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

Section 635.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 31. $ .00 32. Laboratory Equipment Maintenance and Repair 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 1. D = B x C 5. G = F x C REVISED 03-NOV-89 2. Total Column D 6. M = 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 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: 1. D = B x C 6. H = Actual Per Unit Purchase Expense From Outside Laboratory REVISED 03-NOV-89 2. Total Column D 7. I = Total Cost G + H 3. E = Column G, line 2 of BCRR Table 6, 8. J = Cost of Living Allowance (COLA) Minus the Cost of Purchased Outside Laboratory Tests 9. K = I x (COLA % + 100%) 4. F = Column E ÷ Column D Total 10. L = Fee 5. 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: 1. D =  B x C 6. H = Actual Per Unit Purchase Expense REVISED 2. Total Column D 7. I = G + H 03-NOV-89 3. E = Column G, line 4 of BCRR Table 6 8. J = Cost of Living Allowance (COLA) Minus the Cost of Consumed Pharmaceuticals 9. K x (COLA % + 100%) 4. F = Column E ÷ Column D Total 10. L = Fee 5. 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: 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 7 of BCRR Table 6 7. I = G x (COLA % + 100%) 4. F = Column E ÷ Column D Total 8. 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% 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 2.0 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 2.0 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 24. $ 18,291.00 (Worksheet A – Column g, line 1) 25. Medical Facility Costs 25. $ 11,984.00 (Worksheet B – Column d, line 1) 26. Administrative Costs 26. $ 37,724.00 (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. $ 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 34. $ 19,792.00 See page 35. 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 42. $ 819.00 (Worksheet A – Column g, line 2) 43. Laboratory Facility Costs 43. $ 1,598.00 (Worksheet B – Column d, line 2) 44. Laboratory Administration Cost 44. $ 5,716.00 (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. $ 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 87. $ 819.00 (Worksheet A – Column g, line 4) 88. Pharmacy Facility Costs 88. $ 1,198.00 (Worksheet B – Column d, line 4) 89. Pharmacy Administration Cost 89. $ 10,288.00 (Worksheet B – Column g, line 4) 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 90. $ 73,205.00 This total equals BCRR Table 6, Column g, line 4. 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 105. $ 1,911.00 (Worksheet A – Column g, line 7) 106. Counseling and Education Facility Costs 106. $ 2,197.00 (Worksheet B – Column d, line 7) 107. Counseling and Education Administration Costs 107. $ 3,430.00 (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. $ 25,648.00 This total equals BCRR Table 6, Column g, line 7. WORKSHEET A – COLUMN E Salaried Personnel Includes Column C (C + E = E) 1. Medical – line 1 $ 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 .1 Patient Record Clerk 1,150 12. Administration – line 12 $ 44,000 1.0 Project Director 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 1 $ 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 BCRR REPORTING NO. REPORT FOR PERIOD (Circle One & Complete Date) January 198___ through June 198___ HCFA I.D. NO. January 198___ through December 198___ ______ 198___ through_________ 198___ Initial Submission Revision TABLE 6: COSTS BEFORE AND AFTER DISTRIBUTION BY FUNCTIONAL COST CENTER FOR THIS REPORTING PERIOD NOTE: Grantees should complete this table as follows: Annual: The entire table (LINES 1 through 13, COLS. a through g). First six months (unless instructed by the Regional Office to report quarterly for the first three quarters): Complete all of LINE 13, and the applicable cells of COLS. (f) and (g). FUNCTIONAL COST CENTER SALARIED PERSONNEL* (WORKSHEET A, COL. h) OTHER (INCLUDING CONSULTANT AND CONTRACT SERVICES) VALUE OF DONATED MATERIAL & SERVICE** TOTAL BEFORE DISTRIBUTION (COLS. a + b + c + d) TOTAL AFTER DISTRIBUTION OF FACILITY. COSTS*** (WORKSHEET B. COL. e) TOTAL AFTER FINAL DIST OF CLINIC OVERHEAD COSTS (WORKSHEET B. COL. h) (a) (c) (d) (e) (f) (g) HEALTH CARE FUNCTIONS 176,641 33,040 265,389 1) Medical (A) 2) Laboratory Medical (B) 7,819 22,992 39,325 3) X-Ray–Medical (C) 4) Pharmacy–-Medical & Dental (D) 8,819 50,500 73,205 5) Dental (Inc. Lab & X-Ray) (E) 6) Inpatient (F) 7) Other Health (G) 19,061 560 25,648 8) Community Service (H) 9) Environmental (I) 10) Patient Transportation (J) CLINIC OVERHEAD FUNCTIONS 49,187 4,275 57,158 -0- 11) Administration (K) 12) Facility (L) 1,873 16,900 -0- -0- 13) TOTAL (LINES 1 through 12) 263,400 128,267 11,900 403,567 403,567 * Include the costs of salaried personnel, including the costs of fringe benefits paid to employees (see TABLE 6 Worksheet A). ** Include the costs associated with donated personnel, including NHSC assignees. For NHSC personnel, include the reimbursable cost of the assignee(s), not the amount actually reimbursed to the Corps. *** Only the cells not shaded should be completed with the date transferred from Worksheet B. NOTE: The distribution of PERSONNEL COSTS across the functional area should correspond to the distribution of STAFF PERSONNEL EQUIVALENTS shown in TABLE 3. For any individual whose time is split among two or more functions in TABLE 3, the same percentage split should be applied to personnel and consultant costs in this table. All amounts should be rounded off to the nearest dollar. CONSISTENCY CHECK: LINE 13, COL (e) = LINE 13, COL. (g) FREQUENCY OF REPORTING: Semi annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period (June 30 or December 31). 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: 1) Medical (A) 215,681 1,600 60% 11,984 227,665 66% 37,724 265,389 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: 12) Administration  (K) 54,162 400 15% 2,996 57,158 (57,158) -0- 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. 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 on page 18. 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) 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 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: 2. Total Column D 6. H = Actual Perm Unit Purchase Expense From Outside Laboratory 21-Dec-89 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: 2. Total Column D 6. H = Actual Perm Unit Purchase Expense 21-Dec-89 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 5% 20.79 $21.00 Counseling/15Min to 1 Hr 1,564 7.00 10,948 ////////////////////// 1.80 12.60 5% 13.23 14.00 ////////////////////// ////////////////////// ////////////////////// ////////////////////// ////////////////////// ////////////////////// ////////////////////// ////////////////////// ////////////////////// ////////////////////// ////////////////////// ////////////////////// ////////////////////// TOTAL ///////////////////// //////////////// 14.259 $25,648 ///////////////////// /////////////////// ///////////////////// ////////////////// ///////////////////// 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 7 of BCRR Table 6 7. I = G x (COLA % + 100%) 4. F = Column E ÷ Column D Total 8. 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 0% 20% 40% 60% 80% 100% 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) 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