ADMINISTRATIVE CODE

BCRR REPORTING NO.

REPORT FOR PERIOD (Check One & Complete Date)

January 198__ through June 198___

January 198__ through December 198___

_____ 198___ through _____ 198___

□ Initial Submission

□ Revision

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE

Section 635.10 Legislative Base

Section 635.20 Administration

Section 635.30 Definitions

Section 635.35 Incorporated Materials

Section 635.40 Standards and Policies for Personnel of Delegate Agencies

Section 635.50 Standards for Facilities of Delegate Agencies

Section 635.60 Financial Management Systems and Audits of Delegate Agencies

Section 635.70 Charges and Billing Procedures of Delegate Agencies

Section 635.80 Written Policies, Protocols and Procedures of Delegate Agencies

Section 635.90 Required Services

Section 635.100 Referrals and Follow-Up

Section 635.110 Quality Assurance

Section 635.120 Clinic Schedule

Section 635.130 Clinic Management

Section 635.140 Community Education, Information and Education Advisory Committee

Section 635.150 Family Participation Plan

Section 635.160 Applications

Section 635.170 Reporting Requirements

Section 635.180 Termination

Section 635.190 Review Under Administrative Review Law

Section 635.APPENDIX A Illinois Family Planning Clinic Visit Record

Section 635.APPENDIX B A Guide to Cost Analysis Developing Cost Based Fees and Sliding Fee Scale

Section 635.APPENDIX C Family Planning Services Application Packet

Section 635.APPENDIX D Instruction Manual for the BCHS Common Reporting Requirements

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.10 LEGISLATIVE BASE

Section 635.10 Legislative Base

The Family Planning Services and Population Research Act of 1970 (Public Law 91-572 (42 USC 300(a)-300(a)(6)(a))) added Title X to the Public Health Service Act. The Secretary of the Department of Health and Human Services (DHHS) is authorized to make grants to assist in the establishment and operation of voluntary family planning projects. The administration of this program in Illinois became the responsibility of the Illinois Department of Public Health on July 1, 1983 upon the approval of its application for a statewide Family Planning Program.

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.20 ADMINISTRATION

Section 635.20 Administration

a) Planning for all Maternal and Child Health (MCH) programs, including family planning services, is the responsibility of the Illinois Department of Public Health (Department). The Department will develop a program plan for maternal and child health services each year which will assess current needs within the State and provide goals and objectives for improving the health of mothers and children and for reducing infant mortality.

b) Highest priority for funding will be given to those areas in Illinois having high concentrations of low-income or marginal-income families and underserved areas. The Department shall fund delegate agencies which will provide family planning services consistent with the intent of Family Planning legislation.

c) The Department will arrange for the provision of family planning services through agreements with delegate agencies. Each delegate shall be required to enter into a written agreement with the Department.

d) Agencies eligible to apply for funding must be recognized by the Department, i.e. public or private not-for-profit organizations having documented capability of administering and providing qualified family planning services. Each delegate shall operate according to an approved plan written in accordance with this Part which is consistent with Federal and State Regulations (see Section 635.30).

e) The Department will annually evaluate the need for family planning services by using inspections, records and reports in order to develop a statewide plan for the effective and efficient provision of family planning services. Inspections will involve an on-site review of delegate agencies to ensure that implementation of program plans, which are required, are consistent with this Part.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.30 DEFINITIONS

Section 635.30 Definitions

"Agreement" means the written contract between the Department and delegate agency prepared by the Department and authorized by both parties.

"Delegate agency" means a public or private not-for-profit entity which provides family planning services under a negotiated written agreement with the Department.

"Family" means a social unit composed of one person, or two or more persons living together, as a household.

"Family planning services" means those medical, social, educational and referral services related to the avoidance, achievement, timing or spacing of pregnancy.

"Federal and State Regulations" governing Family Planning Services means printed regulations found in the following sources: 42 CFR Subpart B, 50.201-50.209; 42 CFR, Subpart C, 50.301-50.310; 45 CFR 16, 74, 80, 84 and 90.

"Low income family" means a family whose total annual income does not exceed 100 percent of the most recent DHHS Income Poverty Guidelines 54 FR 31, February 16, 1989.

"Marginal income family" means a family whose total annual income is above 100% and does not exceed 250% of the most recent DHHS Income Poverty Guidelines.

"Program Income" means gross income earned by a delegate agency and budgeted in the award period for activities described in the project and generated as a result of that delegate agency having received a grant from the Department. Such income shall include fees for services performed and proceeds from the usage or rental of equipment funded by the grant. Revenues received from taxes, levies, and fines are not considered program income. However, the receipt and expenditure of such revenues shall be recorded as part of the grant or subgrant project budget when such revenues are specifically earmarked for the project's Family Planning Program.

"Project Funds" means all sources of money related to the family planning services program and identified in the agency's family planning budget.

"Satisfactory Performance" means having met or exceeded the program objectives of serving a target population of which 85 percent of the unduplicated users are at or below 150 percent of the Federal Poverty Income Guidelines, as set by the state agency in their agreements with delegate agencies and meeting both the clinical and administrative indicators of the Bureau of Community Health Services (BCHS) of Common Reporting Requirements (BCRR).

"Underserved area" means geographic areas (county or Chicago Community Area) where less than 80 percent of the estimated number of women in need of family planning services are being served.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.35 INCORPORATED MATERIALS

Section 635.35 Incorporated Materials

The following materials are incorporated or referenced in this Part:

a) Federal Statutes and Regulations:

1) Family Planning Services and Population Research Act of 1970, Public Law 91-572, 42 U.S.C. 300 (a)(6)(a).

2) Poverty Income Guidelines, 54 FR 31, February 16, 1989.

3) Title VI, Civil Rights Act of 1964 (42 U.S.C. 2000e et seq).

4) 42 CFR Subpart B, 50.201-50.209; 42 CFR, Subpart C, 50.301-50.310; 45 CFR 16, 74, 80, 84, 90.

5) Accreditation Manual for Hospitals (1989). The Joint Commission, 1 Renaissance Blvd., Oakbrook Terrace IL 60181.

b) State of Illinois Statutes and Regulations:

1) The Ambulatory Surgical Treatment Center Act [210 ILCS 5].

2) Section 15a of State Finance Act [30 ILCS 105].

3) Fiscal Control and Internal Auditing Act [30 ILCS 10].

4) Administrative Review Law [735 ILCS 5/Art. III].

5) Minimum Qualifications for Public Health Personnel Employed by Full-Time Local Health Departments (77 Ill. Adm. Code 600).

6) Ambulatory Surgical Treatment Center Licensing Requirements (77 Ill. Adm. Code 205).

7) Travel (80 Ill. Adm. Code 2800).

8) Rules of Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100).

c) Other Materials

1) Professional Standards of American Institute of Certified Public Accountants (Volume 1, Section 150, November 1982). American Institute of Certified Public Accountants, 1211 Avenue of the Americas, New York, New York 10036-8775

2) Program Guidelines for Project Grants for Family Planning Services published by the U.S. Department of Health and Human Services (U.S. G.P.O. 1981, 0-341-166/6348), U.S. Department of Health and Human Services, Public Health Service, Health Services Administration, Bureau of Community Health Services, Office for Family Planning, 5600 Fishers Lane, Rockville, Maryland 20857.

3) Department of Health and Human Services Instruction Manual for BCHS Common Reporting Requirements (1982). U.S. Department of Health and Human Services, Public Health Service, Health Services Administration, Rockville, Maryland 20857.

4) BCHS Ambulatory Health Care Standards. U.S. Department of Health and Human Services, Public Health Service, Health Services Administration, Bureau of Community Health Services, Rockville, Maryland 20857.

5) Accreditation Manual for Hospitals (1989). The Joint Commission, 1 Renaissance Blvd., Oakbrook Terrace IL 60181.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.40 STANDARDS AND POLICIES FOR PERSONNEL OF DELEGATE AGENCIES

Section 635.40 Standards and Policies for Personnel of Delegate Agencies

a) The qualifications of persons employed by delegate agencies shall meet as a minimum the Department's rules titled Certified Local Health Department Code (77 Ill. Adm. Code 600). Delegate agencies must have a medical director who is a physician licensed to practice medicine in all its branches with Obstetrics/Gynecology training or experience in the delivery of family planning services. The medical director shall be responsible for and supervise the medical care component of the program and approve written policies under which physicians, nurse practitioners, certified nurse midwives, nutritionists and physician assistants provide family planning services. Staff shall possess the appropriate licensure to perform their duties. Copies of licenses must be on file at the agency. Any person employed at an individual delegate agency prior to July 6, 1983, may continue to serve at that agency only; even though the person may not meet the qualifications cited above.

b) Delegate agencies shall have written personnel policies which are in compliance with Title VI, the Civil Rights Act of 1964, (42 U.S.C. 2000e et seq.), available and distributed to all personnel. These shall include staff recruitment, selection, performance evaluation, promotion, termination, compensation, benefits, organizational chart and grievance procedures. All agencies shall also ensure:

1) That personnel records are kept confidential;

2) That personnel policies shall assure that no persons shall be subjected to discrimination on the grounds of age, handicap, race, color, creed, religion, sex or national origin. Affirmative action shall be taken to ensure equality of opportunity in all aspects of employment. Annual comprehensive reviews of operating procedures shall be made to assure that practices continue to be in conformity with the above requirements;

3) That written job descriptions are available for all positions, and that these are reviewed annually and updated when necessary to reflect changes in duties;

4) That an evaluation and review of job performance of all project personnel be conducted annually.

c) That orientation and in-service training of all staff, must be provided. An in-service training policy and plan for skill development and documentation of staff attendance at continuing education activities and other training sessions must be maintained by the delegate agency.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.50 STANDARDS FOR FACILITIES OF DELEGATE AGENCIES

Section 635.50 Standards for Facilities of Delegate Agencies

Clinic facilities of delegate agencies shall be located in areas accessible to clients and should be open at times convenient to those seeking service. Provisions must be made for access by handicapped persons. All facilities must meet applicable local fire and building codes (as evidenced by documentation of approval of authorities charged with enforcing those codes), must provide adequate space, and must ensure privacy for examination and counseling services and must comply with the BCHS Ambulatory Health Care Standards. In addition, all hospital based providers must meet The Joint Commission's Ambulatory Care Program standards. If surgical procedures are to be performed, the facility must be in full compliance with the State's Ambulatory Surgical Treatment Center Licensing Act.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.60 FINANCIAL MANAGEMENT SYSTEMS AND AUDITS OF DELEGATE AGENCIES

Section 635.60 Financial Management Systems and Audits of Delegate Agencies

a) Budgets – All delegate agencies and potential delegate agencies shall submit a budget proposal for each fiscal year for approval by the Department based on subsection (b) of this Section. This budget must include all program income related to family planning and provide for all such income to be retained by the delegate agency and used for program purposes. At least ten percent of the budget must come from sources other than the Family Planning Program grant award.

b) Use of project funds – Funds will be used only for the direct cost of administering, operating and maintaining a project. The following direct costs are examples of those which may be incurred when specified in the Agreement:

1) Personal services costs, including salaries and fringe benefits for full-time and part-time employees of the project.

2) Fees for consultants, specialists and other operating contractual requirements, pursuant to Section 15 of the State Finance Act exclusive of consultant services for patient care.

3) Travel of personnel, consultants and specialists in carrying out the activities approved for the applicant's program. Travel costs are the expenses for transportation, lodging, and subsistence for personnel who are on travel status on official business for the organization. Such costs will be charged on an actual basis, i.e., mileage and per diem when necessary; however, reimbursement shall not exceed the maximum rate established in the Travel Regulations promulgated by the Travel Regulation Council (80 Ill. Adm. Code 3000) effective on the date of travel, unless otherwise agreed upon and specified in the contract drawn between the applicant agency and the Department.

4) Supplies/commodities (see Section 15b of the State Finance Act), as required in the operation of the project, which are directly related to its operations.

5) Direct costs of installation, operation and maintenance of equipment previously included in the project application and directly related to the provision of the service(s) funded. All equipment purchased in total or in part with project funds shall be the property of the Federal Government. A complete and current inventory of equipment shall be maintained and be available for audit. No property shall be sold, leased, or otherwise disposed of without prior written authorization from the Department ("equipment" as defined in Section 20 of the State Finance Act).

6) Purchase of outpatient care.

c) Program Income

1) Program income shall be retained by the delegate agency and used to fund project activities.

2) The delegate agency will charge recipients for services not required in Section 635.90, that are provided by the project, but must apply a schedule of discounts consistent with requirements of Section 635.70(b), and 635.70(c) of this Part and 42 CFR 59.5(a)(8).

d) Reimbursement Procedures

1) Delegate agencies with service grants shall receive reimbursement based upon client service information submitted to the Department's agent through an automated clinic visit record system. The CVR is Appendix A of this Part.

A) The Department will reimburse the delegate agency at the rates shown for those family planning services listed in Appendix C of this Part.

B) Service information for July 1st through December 31^st shall be submitted no later than February 5^th of the contract year. Service information for January 1^st through June 30^th of the contract year shall be submitted no later than August 5^th of the contract year.

C) Payments shall be made to the delegate agency based upon monthly billings prepared by the Department's agent.

D) Delegate agencies must identify each expenditure submitted for reimbursement with a voucher or check number in order to maintain a clearly defined audit trail. All expenditures relating to the Family Planning funded program must be traceable through the delegate agency's internal record system. Invoices, bills, purchase orders, etc., must be attached or cross-referenced on the agency vouchers or check stubs and kept on file for three years beyond the end of the grant award period.

E) Expenditures must be documented by dates of issue of voucher or check, name and address of organization or individual to whom payment was made, and purpose of the expenditure. For periodic charges such as salaries, fringe benefits, rent, utilities, etc., the time period covered must be documented.

F) In cases in which references to patients must be made to maintain an audit trail, agencies shall use record numbers or other means of identification rather than patient names.

G) The delegate agency director or her/his authorized agent must sign the reimbursement request.

2) Delegate agencies will receive sterilization reimbursement based upon submission and program approval of sterilization consent and request for financial assistance.

e) Audits – Audits of the delegate agencies will be conducted at least every two years and will be performed in accordance with the following standards such as, but not limited to, Fiscal Control and Internal Auditing Act in accordance with the standards promulgated by the United States General Accounting Office (45 CFR 74, Appendix G & H) and the Professional Standards of the American Institute of Certified Public Accountants (Volume I, Section 150, November, 1982). Interim audits of the delegate agencies may be conducted at any time by the Department to ensure fiscal/compliance integrity. Agencies shall retain, for at least three years after the end of the grant period all financial records of expenditures, third-party reimbursements and other program income, and inventory records of all equipment with a unit cost in excess of $100.00 purchased from project funds.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.70 CHARGES AND BILLING PROCEDURES OF DELEGATE AGENCIES

Section 635.70 Charges and Billing Procedures of Delegate Agencies

a) Cost Analysis - An annual cost analysis of required services shall be completed by each delegate agency utilizing methodology prescribed by the Department in the Guide to Cost Analysis, Developing Cost Based Fees and Sliding Fee Scale is Appendix B of this Part.

b) Charges - persons with incomes above 250 percent of poverty level are to be charged the full cost for services received, based on the delegate agency's cost analysis. Low income persons are not to be charged for the services provided. No one may be denied services due to an inability to pay. Charges for services provided to minors who request that parents or guardians not be informed must be based only on the resources of the minor. Each delegate agency shall have written policies regarding the procedure to be used to determine the appropriate fee discount for marginal income families, who will be responsible for determining a client's discount, what information shall be collected to determine discount and how that information will be recorded in the client's record, procedures for updating client information, and who is responsible for notifying the client of charges.

c) Billing - Bills to clients shall show total charges less allowable discounts. Every reasonable effort to collect bills must be made; however, client confidentiality must be preserved in any such attempts. Third parties (including a governmental agency) must be billed in full to the extent they are authorized to or are under legal obligation to pay the charge.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.80 WRITTEN POLICIES, PROTOCOLS AND PROCEDURES OF DELEGATE AGENCIES

Section 635.80 Written Policies, Protocols and Procedures of Delegate Agencies

a) The delegate agency must develop written policies, protocols and procedures for family planning services. Written policies, protocols and procedures under which physicians, nurse practitioners, certified nurse midwives, physician assistants and nutritionists provide family planning services must be approved by the delegate agency's medical director.

b) Policies regarding eligibility for services shall not exclude anyone on the basis of duration of residency, age, race, marital status, religion, color, national origin, creed, handicap, sex, number of pregnancies, method of referral, or contraceptive preference. Services shall be provided only on a voluntary basis. These documents shall be updated as needed based on current state of the art in family planning and Federal and State Regulations. Agency protocols will be subject to intensive review at site visits by Department staff to determine their completeness and compliance with this Part.

c) Written policies, protocols and procedures must include:

1) Intake procedures for new clients

2) Patient education

3) Obtaining written informed consent

4) Schedule and content of visits

A) Initial

B) Annual

C) Scheduled return visits, specific to type of method of contraception

D) Problem visits, specific to type of problem

5) Counseling procedures

6) Referral procedures

7) Follow-up procedures for appointments, failed appointments, and referrals

8) Maintenance of client records

9) Approved medical orders

10) Maintenance and distribution of pharmaceuticals

11) Organizational structure of the unit and functional responsibilities of medical, nursing and ancillary personnel

12) Medical Procedures

A) Pap smears and gonorrhea cultures

B) Intrauterine device (IUD) insertions

C) Fitting diaphragms/cervical caps

D) Treatment of sexually transmitted diseases (STD)

E) Initiating oral contraceptives

F) Laboratory procedures

G) Treatment of minor gynecologic problems

H) Other medical procedures performed

13) Release of patient records

14) Emergency procedures

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.90 REQUIRED SERVICES

Section 635.90 Required Services

Delegate agencies are required to deliver the following services and components either directly on-site or by referral. Minimum requirements for routine contraceptive management which shall be met are included in "Program Guidelines for Project Grants for Family Planning Services" published by the U.S. Department of Health and Human Services (42 CFR 59.5). Abortions shall not be provided by delegate agencies as a method of birth control.

a) Client education

1) Male and female anatomy and physiology

2) Conception - the importance of prenatal care, and risks associated with childbearing at the extremes of the reproductive age span; i.e., less than 17 years of age and over 34 years of age

3) Contraception - including action, effectiveness, use benefits, risks and side effects

A) Male and female sterilization

B) Oral contraceptives

C) IUDs

D) Contraceptive sponge

E) Foam, condoms and vaginal contraceptive film

F) Diaphragm and cream/jelly (cervical cap if available)

G) Natural family planning (NFP) (ovulation/sympto-thermal)

H) Withdrawal

I) Post-coital contraception (i.e., Diethylstilbesterol (DES)

J) Abstinence

4) Human immune deficiency virus/AIDS education

b) Counseling

1) Method selection

2) Compliance with treatment

A) Method used

B) Return appointments

C) Follow through with referrals

3) Special Counseling

A) Nutrition problems

B) Sexual/social problems

C) Pregnancy options

D) Genetics

E) Sterilization

c) Examination

1) History

A) Initial history

i) Menstrual history including age of menarche, when periods became regular, date of last normal menstrual period, abnormal periods or intermenstrual bleeding

ii) Past medical/surgical history including allergies, sexually transmitted diseases (STD), immunizations (especially rubella status), medications, review of systems

iii) Pertinent history of biological parents and immediate family including heart disease, strokes before age 50, high blood cholesterol or fats, kidney disease, diabetes, high blood pressure, cancer, genetic problems

iv) Reproductive history, number of pregnancies, outcome, complications and weight of infant at birth

v) Social history including sexual activity, age at first intercourse, frequency of intercourse, number of partners, and drug/tobacco use/abuse

vi) Contraceptive history, including methods used, length of use, major side effects and complications

vii) In utero exposure to diethylstilbestrol (DES)

B) Interim history

i) Interim medical/surgical history

ii) Assessment of any side effects of contraceptive, specific to method used

iii) Menstrual history

2) Physical Exam

A) Initial exam and annual exam

i) Height and weight

ii) Blood Pressure

iii) Thyroid

iv) Heart

v) Lungs

vi) Abdomen

vii) Extremities

viii) Breast with instruction in self-breast exam

ix) Pelvic exam, including external genitalia; speculum exam including vagina, visualization of cervix; bi-manual exam, including uterus, adnexa; and rectal exam as needed

B) Special return visits

i) Intrauterine device (IUD) - abdominal palpation, bi-manual exam and speculum exam for visualization of IUD string (two to six weeks after insertion)

ii) Pill (for women at high risk) - Blood pressure with interim history after initial three months of use, after second three months of use, again after six months of use (3-3-7) and then every six months thereafter alternating with annual exams (6-7), for women at high risk because of factors including, but not limited to, age, weight, blood pressure, liver disease, and/or personal habits

iii) Pill (for women not at high risk) - Blood pressure with interim history after initial three months of use then annual history and examination (including weight, blood pressure, and hematocrit and/or hemoglobin)

iv) Diaphragm/cervical cap - recheck fit (approximately two weeks after initial fitting)

v) Problem visit - review of related system(s), appropriate laboratory tests

vi) Norplant - incision check (approximately two weeks after insertion)

vii) Gonorrhea culture as indicated (previous history of Pelvic Inflammatory Disease (PID), previous history of Gonorrhea Culturing (GC), potential exposure, symptoms, multiple partners)

3) Laboratory tests

A) Initial visit

i) Hemoglobin or hematocrit

ii) Pap smear

iii) Gonorrhea culture for clients requesting IUD insertion, for those with high potential or exposure, or on request

iv) Urinalysis for protein and glucose

B) Annual visits

i) Hemoglobin or hematocrit

ii) Pap smear

iii) Gonorrhea culture for clients with previous history of pelvic inflammatory disease (PID), previous history of gonorrhea, multiple partners, new partner(s), on client request and clients requesting IUD insertion

C) Special tests as indicated

i) Pregnancy test

ii) Wet smear

iii) Urine culture and sensitivities

iv) Blood sugars

v) T(3), T(4), TSH (thyroid hormones)

vi) White blood count (WBC) and differential

vii) Rubella titer if not known

viii) Sickle cell screen if indicated and not known

ix) Herpes titer/culture

x) Blood group and Rh type

xi) VDRL/RPR/serology (test for syphilis)

xii) Liver studies

xiii) Chlamydia test

d) Infertility services

1) Initial infertility history

2) Education

3) Physical exam (same as initial visit)

4) Laboratory tests (same as initial visit)

5) Counseling

6) Referral as indicated

e) Pregnancy Services

1) Pregnancy testing

2) History and physical exam for confirmation

3) Nondirective counseling on all options if test is positive, and referral as requested

4) Family planning information if test is negative

f) Adolescent Services

1) Counseling in all methods

2) History and physical exam as indicated including laboratory tests

3) Parental involvement via agency plan for family participation and as required by applicable federal and State Regulations and administrative rules promulgated pursuant thereto

g) STD Services

1) Laboratory screenings

2) Reporting of positive cases to the State STD Program or its designated agent as required by state or local ordinance

3) Education, counseling, treatment and follow-up of infected individuals

4) Follow-up of contacts for testing/treatment

h) Identification and follow-up of Diethylstilbestrol (DES) exposed clients

1) DES history for clients born between 1940 and 1970

2) Counseling of exposed individuals regarding potential risks/problems

3) Colposcopy or referral for exposed females

(Source: Amended at 18 Ill. Reg. 5969, effective April 1, 1994)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.100 REFERRALS AND FOLLOW-UP

Section 635.100 Referrals and Follow-Up

a) All required family planning services, and all methods of birth control must be provided either directly by the delegate agency or through referrals. When required family planning services are to be provided by referral, written letters of agreement must be maintained at the delegate agency detailing the services to be provided by each party.

b) A directory of agencies with which the delegate agency has referral agreements shall be maintained and available to all delegate agency staff responsible for patient services. This directory shall include the agency name, address, phone number an hours of operation, contact person at the agency, services available, eligibility requirements, and fees for services, if any.

c) Client records should be provided to the referral agency, to facilitate service provision. When requested by the referral agency, these records shall be released only after obtaining written consent of the client. All follow-up activities must respect the confidentiality of the client. A specific method for contacting the client shall be established at the time of entry into services.

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.110 QUALITY ASSURANCE

Section 635.110 Quality Assurance

A system of quality assurance shall be established by each delegate agency. The quality assurance system, at a minimum, will include a monthly chart review to evaluate the completeness of records and compliance of services with approved medical standards and protocols, annual staff evaluation to ensure quality of services, utilization of community needs assessment to ensure targeting of services, log book for documentation and follow-up of referrals, documentation and follow-up for patients with abnormal findings, a methodology to provide follow-up for patients with failed appointments.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.120 CLINIC SCHEDULE

Section 635.120 Clinic Schedule

A clinic schedule must be developed by each delegate agency which will assure that services are provided on the days and at the times when clients can make maximum use of services consistent with efficient clinic management.

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.130 CLINIC MANAGEMENT

Section 635.130 Clinic Management

a) Equipment and supplies used in the facility must be safe and adequate in number for the clinic size. Supplies such as syringes, needles and pharmaceuticals must be kept in a secure place with access limited to appropriate agency staff per agency protocol. An inventory shall be maintained of all supplies.

b) Prescriptions must be filed and filled, or medication supplied under the order of the delegate agency's medical director. Emergency drugs for resuscitation must be on hand and readily available to the examination rooms for use if needed. If rubella vaccines are not provided by the agency, information concerning treatment for the client must be provided.

c) Medical records must be maintained in a systematic, complete, and confidential fashion. These records shall include at a minimum personal data including mechanism for client contact, history, physical exam, lab test, referral with notations regarding follow-up, problem lists, counseling session notations, telephone contacts between client and agency, and educational checklist. All entries in progress notes, physical exams and histories must be signed by the clinician performing the service. Signed informed consent forms must be on file for all treatments and procedures performed.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.140 COMMUNITY EDUCATION, INFORMATION AND EDUCATION ADVISORY COMMITTEE

Section 635.140 Community Education, Information and Education Advisory Committee

a) Delegate agencies are required to plan and implement a community education program which shall be supportive to the acceptance and use of family planning services.

b) Plans shall include:

1) A listing of local entities which serve persons of reproductive age such as clinics, mental health facilities, health departments, churches, hospitals, schools, youth organizations, and other volunteer and community organizations;

2) A curriculum and schedule of contact of in-service training for the staff of the above agencies to provide information on the purpose of family planning, to assist with client counseling, and to develop referral linkages;

3) Provisions for information campaigns to inform the potential user groups of the availability and accessibility of family planning services; and

4) Provision for a community education program to provide information on the benefits of family planning services as well as to provide encouragement to parents to be actively involved in the reproductive health education of their children.

c) Each delegate agency shall have an Information and Education Advisory Committee composed of individuals representative of the community served and knowledgeable about family planning services. The Committee shall have at least five and no more than nine members. The function of the Committee is to review and approve all materials prepared for Family Planning program clients or community information or education. The Committee will be responsible for assuring the accuracy of facts presented and the suitability of the material for the intended audience. Copies of minutes of Committee meetings must be kept on file at the delegate agency and submitted annually to the Department.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.150 FAMILY PARTICIPATION PLAN

Section 635.150 Family Participation Plan

a) Each delegate agency must prepare and implement a plan and procedures to encourage families to participate in the education, counseling, and contraceptive activities of their children who are agency clients.

b) Examples of activities which plans may include are:

1) Special education sessions for parents;

2) Workshops for parents on sexuality education of their children;

3) Encouraging minors to bring their parents with them on clinic visits; and

4) Special counseling procedures for adolescents requesting services concerning parental involvement.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.160 APPLICATIONS

Section 635.160 Applications

a) Distribution of Applications

1) All application materials will be developed and distributed by the Department to existing agencies or new projects in underserved areas based on need in the service area, experience in provision of services and plans to accomplish goals. These are included as Appendix C of this Part.

2) Distribution of application materials will occur on or before March 15th of the prior grant year.

b) Processing of Applications

1) All forms will be provided by the Department. These are included as Appendix C of this Part.

2) Application forms shall be submitted to the Department no later than thirty calendar days from the date of distribution.

3) The Department shall review the applications and request any additional information from the applicant as necessary, to complete or clarify the application.

4) Upon review of the application and recommendations from staff, the Director shall award grant funds to the approved applicants. The Department may award funds for amounts less than requested in the grant application contingent upon the number of applications, Federal funding levels, and State appropriations.

5) The Department will communicate final decisions to each applicant within 45 days of receipt of the completed application or upon notification of appropriation of funds.

c) Budget

1) As part of the project application, all applicants shall submit a budget proposal for the project period. The budget proposal shall be submitted on forms provided by the Department and shall include all information required in the instructions for their completion.

2) The budget shall be divided into major categories of cost. Not all categories will apply to all projects. In preparing its budget, each project should use only those categories applicable to its own operation, including justification for all equipment purchases.

d) Revisions

1) All changes in any delegate agency's project plan and/or budget reflecting increases or decreases in the IDPH grant award, must be submitted in writing and must be determined by the Department to be in compliance with this Part, prior to the implementation of such change.

2) Each proposal for change shall include, at a minimum, a description of the proposed change and a justification stating why such change is necessary. Budget revisions shall specify the number of dollars involved, the type of changes proposed, and the reasons thereof.

3) Revisions may be required by the Department pertaining to a project's funding, duration and amount contingent upon changes in Federal and/or State funding allocations to the Department. Delegate agencies will be notified in writing of any required revisions.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.170 REPORTING REQUIREMENTS

Section 635.170 Reporting Requirements

All reports will be submitted on forms provided by the Department excluding the Information and Education Advisory Committee minutes. Delegate agencies are required to submit the following in accordance with the Family Planning Program annual calendar:

a) A Clinic Visit Record (CVR) form provided by the Department for each client visit to the contracting computer firm. The visit form is the input document for the computer-based information system.

b) Applicable portions of the Bureau of Community Health Services Common Reporting Requirements (BCRR) of the Department of Health and Human Services (DHHS) to the Department (Title X of the Public Health Service Act, 42 U.S.C. 1009, (a), (b), and (c)). Each report shall be submitted in accordance with the DHHS Instruction Manual for the BCHS Common Reporting Requirements included as Appendix D of this Part. Late submission of this report will result in a decrease of 5% in the following year's award.

c) Semiannual and annual performance reports to the Department addressing the following points:

1) Comparison of the objectives in the approved project plan with the actual achievements of the project.

2) Changes in the project; e.g., in facilities or equipment, services and activities, population served, etc.

3) Unresolved problems, e.g., with fiscal resources, external relationships, met and unmet grant conditions and issues which need to be addressed in the future.

d) All minutes of the local Information and Education Advisory Committee activity to the Department.

e) Annual inventory report identifying equipment purchased with project funds during the award period.

f) Semiannual and annual financial status report including all funds utilized for the Family Planning Program to the Department.

g) Quarterly reports to the Department addressing:

1) Community education activity;

2) Sterilization service activity if no annual sterilization waiver letter was provided; and

3) Sexually transmitted diseases (STD) testing activity.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.180 TERMINATION

Section 635.180 Termination

a) All grants shall terminate on the dates specified in the contracts and shall not be extended or renewed except as provided for in this Part.

b) A delegate agency with unsatisfactory performance for two consecutive years may have funding terminated.

c) The grant contract may be terminated by either party upon a 30 day written notice. The Department will distribute unallocated monies to expand existing projects or to fund new projects in underserved areas based on need such as number of low income women in the service area not receiving services in the service area, experience in provision of services, including the availability of an agency willing to provide the services, and plans to accomplish goals.

d) Notice shall be effected by registered mail, by certified mail, or by personal service setting forth the particular reasons for the proposed action and fixing a date, not less than 15 days from the date of such mailing or service, at which time the delegate agency shall be given an opportunity for a hearing. Such hearing shall be conducted by the Director or by a person designated in writing by the Director as Hearing Officer to conduct the hearing. On the basis of any such hearing, or upon default of the delegate agency, the Director shall make a determination specifying his findings and conclusions. A copy of such determination shall be sent by registered mail, by certified mail, or served personally upon the delegate agency. The decision shall become final 35 days after it is so mailed or served, unless the grantee, within such 35 day period, petitions for review pursuant to Section 635.190.

e) The Director, after notice and opportunity for hearing to the delegate agency, may suspend or terminate the grant in any case in which there is or has been a violation of this Part.

f) The procedure governing hearings authorized by this Part shall be in accordance with Rules of Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100).

g) If, however, the Department finds that:

1) The public interest, including financial interest, health, safety, or welfare requires emergency action; (emergency action would result from such instances as, but not limited to bankruptcy or insolvency, fraud, and financial instability) and;

2) Unless the Department receives assurances adequate to the Department from the delegate agency that grant funds held by the delegate agency are secure, and;

3) If the Director incorporates a finding to that effect in the order; then

4) Summary suspension of the grant shall be ordered pending proceedings for termination or referral to State orFederal authorities, which proceedings shall be instituted within one week of summary suspension and promptly determined.

h) In no case where summary suspension has been ordered shall reimbursement be made to the delegate agency for costs incurred or funds expended after the date of summary suspension unless, after conclusion of the proceedings, such reimbursement or payment is ordered by the hearing officer, administrative law judge or court of competent jurisdiction.

(Source: Amended at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.190 REVIEW UNDER ADMINISTRATIVE REVIEW LAW

Section 635.190 Review Under Administrative Review Law

Whenever the Department suspends or terminates a grant the grantee may have such decision judicially reviewed. The provisions of the Administrative Review Law and the rules adopted pursuant thereto shall apply to and govern all proceedings for the judicial review of final administrative decisions of the Department hereunder.

(Source: Added at 14 Ill. Reg. 20783, effective January 1, 1991)

Section 635.APPENDIX A Illinois Family Planning Clinic Visit Record

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.APPENDIX 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

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

Total Column D

I = G + H

03-NOV-89

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

(

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

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)	12,000		80%	4,600	240	158,350	67%	18,291	176,641	33,040	6,000	215,681
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)						44,000	19%	5,187	49,187	4,275	700	54,162
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)
			Total before Distribution Worksheet A, Col (k)		Square Feet of Space Used	% of Square Footage	Amount of Facility Distrib.. to Function	Total after Distrb. of Facility Costs (a+d)	% 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
	3.	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				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)	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

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.APPENDIX C FAMILY PLANNING SERVICES APPLICATION PACKET

Section 635.APPENDIX C Family Planning Services Application Packet

Checklist for Completing the FY90

Family Planning Services Application

Check ( ) the following item for completeness before submitting your application for processing. Each must be addressed, filled in or attached as indicated. CHECKLIST MUST BE SUBMITTED WITH APPLICATION.

Cover Sheet Attachment A
	Complete Sections	2	Applicant Organization
		3	Applicant Certification
		4	Type of Organization
		5	Grant Support Requested
		6	Type of Application
		7	Legislative District
		8	Date of Submission
Health Care Plan
	#10 complete narrative
	#11 define target area
	#12 list clinic(s) names(s)
	and days/hours of operation
	#13 complete budget in accordance
	with the attached budget and
	expenditures category definitions
Checklist – FY 90
	#14 complete cost analysis by IDPH methodology
	Between Page 5 & 6 attach schedule of discounts
	and sliding fee scale with charges based upon
	1989 Poverty Guidelines.
	#15 complete three (3) objectives
	Complete attached Plans to Achieve
	Objective/Program Progress Report
	Forms three (3)

Attachment A

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

535 WEST JEFFERSON STREET

SPRINGFIELD, ILLINOIS 62761

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT

PROGRAM TITLE:

Family Planning Services

BRIEF SUMMARY:

To provide comprehensive family planning services pursuant to the application and assurances

submitted by the grantee. Such services will be delivered in accordance with the Department's applicable rules

entitled Title 77: Public Health, Chapter I: Department of Public Health, Sub Chapter: Maternal and Child Health

Part 635 Program Content and Guidelines for Title X Family Planning Services

APPLICANT ORGANIZATION:

TYPE OF ORGANIZATION:

NAME:

LOCAL HEALTH DEPARTMENT

ADDRESS:

PRIVATE NON-PROFIT AGENCY

OTHER ___________________________

GRANT SUPPORT REQUESTED:

TELEPHONE:

(

)

BEGINNING

ENDING

AMOUNT

FEIN NUMBER:

PROJECT DIRECTOR:

TYPE OF APPLICATION:

INITIAL

CONTINUATION

REVISION

LEGISLATIVE DISTRICT

FINANCE OFFICER:

CONGRESSIONAL

LEGISLATIVE

(State Senate)

REPRESENTATIVE

APPLICANT CERTIFICATION:

(State Representative)

To the best of my knowledge, the data and

statements in this application are true and

correct. The applicant agrees to comply with

all State/Federal statutes and Rules/Regulations

applicable to the program.

DATE OF SUBMISSION:

Month

Date

Year

AUTHORIZED OFFICIAL:

IMPORTANT NOTICE:

This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Illinois Revised Statutes, Ch. 127, Par. 137 et. seq. Failure to provide this information may prevent this form from being processed. This form has been approved by the Forms Management Center.

Date

Signature

4/88

			Agency Name
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT (cont'd.)				DATE FROM: THROUGH
10.	HEALTH CARE PLANS
INSTRUCTIONS:		Complete a narrative summarizing the major features of the project including: 1. statement of need, 2. characteristics of the target area including other Family Planning Resources, 3. methods used to conduct program and 4. measure its success.

USE ADDITIONAL SHEETS IF NECESSARY					3/89

					Agency Name
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT (cont'd.)						DATE FROM: THROUGH
11.	GEOGRAPHIC SERVICE AREA
INSTRUCTIONS:			Define your target service area by listing county(ies) or community(ies) served.


12.	CLINIC(S) SCHEDULE(S)
INSTRUCTIONS:		List all clinics by name, address and days/hours of operation.
Clinic(s) Names(s)/Address(es)				Days/Hours of Operation












USE ADDITIONAL SHEETS IF NECESSARY							3/89

Agency Name

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT - (continued)

DATE FROM: THROUGH

13.

BUDGET

INSTRUCTIONS:

All funds must be identified and assigned to categories in accordance with the budget and expenditures category definitions.

CATEGORY

Family Planning Award

Title XIX

Patient Fees

Other Funds

TOTAL

Budget

Personal Services

Contractual Services

Supplies

Travel

Patient Care

Equipment

Total

*Details must be provided below. Use additional sheets if necessary.

3/89

Illinois Department of Public Health

Division of Family Health

Budget Category Definitions

Personal Services

"The item 'personal services', means the reward or recompense made for personal services rendered by an employee of the delegate agency in support of this project, or any amount required or authorized to be deducted from the salary of any such person or any retirement or tax law, or both, or deductions from the salary of any such person under the Social Security Enabling Act, or deductions from the salary of such person. Any employee is anyone who receives the fringe benefits offered by the delegate agency.

Contractual Services

"The item 'contractual services', means and includes: (a) Expenditures, incident to the current conduct and operation of an office, department, or agency in direct support of this project for postage and postal charges, telephone expenses, printing, office conveniences and services, exclusive of supplies as herein defined: (b) Expenditures of $5,000 or less for repair or maintenance of property or equipment, utility services, professional or technical services; (c) Expenditures pursuant to multi-year lease, lease-purchase or installment purchase contracts for duplicating equipment authorized by the contract.”

Travel

"The item 'travel', shall include any expenditure directly incident to official travel by employees of the project, involving reimbursement to travelers or direct payment to private agencies providing transportation or related services.”

Supplies

"The item 'supplies' means and includes expenditures in connection with current operation and maintenance for the purchase of articles of a consumable nature which show a material change or appreciable depreciation with first usage, repair parts, and including tools and equipment having a unit value not in any instance exceeding $50, but does not include any expenditure for library books or expenditure included in 'permanent improvements’.”

Equipment

(purchase exceeding $100)

"The item 'equipment', shall mean and include all expenditures for library books, and expenditures, having a unit value exceeding $100, for the acquisition, replacement or increase of visible tangible personal property of a non-consumable nature.”

Patient Care

"The item 'patient care' means services necessary for the care of patients that the delegate can not provide other than by an outside vendor. This includes medical and social service contracts.

IDPH (1987)

Illinois Department of Public Health

Division of Family Health

Expenditures per Category

Listed below are examples of the most common charges shown under their appropriate category. If you have any other type of expense, please do not hesitate to call for assistance in placing it in the correct category.

I. Personal Services

1. Fringe benefits

2. Salaries

II. Contractual Services

1. Advertising costs

2. Building and ground maintenance

3. Conference and registration fees

4. Contractual employees

5. Copy machine rental

6. Insurance (building, fire, theft and malpractice)

7. Legal services and accounting fees

8. Postage (including stamps)

9. Printing

10. Rent or lease of space of property

11. Repair and maintenance of furniture and equipment

12. Statistical and tabulation services (data processing)

13. Subscriptions

14. Telephone

15. Utility cost

III. Supplies

1. Contraceptives

2. Educational and instructional materials

3. Medical supplies

4. Office supplies

5. Pamphlets

IV Travel

1. Lodging

2. Per diem

3. Travel expense (mileage, train, or air fare)

V Patient Care

1. Lab Work

2. Nurse practitioner for patient care (contracted out)

3. Physicians for patient care (contracted out)

VI Equipment

1. All equipment that is purchased

IDPH (1987)

Agency Name

APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT (continued)

DATE FROM: THROUGH

14. COST ANALYSIS AND FEES

INSTRUCTIONS: Complete the cost analysis following the cost analysis manual instructions. Attach a copy of your agency's Schedule of Discounts and sliding fee schedule with charges based upon the 1990 federal poverty guidelines.

(a)

Service/Procedure

(b)

Serv. Util.

(c)

RVS

(d)

Total Serv. Units

(e)

Total Cost/Cost Ctr.

(f)

Avg. Cost/Serv. Unit

(g)

Cost/Serv.

(h)

Fee

Medical Cost Center

Minimal

5.00

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

Brief/Intermediate

18.00

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

Extended

30.00

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

IUD Insertion

30.00

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

Diaphragm Fit

15.00

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

Sonography

30.00

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

X-ray/Lost IUD

24.00

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

TOTAL

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

/////////

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

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

///////

Laboratory Cost Ctr.

HGB/HCT

3.00

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

U/A

4.00

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

Pregnancy Test

10.00

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

VDRL

6.00

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

Pap Smear

8.00

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

Gonococcal

6.00

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

Misc. Culture

6.00

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

Bact.Sm./Wet Mount

5.00

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

Sickle Cell

5.00

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

PP Blood Gluc.

6.00

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

Cholesterol Level

6.00

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

SMA-12

16.00

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

Colposcopy

30.00

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

Colp./Biopsy

40.00

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

Chlamydia Test

7.00

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

TOTAL

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

/////////

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

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

///////

Pharmacy Cost Ctr.

Orals

1.20

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

Creams

2.65

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

Jellies

2.65

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

Suppositories (ea.)

0.15

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

Foams

3.00

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

Diaphrams

4.00

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

IUD's

50.00

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

Basal T&C

10.00

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

Sponges (ea.)

1.50

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

Condoms (ea.)

0.22

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

Meds/Vag.Inf.

5.00

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

Meds/STD

5.00

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

Contracep Film

2.00

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

TOTAL

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

/////////

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

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

///////

Ed./Couns. Cost Ctr.

1 hr. Indepth

30.00

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

Couns./15min.-1hr.

5.50

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

TOTAL

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

/////////

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

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

///////

-5-

3/89

Date Cost Analysis Completed

BCRR DATA FROM CY 1989

ATTACH SCHEDULE OF DISCOUNTS AND SLIDING FEE SCALE

WITH CHARGES UTILIZED BY YOUR AGENCY

BASED UPON 1990 REVISED POVERTY GUIDELINES

Agency Name
APPLICATION AND PLAN FOR PUBLIC HEALTH PROGRAM GRANT (cont’d.) DATE FROM: THROUGH
15. OBJECTIVES
INSTRUCTIONS: Complete the objectives below by inserting the numbers that are appropriate for your agency. Agencies must complete objectives #1 and #2 by inserting the numbers that are appropriate for their agency. #3 must be an individual agency objective. Also complete the attached Plans to Achieve Objectives/Program Progress Report forms using these numbers and listing the tasks necessary to meet the objectives.
1. Provide family planning services to 8270_______unduplicated users in need of subsidized
#
family planning services during State Fiscal Year 1991. At least 85% of users will be

in the group with income equal to or less than 150% of poverty; ________% of all users will
#
be teenagers.


2. Provide________ information and education programs for an estimated__________ individuals
#		#
in communities served during State Fiscal Year 19___.

3. Individual Agency Objective

USE ADDITIONAL SHEETS IF NECESSARY	3/89

FAMILY PLANNING SERVICES

PLANS TO ACHIEVE OBJECTIVES

PROGRAM PROGRESS REPORT

AgencyJune 2, 2025________________

Project Period July 1, 1990 – June 30, 1991

Objective

#1 Provide family planning services users in need of subsidized family planning services

during State Fiscal Year 1991. At least 85% of users will be in the group with income equal to

or less than 150% of poverty: % of all users will be teenagers.

S C H E D U L E

Tasks to Meet Objective

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

Status of Task

FAMILY PLANNING SERVICES

PLANS TO ACHIEVE OBJECTIVES

PROGRAM PROGRESS REPORT

Agency____________________________

Project Period July 1, 1990 – June 30, 1991

Objective

#2 Provide Information and education programs for an estimated individuals in

communities served during State Fiscal Year 1991.

S C H E D U L E

Tasks to Meet Objective

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

Status of Task

FAMILY PLANNING SERVICES

PLANS TO ACHIEVE OBJECTIVES

PROGRAM PROGRESS REPORT

Agency____________________________

Project Period July 1, 1990 – June 30, 1991

Objective	#3

S C H E D U L E

Tasks to Meet Objective

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

Status of Task

	Illinois Department of Public Health					Attachment A

ILLINOIS FAMILY PLANNING RATE SCHEDULE
Effective July 1, 1990

SERVICE			RATE	SERVICE			RATE

BILLABLE MEDICAL SERVICES				CONTRACEPTIVE DRUGS & SUPPLIES

Minimal Service Exam		5.50		Oral Contraceptives	1.50/cycle
Brief/Intermediate Exam		12.65		Creams	2.00/tube
Extended Exam		26.65		Jellies	1.30/tube
(Includes $3.50 for provision				Suppositories	.25 each
of basic AIDS education)				Foams	2.00/can
Intrauterine Device Insertion		35.30		Diaphragms	4.50 each
Diaphragm Fit		23.15		Intrauterine Device	84.00 each
Cervical Cap Fit		23.15		Basal Thermometer & Charts	15.00
				Sponges	.50 each
				Condoms	.15 each
				Vag/STD Rx	5.00/medication
				Contraceptive Film	2.00/pkg.
				Cervical Cap	29.95 each

LABORATORY PROCEDURES				STERILIZATION

Hematocrit		3.30		Pre-Counseling	30.00
Hemoglobin		3.30		Female Sterilization
Urinalysis/Dipstick		3.30		(Reimbursement only with prior
Pregnancy Test		8.90		approval from IDPH)
Papanicolaou Smear		8.63		Male Sterilization
Wet Mount/Gram Stain		4.40		(Reimbursement only with prior
Miscellaneous Culture		5.75		approval from IDPH)
Sickle Cell Screening		5.75
Post-prandial Blood Glucose		5.75
Cholesterol Level		6.80
SMA-12 Fasting Level		16.45
Colposcopy		29.75
Colposcopy with Biopsy		39.90
Chlamydia Test		6.50

COMPLICATIONS				BILLABLE COUNSELING

X-rays/Lost IUD		36.40		Indepth/1 Hr.	30.00
Sonography/Lost IUD		60.65		Education/Counseling	5.50
				(15 min – 1 hr.)

	Poverty Level	Reimbursement

	0 - 100%	Full rate + 25%
	101 - 150%	85% of full rate + 15%
	151 - 200%	One-third of full rate + 15%
	201 - 250%	15% only based on one-third rate
	Medicaid	25% of full rate
	251 - Above	No reimbursement

3947f
4 / 89

Illinois Department of Public Health

Family Planning Service Definitions

Billable Medical Services

Reimbursement will be provided for the services and procedures in this section when prescribed, furnished, directed or supervised by a physician. These services are exclusive of laboratory procedures; treatment of complications; billable counseling; and provision of contraceptive drugs, supplies and devices.

1. Family Planning Minimal (Service) Examination – Examination accompanying routine medical revisits to an established client. May include IUD check, diaphragm placement check, visualization of vagina and cervix, possible palpation, weight and blood pressure.

2. Family Planning Brief/Intermediate Examination – Usual examination accompanying problem medical revisits which require a physical examination. Services vary and may include pregnancy diagnosis, vaginal infection, PID, possible IUD complications, follow up on a breast lump or suspicious PAP.

3. Family Planning Extended Examinations – Family planning examinations usually accompanying an initial and annual visit. Examination includes a complete physical including recto-vaginal examination, breast examination, weight and blood pressure.

4. Insertion of IUD – Placement into the uterus (by either the push or withdrawal technique) of an FDA approved contraceptive device following the sounding of the uterus.

5. Diaphragm Fitting – Selection of appropriate size diaphragm based on depth of the vagina and perineal muscle tone.

Laboratory Procedures – The following routine and special laboratory services are reimbursable in connection with the physical examination and evaluation or if needed as a result of positive history or if deemed medically necessary at the time of examination by the attending physician or medical director in charge.

1. Hematocrit/Hemoglobin

2. Urinalysis/Dipstick

3. Pregnancy Test

4. Papanicolaou Smear

5. Wet Mount/Gram Stain – (e.g., Trichomoniasis, Candidiasis, Gardnerella)

6. Miscellaneous Culture – (e.g. Herpes, Urine)

7. Sickle Cell Screening

8. Post-Prandial Blood Glucose

9. Triglycerides Fasting Level Confirmation Test

10. SMA-12

11. Colposcopy – Examination of vagina and cervix by means of the colposcope.

12. Colposcopy with Biopsy – Examination of vagina and cervix by means of the colposcope with removal and examination of tissue.

13. Chlamydia Test – Direct smear FA and enzyme immunoassay (ELISA)

Complications – Occasionally, complications may develop. Such services related to complications will be limited to the following.

1. Sonography/Lost IUD – A record or display obtained by ultrasonic scanning for purpose of locating IUD.

2. X-Ray & Interpretation – Up to two x-rays for the purpose of determining location of IUD.

Billable Counseling

1. Indepth/1 Hr. Counseling – Counseling designed to assist the individual client in understanding and successfully dealing with an identified problem. Such counseling may be related to the emotional aspects of a medical problem or may involve health education. This service should be completed by professional staff such as the public health nurse, health educator or social worker. Such counseling may require only one session or may involve multiple sessions to insure that the client has developed sufficient insight to deal with the related issues. This is not to be understood as a patient education session associated with a medical visit. The time expectation for delivery of this service is approximately 1 hour.

2. Education/counseling (15 minute to 1 hour) – Education or counseling services related to the effective utilization of a family planning method and documented in the patient file. Time expectation for delivery of this service is approximately 15 minutes.

Contraceptive Supplies and Drugs – Reimbursement will be made for the following:

1. Oral Contraceptives

2. Creams

3. Jellies

4. Suppositories

5. Foams

6. Diaphragms

7. IUDs

8. Basal Thermometer & Charts

9. Sponges

10. Condoms

11. Vag/STD Rx

12. Contraceptive Film

Sterilization – The following will be provided under the family planning program if sterilization is medically indicated and IDPH gives prior approval.

1. Pre-Counseling

2. Female Sterilization

3. Male Sterilization

4. Anesthesia

5. Pathology

(Source: Added at 14 Ill. Reg. 20783, effective January 1, 1991)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.APPENDIX D INSTRUCTION MANUAL FOR THE BCHS COMMON REPORTING REQUIREMENTS

Section 635.APPENDIX D Instruction Manual for the BCHS Common Reporting Requirements

FORM APPROVED

OMB NO. 0915-0004

EXPIRES 12/31/82

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

Bureau of Community Health Services

Division of Monitoring and Analysis

5600 Fishers Lane

Rockville, Maryland 20857

(301)443-2376

BUREAU OF COMMUNITY HEALTH SERVICES

COMMON REPORTING REQUIREMENTS

FACE SHEET

1) BCRR Reporting No.

2) Check one:

Initial Submission

Revision

3) REPORT FOR PERIOD (Check One & Complete Date)

January 198__ through June 198___

January 198__ through December 198___

_____ 198___ through _____ 198___

4) Sponsor/Grantee Name

5) Project Name and Address

7) Program(s)*

Grant Number

(a)

(b)

6) Project Name/Address Change

(c)

since last report?

Yes No

(d)

8) Name of Person Preparing Report

(e)

(f)

(g)

9) Area Code and Business Telephone Number of Person Preparing Report

10) Director (name)

Signature & Date

11)

Check those tables not submitted with this report because they are totally inapplicable for the reason listed: (do not submit blank tables)

2-A

Only applies to projects serving migratory and seasonal agricultural workers.

Only applies to primary care projects/grantees.

2-B

Only applies to CH, FP, MH and other projects designed by the Regional Office.

Only applies to projects affected by the Primary Care Effectiveness activity.

*Grantees receiving support from one or more BCHS program will report the identifying code for each program included and the grant number relating to each program (except in free-standing NHSC sites). The codes are as follows:

- Community Health Center (includes RHI,

- National Health Service Corps (BHPDS)

- UHI & Hospital-Affiliated).

- Migrant Health

- Title X Family Planning

Submit:

3 copies to:

the Data Manager

REGIONAL OFFICE

(unless the Regional Office specifies otherwise)

NOTE:

Grantees are in violation of Public Health Service policy if they fail to submit reports that are complete, timely, accurate and valid. Grantees are ineligible to receive continuation support if they have failed to comply with the submission requirements of the BCRR as established by the Regional Office.

Direct questions to the Regional Data Manager.

Check the appropriate reporting period and enter the terminal digit for the year in space 3 on the FACE SHEET and the upper right corner of each table.

Attach an explanation to any table for which:

sampling is used or estimates have been made; and/or

the data is entered inconsistent with the definitions/instructions used in the BCRR Instruction Manual. Contact the Regional Data Manager if non-standard definitions are used.

When submitting revisions of tables that have already been sent to the Regional Office or submitting for the first time a table which was omitted from a previous submission:

Submit only those tables which are being revised (changed) or being submitted for the first time.

Indicate the reporting period for the revised information on both the FACE SHEET and the table(s).

NOTE: The reporting period for the revised information should match the reporting period indicated on the FACE SHEET. Do not include tables with different due dates under one FACE SHEET;

Check the appropriate box (Initial Submission or Revision) on the FACE SHEET and each table revised;

Where a small number of cells are being revised they should be circled to avoid a re-keying of the entire table;

Follow the distribution schedule in 1 above.

(REV. 1/82)

TABLE 1: NUMBER OF USERS BY TYPE OF PROVIDER,

AGE AND SEX FOR THIS REPORTING PERIOD

AGE AND SEX			USERS* BY TYPE OF PROVIDER
			MEDICAL (a)	DENTAL (b)
Female:
1)	0-4
2)	5-9
3)	10-14
4)	15-19
5)	20-34
6)	35-44
7)	45-64
8)	65 and over
9)	SUBTOTAL
	(LINES 1 through 8)
Male:
10)		0-4
11)		5-9
12)		10-14
13)		15-19
14)		20-34
15)		35-44
16)		45-64
17)		65 and over
18)		SUBTOTAL
		(LINES 10 through 17)
19)		TOTAL
		(LINES 9 + 18)

*A user is an individual who has had one or more encounters during the reporting period covered by this table (January - June or January - December).

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 2-A: UTILIZATION OF SPECIAL POPULATION GROUPS

FOR THIS REPORTING PERIOD

NOTE: This table applies to any grantee servicing migratory and/or seasonal agricultural workers and their family members.

TYPE OF USER

MEDICAL

USERS*

(a)

DENTAL

USERS*

(b)

Migratory Agricultural Workers and Family Members

Seasonal Agricultural Workers and Family Members

*A user is an individual who has had one or more encounters during the reporting period covered by this table (January - June or January - December).

BCCR REPORTING NO.		REPORT FOR PERIOD (Check One & Complete Date)
				January 198__ through June 198___
				January 198__ through December 198___
				_____ 198___ through _____ 198___
			□ Initial Submission			□ Revision
	FP/FS Delegate?				□ Yes		□ No

TABLE 2-B: NUMBER OF FAMILY PLANNING USERS BY TYPE OF USER AND AGE FOR THIS REPORTING PERIOD

NOTE: This table applies only to CH, FP, MH, and all other projects required by the Regional Office to report this table. Grantees which are required to submit this table but do no receive Title X funding should report all female Family Planning Users, regardless of income, on LINE 1.

TYPE OF FAMILY PLANNING USER		FAMILY PLANNING USERS* (a)
1)	Women at or below 150% of Poverty Level
2)	Women above 150% of Poverty Level
3)	Men
4)	TOTAL (LINES 1+2)
Female Adolescent Users of Family Planning Services (Subset of LINE 4)
5)	Under 20 years old
6)	15-19 Year Olds

*A Family Planning user is an individual who has had one or more Family Planning Encounters (Medical or Other Health) during the reporting period covered by this table (January - June or January - December).

	BCCR REPORTING NO.	REPORT FOR PERIOD (Check One & Complete Date)
HCFA I.D. NO.				January 198__ through June 198___
				January 198__ through December 198___
				_____ 198___ through _____ 198___
			□ Initial Submission		□ Revision

TABLE 3: PERSONNEL BY FUNCTIONAL COST CENTER AND ENCOUNTERS BY TYPE OF PROVIDER FOR THIS REPORTING PERIOD

PERSONNEL BY FUNCTIONAL COST CENTER*					STAFF* PERSONNEL EQUIVALENTS		ENCOUNTERS
					STAFF* PERSONNEL EQUIVALENTS		Onsite With Staff Providers	All Other (Including Offsite and Nonstaff)
					(a)**	(b)***	(c)	(d)
MEDICAL SERVICES			(A)	1) Primary Care Physicians
				2) Psychiatrists
				3) Other Medical/Surgical Specialists
				4) Midlevel Practitioners
				5) Nurses − Medical
				6) Medical Support
ANCIL- LARY SERVICES			(B)	7) Laboratory-Medical
			(C)	8) X-Ray-Medical
			(D)	9) Pharmacy-Medical & Dental
DENTAL SERVICES				10) Dentists
			(E)	11) Dental Hygienists/ Oral Therapists
				12) Dental Support
OTHER HEALTH SERVICES		(G)		13) Education/Social Service
				14) Other Health
				15)
				16) Other Health Support
SUPPORT SERVICES		(H)		17) Community Service
		(I)		18) Environmental Health
		(J)		19) Patient Transportation
				20) Patient Records
CLINIC OVER- HEAD		(K)		21) Administration
CLINIC OVER- HEAD		(L)		22) Facility
				23) TOTAL (LINES 1 through 22)
*	Assign staff time by function performed, not title. See instructions for this table.
**	Include only NHSC personnel in Column (a).
***	Include salaried personnel, as well as the personnel equivalents of any non-salaried personnel (contractual or donated) who work for the grantee on a scheduled time basis. (See definition of "Staff.") Include WIC, VISTA and volunteer staff, where appropriate.
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 4: HOSPITAL INPATIENT CARE BY TYPE OF

ENCOUNTER FOR THIS REPORTING PERIOD

NOTE: To be completed by all primary care grantees/projects. Primary care grantees/projects include: CH, HC, and MH.

TYPE OF SERVICE		PATIENT ADMISSIONS BY PROJECT STAFF (a)	HOSPITAL INPATIENT ENCOUNTERS BY PROJECT STAFF* (b)
1)	Pediatrics
2)	Internal Medicine
3)	Obstetrics

4)	Other (Specify)

*Project staff include salaried, contracted or donated medical personnel, i.e., physicians and midlevel practitioners.

TABLE 5: SELECTED CLINICAL SERVICES FOR THIS REPORTING PERIOD

NOTE: Only applies to projects affected by Primary Care Effectiveness activity, as follows: CH, FP, HC and MH.

Clinical

User Category

Records Sampled

(a)

Records in Compliance

(b)

Immunization

24-27 months

Immunization

6 year olds

Adolescent Family Planning

Counseling (under 20 years)

Pap Smear Follow-up

Hypertension Follow-up

(10 years and over)

Anemia Screening

24-27 months

FREQUENCY OF REPORTING: Semi-annually (January 1 - June 30, July 1 - December 31)

BCRR REPORTING NO.	REPORT FOR PERIOD (Check One & Complete Date)
HCFA I.D. NO.				January 198__ through June 198___
			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)
FUNCTIONAL COST CENTER		(a)	(c)	(d)	(e)	(f)	(g)
HEALTH CARE FUNCTIONS
1)	Medical (A)
2)	Laboratory-Medical (B)
3)	X-Ray Medical (C)
4)	Pharmacy-Medical & Dental (D)
5)	Dental (inc. Lab & X-Ray) (E)
6)	Inpatient (F)
7)	Other Health (G)
8)	Community Service (H)
9)	Environment (I)
10)	Patient Transportation (J)
CLINIC OVERHEAD FUNCTIONS
11)	Administration (K)						- 0 -
12)	Facility (L)					- 0 -	- 0 -
13)	TOTAL (LINES 1 though 12)

*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 data transferred from Worksheet B.

NOTE: The distribution of PERSONNEL COSTS across from the functional areas 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)

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.

DISTRIBUTION OF PATIENT RECORDS COSTS

DISTRIBUTION OF FRINGE

BENEFITS COSTS

Other Costs

Value of

Donated Mat.

& Svcs.

Total Before

Distribution

FUNCTIONAL

COST CENTERS

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

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(k)

HEALTH CARE FUNCTIONS

Medical (A)

Laboratory-Medical (B)

X-Ray - Medical (C)

Pharmacy-Medical & Dental (D)

Dental (Lab & X-Ray) (E)

Inpatient (F)

Other Health (G)

Community Service (H)

Environmental (I)

10)

Patient Transportation (J)

11)

Patient Records

( )

CLINIC OVERHEAD FUNCTIONS:

12)

Administration (K)

13)

Facility (L)

14)

Fringe Benefits

( )

15)

TOTAL (LINES 1 though 14)

100%

-0-

100%

-0-

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.

			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)
FUNCTIONAL COST CENTERS			Total before Distribution Worksheet A, Col (k)	Square Feet of Space Used	% of Square Footage	Amount of Facility Distrb. to Functions	Total after Distrb. of Facility Costs (a + d)	% 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)
2)	Laboratory -- Medical (B)
3)	X-Ray -- Medical (C)
4)	Pharmacy-Medical & Dental (D)
5)	Dental (Lab & X-Ray) (E)
6)	Inpatient (F)
7)	Other Health (G)
8)	Community Service (H)
9)	Environmental (I)
10)	Patient Transportation (J)
11)	SUBTOTAL (LINES 1 through 10)							100%
CLINIC OVERHEAD FUNCTIONS:									( )	-0-
12)	Administration (K)								( )	-0-
13)	Facility (L)					( )	-0-			-0-
14)	SUBTOTAL (LINES 12 + 13)
15)	GRAND TOTAL				100%	-0-			-0-
		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), COL. (h) should all be equal.

TABLE 7: ACCOUNTS RECEIVABLE, CHARGES AND COLLECTIONS

BY SOURCE OF FUNDS FOR THIS REPORTING PERIOD

SOURCE OF FUNDS			ACCOUNTS RECEIVABLE AT BEGINNING OF THIS PERIOD	FULL CHARGES AND PREMIUMS DURING THIS PERIOD*	AMOUNT COLLECTED DURING THIS PERIOD		ADJUSTMENTS (identify below)**	ACCOUNTS RECEIVABLE AT END OF THIS PERIOD
			(a)	(b)	(c)		(d)	(e)
1) Medicare (Title XVIII)
2) Medicaid (Title XIX)
3) Title XX
4) Other Third Parties
5) Patient Fees/Premiums
6) TOTAL (LINES 1+2+3+4+5)
Charges or premiums prior to adjustments for patients' ability to pay, third party disallowances, etc. If Full Charges/Premiums are based upon a negotiated or contractual arrangement with a third party payor, and are not generally reflective of the costs of operation, footnote and explain below (name of third party, per unit, service, or capitation reimbursement rate or dollar limit). *Breakdown of Adjustments by Type
DESCRIPTION					AMOUNT
	7) Disallowances and Reductions (Contractual Allowances)					$
	8) Sliding Payment Scale Adjustments					$
	9) Bad Debt Write Off					$
	10) Other (Specify)					$
	CONSISTENCY CHECKS:
		1. COL. (e) should equal COL. (a) + COL. (b) – COL. (c) – COL. (d)
		2. The amount entered in COL. (a) should equal the amount entered in COL. (e) of the TABLE 7 for the preceding calendar year.
		When TABLE 7 is completed for the same reporting period as TABLE 8, then:
		3. LINE 6, COL. (c) should equal TABLE 8: LINE 16 COL. (a).
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.

TABLE 8: SUMMARY OF RECEIPTS AND EXPENDITURES

FOR THIS REPORTING PERIOD

NOTE: This table applies to grantee receipts and expenditures associated with services or activities in the approved application for BCHS funds, including those associated with delegate agency operations.

Grantees should complete this table as follows:

Annual: The entire table (LINES 1 through 23, COL. a).

First Six Months (unless instructed by the Regional Office to report quarterly for the first three quarters):

LINES 10, 16, 20 and 21 through 23, COL. (a).

		Summary of Receipts and Expenditures		Actual for Reporting Period (a)
Federal Grants		1)	Section 329 (Migrant Health)
		2)	Section 330 (Community Health Center)
		3)	MCH Block Grants*
		4)	Title X (Family Planning)**
		5)	Section 340 (Primary Care R & D)
		6)	Appalachian Health
		7)	Black Lung Clinic Program
		8)	WIC***
		9)	Other (Specify)****8270_______
		10)	SUBTOTAL (LINES 1 through 9)
Payment for Services		11)	Title XVIII (Medicare)
		12)	Title XIX (Medicaid)
		13)	Title XX
		14)	Other Third Parties
		15)	Patient Collections
		16)	SUBTOTAL (LINES 11 through 15)
Other Sources		17)	State
		18)	Local
		19)	Other (Specify)**** June 2, 2025_
		20)	SUBTOTAL (LINES 17 through 19)
Expendi- tures		21)	Capital Expenditures
		22)	Non-Capital Expenditures*****
		23)	SUBTOTAL (LINES 21 + 22)
*	Any form of State assistance through MCH Block
**	Indicate Title X funds received directly from the Federal government or indirectly through a delegate agency type relationship on LINE 4. Indicate other Federal grants received directly or indirectly on LINE 9.
***	Only include monies received for administration and operation of the WIC program, not the monies received for food. Do not include money spent on food on LINE 22.
****	Enter NHSC loans on LINE 19.
*****	Include all actual expenditures by the grantee and its delegates on LINE 22. Payments made to the Federal government during the reporting period for the cost of NHSC assignees are entered on LINE 22.
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).

(Source: Added at 14 Ill. Reg. 20783, effective January 1, 1991)