet A, Column E, line 7.
OTHER COUNSELING AND EDUCATION EXPENSES
	95. Counseling and Educational Services Staff Travel Expense					95.		$			.00
	96. Counseling and Educational Services Equipment Rental					96.		$			.00
	97. Counseling Expense or Lease Expense and Educational Services Equipment Depreciation					97.		$			.00
	98. Counseling and Educational Services Equipment Repair and Maintenance Expense					98.		$			.00
	99. Counseling and Educational Supplies Expense					99.		$			500.00
	100. Other Counseling and Educational Expense					100.		$			60.00
	101. Total Family Planning Counseling and Educational Services Direct Expenses					101.		$			560.00
	Total on line 101 is equal to BCRR Table 6, worksheet A, Column I, line 7.
DONATED EDUCATION AND COUNSELING EXPENSES
	102. Value of Counselors Donated Time					102.		$			400.00
	103. Value of Other Donated Counseling and Educational Services Expense					103.		$			.00
	104. Total Donated Counseling and Educational Services Expenses					104.		$			400.00
	(Sum of lines 102 through 103)
	Total on line 104 is equal to BCRR Table 6, worksheet A, Column j, line 7.
COUNSELING AND EDUCATIONAL INDIRECT EXPENSES
	105. Counseling and Education Fringe Benefits (Worksheet A - Column g, line 7)					105.		$			1,911.00
	106. Counseling and Education Facility Costs (Worksheet B - Column d, line 7)					106.		$			2,197.00
	107. Counseling and Education Administration Costs (Worksheet B - Column g, line 7)					107.		$			3,430.00
To arrive at the total Counseling and Education costs you will add salary and wages (92), other costs (101) and Donated Counseling and Educational Services (104) to fringe benefits (105), facility costs (106) and administrative costs (107).
	108. Total Counseling and Education Costs This total equals BCRR Table 6, Column g, line 7.					108.		$			25,648.00

WORKSHEET A - COLUMN E

Salaried Personnel Includes Column C (C + E = E)

1. Medical - line	$	158,350
.5 OB/GYN Physician	50,000
2.0 OB/GYN Nurse Practitioners	52,000
1.5 RN's	24,000
2.0 LPN's	22,000
.5 Medical Appt. Sec'y.	5,750
Add Column C
.4 Patient Records Clerk	4,600
2. Laboratory - line 2	$	7,000
0.5 Lab Technician	7,000
4. Pharmacy - line 4	$	8,000
.5 R.N.	8,000
7. Other Health - line 7	$	17,150
1.0 Health Educator	16,000
Add Column C
Patient Record Clerk	1,150
12. Administration - line 12	$	44,000
Patient Record Clerk	20,000
1.0 Admin. Sec'y/Recept.	12,000
1.0 Bookkeeper	12,000
13. Facility - line 13	$	1,600
.2 Custodian	1,600
15. TOTAL - LINE 15	$	236,100

WORKSHEET A - COLUMN I

Other Costs Include Column D (D + I = I)

1. Medical - line	$	33,040
Contractual N.P.	17,000
Medical Supplies	10,000
Medical Equipment Depreciation	800
Medical Malpractice Insurance	5,000
Add Column D
Patient Records Cost	240
2. Laboratory - line 2	$	22,992
Outside Laboratory	19,792
Laboratory Supplies	3,000
Laboratory Depreciation	200
3. Pharmacy - line 4	$	50,500
Contraceptives Used	50,500
7. Other Health	$	560
Health Education Supplies	500
Add Column D	60
12. Administration - line 12	$	4,275
Accountant Fee	800
Attorney Fee	100
Administrative Supplies	500
Equipment Depreciation	900
Fidelity Bonding	100
Telephone	740
Photo Copy	560
Postage	375
Administrative Travel	200
13. Facility - line 13	$	16,900
Security	2,000
Housekeeping Supplies	100
Facility Insurance	1,000
Rent	12,000
Utilities	1,800
15. TOTAL - LINE 15	$	128,267

WORKSHEET A - COLUMN J

Value of Donated Materials and Services

1. Medical - line 1
Volunteer R.N.'s	$	6,000
2. Laboratory - line 2
Free gc's done by the State lab	1,200
4. Pharmacy - line 4
Contraceptives donated by a closing clinic	2,400
7. Other Health - line 7
Volunteer counselor	400
12. Administrator's Time	700
13. Free rent at second site	1,200
15. TOTAL - LINE 15	11,900

Click here to view image

TABLE 6 WORKSHEET A: DISTRIBUTION OF PATIENT RECORDS COSTS AND FRINGE BENEFITS ACROSS FUNCTIONAL COST CENTERS

NOTE: If this Worksheet is used, it must be retained by the grantee.

It should not be submitted with TABLE 6.

FUNCTIONAL COST CENTERS	DISTRIBUTION OF PATIENT RECORDS COSTS				DISTRUBTION OF FRINGE BENEFITS COSTS
	Number of Encounters	% of Total Encounters	Amount of Personnel Distrb. to Functions	Amount of Other Distrb. to Functions	Salaried Personnel Costs (inc. Col. C)	% of Total Salaries	Amount of Fringe Benefits Distrb. to Functions	Total Salaried Personnel Costs	Other Costs	Value of Donated Mat. & Svcs.	Total Before Distribution
	(a)	(b)	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(k)
HEALTH CARE FUNCTIONS:	12,000	80%	4,600	240	158,350	67%	18,291	176,641	33,040	6,000	215,681
1) Medical (A)
2) Laboratory - Medical (B)		7,000	3%	819	7,819	22,992	1,200	32,011
3) X-Ray - Medical (C)
4) Pharmacy - Medical & Dental (D)		8,000	3%	819	8,819	50,500	2,400	61,719
5) Dental (Lab & X-Ray) (E)	-0-
6) Inpatient (F)
7) Other Health (G)	3,000	20%	1,150	60	17,150	7%	1,911	19,061	560	400	20,021
8) Community Service (H)
9) Environmental (I)
10) Patient Transportation (J)
11) Patient Records		(5750)	(300)
CLINIC OVERHEAD FUNCTIONS					44,000	19%	5,187	49,187	4,275	700	54,162
12) Administration (K)
13) Facility (L)		1,600	1%	273	1,873	16,900	1,200	19,973
14) Fringe Benefits		(27300)
15) TOTAL (LINES 1 through 14)	15,000	100%	-0-	-0-	236,100	100%	-0-	263,400	128,267	11,900	403,567

TABLE 6 WORKSHEET B:

DISTRIBUTION OF CLINIC OVERHEAD COSTS ACROSS HEALTH CARE COST CENTERS

NOTE: If this Worksheet is used, it must be retained by the grantee.

It should not be submitted with TABLE 6

FUNCTIONAL COST CENTERS	Total before Distribution Worksheet A, Col (k)	DISTRIBUTION OF FACILITY COSTS			Total after Distrb. of Facility Costs (a+d)	DISTRIBUTION OF ADMINISTRATION COSTS		Total after Final Distrb. of Clinic Overhead Costs (e & g)
		Square Feet of Space Used	% of Square Footage	Amount of Facility Distrib.. to Function		% of Health Care Cost Subtotal	Amount of Admin. Distrb. to Functions
	(a)	(b)	(c)	(d)	(e)	(f)	(g)	(h)
HEALTH CARE FUNCTIONS:	215,681	1,600	60%	11,984	227,665	66%	37,724	265,389
1) Medical (A)
2) Laboratory - Medical (B)	32,011	200	8%	1,598	33,609	10%	5,716	39,325
3) X-Ray - Medical (C)
4) Pharmacy - Medical & Dental (D)	61,719	150	6%	1,198	62,917	18%	10,288	73,205
5) Dental (Lab & X-Ray) (E)
6) Inpatient (F)
7) Other Health (G)	20,021	300	11%	2,197	22,218	6%	3,430	25,648
8) Community Service (H)
9) Environmental (l)
10) Patient Transportation (J)
11) SUBTOTAL (LINES 1 through 10)		346,409	100%
CLINIC OVERHEAD FUNCTIONS:	54,162	400	15%	2,996	57,158		(57,158)	-0-
12) Administration (K)
13) Facility (L)	19,973	(9,973)	-0-	-0-
14) SUBTOTAL (LINES 12 x 13)
15) GRAND TOTAL	403,567	2,650	100%	-0-	403,567	-0-	403,567

CONSISTENCY CHECKS:

1. COL. (a) equals TABLE 6: COL. (e)

2. COL. (e) equals TABLE 6 COL. (f)

3. COL. (h) equals TABLE 6 COL. (g)

4. LINE 15, COL. (a), COL. (e), and COL. (h) should all be equal.

DETERMINATION OF COST PER PROCEDURE

The purpose of this step is to distribute health care costs to particular procedures to derive the unit cost of each procedures. The cost per procedure should be computed for all procedures. The cost per procedure information is useful for managers in establishing charges and for analyzing the benefit of continuing to provide specific services. There may be some cases in which the cost per procedure requires a charge so far above the competitive rate (what other providers in the area would charge for that service) that the charge is prohibitive. This should be a signal to management that steps must be taken to lower costs in the future or consideration should be given to phasing out that service and making alternative arrangements.

Prepare a Cost of Service/Fee Determination Worksheet for each cost center. See Attachments B, C, D and E.

MEDICAL COST CENTER

Attachment B

1.	Column A -	List procedure.
2.	Column B -	List Service Utilization/Frequency of Procedure.
3.	Column C -	List Relative Value for Procedure from Page 18.
4.	Column D -	Column B x Column C. Total Column D.
5.	Column E -	Cost center amount from BCRR Table 6, Column G, line 1.
6.	Column F -	Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item.
7.	Column G -	The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service.
8.	Column H -	Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
9.	Column I -	Adjusted cost equals cost/service in Column G times Column H, cost of living allowance (COLA)% plus 100%.
Example:
$10.00 X 105% = $10.50
10.	Column J -	The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.

LABORATORY COST CENTER

Attachment C

1.	Column A -	List lab services provided.
2.	Column B -	List Service Utilization/Frequency of Procedure.
3.	Column C -	List Relative Value for Procedure from Page 18.
4.	Column D -	Column B X Column C. Total Column D.
5.	Column E -	Cost center amount from BCRR Table 6, Column G, line 2, minus the cost of PURCHASED OUTSIDE LABORATORY TESTS equals adjusted total cost/cost center. OUTSIDE LABORATORY TESTS ARE THOSE TESTS NOT PERFORMED BY THE AGENCY. This does not include collection of specimens.
6.	Column F -	Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit.
7.	Column G -	Adjusted cost/service equals the dollar amount in Column F times each relative value of Column C. This amount represents the cost for each specific service. Column F X Column C.
8.	Column H -	Enter the per unit purchase expense of OUTSIDE LABORATORY TESTS on the appropriate line or lines. This additional purchase expense applies only to designated tests. See designated list on page 35.
For nondesignated test, Column H equals ZERO.
9.	Column I -	Total base cost equals adjusted cost/service plus per unit purchase expense. Column G + Column H.
10.	Column J -	Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
11.	Column K -	Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA)% plus 100%.
Example:
$4.60 X 105% = $4.83
12.	Column L -	The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.

PHARMACY COST CENTER

Attachment D

1.	Column A -	List pharmaceuticals provided.
2.	Column B -	List Service Utilization.
3.	Column C -	List Relative Value for Pharmaceuticals from page 18.
4.	Column D -	Column B X Column C. Total Column D.
5.	Column E -	Cost center amount from BCRR Table 6, Column G, line 4, minus the cost of consumed pharmaceuticals equals adjusted total cost/cost center.
6.	Column F -	Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit.
7.	Column G -	Adjusted cost/service equals the dollar amount in Column F, times each relative value of Column C. This amount represents the cost for each specific service. Column F x Column C.
8.	Column H -	Equals the purchase expense per pharmaceutical unit. To arrive at an average per unit purchase expense, for Attachment D, Column H, when several brands of a pharmaceutical are purchased at different prices you will divide the total dollar value of those pharmaceuticals consumed during that period by the total number of units of those pharmaceuticals consumed during the same reporting period.
9.	Column I -	Total base cost equals adjusted cost/service plus per unit purchase expense. Column G + Column H.
10.	Column J -	Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
11.	Column K -	Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA)% plus 100%.
Example:
		$4.60 X 105% = $4.83
12.	Column L -	The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.

EDUCATION/COUNSELING COST CENTER

Attachment E

1.	Column A -	List procedure.
2.	Column B -	List Service Utilization/Frequency of Procedure.
3.	Column C -	List Relative Value for Procedure from Page 18.
4.	Column D -	Column B X Column C. Total Column D.
5.	Column E -	Cost center amount from BCRR, Table 6, Column G, line 7.
6.	Column F -	Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item.
7.	Column G -	The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service.
8.	Column H -	Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
9.	Column I -	Adjusted cost equals cost/service in Column G times Column H, cost of living allowance (COLA)% plus 100%.
Example:
$10.00 X 105% = $10.50
10.	Column J -	The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.

Attachment B

COST OF SERVICE/FEE DETERMINATION WORKSHEET									EDICAL COST CENTER
(A) SERVICE/PROCEDURE	(B) SERVICE UTILIZATION (FREQUENCY)	(C) RVS VALUE	(D) TOTALSERVICE UNITS	(E) TOTAL COST/ COST/CENTER	(F) AVERAGE COST/SERVICE UNIT	(G) COST/ SERVICE	(H) COST OF LIVING ALLOWANCE	`(I) ADJUSTED COST	(J) FEE
Minimal Service	900	11.00	9,900	/////////////////	$1.21	$13.31	5%	$13.98	$14.00
Brief/Intermediate Exam	1,500	18.00	27,000	///////////////////	1.21	21.78	5%	22.87	23.00
Extended Exam	6,000	30.00	180,000	/////////////////	1.21	36.30	5%	38.12	39.00
IUD Insertion	24	30.00	720	/////////////////	1.21	36.30	5%	38.12	39.00
Diaphragm Fit	124	15.00	1,860	/////////////////	1.21	18.15	5%	19.06	20.00
Sonography/lost IUD	1	30.00	30	/////////////////	1.21	36.30	5%	38.12	39.00
X-ray/lost IUD	1	24.00	24	/////////////////	1.21	29.04	5%	30.49	31.00
	////////////////
	////////////////
	////////////////
	////////////////
	////////////////
	////////////////
	////////////////
	////////////////
TOTAL	////////////////////	////////////////	219,534	$265,389	///////////////////	///////////	///////////////////	/////////////////	///////////////
NOTES:	1. D = B x C			5. G = F x C				REVISED: 03-Nov-89
	2. Total Column D			6. H = Cost of Living Allowance (COLA)
	3. E = Column G, line 1 of BCRR Table 6			7. I = G x (COLA % + 100%)
	4. F = Column E / Column D Total			8. J = Fee

Attachment C

COST OF SERVICE/FEE DETERMINATION WORKSHEET													LABORATORY COST CENTER
(A) SERVICE/PROCEDURE			(B) SERVICE UTILIZATION (FREQUENCY)	(C) RVS VALUE	(D) TOTAL SERVIOCE UNITSS	(E) ADJUSTED TOTAL COST/ \COST /CENTER	(F) AVERAGE COST/SERVICE UNIT		(G) COST/ SERVICE ADJUSTED	(H) PER UNIT PURCHASE EXPENSE	(I) TOTAL BASE COST	(J) COST OF LIVING ALLOWANCE	(K) ADJUSTED COST	(L) FEES
MGS/HCT			3,890	3.00	11,670	///////////////////////	$ .26		$ .78	-0-	$ .78	5%	$ .82	$ 1.00
Urinalysis			3,799	4.00	15,196	///////////////////////	.26		1.04	-0-	1.04	5%	1.09	2.00
Pregnancy Tex			1,025	10.00	10,250	///////////////////////	.26		2.60	-0-	2.60	5%	2.73	3.00
VDRL/RPR			8	6.00	48	///////////////////////	.26		1.56	4.00	5.56	5%	5.84	6.00
Pap Smear			4,000	8.00	32,000	///////////////////////	.26		2.08	3.50	5.58	5%	5.86	6.00
Gonorrhea Culture			8	8.00	48	///////////////////////	.26		1.56	6.50	8.06	5%	8.46	9.00
Miscellaneous Culture			40	8.00	240	///////////////////////	.26		1.56	18.00	19.56	5%	20.54	21.00
Bacterial Smear/Wet Mount			305	5.00	1,525	///////////////////////	.26		1.30	-0-	1.30	5%	1.37	2.00
Sickle Cell			100	5.00	500	///////////////////////	.26		1.30	5.00	6.30	5%	6.62	7.00
Blood Glucose			20	6.00	120	///////////////////////	.26		1.56	4.50	6.06	5%	6.36	7.00
Cholesterol Level			10	6.00	60	///////////////////////	.26		1.56	4.00	5.56	5%	5.84	6.00
SMA - 12			10	16.00	160	///////////////////////	.26		4.16	6.75	10.91	5%	11.46	12.00
Colposcopy			4	30.0	120	///////////////////////	.26		7.80	40.00	47.80	5%	50.19	51.00
Colposcopy and Biopsy			1	40.00	40	///////////////////////	.26		10.40	50.00	60.40	5%	63.42	64.00
Chlmaydia			510	7.00	3,570	///////////////////////	.26		1.82	8.00	9.82	5%	10.31	11.00
TOTAL			/////////////////////	////////////	75,547	19,533	////////////////////////		///////////////////	//////////////////	///////////////	////////////////////////////	///////////////////	///////////////////
NOTES:	1.		D = B x C				5.		G = F x C				REVISED: 21-Dec-89
2.		Total Column D				6.		H = Actual Perm Unit Purchase Expense From Outside Laboratory
3.		E = Column G, line 2 of BCRR, Table 6, Minus the Cost of Purchased Outside Laboratory Tests ($39,325 - $19,792=$19,533)				7.		I = Total Cost G+H
4.		F = Column E / Column D Total				8.		J = Cost of Living Allowance (COLA)
							9.		K = Ix(COLA%=100%)
							10.		L = Fee

Attachment D

COST OF SERVICE/FEE DETERMINATION WORKSHEET													PHARMACY COST CENTER
(A) SERVICE/PROCEDURE			(B) SERVICE UTILIZATION (FREQUENCY)	(C) RVS VALUE	(D) TOTAL SERVIOCE UNITSS	(E) ADJUSTED TOTAL COST/ COST /CENTER	(F) AVERAGE COST/SERVICE UNIT		(G) COST/ SERVICE ADJUSTED	(H) PER UNIT PURCHASE EXPENSE	(I) TOTAL BASE COST	(J) COST OF LIVING ALLOWANCE	(K) ADJUSTED COST	(L) FEE
Orals			58,500	1.20	70,200.00	///////////////////////////	.26		.31	.70	1.01	5%	1.06	2.00
Creams			54	2.65	143.10	///////////////////////////	.26		.69	1.00	1.69	5%	1.77	2.00
Jellies			50	2.65	132.50	///////////////////////////	.26		.69	1.00	1.69	5%	1.77	2.00
Suppositories (each)			5	0.15	.75	///////////////////////////	.26		.04	.20	.24	5%	.25	.25
Foams			2,304	3.00	6,912.00	///////////////////////////	.26		.78	.90	1.68	5%	1.76	2.00
Diaphragms			124	4.00	496.00	///////////////////////////	.26		1.04	3.00	4.04	5%	4.24	5.00
IUDS			24	50.00	1,200.00	///////////////////////////	.26		13.00	36.00	49.00	5%	51.45	52.00
Basal T&C			2	10.00	20.00	///////////////////////////	.26		2.60	16.50	19.10	5%	20.05	21.00
Sponges (each)			152	1.50	228.00	///////////////////////////	.26		.39	.50	.89	5%	.93	1.00
Condoms (each)			18,500	0.22	4,070.00	///////////////////////////	.26		.06	.05	.11	5%	..12	.25
Meds/Vag Inf			540	5.00	2,700.00	///////////////////////////	.26		1.30	4.70	6.00	5%	6.30	7.00
Meds/STD			539	5.00	2,695.00	///////////////////////////	.26		1.30	4.70	6.00	5%	6.30	7.00
Contraceptive Film			10	2.00	20.00	///////////////////////////	.26		.52	3.00	3.52	5%	3.70	4.00
			///////////////////////////
			///////////////////////////
TOTAL			////////////////////////	/////////////	88,817.35	$22,705	///////////////////////////		///////////////////////	/////////////////////	///////////////	/////////////////////////	/////////////////////	//////////////////////
NOTES:	1.		D = B x C				5.		G = F x C					REVISED: 21-Dec-89
2.		Total Column D				6.		H = Actual Perm Unit Purchase Expense
	3.		E = Column G, line 2 of BCRR, Table Minus the Cost of Consumed				7.		I = G + H
			Pharmaceuticals (($73,205 - $50,50 0 = $22,705)				8.		J = Cost of Living Allowance (COLA)
4.		F = Column E / Column D Total				9.		K = I x (COLA% + 100%)
							10.		L = Fee

Attachment E

COST OF SERVICE/FEE DETERMINATION WORKSHEET

EDUCATION, COUNSELING

COST CENTER

(A)

SERVICE PROCEDURE

(B)

SERVICE UTILIZATION (FREQUENCY)

(C)

RVS VALUE

(D)

TOTAL SERVICE UNITS

(E)

TOTAL COST/ COST/CENTER

(F)

AVERAGE COST/SERVICE UNIT

(G)

COST/ SERVICE

(H)

COST OF LIVING ALLOWANCE

(I)

ADJUSTED COST

(J)

FEE

Indepth 1 Hour

301

11.00

3,311

//////////////////////

1.80

19.80

20.79

$21.00

Counseling/15Min to 1 Hr

1,564

7.00

10,948

//////////////////////

1.80

12.60

13.23

14.00

//////////////////////

TOTAL

/////////////////////

////////////////

14.259

$25,648

/////////////////////

///////////////////

/////////////////////

//////////////////

/////////////////////

NOTES:

D = B x C

G = F x C

REVISED: 03 Nov-89

Total Column D

H = Cost of Living Allowance (COLA)

E = Column G, line 7 of BCRR Table 6

I = G x (COLA % + 100%)

F = Column E / Column D Total

J = Fee

Attachment F

E X A M P L E
POVERTY INCOME GUIDELINES CLIENT FEE DISCOUNT CATEGORIES Family Planning Services 1989 Revised Guidelines as published in Federal Register, 2/16/89, Vol. 54 No. 31																	03/08/89
FAMILY SIZE		0%			20%			40%			60%			80%			100%
FAMILY SIZE		A	B	C	D	E	F	G	H	I	J	K
1		0	-	5980	5981	-	8224	8225	-	10467	10468	-	12711	12712	-	14950	14951
2		0	-	8020	8021	-	11029	11030	-	14037	14038	-	17046	17047	-	20050	20051
3		0	-	10060	10061	-	13834	13835	-	17607	17608	-	21381	21382	-	25150	25151
4		0	-	12100	12101	-	16639	16640	-	21177	21178	-	25716	25717	-	30250	30251
5		0	-	14140	14141	-	19444	19445	-	24747	24748	-	30051	30052	-	35350	35351
6		0	-	16180	16181	-	22249	22250	-	28317	28318	-	34386	34387	-	40450	40451
7		0	-	18220	18221	-	25054	25055	-	31887	31888	-	38721	38722	-	45550	45551
8		0	-	20260	20261	-	27859	27860	-	35457	35458	-	43056	43057	-	50650	50651
*	FOR FAMILY UNITS WITH MORE THAN 8 MEMBERS, FOR EACH ADDITIONAL MEMBER ADD TO COLUMN B: $2,040
**	POVERTY LEVEL: $5,980
B	=	Family size = 1 = Poverty Level
B	=	All other Family size = Previous Family size Poverty Level plus $2,040
C	=	(B+1)
D	=	(J-B)/4+C
E	=	(D+1)
F	=	(J-B)/4+E
G	=	(F+1)
H	=	(J-B)/4+G
I	=	(H+I)
J	=	(Bx2.5)
K	=	(J+1)

Attachment G

SLIDING FEE SCALE
SERVICE/PROCEDURES	COST/ SERVICES		FEE		0%	20%	40%	60%	80%	100%
(a)	COST/ SERVICES		FEE		0%	20%	40%	60%	80%	100%
Minimal Services	$13.98	$14.00		N.C.	2.80	5.60	8.40	11.20	14.00
Brief/Intermediate Exam	22.87	23.00		N.C.	4.60	9.20	13.80	18.40	23.00
Extended Exam	38.12	39.00		N.C.	7.80	15.60	23.40	31.20	39.00
IUD Insertion	38.12	39.00		N.C.	7.80	15.60	23.40	31.20	39.00
Diaphragm Fit	19.06	20.00		N.C.	4.00	8.00	12.00	16.00	20.00
Sonography/lost IUD	38.12	39.00		N.C.	7.80	15.60	23.40	31.20	39.00
X-ray/lost IUD	30.49	31.00		N.C.	6.20	12.40	18.60	24.80	31.00
HCT/HBG	.82	1.00		N.C.	.20	.40	.60	.80	1.00
Urinalysis	1.09	2.00		N.C.	.40	.80	1.20	1.60	2.00
Pregnancy Test	2.73	3.00		N.C.	.60	1.20	1.80	2.40	3.00
VDRL/RPR	5.84	6.00		N.C.	1.20	2.40	3.60	4.80	6.00
Pap Smear	5.86	6.00		N.C.	1.20	2.40	3.60	4.80	6.00
Gonorrhea Culture	8.46	9.00		N.C.	1.80	3.60	5.40	7.20	9.00
Miscellaneous Culture	20.54	21.00		N.C.	4.20	8.40	12.60	16.80	21.00
Bacterial Smear/Wet Mount	1.37	2.00		N.C.	.40	.80	1.20	1.60	2.00
Sickle Cell	6.62	7.00		N.C.	1.40	2.80	4.20	5.60	7.00
PP Blood Glucose	6.36	7.00		N.C.	1.40	2.80	4.20	5.60	7.00
Cholesterol Level	5.84	6.00		N.C.	1.20	2.40	3.60	4.80	6.00
SMA - 12	11.46	12.00		N.C.	2.40	4.80	7.20	9.60	12.00
Colposcopy	50.19	51.00		N.C.	10.20	20.40	30.60	40.80	51.00
Colposcopy and Biopsy	63.42	64.00		N.C.	12.80	25.60	38.40	51.20	64.00
Chlamydia	10.31	11.00		N.C.	2.20	4.40	6.60	8.80	11.00
Orals	1.06	2.00		N.C.	.40	.80	1.20	1.60	2.00
Creams	1.77	2.00		N.C.	.40	.80	1.20	1.60	2.00
Jellies	1.77	2.00		N.C.	.40	.80	1.20	1.60	2.00
Suppositories (each)	*	.25	.25		N.C.	.05	.10	.15	.20	.25
Foams	1.76	2.00		N.C.	.40	.80	1.20	1.60	2.00
Diaphragms	4.24	5.00		N.C.	1.00	2.00	3.00	4.00	5.00
IUDS	51.45	52.00		N.C.	10.40	20.80	31.20	41.60	52.00
Basal T & C	20.05	21.00		N.C	4.20	8.40	12.60	16.80	21.00
Sponges (each)	.93	1.00		N.C.	.20	.40	.60	.80	1.00
Condoms (each)	*	.12	.25		N.C.	.05	.10	.15	.20	.25
Meds/Vag Inf	6.30	7.00		N.C.	1.40	2.80	4.20	5.60	7.00
Meds/STD	6.30	7.00		N.C.	1.40	2.80	4.20	5.60	7.00
Contraceptive Film	3.70	4.00		N.C.	.80	1.60	2.40	3.20	4.00
In-depth 1 Hour	20.79	21.00		N.C.	4.20	8.40	12.60	16.80	21.00
Counseling/15 Min. to 1 Hr.	13.23	14.00		N.C.	2.80	5.60	8.40	11.20	14.00
*Round to nearest .25

Ill. Admin. Code tit. 77, pt. 635, app B