CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER i: 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.
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TABLE OF CONTENTS |
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INTRODUCTION............................................................................................................................. |
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APPROACH...................................................................................................................................... |
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FUNCTIONAL AREAS..................................................................................................................... |
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DETERMINATION OF COST PER PROCEDURE............................................................................. |
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PREPARE A COST OF SERVICE/FEE DETERMINATION WORKSHEET FOR EACH COST CENTER........................................................................... |
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EXPENSE ALLOCATIONS FOR THE BCRR.................................................................................... |
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RELATIVE VALUES........................................................................................................................ |
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OPTIONAL REVENUE ANALYSIS.................................................................................................. |
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CALCULATING THE SCHEDULE OF DISCOUNTS........................................................................ |
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DEVELOPMENT OF A SLIDING FEE SCALE.................................................................................. |
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ATTACHMENTS |
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ATTACHMENT A: |
SAMPLES OF ADMINISTRATIVE COSTS...................................................... |
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ATTACHMENT B: |
MEDICAL COST CENTER WORKSHEET....................................................... |
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ATTACHMENT C: |
LABORATORY COST CENTER WORKSHEET............................................... |
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ATTACHMENT D: |
PHARMACY COST CENTER WORKSHEET................................................... |
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ATTACHMENT E: |
EDUCATION/COUNSELING COST CENTER WORKSHEET.......................... |
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ATTACHMENT F: |
POVERTY INCOME GUIDELINES – CLIENT FEE DISCOUNT CATEGORIES |
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ATTACHMENT G: |
SLIDING FEE SCALE....................................................................................... |
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LIST OF EXAMPLES |
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ALLOCATION OF MONIES FOR BCRR.......................................................................................... |
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COMPLETED BCRR FROM ABOVE ALLOCATIONS..................................................................... |
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DETERMINATION OF COST PER PROCEDURE............................................................................. |
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FEE DETERMINATION WORKSHEETS.......................................................................................... |
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Medical........................................................................................................... |
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Laboratory...................................................................................................... |
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Pharmacy........................................................................................................ |
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Education and Counseling................................................................................ |
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POVERTY INCOME GUIDELINES – CLIENT FEE DISCOUNT CATEGORIES............................... |
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SAMPLE SLIDING FEE SCALE........................................................................................................ |
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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.
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MEDICAL COST CENTER |
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Attachment B |
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1. |
Column A |
– |
List procedure |
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2. |
Column B |
– |
List Service Utilization/Frequency of Procedure. |
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3. |
Column C |
– |
List Relative Value for Procedure. |
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4. |
Column D |
– |
Column B X Column C. Total Column D. |
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5. |
Column E |
– |
Cost center amount from BCRR Table 6, Column G, line 1. |
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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. |
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7. |
Column G |
– |
The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service. |
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8. |
Column H |
– |
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH. |
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9. |
Column I |
– |
Adjusted cost equal's cost/service in Column G times Column H, cost of living allowance (COLA) % plus 100%. |
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Example: |
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$10.00 X 105% = $10.50 |
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10. |
Column J |
– |
The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar. |
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LABORATORY COST CENTER |
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Attachment C |
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1. |
Column A |
– |
List lab services provided. |
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2. |
Column B |
– |
List Service Utilization/Frequency of Procedure. |
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3. |
Column C |
– |
List Relative Value for Procedure. |
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4. |
Column D |
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Column B X Column C. Total Column D. |
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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. |
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6. |
Column F |
– |
Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit. |
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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. |
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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. |
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9. |
Column I |
– |
Total base cost equals adjusted cost/service plus per unit purchase expenses. Column G + Column H. |
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10. |
Column J |
– |
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH. |
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11. |
Column K |
– |
Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA) % plus 100%. |
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Example: |
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$4.60 X 105% = $4.83 |
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12. |
Column L |
– |
The full fee to be charged and should approximate Column K. Cor convenience round up to nearest dollar. |
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PHARMACY COST CENTER |
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Attachment D |
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1. |
Column A |
– |
List pharmaceuticals provided. |
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2. |
Column B |
– |
List Service Utilization. |
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3. |
Column C |
– |
List Relative Value for Pharmaceuticals. |
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4. |
Column D |
– |
Column B X Column C. Total Column D. |
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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. |
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6. |
Column F |
– |
Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit. |
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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. |
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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. |
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9. |
Column I |
– |
Total base cost equals adjusted cost/service plus per unit purchase expense. Column G + Column H. |
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10. |
Column J |
– |
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH. |
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11. |
Column K |
– |
Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA) % plus 100%. |
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Example: |
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$4.60 X 105% = $4.83 |
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12. |
Column L |
– |
The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar. |
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EDUCATION/COUNSELING COST CENTER |
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Attachment E |
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1. |
Column A |
– |
List procedure. |
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2. |
Column B |
– |
List Service Utilization/Frequency of Procedure. |
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3. |
Column C |
– |
List Relative Value for Procedure. |
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4. |
Column D |
– |
Column B X Column C. Total Column D. |
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5. |
Column E |
– |
Cost center amount from BCRR, Table 6, Column G, line 7. |
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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. |
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7. |
Column G |
– |
The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service. |
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8. |
Column H |
– |
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH. |
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9. |
Column I |
– |
Adjusted cost equals cost/service in Column G times Column H, cost of living allowance (COLA)% plus 100%. |
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Example: |
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$10.00 X 105% = $10.50 |
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10. |
Column J |
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The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar. |
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MEDICAL COST CENTER |
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CLIENT EXAMINATION DIRECT EXPENSES SALARIES AND WAGES (Include only those staff who perform or assist in performing client examinations.) |
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1. |
Physician |
1. |
$ |
.00 |
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2. |
Physician Assistants |
2. |
$ |
.00 |
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3. |
Nurse Practitioners |
3. |
$ |
.00 |
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4. |
Nurse Midwives |
4. |
$ |
.00 |
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5. |
Other Nurses |
5. |
$ |
.00 |
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MEDICAL SUPPORT |
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6. |
Medical Appointment Secretary |
6. |
$ |
.00 |
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7. |
Portion of Client Records Clerk |
7. |
$ |
.00 |
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8. |
Total Salaries |
8. |
$ |
.00 |
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Total on line 8 is equal to BCRR Table 6, worksheet A, column E, line 1. |
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OTHER CLIENT EXAMINATION EXPENSES |
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9. |
Contractual Examiners Fees |
9. |
$ |
.00 |
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10. |
Client Examination Equipment Lease or Rental |
10. |
$ |
.00 |
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11. |
Client Examination Equipment Depreciation |
11. |
$ |
.00 |
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12. |
Client Examination Equipment Depreciation Expense |
12. |
$ |
.00 |
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13. |
Client Examination Supplies Expense |
13. |
$ |
.00 |
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14. |
Client Examination Staff Travel Expense |
14. |
$ |
.00 |
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15. |
Malpractice Insurance |
15. |
$ |
.00 |
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16. |
Other Client Examination Expenses |
16. |
$ |
.00 |
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17. |
Total Other Client Examination Expenses |
17. |
$ |
.00 |
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(Sum of lines 9 through 16) Total on line 17 is equal to BCRR Table 6, worksheet A, Column I, line 1. |
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DONATED MEDICAL EXPENSES |
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18. |
Value of Physician's Donated Time |
18. |
$ |
.00 |
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19. |
Value of Nurse Midwife/N.P.'s Donated Time |
19. |
$ |
.00 |
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20. |
Value of R.N.'s Donated Time |
20. |
$ |
.00 |
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21. |
Value of LPN's Donated Time |
21. |
$ |
.00 |
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22. |
Value of other Donated Medical Expenses |
22. |
$ |
.00 |
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23. |
Total Donated Services and Materials |
23. |
$ |
.00 |
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(Sum of lines 18 through 22) Total on line 23 is equal to BCRR Table 6, worksheet A, Column j, line 1. |
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PATIENT EXAM INDIRECT COSTS |
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24. |
Medical Fringe Benefits |
24. |
$ |
.00 |
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(Worksheet A – Column g, line 1) |
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25. |
Medical Facility Costs |
25. |
$ |
.00 |
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(Worksheet B – Column d, line 1) |
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26. |
Administrative Costs |
26. |
$ |
.00 |
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(Worksheet B – Column g, line 1) |
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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). |
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27. |
Total Medical Costs |
27. |
$ |
.00 |
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This total equals BCRR Table 6, Column g, line 1. |
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LABORATORY COST CENTER |
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LABORATORY SERVICES DIRECT EXPENSES |
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28. |
Salaries and Wages (include only those staff who |
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perform tests, assist in tests or prepare specimens) |
28. |
$ |
.00 |
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29. |
Total |
29. |
$ |
.00 |
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Total on line 29 is equal to BCRR Table 6, worksheet A, Column E, line 2. |
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OTHER LABORATORY EXPENSES |
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30. |
Laboratory Equipment Lease or Rental Expense |
30. |
$ |
.00 |
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31. |
Laboratory Equipment Depreciation Expense |
31. |
$ |
.00 |
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32. |
Laboratory Equipment Maintenance and Repair Expense |
32. |
$ |
.00 |
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33. |
Laboratory Supplies Expense |
33. |
$ |
.00 |
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34. |
Purchased Outside Laboratory Services Expense |
34. |
$ |
.00 |
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35. |
Other Laboratory Expenses |
35. |
$ |
.00 |
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36. |
Total Other Laboratory Services Direct Expenses |
36. |
$ |
.00 |
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(Sum of lines 30 through 35) Total on line 36 is equal to BCRR Table 6, worksheet A, Column I, line 2. |
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DONATED LABORATORY EXPENSES |
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37. |
Value of Lab Technician's Donated Time |
37. |
$ |
.00 |
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38. |
Value of Donated Lab Supplies |
38. |
$ |
.00 |
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39. |
Value of Donated Lab Tests |
39. |
$ |
.00 |
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40. |
Value of other Donated Lab Expenses |
40. |
$ |
.00 |
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41. |
Total Donated Laboratory Services and Materials |
41. |
$ |
.00 |
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(Sum of lines 37 through 40) Total on line 41 is equal to BCRR Table 6, worksheet A, Column j, line 2. |
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LABORATORY SERVICES INDIRECT EXPENSES |
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42. |
Laboratory Fringe Benefits |
42. |
$ |
.00 |
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(Worksheet A – Column g, line 2) |
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43. |
Laboratory Facility Costs |
43. |
$ |
.00 |
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(Worksheet B – Column d, line 2) |
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44. |
Laboratory Administration Costs |
44. |
$ |
.00 |
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(Worksheet B – Column g, line 2) |
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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). |
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45. |
Total Laboratory Costs |
45. |
$ |
.00 |
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This total equals BCRR Table 6, Column g, line 2. |
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OUTSIDE LABORATORY TESTS: |
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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. |
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OUTSIDE LABORATORY COST AREA
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Type of Supply |
Your Cost/Unit x Number Used = Total Expense* |
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46. |
VDRL/RPR |
$ |
x |
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$ |
.00 |
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47. |
Pap Smear |
$ |
x |
47. |
$ |
.00 |
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48. |
Gonorrhea Culture |
$ |
x |
48. |
$ |
.00 |
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49. |
Miscellaneous Culture |
$ |
x |
49. |
$ |
.00 |
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50. |
Sickle Cell |
$ |
x |
50. |
$ |
.00 |
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51. |
PP Blood Glucose |
$ |
x |
51. |
$ |
.00 |
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52. |
Cholesterol Level |
$ |
x |
52. |
$ |
.00 |
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53. |
SMA 12 |
$ |
x |
53. |
$ |
.00 |
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54. |
Colposcopy |
$ |
x |
54. |
$ |
.00 |
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55. |
Colposcopy and Biopsy |
$ |
x |
55. |
$ |
.00 |
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56. |
Chlamydia |
$ |
x |
56. |
$ |
.00 |
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57. |
Total Outside Laboratory Fees |
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57. |
$ |
.00 |
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*Round to the nearest dollar amount. |
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58. |
Adjusted total cost/center: |
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58. |
$ |
.00 |
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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. |
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PHARMACY COST CENTER |
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Supplies Consumed During Reporting Period: |
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Type of Supply |
Your Cost/Unit x *Number Used = Total Expense* |
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59. |
Oral Contraceptives |
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x |
59. |
$ |
.00 |
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60. |
Cream |
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x |
60. |
$ |
.00 |
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61. |
Jelly |
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x |
61. |
$ |
.00 |
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62. |
Suppository (each) |
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x |
62. |
$ |
.00 |
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63. |
Foam |
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x |
63. |
$ |
.00 |
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64. |
Diaphragm |
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x |
64. |
$ |
.00 |
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65. |
IUD |
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x |
65. |
$ |
.00 |
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66. |
Basal T & C |
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x |
66. |
$ |
.00 |
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67. |
Sponges (each) |
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x |
67. |
$ |
.00 |
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68. |
Condoms (each) |
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x |
68. |
$ |
.00 |
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69. |
Meds/Vag. Inf. |
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x |
69. |
$ |
.00 |
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70. |
Meds/Std Rx |
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x |
70. |
$ |
.00 |
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71. |
Contraceptive Film |
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x |
71. |
$ |
.00 |
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*The number used for each type of supply will come from your inventory sheets. |
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72. |
Total (Sum of lines 59 through 71) |
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72. |
$ |
.00 |
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PROVISION OF CONTGRACEPTIVE DRUGS/SUPPLIES DIRECT EXPENSES |
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73. |
Salaries and Wages for Staff Who Dispense or |
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Assist in Providing Contraceptive Drugs and Supplies |
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73. |
$ |
.00 |
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74. |
Total |
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74. |
$ |
.00 |
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Total on line 74 is equal to BCRR Table 6, worksheet A, Column E, line 4. |
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OTHER PHARMACY EXPENSES |
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75. |
Provision of Drugs and Supplies Equipment |
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Lease or Rental Expense |
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75. |
$ |
.00 |
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76. |
Provision of Drugs and Supplies Depreciation Expense |
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76. |
$ |
.00 |
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77. |
Provision of Drugs and Supplies Equipment Maintenance and Repair Expense |
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77. |
$ |
.00 |
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78. |
Dispensing Supplies Expense |
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78. |
$ |
.00 |
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|
79. |
Other Pharmacy Expenses |
|
|
79. |
$ |
.00 |
||
|
80. |
Total (Sum of lines 75 through 79) |
|
|
80. |
$ |
.00 |
||
|
81. |
Total All Pharmacy Expenses |
|
|
81. |
$ |
.00 |
||
|
|
(Sum of lines 72 and 80) Total on line 81 is equal to BCRR Table 6, worksheet A, Column I, line 4. |
|
|
|
|
|||
|
DONATED PHARMACY EXPENSES |
|||||||||
|
82. |
Value of Pharmacists' Donated Time |
|
82. |
$ |
.00 |
|||
|
83. |
Value of Donated Pharmacy Supplies |
|
83. |
$ |
.00 |
|||
|
84. |
Value of Donated Contraceptive Supplies |
|
84. |
$ |
.00 |
|||
|
85. |
Value of Other Donated Pharmacy Expenses |
|
85. |
$ |
.00 |
|||
|
86. |
Total Donated Pharmacy Services and Materials |
|
86. |
$ |
.00 |
|||
|
|
(Sum of lines 82 through 85) Total on line 86 is equal to BCRR Table 6, worksheet A, Column j, line 4. |
|
|
|
|
|||
|
PHARMACY SERVICES INDIRECT EXPENSES |
|||||||||
|
87. |
Pharmacy Fringe Benefits |
|
87. |
$ |
.00 |
|||
|
|
(Worksheet A – Column g, line 4) |
|
|
|
|
|||
|
88. |
Pharmacy Facility Costs |
|
|
88. |
$ |
.00 |
||
|
|
(Worksheet B – Column d, line 4) |
|
|
|
|
|||
|
89. |
Pharmacy Administration Costs |
|
89. |
$ |
.00 |
|||
|
|
(Worksheet B – Column g, line 4) |
|
|
|
|
|||
|
To arrive at the total Pharmacy costs you will add salary and wages (74), other costs (81) and donated services and materials (86) to fringe benefits (87), facility costs (88) and administrative costs (89). |
|||||||||
|
90 |
Total Pharmacy Costs |
|
90. |
$ |
.00 |
|||
|
|
This total equals BCRR Table 6, Column g, line 4. |
|
|
|
|
|||
|
91. |
Adjusted total cost center |
|
91. |
$ |
.00 |
|||
|
To arrive at the total adjusted cost/center you must subtract the dollar amount of consumed contraceptives, drugs/supplies, from you BCRR total on Table 6, Column G, line 4, which is the amount on Line 90, minus line 72, equals the amount on line 91. This is the amount to be used in the adjusted Total cost/center, Attachment D, Column E. |
|||||||||
|
COUNSELING AND EDUCATION COST CENTER |
||||||||
|
FAMILY PLANNING COUNSELING AND EDUCATIONAL DIRECT EXPENSES |
|||||||||
|
92. |
Salaries and Wages, Family Planning |
|
92. |
$ |
.00 |
|||
|
|
Counselors, Educators and Assistants |
|
|
|
|
|||
|
93. |
Portion of Client Records Clerk |
|
93. |
$ |
.00 |
|||
|
94. |
Total |
|
94. |
$ |
.00 |
|||
|
|
Total on line 94 is equal to BCRR Table t, worksheet A, Column E, line 7. |
|
|
|
|
|||
|
OTHER COUNSELING AND EDUCATION EXPENSES |
|||||||||
|
95. |
Counseling and Educational Services |
|
95. |
$ |
.00 |
|||
|
|
Staff Travel Expense |
|
|
|
|
|
||
|
96. |
Counseling and Educational Services |
|
96. |
$ |
.00 |
|||
|
|
Equipment Rental |
|
|
|
|
|
||
|
97. |
Counseling Expense or Lease Expense and |
|
97. |
$ |
.00 |
|||
|
|
Educational Services Equipment Depreciation |
|
|
|
|
|||
|
98. |
Counseling and Educational Services Equipment |
98. |
$ |
.00 |
||||
|
|
Repair and Maintenance Expense |
|
|
|
|
|
||
|
99. |
Counseling and Educational Supplies Expense |
|
99. |
$ |
.00 |
|||
|
100. |
Other Counseling and Educational Expense |
|
100. |
$ |
.00 |
|||
|
101. |
Total Family Planning Counseling and Educational Services Direct Expenses |
101. |
$ |
.00 |
||||
|
|
Total on line 101 is equal to BCRR Table 6, worksheet A, Column I, line 7. |
|
|
|
||||
|
DONATED EDUCATION AND COUNSELING EXPENSES |
|||||||||
|
102. |
Value of Counselors Donated Time |
|
102. |
$ |
.00 |
|||
|
103. |
Value of Other Donated Counseling and Educational Services Expenses |
103. |
$ |
.00 |
||||
|
104. |
Total Donated Counseling and Educational Services Expenses |
104. |
$ |
.00 |
||||
|
|
(Sum of lines 102 and 103) Total on line 104 is equal to BCRR Table 6, worksheet A, Column j, line 7. |
|
|
|
|
|||
|
COUNSELING AND EDUCATIONAL INDIRECT EXPENSES |
|||||||||
|
105. |
Counseling and Education Fringe Benefits |
105. |
$ |
.00 |
||||
|
|
(Worksheet A – Column g, line 7) |
|
|
|
|
|
||
|
106. |
Counseling and Education Facility Costs |
106. |
$ |
.00 |
||||
|
|
(Worksheet B – Column d, line 7) |
|
|
|
|
|
||
|
107. |
Counseling and Education Administration Costs |
107. |
$ |
.00 |
||||
|
|
(Worksheet B – Column g, line 7) |
|
|
|
|
|
||
|
To arrive at the total Counseling and Education costs you will add salary and wages (92), other costs (101) and Donated Counseling and Educational Services (104) to fringe benefits (105), facility costs (106) and administrative costs (107). |
|||||||||
|
108. |
Total Counseling and Education Costs |
108. |
$ |
.00 |
||||
|
|
This total equals BCRR Table 6, Column g, line 7. |
|
|
|
||||
FAMILY PLANNING CLIENT VISIT RELATIVE VALUES
|
SERVICES |
RVS |
|
MEDICAL SERVICES VISITS |
|
|
Minimal Service |
11.00 |
|
Brief/Intermediate Exam |
18.00 |
|
Extended Exam |
30.00 |
|
Insertion of IUD |
30.00 |
|
Diaphragm Fit |
15.00 |
|
Sonography/lost IUD |
30.00 |
|
X-ray/lost IUD |
24.00 |
|
LAB PROCEDURES |
|
|
Hematocrit/Hemoglobin |
3.00 |
|
U/A Dip Stick |
4.00 |
|
Pregnancy Test |
10.00 |
|
VDRL/RPR |
6.00 |
|
Pap Smear |
8.00 |
|
Gonorrhea Culture |
6.00 |
|
Bacterial Smear/Wet Mount |
5.00 |
|
Miscellaneous Culture |
6.00 |
|
Sickle Cell |
5.00 |
|
P.P. Blood Glucose |
6.00 |
|
Triglycerides |
6.00 |
|
SMA 12 |
16.00 |
|
Colposcopy |
30.00 |
|
Colposcopy with Biopsy |
40.00 |
|
Chlamydia |
7.00 |
|
Miscellaneous Culture |
3.00 |
|
Sickle Cell |
4.00 |
|
P.P. Blood Glucose |
10.00 |
|
Triglycerides |
6.00 |
|
SMA 12 |
8.00 |
|
Colposcopy |
6.00 |
|
Colposcopy with Biopsy |
5.00 |
|
Chlamydia |
6.00 |
|
CONTRACEPTIVE DRUGS/SUPPLIES |
|
|
Orals |
1.20 |
|
Creams |
2.65 |
|
Jellies |
2.65 |
|
Suppositories (each) |
.15 |
|
Foams |
3.00 |
|
Diaphragm |
4.00 |
|
Basal T & C |
10.00 |
|
IUD |
50.00 |
|
Sponges (each) |
1.50 |
|
Condoms (each) |
.22 |
|
Meds/Vag. Inf. |
5.00 |
|
Meds/STD |
5.00 |
|
Contraceptive Film |
2.00 |
|
EDUCATION AND COUNSELING |
|
|
In-depth/1 hour |
11.00 |
|
15 min. to 1 Hour |
7.00 |
|
|
|
|
Revised |
|
|
11/89 |
|
|
CALCULATING THE SCHEDULE OF DISCOUNTS |
|
||||||
|
1. |
Determine the number of payment categories. |
|
|||||
|
Example: |
For the purpose of this manual, we will use a six step schedule. |
|
|||||
|
2. |
The income levels for the zero pay category will be the poverty levels published annually in the Federal Register. (See Attachment F) |
|
|||||
|
Example: |
The poverty level for a one person family is $5,980; for a two person family the poverty level is $8,020, etc. |
|
|||||
|
3. |
The income levels for the full fee will be 250% of the poverty level plus $1.00. |
|
|||||
|
Example: |
For Family Size of 1, 100% pay = $5,980 x 2.5 = t$14,950 + $1 or $14,951 |
|
|||||
|
4. |
To determine the income levels between 0% pay and 250% pay, use the following formula: |
|
|||||
|
The 250% income level minus the poverty level, divided by the number of payment categories, minus 2. |
|
||||||
|
The result of this computation is the dollar range for each step. |
|
||||||
|
Example: |
Family Size 1 - $14,950 (full fee > 250%) minus $5,980 (0%) = $8,970 divided by 4 (6 steps–2 steps) = $2,242.50 step interval. |
|
|||||
|
5. |
The lower limit of each step is $1 more than the upper limit of the preceding step. |
|
|||||
|
Example: |
Family Size 1, upper limit of 0% pay is $5,980, lower limit of the next category (20%) is $5,981. |
|
|||||
|
6. |
The upper level for each step is computed by adding the dollar interval computed in Step 4 to the upper limit of the preceding step. |
|
|||||
|
Example: |
Family Size 1 – upper limit of 0% pay is $5,980; upper limit of the next category is $5,981 + $2,243 or $8,224. See Attachment F. |
||||||
DEVELOPMENT OF A SLIDING FEE SCALE
Federal regulations require that we provide family planning services on a sliding fee scale to allow persons to receive services regardless of their income level and subsequent ability to pay. Client or family income level is the determining factor for what level or percentage of the full fee a client will be charged.
A fee system must be developed and reevaluated at least annually after completing a cost analysis. The sliding fee scale will be based on the most current Federal Poverty Income Guidelines (See Attachment F). All clients must update their financial status every 12 months.
A sliding fee scale must be simple to be useful. Any fee scale which is over burdensome to the cashier or person computing the fee loses its value as the time required to compute the fee increases. Fees must be reasonable, related to cost and not provide a barrier to care. In selecting the client fee discount categories, it is important to remember that too few categories may either classify many clients at the lower end, reducing income, or at the upper end, discouraging clients to seek care because of the cost, thereby also reducing income. Too many categories may be difficult to implement and administer. For the purpose of this manual, we will use a six step sliding fee scale. See Attachment G.
|
Attachment A |
|
|
EXAMPLES OF ADMINISTRATIVE COSTS |
|
|
1. |
Project Director |
|
2. |
Administrative Secretary and Receptionist |
|
3. |
Bookkeeper |
|
4. |
Administrative supplies |
|
5. |
Administrative staff travel and per diem |
|
6. |
Vehicle rental or lease expense |
|
7. |
Auditing and accounting |
|
8. |
Legal fees |
|
9. |
Consultants expense |
|
10. |
Dues and subscriptions |
|
11. |
Advertising |
|
12. |
Postage |
|
13. |
Printing |
|
14. |
Purchased staff training |
|
15. |
Fidelity bonding |
|
16. |
Photo copy |
|
17. |
Equipment depreciation |
|
EXAMPLES OF FACILITY COSTS |
|
|
1. |
Custodian or Janitorial Contractual Services |
|
2. |
Building rental |
|
3. |
Building depreciation |
|
4. |
Building and contents insurance |
|
5. |
Building maintenance and repair |
|
6. |
Security |
|
7. |
Utilities |
|
8. |
Telephone |
|
9. |
Janitorial supplies |
|
Attachment B |
|||||||||||||||
|
COST OF SERVICE/FEE DETERMINATION WORKSHEET |
MEDICAL COST CENTER |
||||||||||||||
|
(A)
SERVICE/PROCEDURE |
(B)
SERVICE UTILIZATION (FREQUENCY) |
(C)
RVS VALUE |
(D)
TOTAL SERVICE UNITS |
(E)
TOTAL COST/ COST/CENTER |
(F)
AVERAGE COST/SERVICE UNIT |
(G)
COST/ SERVICE |
(H)
COST OF LIVING ALLOWANCE |
(I)
ADJUSTED COST |
(J)
FEE |
||||||
|
Minimal Service |
|
11.00 |
|
//////////////////////////// |
|
|
|
|
|
||||||
|
Brief/Intermediate Exam |
|
18.00 |
|
//////////////////////////// |
|
|
|
|
|
||||||
|
Extended Exam |
|
30.00 |
|
//////////////////////////// |
|
|
|
|
|
||||||
|
IUD Insertion |
|
30.00 |
|
//////////////////////////// |
|
|
|
|
|
||||||
|
Diaphragm Fit |
|
15.00 |
|
//////////////////////////// |
|
|
|
|
|
||||||
|
Sonography/lost IUD |
|
30.00 |
|
//////////////////////////// |
|
|
|
|
|
||||||
|
X-ray/lost IUD |
|
24.00 |
|
//////////////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
//////////////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
//////////////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
//////////////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
//////////////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
//////////////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
//////////////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
//////////////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
//////////////////////////// |
|
|
|
|
|
||||||
|
TOTAL |
////////////////////////// |
//////////////// |
|
|
////////////////////////////// |
/////////////////// |
///////////////////////////////// |
///////////////////////// |
/////////////////////////////////// |
||||||
|
NOTES |
1. |
D = B x C |
5. |
G = F x C |
|
REVISED 03-NOV-89 |
|||||||||
|
|
2. |
Total Column D |
6. |
M = Cost of Living Allowance (COLA) |
|||||||||||
|
3. |
E = Column G, line 1 of BCRR Table 6 |
7. |
I = G x (COLA % + 100%) |
||||||||||||
|
4. |
F = Column E ÷ Column D Total |
8. |
J = Fee |
||||||||||||
Attachment C |
||||||||||||||
|
|
||||||||||||||
|
COST OF SERVICE/FEE DETERMINATION WORKSHEET |
LABORATORY COST CENTER |
|||||||||||||
|
(A)
SERVICE/PROCEDURE |
(B)
SERVICE UTILIZATION (FREQUENCY) |
(C)
RVS VALUE |
(D)
TOTAL SERVICE UNITS |
(E)
ADJUSTED TOTAL COST/ COST/CENTER |
(F)
AVERAGE COST/SERVICE UNIT |
(G)
COST/ SERVICE ADJUSTED |
(H)
PER UNIT PURCHASE EXPENSE |
(I)
TOTAL BASE COST |
(J)
COST OF LIVING ALLLOWANCE |
(K)
ADJUSTED COST |
(L)
FEE |
|||
|
HGB/HCT |
|
3.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
Urinalysis |
|
4.00 |
|
/////////////////////////// |
|
|
|
|
|
|
|
|||
|
Pregnancy Test |
|
10.00 |
|
//////////////////////////// |
|
|
|
|
|
|
|
|||
|
VDRL/RPR |
|
6.00 |
|
/////////////////////////// |
|
|
|
|
|
|
|
|||
|
Pap Smear |
|
8.00 |
|
/////////////////////////// |
|
|
|
|
|
|
|
|||
|
Gonorrhea Culture |
|
6.00 |
|
/////////////////////////// |
|
|
|
|
|
|
|
|||
|
Miscellaneous Culture |
|
6.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
Bacterial Smear/Wet Mount |
|
5.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
Sickle Cell |
|
5.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
P.P. Blood Glucose |
|
6.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
Cholesterol Level |
|
6.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
SMA – 12 |
|
16.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
Colposcopy |
|
30.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
Colposcopy and Biopsy |
|
40.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
Chlamydia |
|
7.00 |
|
////////////////////////// |
|
|
|
|
|
|
|
|||
|
TOTAL |
///////////////////////// |
//////////////// |
|
|
//////////////////////// |
/////////////////// |
///////////////////////// |
////////////////// |
//////////////////// |
//////////////// |
///////////////// |
|||
|
NOTES: |
1. |
D = B x C |
6. |
H = Actual Per Unit Purchase Expense From Outside Laboratory |
REVISED 03-NOV-89 |
|||||||||
|
|
2. |
Total Column D |
7. |
I = Total Cost G + H |
||||||||||
|
3. |
E = Column G, line 2 of BCRR Table 6, |
8. |
J = Cost of Living Allowance (COLA) |
|||||||||||
|
|
Minus the Cost of Purchased Outside Laboratory Tests |
9. |
K = I x (COLA % + 100%) |
|||||||||||
|
4. |
F = Column E ÷ Column D Total |
10. |
L = Fee |
|||||||||||
|
5. |
G = F x C |
|
||||||||||||
|
Attachment D |
|||||||||||||||
|
|
|||||||||||||||
|
COST OF SERVICE/FEE DETERMINATION WORKSHEET |
|
PHARMACY COST CENTER |
|||||||||||||
|
(A)a
SERVICE/PROCEDURE |
(B)
SERVICE UTILIZATION (FREQUENCY) |
(C)
RVS VALUE |
(D)
TOTAL SERVICE UNITS |
(E)
ADJUSTED TOTAL COST/ COST/CENTER |
(F)
AVERAGE COST/SERVICE UNIT |
(G)
COST/ SERVICE ADJUSTED |
(H)
PER UNIT PURCHASE EXPENSE |
(I)
TOTAL BASE COST |
(J)
COST OF LIVING ALLOWANCE |
(K)
ADJUSTED COST |
(L)
FEE |
||||
|
Orals |
|
1.20 |
|
////////////////////// |
|
|
|
|
|
|
|
||||
|
Creams |
|
2.65 |
|
////////////////////// |
|
|
|
|
|
|
|
||||
|
Jellies |
|
2.65 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
Suppositories (each) |
|
0.15 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
Foams |
|
3.00 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
Diaphragms |
|
4.00 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
IUDS |
|
50.00 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
Basal T & C |
|
10.00 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
Sponges (each) |
|
1.50 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
Condoms (each) |
|
0.22 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
Meds/Vag Inf |
|
5.00 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
Meds/STD |
|
5.00 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
Contraceptive Film |
|
2.00 |
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
|
|
|
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
|
|
|
|
/////////////////////// |
|
|
|
|
|
|
|
||||
|
TOTAL |
///////////////////////// |
////////////// |
|
|
//////////////////////// |
////////////////////// |
//////////////////// |
//////////////// |
///////////////////// |
//////////////////// |
////////////////////// |
||||
|
NOTES: |
1. |
D = B x C |
6. |
H = Actual Per Unit Purchase Expense |
|
REVISED |
|||||||||
|
|
2. |
Total Column D |
7. |
I = G + H |
|
03-NOV-89 |
|||||||||
|
3. |
E = Column G, line 4 of BCRR Table 6 |
8. |
J = Cost of Living Allowance (COLA) |
|
|||||||||||
|
|
Minus the Cost of Consumed Pharmaceuticals |
9. |
K x (COLA % + 100%) |
||||||||||||
|
4. |
F = Column E ÷ Column D Total |
10. |
L = Fee |
||||||||||||
|
5. |
G = F x C |
|
|||||||||||||
|
Attachment E |
|||||||||||||||
|
|
|||||||||||||||
|
COST OF SERVICE/FEE DETERMINATION WORKSHEET |
EDUCATION/COUNSELING COST CENTER |
||||||||||||||
|
(A)
SERVIC/PROCEDURE |
(B)
SERVICE UTILIZATION (FREQUENCY) |
(C)
RVS VLAUE |
(D)
TOTAL SERVICE UNITS |
(E)
TOTAL COST/ COST/CENTER |
(F)
AVERAGE COST/SERVICE UNIT |
(G)
COST/ SERVICE |
( H)
COST OF LIVING ALLOWANCE |
(I)
ADJUSTED COST |
(J)
FEE |
||||||
|
Indepth 1 Hour |
|
11.00 |
|
/////////////////// |
|
|
|
|
|
||||||
|
Counseling/15 Min to 1 Hr |
|
7.00 |
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
|
|
|
|
/////////////////// |
|
|
|
|
|
||||||
|
TOTAL |
//////////////////// |
/////////////// |
|
|
//////////////////// |
////////////// |
////////////////// |
///////////////// |
////////////// |
||||||
|
|
|
|
|
|
|
|
|||||||||
|
NOTES: |
1. |
D = B x C |
5. |
G = F x C |
|
REVISED 03-NOV-89 |
|||||||||
|
|
2. |
Total Column D |
6. |
H = Cost of Living Allowance (COLA) |
|||||||||||
|
3. |
E = Column G, line 7 of BCRR Table 6 |
7. |
I = G x (COLA % + 100%) |
||||||||||||
|
4. |
F = Column E ÷ Column D Total |
8. |
J = Fee |
||||||||||||
|
Attachment F |
||||||||||||||||||||
|
EXAMPLE |
||||||||||||||||||||
|
POVERTY INCOME GUIDELINES |
||||||||||||||||||||
|
CLIENT FEE DISCOUNT CATEGORIES |
03/08/89 |
|||||||||||||||||||
|
Family Planning Services |
||||||||||||||||||||
|
1989 Revised Guidelines as published in Federal Register, 2/16/89, Vol. 54, No. 31 |
||||||||||||||||||||
|
|
||||||||||||||||||||
|
FAMILY SIZE |
|
0% |
|
|
20% |
|
|
40% |
|
|
60% |
|
|
80% |
|
100% |
||||
|
A |
|
B |
C |
|
D |
E |
|
F |
G |
|
H |
I |
|
J |
K |
|||||
|
1 |
0 |
– |
5980 |
5981 |
– |
8224 |
8225 |
– |
10467 |
10468 |
– |
12711 |
12712 |
– |
14950 |
14951 |
||||
|
2 |
0 |
– |
8020 |
8021 |
– |
11029 |
11030 |
– |
14037 |
14038 |
– |
17046 |
17047 |
– |
20050 |
20051 |
||||
|
3 |
0 |
– |
10060 |
10061 |
– |
13834 |
13835 |
– |
17607 |
17608 |
– |
21381 |
21382 |
– |
25150 |
25151 |
||||
|
4 |
0 |
– |
12100 |
12101 |
– |
16639 |
16640 |
– |
21177 |
21178 |
– |
25716 |
25717 |
– |
30250 |
30251 |
||||
|
5 |
0 |
– |
14140 |
14141 |
– |
19444 |
19445 |
– |
24747 |
24748 |
– |
30051 |
30052 |
– |
35350 |
35351 |
||||
|
6 |
0 |
– |
16180 |
16181 |
– |
22249 |
22250 |
– |
28317 |
28318 |
– |
34386 |
34387 |
– |
40450 |
40451 |
||||
|
7 |
0 |
– |
18220 |
18221 |
– |
25054 |
25055 |
– |
31887 |
31888 |
– |
38721 |
38722 |
– |
45550 |
45551 |
||||
|
8 |
0 |
– |
20260 |
20261 |
– |
27859 |
27860 |
– |
35457 |
35458 |
– |
43056 |
43057 |
– |
50650 |
50651 |
||||
|
* |
FOR FAMILY UNITS WITH MORE THAN 8 MEMBERS, FOR EACH ADDITIONAL MEMBER AND ADD TO COLUMN B; $2,040 |
|||||||||||||||||||
|
** |
POVERTY LEVEL |
$5,980 |
||||||||||||||||||
|
|
||||||||||||||||||||
|
B |
= |
Family size = 1 = Poverty Level |
||||||||||||||||||
|
B |
= |
All other Family size = Previous Family size Poverty Level plus $2,040 |
||||||||||||||||||
|
C |
= |
(B + 1) |
||||||||||||||||||
|
D |
|
(J – B) / 4 + C |
||||||||||||||||||
|
E |
|
(D + 1) |
||||||||||||||||||
|
F |
= |
(J–B) / 4 + E |
||||||||||||||||||
|
G |
= |
(F + 1) |
||||||||||||||||||
|
H |
= |
(J–B) / 4 + G |
||||||||||||||||||
|
I |
= |
(H + 1) |
||||||||||||||||||
|
J |
= |
(B x 2.5) |
||||||||||||||||||
|
K |
= |
(J + 1) |
||||||||||||||||||
|
Attachment G |
||||||||||||||||
|
SLIDING FEE SCALE |
||||||||||||||||
|
********************************************************************************************************************** |
||||||||||||||||
|
SERVICE/PROCEDURES (a) |
COST/ SERVICES |
|
FEE |
|
0% |
|
20% |
|
40% |
|
60% |
|
80% |
|
100% |
|
|
Minimal Services |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Brief/Intermediate Exam |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Extended Exam |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
IUD Insertion |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Diaphragm Fit |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sonography/lost IUD |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
X-ray/lost IUD |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
HCT/HBG |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Urinalysis |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Pregnancy Test |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
VDRL/RPR |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Pap Smear |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Gonorrhea Culture |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Miscellaneous Culture |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Bacterial Smear/Wet Mount |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sickle Cell |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
PP Blood Glucose |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Cholesterol Level |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SMA-12 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Colposcopy |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Colposcopy and Biopsy |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Chlamydia |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Orals |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Creams |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Jellies |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Suppositories (each) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Foams |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Diaphragms |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
IUDS |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Basal T & C |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Sponges (each) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Condoms (each) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Meds/Vag Inf |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Meds/STD |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Contraceptive Film |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||||
|
In-depth 1 Hour |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Counseling/15 Min. to 1 Hr. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
********************************************************************************************************************** |
||||||||||||||||
|
ALLOCATION OF MONIES FOR BCRR |
||||||
|
SALARIES |
EQUIPMENT DEPRECIATION |
|||||
|
|
||||||
|
0.5 |
OB/GYN Physician |
50,000 |
|
Medical |
800 |
|
|
2.0 |
OB/GYN Nurse Practitioners |
52,000 |
|
Laboratory |
200 |
|
|
1.5 |
RN’s |
24,000 |
|
Patient Records |
100 |
|
|
0.5 |
RN (Pharmacy) |
8,000 |
|
Administration |
900 |
|
|
2.0 |
LPN’s |
22,000 |
|
|||
|
0.5 |
Medical Appt. Secy. |
5,750 |
||||
|
0.5 |
Client Records Clerk |
5,750 |
|
INSURANCE |
||
|
1.0 |
Health Educator |
16,000 |
|
|||
|
0.5 |
Laboratory Technician |
7,000 |
|
Medical Malpractice |
5,000 |
|
|
1.0 |
Project Director |
20,000 |
|
Fidelity Bonding |
100 |
|
|
1.0 |
Admin. Secy./Recept. |
12,000 |
|
Facility (fire, flood) |
1,000 |
|
|
1.0 |
Bookkeeper |
12,000 |
|
|
|
|
|
0.2 |
Custodian |
1,600 |
|
|
|
|
|
|
RENT |
12,000 |
||||
|
UTILITIES |
1,800 |
|||||
|
TELEPHONE |
740 |
|||||
|
FRINGE BENEFITS |
27,300 |
|
PHOTO COPY |
560 |
||
|
|
POSTAGE |
375 |
||||
|
|
ADMIN. TRAVEL |
200 |
||||
|
CONSULTANT & CONTRACT SERVICES |
||||||
|
|
||||||
|
Nurse Practitioner |
17,000 |
|
SQUARE FOOTAGE |
|
||
|
Outside Laboratory |
19,792 |
|
|
|
||
|
Account’s Fee |
800 |
|
Medical |
1,600 sq' |
||
|
Attorney’s Fee |
100 |
|
Laboratory |
200 |
||
|
Security |
2,000 |
|
Other Health |
300 |
||
|
|
Administration |
400 |
||||
|
|
2,500 sq' |
|||||
|
|
||||||
|
SUPPLIES |
||||||
|
|
||||||
|
Medical |
10,000 |
|
||||
|
Laboratory |
3,000 |
|||||
|
Health Education |
500 |
|||||
|
Pharmacy |
1,000 |
|||||
|
Patient Records |
200 |
|||||
|
Administration |
500 |
|||||
|
Housekeeping |
100 |
|||||
|
|
||||||
|
DONATED MATERIALS |
||||||
|
|
||||||
|
Volunteer R.N.’s |
6,000 |
|
||||
|
GC’s done by State lab |
1,200 |
|||||
|
Contraceptives from closing clinic |
2,400 |
|||||
|
Volunteer Counselor |
400 |
|||||
|
Administrator’s time |
700 |
|||||
|
Rent at 2nd 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___ |
|||||||||||||||||
|
|
|||||||||||||||||||
|
|
|||||||||||||||||||
|
TABLE 6: COSTS BEFORE AND AFTER DISTRIBUTION BY FUNCTIONAL |
|||||||||||||||||||
|
COST CENTER FOR THIS REPORTING PERIOD |
|||||||||||||||||||
|
|
|||||||||||||||||||
|
|
NOTE: Grantees should complete this table as follows: |
||||||||||||||||||
|
|
Annual: The entire table (LINES 1 through 13, COLS. a through g). |
||||||||||||||||||
|
First six months (unless instructed by the Regional Office to report quarterly for the first three quarters): |
|||||||||||||||||||
|
|
Complete all of LINE 13, and the applicable cells of COLS. (f) and (g). |
||||||||||||||||||
|
|
|||||||||||||||||||
|
FUNCTIONAL COST CENTER |
SALARIED PERSONNEL* (WORKSHEET A, COL. h) |
|
OTHER (INCLUDING CONSULTANT AND CONTRACT SERVICES) |
VALUE OF DONATED MATERIAL & SERVICE** |
TOTAL BEFORE DISTRIBUTION (COLS. a + b + c + d) |
TOTAL AFTER DISTRIBUTION OF FACILITY. COSTS*** (WORKSHEET B. COL. e) |
TOTAL AFTER FINAL DIST OF CLINIC OVERHEAD COSTS (WORKSHEET B. COL. h) |
||||||||||||
|
(a) |
(c) |
(d) |
(e) |
(f) |
(g) |
||||||||||||||
|
HEALTH CARE FUNCTIONS |
176,641 |
|
33,040 |
|
|
|
265,389 |
||||||||||||
|
1) |
Medical (A) |
||||||||||||||||||
|
2) |
Laboratory Medical (B) |
7,819 |
|
22,992 |
|
|
|
39,325 |
|||||||||||
|
3) |
X-Ray–Medical (C) |
|
|
|
|
|
|
|
|||||||||||
|
4) |
Pharmacy–-Medical & Dental (D) |
8,819 |
|
50,500 |
|
|
|
73,205 |
|||||||||||
|
5) |
Dental (Inc. Lab & X-Ray) (E) |
|
|
|
|
|
|
|
|||||||||||
|
6) |
Inpatient (F) |
|
|
|
|
|
|
|
|||||||||||
|
7) |
Other Health (G) |
19,061 |
|
560 |
|
|
|
25,648 |
|||||||||||
|
8) |
Community Service (H) |
|
|
|
|
|
|
|
|||||||||||
|
9) |
Environmental (I) |
|
|
|
|
|
|
|
|||||||||||
|
10) |
Patient Transportation (J) |
|
|
|
|
|
|
|
|||||||||||
|
CLINIC OVERHEAD FUNCTIONS |
49,187 |
|
4,275 |
|
|
57,158 |
-0- |
||||||||||||
|
11) |
Administration (K) |
||||||||||||||||||
|
12) |
Facility (L) |
1,873 |
|
16,900 |
|
|
-0- |
-0- |
|||||||||||
|
13) |
TOTAL (LINES 1 through 12) |
263,400 |
|
128,267 |
11,900 |
403,567 |
|
403,567 |
|||||||||||
|
|
|||||||||||||||||||
|
* |
Include the costs of salaried personnel, including the costs of fringe benefits paid to employees (see TABLE 6 Worksheet A). |
||||||||||||||||||
|
|
|||||||||||||||||||
|
** |
Include the costs associated with donated personnel, including NHSC assignees. For NHSC personnel, include the reimbursable cost of the assignee(s), not the amount actually reimbursed to the Corps. |
||||||||||||||||||
|
|
|||||||||||||||||||
|
*** |
Only the cells not shaded should be completed with the date transferred from Worksheet B. |
||||||||||||||||||
|
|
|||||||||||||||||||
|
NOTE: |
The distribution of PERSONNEL COSTS across the functional area should correspond to the distribution of STAFF PERSONNEL EQUIVALENTS shown in TABLE 3. For any individual whose time is split among two or more functions in TABLE 3, the same percentage split should be applied to personnel and consultant costs in this table. |
||||||||||||||||||
|
All amounts should be rounded off to the nearest dollar. |
|||||||||||||||||||
|
CONSISTENCY CHECK: LINE 13, COL (e) = LINE 13, COL. (g) |
|
||||||||||||||||||
|
FREQUENCY OF REPORTING: Semi annually unless otherwise instructed by the Regional Office. Data are reported on a calendar year-to-date basis from January first through the ending month of the reporting period (June 30 or December 31). |
|||||||||||||||||||
|
TABLE 6 WORKSHEET A: DISTRIBUTION OF PATIENT RECORDS COSTS AND FRINGE BENEFITS ACROSS FUNCTIONAL COST CENTERS |
|||||||||||||
|
|
|||||||||||||
|
NOTE: |
If this Worksheet is used, it must be retained by the grantee. |
||||||||||||
|
|
It should not be submitted with TABLE 6. |
||||||||||||
|
|
|||||||||||||
|
FUNCTIONAL COST CENTERS |
DISTRIBUTION OF PATIENT RECORDS COSTS |
DISTRUBTION OF FRINGE BENEFITS COSTS |
|
|
|
||||||||
|
Number of Encounters |
% of Total Encounters
|
Amount of Personnel Distrb. to Functions |
Amount of Other Distrb. to Functions |
Salaried Personnel Costs (inc. Col. C) |
% of Total Salaries |
Amount of Fringe Benefits Distrb. to Functions |
Total Salaried Personnel Costs |
Other Costs |
Value of Donated Mat. & Svcs. |
Total Before Distribution |
|||
|
(a) |
(b) |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
(i) |
(j) |
(k) |
|||
|
HEALTH CARE FUNCTIONS: |
12,000 |
80% |
4,600 |
240 |
158,350 |
67% |
18,291 |
176,641 |
33,040 |
6,000 |
215,681 |
||
|
1) |
Medical (A) |
||||||||||||
|
2) |
Laboratory – Medical (B) |
|
|
|
|
7,000 |
3% |
819 |
7,819 |
22,992 |
1,200 |
32,011 |
|
|
3) |
X-Ray – Medical (C) |
|
|
|
|
|
|
|
|
|
|
|
|
|
4) |
Pharmacy – Medical & Dental (D) |
|
|
|
|
8,000 |
3% |
819 |
8,819 |
50,500 |
2,400 |
61,719 |
|
|
5) |
Dental (Lab & X-Ray) (E) |
-0- |
|
|
|
|
|
|
|
|
|
|
|
|
6) |
Inpatient (F) |
|
|
|
|
|
|
|
|
|
|
|
|
|
7) |
Other Health (G) |
3,000 |
20% |
1,150 |
60 |
17,150 |
7% |
1,911 |
19,061 |
560 |
400 |
20,021 |
|
|
8) |
Community Service (H) |
|
|
|
|
|
|
|
|
|
|
|
|
|
9) |
Environmental (I) |
|
|
|
|
|
|
|
|
|
|
|
|
|
10) |
Patient Transportation (J) |
|
|
|
|
|
|
|
|
|
|
|
|
|
11) |
Patient Records |
|
|
(5750) |
(300) |
|
|
|
|
|
|
|
|
|
CLINIC OVERHEAD FUNCTIONS |
|
|
|
|
44,000 |
19% |
5,187 |
49,187 |
4,275 |
700 |
54,162 |
||
|
12) |
Administration (K) |
||||||||||||
|
13) |
Facility (L) |
|
|
|
|
1,600 |
1% |
273 |
1,873 |
16,900 |
1,200 |
19,973 |
|
|
14) |
Fringe Benefits |
|
|
|
|
|
|
(27300) |
|
|
|
|
|
|
15) |
TOTAL (LINES 1 through 14) |
15,000 |
100% |
-0- |
-0- |
236,100 |
100% |
-0- |
263,400 |
128,267 |
11,900 |
403,567 |
|
|
TABLE 6 WORKSHEET B: DISTRIBUTION OF CLINIC OVERHEAD COSTS ACROSS HEALTH CARE COST CENTERS
NOTE: If this Worksheet is used, it must be retained by the grantee. It should not be submitted with TABLE 6 |
|||||||||||
|
FUNCTIONAL COST CENTERS |
Total before Distribution Worksheet A, Col (k) |
DISTRIBUTION OF FACILITY COSTS |
Total after Distrb. of Facility Costs (a+d) |
DISTRIBUTION OF ADMINISTRATION COSTS |
Total after Final Distrb. of Clinic Overhead Costs (e & g) |
||||||
|
Square Feet of Space Used |
% of Square Footage |
Amount of Facility Distrib.. to Function |
% of Health Care Cost Subtotal |
Amount of Admin. Distrb. to Functions |
|||||||
|
(a) |
(b) |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
||||
|
HEALTH CARE FUNCTIONS: |
|
|
|
|
|
|
|
|
|||
|
1) |
Medical (A) |
215,681 |
1,600 |
60% |
11,984 |
227,665 |
66% |
37,724 |
265,389 |
||
|
2) |
Laboratory – Medical (B) |
32,011 |
200 |
8% |
1,598 |
33,609 |
10% |
5,716 |
39,325 |
||
|
3) |
X-Ray – Medical (C) |
|
|
|
|
|
|
|
|
||
|
4) |
Pharmacy – Medical & Dental (D) |
61,719 |
150 |
6% |
1,198 |
62,917 |
18% |
10,288 |
73,205 |
||
|
5) |
Dental (Lab & X-Ray) (E) |
|
|
|
|
|
|
|
|
||
|
6) |
Inpatient (F) |
|
|
|
|
|
|
|
|
||
|
7) |
Other Health (G) |
20,021 |
300 |
11% |
2,197 |
22,218 |
6% |
3,430 |
25,648 |
||
|
8) |
Community Service (H) |
|
|
|
|
|
|
|
|
||
|
9) |
Environmental (l) |
|
|
|
|
|
|
|
|
||
|
10) |
Patient Transportation (J) |
|
|
|
|
|
|
|
|
||
|
11) |
SUBTOTAL (LINES 1 through 10) |
|
|
|
|
346,409 |
100% |
|
|
||
|
CLINIC OVERHEAD FUNCTIONS: |
|
|
|
|
|
|
|
|
|||
|
12) |
Administration (K) |
54,162 |
400 |
15% |
2,996 |
57,158 |
|
(57,158) |
-0- |
||
|
13) |
Facility (L) |
19,973 |
|
|
(9,973) |
-0- |
|
|
-0- |
||
|
14) |
SUBTOTAL (LINES 12 x 13) |
|
|
|
|
|
|
|
|
||
|
15) |
GRAND TOTAL |
403,567 |
2,650 |
100% |
-0- |
403,567 |
|
-0- |
403,567 |
||
|
|
CONSISTENCY CHECKS: |
||||||||||
|
|
1. |
COL. (a) equals TABLE 6: COL. (e) |
|||||||||
|
|
2. |
COL. (e) equals TABLE 6 COL. (f) |
|||||||||
|
|
3. |
COL. (h) equals TABLE 6 COL. (g) |
|||||||||
|
|
4. |
LINE 15, COL. (a), COL. (e), and COL. (h) should all be equal. |
|||||||||
|
DETERMINATION OF COST PER PROCEDURE |
||
|
The purpose of this step is to distribute health care costs to particular procedures to derive the unit cost of each procedures. The cost per procedure should be computed for all procedures. The cost per procedure information is useful for managers in establishing charges and for analyzing the benefit of continuing to provide specific services. There may be some cases in which the cost per procedure requires a charge so far above the competitive rate (what other providers in the area would charge for that service) that the charge is prohibitive. This should be a signal to management that steps must be taken to lower costs in the future or consideration should be given to phasing out that service and making alternative arrangements. |
||
|
|
||
|
In order to determine the cost you must define the specific procedures performed in each cost center and determine how many times or frequency the procedure is performed. We have assigned relative values to procedures on page 18. |
||
|
|
||
|
Prepare a Cost of Service/Fee Determination Worksheet for each cost center. See Attachments |
||
|
B, C, D and E. |
||
|
|
||
|
MEDICAL COST CENTER |
||
|
Attachment B |
||
|
1. |
Column A – |
List procedure. |
|
2. |
Column B – |
List Service Utilization/Frequency of Procedure. |
|
3. |
Column C – |
List Relative Value for Procedure from Page 18. |
|
4. |
Column D – |
Column B x Column C. Total Column D. |
|
5. |
Column E – |
Cost center amount from BCRR Table 6, Column G, line 1. |
|
6. |
Column F – |
Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item. |
|
|
|
|
|
7. |
Column G – |
The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service. |
|
|
|
|
|
8. |
Column H – |
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH. |
|
9. |
Column I – |
Adjusted cost equals cost/service in Column G times Column H, cost of living allowance (COLA)% plus 100%. |
|
|
Example : |
||
|
|
$10.00 X 105% = $10.50 |
||
|
10. |
Column J – |
The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar. |
|
|
|
|||
|
LABORATORY COST CENTER |
|||
|
Attachment C |
|||
|
1. |
Column A – |
List lab services provided. |
|
|
2. |
Column B – |
List Service Utilization/Frequency of Procedure. |
|
|
3. |
Column C – |
List Relative Value for Procedure from Page 18. |
|
|
4. |
Column D – |
Column B X Column C. Total Column D. |
|
|
5. |
Column E – |
Cost center amount from BCRR Table 6, Column G, line 2, minus the cost of PURCHASED OUTSIDE LABORATORY TESTS equals adjusted total cost/cost center. OUTSIDE LABORATORY TESTS ARE THOSE TESTS NOT PERFORMED BY THE AGENCY. This does not include collection of specimens. |
|
|
6. |
Column F – |
Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit. |
|
|
7. |
Column G – |
Adjusted cost/service equals the dollar amount in Column F times each relative value of Column C. This amount represents the cost for each specific service. Column F X Column C. |
|
|
8. |
Column H – |
Enter the per unit purchase expense of OUTSIDE LABORATORY TESTS on the appropriate line or lines. This additional purchase expense applies only to designated tests. See designated list on page 35. |
|
|
|
For nondesignated test, Column H equals ZERO. |
||
|
9. |
Column I – |
Total base cost equals adjusted cost/service plus per unit purchase expense. Column G + Column H. |
|
|
10. |
Column J – |
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH. |
|
|
11. |
Column K – |
Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA)% plus 100%. |
|
|
|
Example: |
||
|
|
$4.60 X 105% = $4.83 |
||
|
12. |
Column L – |
The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar. |
|
|
PHARMACY COST CENTER |
|||
|
Attachment D |
|||
|
1. |
Column A – |
List pharmaceuticals provided. |
|
|
2. |
Column B – |
List Service Utilization. |
|
|
3. |
Column C – |
List Relative Value for Pharmaceuticals from page 18. |
|
|
4. |
Column D – |
Column B X Column C. Total Column D. |
|
|
5. |
Column E – |
Cost center amount from BCRR Table 6, Column G, line 4, minus the cost of consumed pharmaceuticals equals adjusted total cost/cost center. |
|
|
6. |
Column F – |
Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit. |
|
|
7. |
Column G – |
Adjusted cost/service equals the dollar amount in Column F, times each relative value of Column C. This amount represents the cost for each specific service. Column F x Column C. |
|
|
8. |
Column H – |
Equals the purchase expense per pharmaceutical unit. To arrive at an average per unit purchase expense, for Attachment D, Column H, when several brands of a pharmaceutical are purchased at different prices you will divide the total dollar value of those pharmaceuticals consumed during that period by the total number of units of those pharmaceuticals consumed during the same reporting period. |
|
|
9. |
Column I – |
Total base cost equals adjusted cost/service plus per unit purchase expense. Column G + Column H. |
|
|
10. |
Column J – |
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH. |
|
|
11. |
Column K – |
Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA)% plus 100%. |
|
|
Example: |
|||
|
|
$4.60 X 105% = $4.83 |
||
|
12. |
Column L – |
The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar. |
|
|
|
||
|
EDUCATION/COUNSELING COST CENTER |
||
|
Attachment E |
||
|
1. |
Column A – |
List procedure. |
|
2. |
Column B – |
List Service Utilization/Frequency of Procedure. |
|
3. |
Column C – |
List Relative Value for Procedure from Page 18. |
|
4. |
Column D – |
Column B X Column C. Total Column D. |
|
5. |
Column E – |
Cost center amount from BCRR, Table 6, Column G, line 7. |
|
6. |
Column F – |
Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item. |
|
7. |
Column G – |
The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service. |
|
8. |
Column H – |
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH. |
|
9. |
Column I – |
Adjusted cost equals cost/service in Column G times Column H, cost of living allowance (COLA)% plus 100%. |
|
|
||
|
Example: |
||
|
$10.00 X 105% = $10.50 |
||
|
10. |
Column J – |
The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar. |
Attachment B
|
COST OF SERVICE/FEE DETERMINATION WORKSHEET |
EDICAL COST CENTER |
||||||||||||
|
(A)
SERVICE/PROCEDURE |
(B) SERVICE UTILIZATION (FREQUENCY) |
(C) RVS VALUE |
(D) TOTAL SERVICE UNITS |
(E) TOTAL COST/ COST/CENTER |
(F) AVERAGE COST/SERVICE UNIT |
(G) COST/ SERVICE |
(H) COST OF LIVING ALLOWANCE |
`(I) ADJUSTED COST |
(J)
FEE |
||||
|
Minimal Service |
900 |
11.00 |
9,900 |
///////////////// |
$1.21 |
$13.31 |
5% |
$13.98 |
$14.00 |
||||
|
Brief/Intermediate Exam |
1,500 |
18.00 |
27,000 |
/////////////////// |
1.21 |
21.78 |
5% |
22.87 |
23.00 |
||||
|
Extended Exam |
6,000 |
30.00 |
180,000 |
///////////////// |
1.21 |
36.30 |
5% |
38.12 |
39.00 |
||||
|
IUD Insertion |
24 |
30.00 |
720 |
///////////////// |
1.21 |
36.30 |
5% |
38.12 |
39.00 |
||||
|
Diaphragm Fit |
124 |
15.00 |
1,860 |
///////////////// |
1.21 |
18.15 |
5% |
19.06 |
20.00 |
||||
|
Sonography/lost IUD |
1 |
30.00 |
30 |
///////////////// |
1.21 |
36.30 |
5% |
38.12 |
39.00 |
||||
|
X-ray/lost IUD |
1 |
24.00 |
24 |
///////////////// |
1.21 |
29.04 |
5% |
30.49 |
31.00 |
||||
|
|
|
|
|
//////////////// |
|
|
|
|
|
||||
|
|
|
|
|
//////////////// |
|
|
|
|
|
||||
|
|
|
|
|
//////////////// |
|
|
|
|
|
||||
|
|
|
|
|
//////////////// |
|
|
|
|
|
||||
|
|
|
|
|
//////////////// |
|
|
|
|
|
||||
|
|
|
|
|
//////////////// |
|
|
|
|
|
||||
|
|
|
|
|
//////////////// |
|
|
|
|
|
||||
|
|
|
|
|
//////////////// |
|
|
|
|
|
||||
|
TOTAL |
//////////////////// |
//////////////// |
219,534 |
$265,389 |
/////////////////// |
/////////// |
/////////////////// |
///////////////// |
/////////////// |
||||
|
|
|||||||||||||
|
NOTES: |
1. |
D = B x C |
5. |
G = F x C |
REVISED: 03-Nov-89 |
||||||||
|
|
2. |
Total Column D |
6. |
H = Cost of Living Allowance (COLA) |
|
||||||||
|
|
3. |
E = Column G, line 1 of BCRR Table 6 |
7. |
I = G x (COLA % + 100%) |
|
||||||||
|
|
4. |
F = Column E ÷ Column D Total |
8. |
J = Fee |
|
||||||||
Attachment C
|
COST OF SERVICE/FEE DETERMINATION WORKSHEET |
LABORATORY
COST CENTER |
||||||||||||||||
|
(A)
SERVICE/PROCEDURE |
(B)
SERVICE UTILIZATION (FREQUENCY) |
(C)
RVS VALUE |
(D)
TOTAL SERVIOCE UNITSS |
(E)
ADJUSTED TOTAL COST/ COST /CENTER |
(F)
AVERAGE COST/SERVICE UNIT |
(G)
COST/ SERVICE ADJUSTED |
(H)
PER UNIT PURCHASE EXPENSE |
(I)
TOTAL BASE COST |
(J)
COST OF LIVING ALLOWANCE |
(K)
ADJUSTED COST |
(L)
FEES |
||||||
|
MGS/HCT |
3,890 |
3.00 |
11,670 |
/////////////////////// |
$ .26 |
$ .78 |
-0- |
$ .78 |
5% |
$ .82 |
$ 1.00 |
||||||
|
Urinalysis |
3,799 |
4.00 |
15,196 |
/////////////////////// |
.26 |
1.04 |
-0- |
1.04 |
5% |
1.09 |
2.00 |
||||||
|
Pregnancy Tex |
1,025 |
10.00 |
10,250 |
/////////////////////// |
.26 |
2.60 |
-0- |
2.60 |
5% |
2.73 |
3.00 |
||||||
|
VDRL/RPR |
8 |
6.00 |
48 |
/////////////////////// |
.26 |
1.56 |
4.00 |
5.56 |
5% |
5.84 |
6.00 |
||||||
|
Pap Smear |
4,000 |
8.00 |
32,000 |
/////////////////////// |
.26 |
2.08 |
3.50 |
5.58 |
5% |
5.86 |
6.00 |
||||||
|
Gonorrhea Culture |
8 |
8.00 |
48 |
/////////////////////// |
.26 |
1.56 |
6.50 |
8.06 |
5% |
8.46 |
9.00 |
||||||
|
Miscellaneous Culture |
40 |
8.00 |
240 |
/////////////////////// |
.26 |
1.56 |
18.00 |
19.56 |
5% |
20.54 |
21.00 |
||||||
|
Bacterial Smear/Wet Mount |
305 |
5.00 |
1,525 |
/////////////////////// |
.26 |
1.30 |
-0- |
1.30 |
5% |
1.37 |
2.00 |
||||||
|
Sickle Cell |
100 |
5.00 |
500 |
/////////////////////// |
.26 |
1.30 |
5.00 |
6.30 |
5% |
6.62 |
7.00 |
||||||
|
Blood Glucose |
20 |
6.00 |
120 |
/////////////////////// |
.26 |
1.56 |
4.50 |
6.06 |
5% |
6.36 |
7.00 |
||||||
|
Cholesterol Level |
10 |
6.00 |
60 |
/////////////////////// |
.26 |
1.56 |
4.00 |
5.56 |
5% |
5.84 |
6.00 |
||||||
|
SMA – 12 |
10 |
16.00 |
160 |
/////////////////////// |
.26 |
4.16 |
6.75 |
10.91 |
5% |
11.46 |
12.00 |
||||||
|
Colposcopy |
4 |
30.0 |
120 |
/////////////////////// |
.26 |
7.80 |
40.00 |
47.80 |
5% |
50.19 |
51.00 |
||||||
|
Colposcopy and Biopsy |
1 |
40.00 |
40 |
/////////////////////// |
.26 |
10.40 |
50.00 |
60.40 |
5% |
63.42 |
64.00 |
||||||
|
Chlmaydia |
510 |
7.00 |
3,570 |
/////////////////////// |
.26 |
1.82 |
8.00 |
9.82 |
5% |
10.31 |
11.00 |
||||||
|
TOTAL |
///////////////////// |
//////////// |
75,547 |
19,533 |
//////////////////////// |
/////////////////// |
////////////////// |
/////////////// |
//////////////////////////// |
/////////////////// |
/////////////////// |
||||||
|
NOTES: |
1. |
D = B x C |
5. |
G = F x C |
REVISED: |
||||||||||||
|
|
2. |
Total Column D |
6. |
H = Actual Perm Unit Purchase Expense From Outside Laboratory |
21-Dec-89 |
||||||||||||
|
|
3. |
E = Column G, line 2 of BCRR, Table 6, Minus the Cost of Purchased Outside Laboratory Tests ($39,325 – $19,792=$19,533) |
7. |
I = Total Cost G+H |
|||||||||||||
|
|
4. |
F = Column E ÷ Column D Total |
8. |
J = Cost of Living Allowance (COLA) |
|||||||||||||
|
|
9. |
K = Ix(COLA%=100%) |
|||||||||||||||
|
10. |
L = Fee |
||||||||||||||||
Attachment D
|
COST OF SERVICE/FEE DETERMINATION WORKSHEET |
PHARMACY
COST CENTER |
|||||||||||||||
|
(A)
SERVICE/PROCEDURE |
(B) SERVICE UTILIZATION (FREQUENCY) |
(C)
RVS VALUE |
(D) TOTAL SERVIOCE UNITSS |
(E) ADJUSTED TOTAL COST/ COST /CENTER |
(F) AVERAGE COST/SERVICE UNIT |
(G) COST/ SERVICE ADJUSTED |
(H) PER UNIT PURCHASE EXPENSE |
(I) TOTAL BASE COST |
(J) COST OF LIVING ALLOWANCE |
(K)
ADJUSTED COST |
(L)
FEE |
|||||
|
Orals |
58,500 |
1.20 |
70,200.00 |
/////////////////////////// |
.26 |
.31 |
.70 |
1.01 |
5% |
1.06 |
2.00 |
|||||
|
Creams |
54 |
2.65 |
143.10 |
/////////////////////////// |
.26 |
.69 |
1.00 |
1.69 |
5% |
1.77 |
2.00 |
|||||
|
Jellies |
50 |
2.65 |
132.50 |
/////////////////////////// |
.26 |
.69 |
1.00 |
1.69 |
5% |
1.77 |
2.00 |
|||||
|
Suppositories (each) |
5 |
0.15 |
.75 |
/////////////////////////// |
.26 |
.04 |
.20 |
.24 |
5% |
.25 |
.25 |
|||||
|
Foams |
2,304 |
3.00 |
6,912.00 |
/////////////////////////// |
.26 |
.78 |
.90 |
1.68 |
5% |
1.76 |
2.00 |
|||||
|
Diaphragms |
124 |
4.00 |
496.00 |
/////////////////////////// |
.26 |
1.04 |
3.00 |
4.04 |
5% |
4.24 |
5.00 |
|||||
|
IUDS |
24 |
50.00 |
1,200.00 |
/////////////////////////// |
.26 |
13.00 |
36.00 |
49.00 |
5% |
51.45 |
52.00 |
|||||
|
Basal T&C |
2 |
10.00 |
20.00 |
/////////////////////////// |
.26 |
2.60 |
16.50 |
19.10 |
5% |
20.05 |
21.00 |
|||||
|
Sponges (each) |
152 |
1.50 |
228.00 |
/////////////////////////// |
.26 |
.39 |
.50 |
.89 |
5% |
.93 |
1.00 |
|||||
|
Condoms (each) |
18,500 |
0.22 |
4,070.00 |
/////////////////////////// |
.26 |
.06 |
.05 |
.11 |
5% |
..12 |
.25 |
|||||
|
Meds/Vag Inf |
540 |
5.00 |
2,700.00 |
/////////////////////////// |
.26 |
1.30 |
4.70 |
6.00 |
5% |
6.30 |
7.00 |
|||||
|
Meds/STD |
539 |
5.00 |
2,695.00 |
/////////////////////////// |
.26 |
1.30 |
4.70 |
6.00 |
5% |
6.30 |
7.00 |
|||||
|
Contraceptive Film |
10 |
2.00 |
20.00 |
/////////////////////////// |
.26 |
.52 |
3.00 |
3.52 |
5% |
3.70 |
4.00 |
|||||
|
|
|
|
|
/////////////////////////// |
|
|
|
|
|
|
|
|||||
|
|
|
|
|
/////////////////////////// |
|
|
|
|
|
|
|
|||||
|
TOTAL |
//////////////////////// |
///////////// |
88,817.35 |
$22,705 |
/////////////////////////// |
/////////////////////// |
///////////////////// |
/////////////// |
///////////////////////// |
///////////////////// |
////////////////////// |
|||||
|
NOTES: |
1. |
D = B x C |
5. |
G = F x C |
REVISED: |
|||||||||||
|
|
2. |
Total Column D |
6. |
H = Actual Perm Unit Purchase Expense |
21-Dec-89 |
|||||||||||
|
|
3. |
E = Column G, line 2 of BCRR, Table Minus the Cost of Consumed |
7. |
I = G + H |
||||||||||||
|
Pharmaceuticals (($73,205 – $50,50 0 = $22,705) |
8. |
J = Cost of Living Allowance (COLA) |
||||||||||||||
|
|
4. |
F = Column E ÷ Column D Total |
9. |
K = I x (COLA% + 100%) |
||||||||||||
|
|
10. |
L = Fee |
||||||||||||||
Attachment E
|
COST OF SERVICE/FEE DETERMINATION WORKSHEET |
EDUCATION, COUNSELING COST CENTER |
|||||||||||||
|
(A)
SERVICE PROCEDURE |
(B) SERVICE UTILIZATION (FREQUENCY) |
(C) RVS VALUE |
(D) TOTAL SERVICE UNITS |
(E) TOTAL COST/ COST/CENTER |
(F) AVERAGE COST/SERVICE UNIT |
(G) COST/ SERVICE |
(H) COST OF LIVING ALLOWANCE |
(I) ADJUSTED COST |
(J)
FEE |
|||||
|
Indepth 1 Hour |
301 |
11.00 |
3,311 |
////////////////////// |
1.80 |
19.80 |
5% |
20.79 |
$21.00 |
|||||
|
Counseling/15Min to 1 Hr |
1,564 |
7.00 |
10,948 |
////////////////////// |
1.80 |
12.60 |
5% |
13.23 |
14.00 |
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
|
|
|
|
////////////////////// |
|
|
|
|
|
|||||
|
TOTAL |
///////////////////// |
//////////////// |
14.259 |
$25,648 |
///////////////////// |
/////////////////// |
///////////////////// |
////////////////// |
///////////////////// |
|||||
|
NOTES: |
1. |
D = B x C |
5. |
G = F x C |
REVISED: 03 Nov-89 |
|||||||||
|
|
2. |
Total Column D |
6. |
H = Cost of Living Allowance (COLA) |
||||||||||
|
|
3. |
E = Column G, line 7 of BCRR Table 6 |
7. |
I = G x (COLA % + 100%) |
||||||||||
|
|
4. |
F = Column E ÷ Column D Total |
8. |
J = Fee |
||||||||||
Attachment F
|
E X A M P L E |
|
||||||||||||||||||
|
POVERTY INCOME GUIDELINES CLIENT FEE DISCOUNT CATEGORIES Family Planning Services 1989 Revised Guidelines as published in Federal Register, 2/16/89, Vol. 54 No. 31
|
03/08/89 |
||||||||||||||||||
|
FAMILY |
0% |
20% |
40% |
60% |
80% |
100% |
|||||||||||||
|
SIZE |
A |
|
B |
C |
|
D |
E |
|
F |
G |
|
H |
I |
|
J |
K |
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
1 |
0 |
– |
5980 |
5981 |
– |
8224 |
8225 |
– |
10467 |
10468 |
– |
12711 |
12712 |
– |
14950 |
14951 |
|||
|
2 |
0 |
– |
8020 |
8021 |
– |
11029 |
11030 |
– |
14037 |
14038 |
– |
17046 |
17047 |
– |
20050 |
20051 |
|||
|
3 |
0 |
– |
10060 |
10061 |
– |
13834 |
13835 |
– |
17607 |
17608 |
– |
21381 |
21382 |
– |
25150 |
25151 |
|||
|
4 |
0 |
– |
12100 |
12101 |
– |
16639 |
16640 |
– |
21177 |
21178 |
– |
25716 |
25717 |
– |
30250 |
30251 |
|||
|
5 |
0 |
– |
14140 |
14141 |
– |
19444 |
19445 |
– |
24747 |
24748 |
– |
30051 |
30052 |
– |
35350 |
35351 |
|||
|
6 |
0 |
– |
16180 |
16181 |
– |
22249 |
22250 |
– |
28317 |
28318 |
– |
34386 |
34387 |
– |
40450 |
40451 |
|||
|
7 |
0 |
– |
18220 |
18221 |
– |
25054 |
25055 |
– |
31887 |
31888 |
– |
38721 |
38722 |
– |
45550 |
45551 |
|||
|
8 |
0 |
– |
20260 |
20261 |
– |
27859 |
27860 |
– |
35457 |
35458 |
– |
43056 |
43057 |
– |
50650 |
50651 |
|||
|
|
|||||||||||||||||||
|
* |
FOR FAMILY UNITS WITH MORE THAN 8 MEMBERS, FOR EACH ADDITIONAL MEMBER ADD TO COLUMN B: $2,040 |
||||||||||||||||||
|
** |
POVERTY LEVEL: $5,980 |
||||||||||||||||||
|
B |
= |
Family size = 1 = Poverty Level |
|||||||||||||||||
|
B |
= |
All other Family size = Previous Family size Poverty Level plus $2,040 |
|||||||||||||||||
|
C |
= |
(B+1) |
|||||||||||||||||
|
D |
= |
(J-B)/4+C |
|||||||||||||||||
|
E |
= |
(D+1) |
|||||||||||||||||
|
F |
= |
(J-B)/4+E |
|||||||||||||||||
|
G |
= |
(F+1) |
|||||||||||||||||
|
H |
= |
(J-B)/4+G |
|||||||||||||||||
|
I |
= |
(H+I) |
|||||||||||||||||
|
J |
= |
(Bx2.5) |
|||||||||||||||||
|
K |
= |
(J+1) |
|||||||||||||||||
Attachment G
|
SLIDING FEE SCALE |
||||||||||||||||||
|
SERVICE/PROCEDURES |
COST/ SERVICES |
FEE |
0% |
20% |
40% |
60% |
80% |
100% |
||||||||||
|
(a) |
||||||||||||||||||
|
Minimal Services |
|
$13.98 |
|
$14.00 |
|
N.C. |
|
2.80 |
|
5.60 |
|
8.40 |
|
11.20 |
|
14.00 |
||
|
Brief/Intermediate Exam |
|
22.87 |
|
23.00 |
|
N.C. |
|
4.60 |
|
9.20 |
|
13.80 |
|
18.40 |
|
23.00 |
||
|
Extended Exam |
|
38.12 |
|
39.00 |
|
N.C. |
|
7.80 |
|
15.60 |
|
23.40 |
|
31.20 |
|
39.00 |
||
|
IUD Insertion |
|
38.12 |
|
39.00 |
|
N.C. |
|
7.80 |
|
15.60 |
|
23.40 |
|
31.20 |
|
39.00 |
||
|
Diaphragm Fit |
|
19.06 |
|
20.00 |
|
N.C. |
|
4.00 |
|
8.00 |
|
12.00 |
|
16.00 |
|
20.00 |
||
|
Sonography/lost IUD |
|
38.12 |
|
39.00 |
|
N.C. |
|
7.80 |
|
15.60 |
|
23.40 |
|
31.20 |
|
39.00 |
||
|
X-ray/lost IUD |
|
30.49 |
|
31.00 |
|
N.C. |
|
6.20 |
|
12.40 |
|
18.60 |
|
24.80 |
|
31.00 |
||
|
|
||||||||||||||||||
|
HCT/HBG |
|
.82 |
|
1.00 |
|
N.C. |
|
.20 |
|
.40 |
|
.60 |
|
.80 |
|
1.00 |
||
|
Urinalysis |
|
1.09 |
|
2.00 |
|
N.C. |
|
.40 |
|
.80 |
|
1.20 |
|
1.60 |
|
2.00 |
||
|
Pregnancy Test |
|
2.73 |
|
3.00 |
|
N.C. |
|
.60 |
|
1.20 |
|
1.80 |
|
2.40 |
|
3.00 |
||
|
VDRL/RPR |
|
5.84 |
|
6.00 |
|
N.C. |
|
1.20 |
|
2.40 |
|
3.60 |
|
4.80 |
|
6.00 |
||
|
Pap Smear |
|
5.86 |
|
6.00 |
|
N.C. |
|
1.20 |
|
2.40 |
|
3.60 |
|
4.80 |
|
6.00 |
||
|
Gonorrhea Culture |
|
8.46 |
|
9.00 |
|
N.C. |
|
1.80 |
|
3.60 |
|
5.40 |
|
7.20 |
|
9.00 |
||
|
Miscellaneous Culture |
|
20.54 |
|
21.00 |
|
N.C. |
|
4.20 |
|
8.40 |
|
12.60 |
|
16.80 |
|
21.00 |
||
|
Bacterial Smear/Wet Mount |
|
1.37 |
|
2.00 |
|
N.C. |
|
.40 |
|
.80 |
|
1.20 |
|
1.60 |
|
2.00 |
||
|
Sickle Cell |
|
6.62 |
|
7.00 |
|
N.C. |
|
1.40 |
|
2.80 |
|
4.20 |
|
5.60 |
|
7.00 |
||
|
PP Blood Glucose |
|
6.36 |
|
7.00 |
|
N.C. |
|
1.40 |
|
2.80 |
|
4.20 |
|
5.60 |
|
7.00 |
||
|
Cholesterol Level |
|
5.84 |
|
6.00 |
|
N.C. |
|
1.20 |
|
2.40 |
|
3.60 |
|
4.80 |
|
6.00 |
||
|
SMA – 12 |
|
11.46 |
|
12.00 |
|
N.C. |
|
2.40 |
|
4.80 |
|
7.20 |
|
9.60 |
|
12.00 |
||
|
Colposcopy |
|
50.19 |
|
51.00 |
|
N.C. |
|
10.20 |
|
20.40 |
|
30.60 |
|
40.80 |
|
51.00 |
||
|
Colposcopy and Biopsy |
|
63.42 |
|
64.00 |
|
N.C. |
|
12.80 |
|
25.60 |
|
38.40 |
|
51.20 |
|
64.00 |
||
|
Chlamydia |
|
10.31 |
|
11.00 |
|
N.C. |
|
2.20 |
|
4.40 |
|
6.60 |
|
8.80 |
|
11.00 |
||
|
|
||||||||||||||||||
|
Orals |
|
1.06 |
|
2.00 |
|
N.C. |
|
.40 |
|
.80 |
|
1.20 |
|
1.60 |
|
2.00 |
||
|
Creams |
|
1.77 |
|
2.00 |
|
N.C. |
|
.40 |
|
.80 |
|
1.20 |
|
1.60 |
|
2.00 |
||
|
Jellies |
|
1.77 |
|
2.00 |
|
N.C. |
|
.40 |
|
.80 |
|
1.20 |
|
1.60 |
|
2.00 |
||
|
Suppositories (each) |
* |
.25 |
|
.25 |
|
N.C. |
|
.05 |
|
.10 |
|
.15 |
|
.20 |
|
.25 |
||
|
Foams |
|
1.76 |
|
2.00 |
|
N.C. |
|
.40 |
|
.80 |
|
1.20 |
|
1.60 |
|
2.00 |
||
|
Diaphragms |
|
4.24 |
|
5.00 |
|
N.C. |
|
1.00 |
|
2.00 |
|
3.00 |
|
4.00 |
|
5.00 |
||
|
IUDS |
|
51.45 |
|
52.00 |
|
N.C. |
|
10.40 |
|
20.80 |
|
31.20 |
|
41.60 |
|
52.00 |
||
|
Basal T & C |
|
20.05 |
|
21.00 |
|
N.C |
|
4.20 |
|
8.40 |
|
12.60 |
|
16.80 |
|
21.00 |
||
|
Sponges (each) |
|
.93 |
|
1.00 |
|
N.C. |
|
.20 |
|
.40 |
|
.60 |
|
.80 |
|
1.00 |
||
|
Condoms (each) |
* |
.12 |
|
.25 |
|
N.C. |
|
.05 |
|
.10 |
|
.15 |
|
.20 |
|
.25 |
||
|
Meds/Vag Inf |
|
6.30 |
|
7.00 |
|
N.C. |
|
1.40 |
|
2.80 |
|
4.20 |
|
5.60 |
|
7.00 |
||
|
Meds/STD |
|
6.30 |
|
7.00 |
|
N.C. |
|
1.40 |
|
2.80 |
|
4.20 |
|
5.60 |
|
7.00 |
||
|
Contraceptive Film |
|
3.70 |
|
4.00 |
|
N.C. |
|
.80 |
|
1.60 |
|
2.40 |
|
3.20 |
|
4.00 |
||
|
|
||||||||||||||||||
|
In-depth 1 Hour |
|
20.79 |
|
21.00 |
|
N.C. |
|
4.20 |
|
8.40 |
|
12.60 |
|
16.80 |
|
21.00 |
||
|
Counseling/15 Min. to 1 Hr. |
|
13.23 |
|
14.00 |
|
N.C. |
|
2.80 |
|
5.60 |
|
8.40 |
|
11.20 |
|
14.00 |
||
|
|
||||||||||||||||||
|
*Round to nearest .25 |
||||||||||||||||||