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Illinois Administrative Code (Last Updated: March 27, 2024) |
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TITLE77. PUBLIC HEALTH |
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PART635. FAMILY PLANNING SERVICES CODE |
§635.APPENDIX B. A Guide to Cost Analysis Developing Cost Based Fees and Sliding Fee Scale
-
Illinois Department of Public Health
A Guide to Cost Analysis
Developing Cost Based Fees
and
Sliding Fee Scale
Revised 11/89
A.B.A.
TABLE OF CONTENTS
INTRODUCTION.............................................................................................................................
APPROACH......................................................................................................................................
FUNCTIONAL AREAS.....................................................................................................................
DETERMINATION OF COST PER PROCEDURE.............................................................................
PREPARE A COST OF SERVICE/FEE DETERMINATION
WORKSHEET FOR EACH COST CENTER...........................................................................
EXPENSE ALLOCATIONS FOR THE BCRR....................................................................................
RELATIVE VALUES........................................................................................................................
OPTIONAL REVENUE ANALYSIS..................................................................................................
CALCULATING THE SCHEDULE OF DISCOUNTS........................................................................
DEVELOPMENT OF A SLIDING FEE SCALE..................................................................................
ATTACHMENTS
ATTACHMENT A:
SAMPLES OF ADMINISTRATIVE COSTS......................................................
ATTACHMENT B:
MEDICAL COST CENTER WORKSHEET.......................................................
ATTACHMENT C:
LABORATORY COST CENTER WORKSHEET...............................................
ATTACHMENT D:
PHARMACY COST CENTER WORKSHEET...................................................
ATTACHMENT E:
EDUCATION/COUNSELING COST CENTER WORKSHEET..........................
ATTACHMENT F:
POVERTY INCOME GUIDELINES – CLIENT FEE DISCOUNT CATEGORIES
ATTACHMENT G:
SLIDING FEE SCALE.......................................................................................
LIST OF EXAMPLES
ALLOCATION OF MONIES FOR BCRR..........................................................................................
COMPLETED BCRR FROM ABOVE ALLOCATIONS.....................................................................
DETERMINATION OF COST PER PROCEDURE.............................................................................
FEE DETERMINATION WORKSHEETS..........................................................................................
Medical...........................................................................................................
Laboratory......................................................................................................
Pharmacy........................................................................................................
Education and Counseling................................................................................
POVERTY INCOME GUIDELINES – CLIENT FEE DISCOUNT CATEGORIES...............................
SAMPLE SLIDING FEE SCALE........................................................................................................
COST BASED FEES
INTRODUCTION
Federal regulations require that each family planning project have a schedule of fees for the services it provides. You must develop realistic fees which reflect the cost of operation, yet are competitive to the local market. There must be a corresponding schedule of discounts which will be used by individuals based on their ability to pay.
It is now necessary for family planning providers to concentrate on management plans which will provide them with the information to develop, implement and analyze their efficiency, thus controlling costs. Only agencies with a sound financial management plan will remain financially viable.
The object of this manual is to help you determine the cost of providing services and setting the fees to be charged using Bureau of Community Health Services Common Reporting Requirements (BCRR) data with some modifications and utilization data provided by your CVR's.
Costs will come from using the financial information you reported in the various cost centers of your BCRR, Table 6, Column g. We would suggest completing the expense allocations pages to check the accuracy of your allocations on the BCRR and to insure accurate fees.
Utilization figures must be collected over the same period as the reported costs. Specific procedure data, not encounter data, must be used, since the purpose is to derive a cost per procedure. An actual count of your procedures over a specific time period may be obtained from your population profile as reported from your CVR's or you may use a daily log of clinic activity.
APPROACH
Rates charged for each service should reflect both direct and indirect costs. Direct costs include expenses associated with providing patient care (i.e., physician, nursing, supplies, etc.) plus an amount of overhead or indirect costs which are expended to support direct patient care (i.e., administration, housekeeping, rent, etc.). In order to arrive at a true cost you must include the value of donated goods and services. You have allocated your overhead or indirect costs to the various cost centers on Table 6, worksheets A and B (administration, facility costs and fringe benefits) so that the amount on Table 6, column g in each cost center represents your total costs. Examples of administrative and facility costs are Attachment A.
There are seven steps in the development of cost based fee:
1. Identify the functional cost centers.
2. Identify services provided in each cost center.
3. Collect utilization data on services provided.
4. Collect direct cost data for each functional cost center.
5. Allocate overhead costs to functional cost centers.
6. Determine total units of service provided.
7. Determine cost of each service.
FUNCTIONAL AREAS
The health care functional areas within a family planning program represent a separation of functions within the program. A typical family planning program will provide services within four functional areas:
A. MEDICAL (CLINIC) OPERATIONS
Medical services delivered in providing a family planning method of a patient, and the diagnosis and treatment of related problems; excludes x-ray, laboratory and pharmacy services.
B. LABORATORY
Laboratory services provided by the family planning program including specimen collection and preparation for referral to outside laboratories.
C. PHARMACY
Services provided in the dispensing of contraceptives and medications to the family planning patient.
D. HEALTH EDUCATION/COUNSELING
Services provided to the client or prospective client for family planning related problem resolution or information. Includes tubal ligation counseling, fertility awareness and similar services.
DETERMINATION OF COST PER PROCEDURE
The purpose of this step is to distribute health care costs to particular procedures to derive the unit cost of each procedure. The cost per procedure should be computed for all procedures. The cost per procedure information is useful for managers in establishing charges and for analyzing the benefit of continuing to provide specific services. There may be some cases in which the cost per procedure requires a charge so far above the competitive rate (what other providers in the area would charge for that service) that the charge is prohibitive. This should be a signal to management that steps must be taken to lower costs in the future or consideration should be given to phasing out that service and making alternative arrangements.
In order to determine the cost you must define the specific procedures performed in each cost center and determine how many times or frequency the procedure is performed. We have assigned relative values to procedures.
Prepare a Cost of Service/Fee Determination Worksheet for each cost center. See Attachment B, C, D and E.
MEDICAL COST CENTER
Attachment B
1.
Column A
–
List procedure
2.
Column B
–
List Service Utilization/Frequency of Procedure.
3.
Column C
–
List Relative Value for Procedure.
4.
Column D
–
Column B X Column C. Total Column D.
5.
Column E
–
Cost center amount from BCRR Table 6, Column G, line 1.
6.
Column F
–
Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item.
7.
Column G
–
The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service.
8.
Column H
–
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
9.
Column I
–
Adjusted cost equal's cost/service in Column G times Column H, cost of living allowance (COLA) % plus 100%.
Example:
$10.00 X 105% = $10.50
10.
Column J
–
The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.
LABORATORY COST CENTER
Attachment C
1.
Column A
–
List lab services provided.
2.
Column B
–
List Service Utilization/Frequency of Procedure.
3.
Column C
–
List Relative Value for Procedure.
4.
Column D
Column B X Column C. Total Column D.
5.
Column E
–
Cost center amount from BCRR Table 6, Column G, line 2, minus the cost of PURCHASED OUTSIDE LABORATORY TESTS equals adjusted total cost/cost center. OUTSIDE LABORATORY TESTS ARE THOSE TESTS NOT PERFORMED BY THE AGENCY. This does not include collection of specimens.
6.
Column F
–
Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit.
7.
Column G
–
Adjusted cost/service equals the dollar amount in Column F times each relative value of Column C. This amount represents the cost for each specific service. Column F X Column C.
8.
Column H
–
Enter the per unit purchase expense of OUTSIDE LABORATORY TESTS on the appropriate line or lines. This additional purchase expense applies only to designated tests. For nondesignated test, Column H equals ZERO.
9.
Column I
–
Total base cost equals adjusted cost/service plus per unit purchase expenses. Column G + Column H.
10.
Column J
–
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
11.
Column K
–
Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA) % plus 100%.
Example:
$4.60 X 105% = $4.83
12.
Column L
–
The full fee to be charged and should approximate Column K. Cor convenience round up to nearest dollar.
PHARMACY COST CENTER
Attachment D
1.
Column A
–
List pharmaceuticals provided.
2.
Column B
–
List Service Utilization.
3.
Column C
–
List Relative Value for Pharmaceuticals.
4.
Column D
–
Column B X Column C. Total Column D.
5.
Column E
–
Cost center amount from BCRR Table 6, Column G, line 4, minus the cost of consumed pharmaceuticals equals adjusted total cost/cost center.
6.
Column F
–
Total adjusted cost center, Column E, divided by total service units, Column D, equals Column F, the average cost/service unit.
7.
Column G
–
Adjusted cost/service equals the dollar amount in Column F, times each relative value of Column C. This amount represents the cost for each specific service. Column F x Column C.
8.
Column H
–
Equals the purchase expense per pharmaceutical unit. To arrive at an average per unit purchase expense, for Attachment D, Column H, when several brands of a pharmaceutical are purchased at different prices you will divide the total dollar value of those pharmaceuticals consumed during that period by the total number of units of those pharmaceuticals consumed during the same reporting period.
9.
Column I
–
Total base cost equals adjusted cost/service plus per unit purchase expense. Column G + Column H.
10.
Column J
–
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
11.
Column K
–
Adjusted cost equals total base cost in Column I times Column J, cost of living allowance (COLA) % plus 100%.
Example:
$4.60 X 105% = $4.83
12.
Column L
–
The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.
EDUCATION/COUNSELING COST CENTER
Attachment E
1.
Column A
–
List procedure.
2.
Column B
–
List Service Utilization/Frequency of Procedure.
3.
Column C
–
List Relative Value for Procedure.
4.
Column D
–
Column B X Column C. Total Column D.
5.
Column E
–
Cost center amount from BCRR, Table 6, Column G, line 7.
6.
Column F
–
Total Column E divided by total Column D. This gives you your average cost/service unit which is listed for each line item.
7.
Column G
–
The dollar amount in Column F times each RVS of Column C. This amount represents the cost for each specific service.
8.
Column H
–
Cost of living allowance (COLA). Use the most recent consumer price index provided by IDPH.
9.
Column I
–
Adjusted cost equals cost/service in Column G times Column H, cost of living allowance (COLA)% plus 100%.
Example:
$10.00 X 105% = $10.50
10.
Column J
The full fee to be charged and should approximate Column K. For convenience round up to nearest dollar.
MEDICAL COST CENTER
CLIENT EXAMINATION DIRECT EXPENSES SALARIES AND WAGES
(Include only those staff who perform or assist in performing client examinations.)
1.
Physician
1.
$
.00
2.
Physician Assistants
2.
$
.00
3.
Nurse Practitioners
3.
$
.00
4.
Nurse Midwives
4.
$
.00
5.
Other Nurses
5.
$
.00
MEDICAL SUPPORT
6.
Medical Appointment Secretary
6.
$
.00
7.
Portion of Client Records Clerk
7.
$
.00
8.
Total Salaries
8.
$
.00
Total on line 8 is equal to BCRR Table 6, worksheet A, column E, line 1.
OTHER CLIENT EXAMINATION EXPENSES
9.
Contractual Examiners Fees
9.
$
.00
10.
Client Examination Equipment Lease or Rental
10.
$
.00
11.
Client Examination Equipment Depreciation
11.
$
.00
12.
Client Examination Equipment Depreciation Expense
12.
$
.00
13.
Client Examination Supplies Expense
13.
$
.00
14.
Client Examination Staff Travel Expense
14.
$
.00
15.
Malpractice Insurance
15.
$
.00
16.
Other Client Examination Expenses
16.
$
.00
17.
Total Other Client Examination Expenses
17.
$
.00
(Sum of lines 9 through 16)
Total on line 17 is equal to BCRR Table 6, worksheet A, Column I, line 1.
DONATED MEDICAL EXPENSES
18.
Value of Physician's Donated Time
18.
$
.00
19.
Value of Nurse Midwife/N.P.'s Donated Time
19.
$
.00
20.
Value of R.N.'s Donated Time
20.
$
.00
21.
Value of LPN's Donated Time
21.
$
.00
22.
Value of other Donated Medical Expenses
22.
$
.00
23.
Total Donated Services and Materials
23.
$
.00
(Sum of lines 18 through 22)
Total on line 23 is equal to BCRR Table 6, worksheet A, Column j, line 1.
PATIENT EXAM INDIRECT COSTS
24.
Medical Fringe Benefits
24.
$
.00
(Worksheet A – Column g, line 1)
25.
Medical Facility Costs
25.
$
.00
(Worksheet B – Column d, line 1)
26.
Administrative Costs
26.
$
.00
(Worksheet B – Column g, line 1)
To arrive at the total medical costs you will add salary and wages (8), other costs (17) and donated services and materials (23) to the fringe benefits (24), facility costs (25) and administrative costs (26).
27.
Total Medical Costs
27.
$
.00
This total equals BCRR Table 6, Column g, line 1.
LABORATORY COST CENTER
LABORATORY SERVICES DIRECT EXPENSES
28.
Salaries and Wages (include only those staff who
perform tests, assist in tests or prepare specimens)
28.
$
.00
29.
Total
29.
$
.00
Total on line 29 is equal to BCRR Table 6, worksheet A, Column E, line 2.
OTHER LABORATORY EXPENSES
30.
Laboratory Equipment Lease or Rental Expense
30.
$
.00
31.
Laboratory Equipment Depreciation Expense
31.
$
.00
32.
Laboratory Equipment Maintenance and Repair Expense
32.
$
.00
33.
Laboratory Supplies Expense
33.
$
.00
34.
Purchased Outside Laboratory Services Expense
34.
$
.00
35.
Other Laboratory Expenses
35.
$
.00
36.
Total Other Laboratory Services Direct Expenses
36.
$
.00
(Sum of lines 30 through 35)
Total on line 36 is equal to BCRR Table 6, worksheet A, Column I, line 2.
DONATED LABORATORY EXPENSES
37.
Value of Lab Technician's Donated Time
37.
$
.00
38.
Value of Donated Lab Supplies
38.
$
.00
39.
Value of Donated Lab Tests
39.
$
.00
40.
Value of other Donated Lab Expenses
40.
$
.00
41.
Total Donated Laboratory Services and Materials
41.
$
.00
(Sum of lines 37 through 40)
Total on line 41 is equal to BCRR Table 6, worksheet A, Column j, line 2.
LABORATORY SERVICES INDIRECT EXPENSES
42.
Laboratory Fringe Benefits
42.
$
.00
(Worksheet A – Column g, line 2)
43.
Laboratory Facility Costs
43.
$
.00
(Worksheet B – Column d, line 2)
44.
Laboratory Administration Costs
44.
$
.00
(Worksheet B – Column g, line 2)
To arrive at the total laboratory expenses you will add salary and wages (29), other costs (36) and donated services and materials (41) to the fringe benefits (42), facility costs (43) and administrative costs (44).
45.
Total Laboratory Costs
45.
$
.00
This total equals BCRR Table 6, Column g, line 2.
OUTSIDE LABORATORY TESTS:
Any laboratory test completed by an outside incorporated entity. An invoice and payment to the entity for services must exist.
If you have "purchased outside laboratory fees" which will be included in total laboratory expenses for you BCRR information, you must now subtract the dollar amount of those purchases from your BCRR total on Table 6, Column G, line 2 to arrive at the dollar amount to be used in your total adjusted cost/center of Attachment C, Column E. You WILL NOT use the amount from you BCRR Table 6, Column G, line 2 for this amount.
OUTSIDE LABORATORY COST AREA
Type of Supply
Your Cost/Unit x Number Used = Total Expense*
46.
VDRL/RPR
$
x
$
.00
47.
Pap Smear
$
x
47.
$
.00
48.
Gonorrhea Culture
$
x
48.
$
.00
49.
Miscellaneous Culture
$
x
49.
$
.00
50.
Sickle Cell
$
x
50.
$
.00
51.
PP Blood Glucose
$
x
51.
$
.00
52.
Cholesterol Level
$
x
52.
$
.00
53.
SMA 12
$
x
53.
$
.00
54.
Colposcopy
$
x
54.
$
.00
55.
Colposcopy and Biopsy
$
x
55.
$
.00
56.
Chlamydia
$
x
56.
$
.00
57.
Total Outside Laboratory Fees
57.
$
.00
*Round to the nearest dollar amount.
58.
Adjusted total cost/center:
58.
$
.00
Line 45, subtract Line 67, equals amount on Line 58. This is the amount to be used in the Adjusted Total Cost/Center, Attachment C, Column E.
PHARMACY COST CENTER
Supplies Consumed During Reporting Period:
Type of Supply
Your Cost/Unit x *Number Used = Total Expense*
59.
Oral Contraceptives
x
59.
$
.00
60.
Cream
x
60.
$
.00
61.
Jelly
x
61.
$
.00
62.
Suppository (each)
x
62.
$
.00
63.
Foam
x
63.
$
.00
64.
Diaphragm
x
64.
$
.00
65.
IUD
x
65.
$
.00
66.
Basal T & C
x
66.
$
.00
67.
Sponges (each)
x
67.
$
.00
68.
Condoms (each)
x
68.
$
.00
69.
Meds/Vag. Inf.
x
69.
$
.00
70.
Meds/Std Rx
x
70.
$
.00
71.
Contraceptive Film
x
71.
$
.00
*The number used for each type of supply will come from your inventory sheets.
72.
Total (Sum of lines 59 through 71)
72.
$
.00
PROVISION OF CONTGRACEPTIVE DRUGS/SUPPLIES DIRECT EXPENSES
73.
Salaries and Wages for Staff Who Dispense or
Assist in Providing Contraceptive Drugs and Supplies
73.
$
.00
74.
Total
74.
$
.00
Total on line 74 is equal to BCRR Table 6, worksheet A, Column E, line 4.
OTHER PHARMACY EXPENSES
75.
Provision of Drugs and Supplies Equipment
Lease or Rental Expense
75.
$
.00
76.
Provision of Drugs and Supplies Depreciation Expense
76.
$
.00
77.
Provision of Drugs and Supplies Equipment Maintenance and Repair Expense
77.
$
.00
78.
Dispensing Supplies Expense
78.
$
.00
79.
Other Pharmacy Expenses
79.
$
.00
80.
Total (Sum of lines 75 through 79)
80.
$
.00
81.
Total All Pharmacy Expenses
81.
$
.00
(Sum of lines 72 and 80)
Total on line 81 is equal to BCRR Table 6, worksheet A, Column I, line 4.
DONATED PHARMACY EXPENSES
82.
Value of Pharmacists' Donated Time
82.
$
.00
83.
Value of Donated Pharmacy Supplies
83.
$
.00
84.
Value of Donated Contraceptive Supplies
84.
$
.00
85.
Value of Other Donated Pharmacy Expenses
85.
$
.00
86.
Total Donated Pharmacy Services and Materials
86.
$
.00
(Sum of lines 82 through 85)
Total on line 86 is equal to BCRR Table 6, worksheet A, Column j, line 4.
PHARMACY SERVICES INDIRECT EXPENSES
87.
Pharmacy Fringe Benefits
87.
$
.00
(Worksheet A – Column g, line 4)
88.
Pharmacy Facility Costs
88.
$
.00
(Worksheet B – Column d, line 4)
89.
Pharmacy Administration Costs
89.
$
.00
(Worksheet B – Column g, line 4)
To arrive at the total Pharmacy costs you will add salary and wages (74), other costs (81) and donated services and materials (86) to fringe benefits (87), facility costs (88) and administrative costs (89).
90
Total Pharmacy Costs
90.
$
.00
This total equals BCRR Table 6, Column g, line 4.
91.
Adjusted total cost center
91.
$
.00
To arrive at the total adjusted cost/center you must subtract the dollar amount of consumed contraceptives, drugs/supplies, from you BCRR total on Table 6, Column G, line 4, which is the amount on Line 90, minus line 72, equals the amount on line 91. This is the amount to be used in the adjusted Total cost/center, Attachment D, Column E.
COUNSELING AND EDUCATION COST CENTER
FAMILY PLANNING COUNSELING AND EDUCATIONAL DIRECT EXPENSES
92.
Salaries and Wages, Family Planning
92.
$
.00
Counselors, Educators and Assistants
93.
Portion of Client Records Clerk
93.
$
.00
94.
Total
94.
$
.00
Total on line 94 is equal to BCRR Table t, worksheet A, Column E, line 7.
OTHER COUNSELING AND EDUCATION EXPENSES
95.
Counseling and Educational Services
95.
$
.00
Staff Travel Expense
96.
Counseling and Educational Services
96.
$
.00
Equipment Rental
97.
Counseling Expense or Lease Expense and
97.
$
.00
Educational Services Equipment Depreciation
98.
Counseling and Educational Services Equipment
98.
$
.00
Repair and Maintenance Expense
99.
Counseling and Educational Supplies Expense
99.
$
.00
100.
Other Counseling and Educational Expense
100.
$
.00
101.
Total Family Planning Counseling and Educational Services Direct Expenses
101.
$
.00
Total on line 101 is equal to BCRR Table 6, worksheet A, Column I, line 7.
DONATED EDUCATION AND COUNSELING EXPENSES
102.
Value of Counselors Donated Time
102.
$
.00
103.
Value of Other Donated Counseling and Educational Services Expenses
103.
$
.00
104.
Total Donated Counseling and Educational Services Expenses
104.
$
.00
(Sum of lines 102 and 103)
Total on line 104 is equal to BCRR Table 6, worksheet A, Column j, line 7.
COUNSELING AND EDUCATIONAL INDIRECT EXPENSES
105.
Counseling and Education Fringe Benefits
105.
$
.00
(Worksheet A – Column g, line 7)
106.
Counseling and Education Facility Costs
106.
$
.00
(Worksheet B – Column d, line 7)
107.
Counseling and Education Administration Costs
107.
$
.00
(Worksheet B – Column g, line 7)
To arrive at the total Counseling and Education costs you will add salary and wages (92), other costs (101) and Donated Counseling and Educational Services (104) to fringe benefits (105), facility costs (106) and administrative costs (107).
108.
Total Counseling and Education Costs
108.
$
.00
This total equals BCRR Table 6, Column g, line 7.
FAMILY PLANNING CLIENT VISIT RELATIVE VALUES
SERVICES
RVS
MEDICAL SERVICES VISITS
Minimal Service
11.00
Brief/Intermediate Exam
18.00
Extended Exam
30.00
Insertion of IUD
30.00
Diaphragm Fit
15.00
Sonography/lost IUD
30.00
X-ray/lost IUD
24.00
LAB PROCEDURES
Hematocrit/Hemoglobin
3.00
U/A Dip Stick
4.00
Pregnancy Test
10.00
VDRL/RPR
6.00
Pap Smear
8.00
Gonorrhea Culture
6.00
Bacterial Smear/Wet Mount
5.00
Miscellaneous Culture
6.00
Sickle Cell
5.00
P.P. Blood Glucose
6.00
Triglycerides
6.00
SMA 12
16.00
Colposcopy
30.00
Colposcopy with Biopsy
40.00
Chlamydia
7.00
Miscellaneous Culture
3.00
Sickle Cell
4.00
P.P. Blood Glucose
10.00
Triglycerides
6.00
SMA 12
8.00
Colposcopy
6.00
Colposcopy with Biopsy
5.00
Chlamydia
6.00
CONTRACEPTIVE DRUGS/SUPPLIES
Orals
1.20
Creams
2.65
Jellies
2.65
Suppositories (each)
.15
Foams
3.00
Diaphragm
4.00
Basal T & C
10.00
IUD
50.00
Sponges (each)
1.50
Condoms (each)
.22
Meds/Vag. Inf.
5.00
Meds/STD
5.00
Contraceptive Film
2.00
EDUCATION AND COUNSELING
In-depth/1 hour
11.00
15 min. to 1 Hour
7.00
Revised
11/89
CALCULATING THE SCHEDULE OF DISCOUNTS
1.
Determine the number of payment categories.
Example:
For the purpose of this manual, we will use a six step schedule.
2.
The income levels for the zero pay category will be the poverty levels published annually in the Federal Register. (See Attachment F)
Example:
The poverty level for a one person family is $5,980; for a two person family the poverty level is $8,020, etc.
3.
The income levels for the full fee will be 250% of the poverty level plus $1.00.
Example:
For Family Size of 1, 100% pay = $5,980 x 2.5 = t$14,950 + $1 or $14,951
4.
To determine the income levels between 0% pay and 250% pay, use the following formula:
The 250% income level minus the poverty level, divided by the number of payment categories, minus 2.
The result of this computation is the dollar range for each step.
Example:
Family Size 1 - $14,950 (full fee > 250%) minus $5,980 (0%) = $8,970 divided by 4 (6 steps–2 steps) = $2,242.50 step interval.
5.
The lower limit of each step is $1 more than the upper limit of the preceding step.
Example:
Family Size 1, upper limit of 0% pay is $5,980, lower limit of the next category (20%) is $5,981.
6.
The upper level for each step is computed by adding the dollar interval computed in Step 4 to the upper limit of the preceding step.
Example:
Family Size 1 – upper limit of 0% pay is $5,980; upper limit of the next category is $5,981 + $2,243 or $8,224. See Attachment F.
DEVELOPMENT OF A SLIDING FEE SCALE
Federal regulations require that we provide family planning services on a sliding fee scale to allow persons to receive services regardless of their income level and subsequent ability to pay. Client or family income level is the determining factor for what level or percentage of the full fee a client will be charged.
A fee system must be developed and reevaluated at least annually after completing a cost analysis. The sliding fee scale will be based on the most current Federal Poverty Income Guidelines (See Attachment F). All clients must update their financial status every 12 months.
A sliding fee scale must be simple to be useful. Any fee scale which is over burdensome to the cashier or person computing the fee loses its value as the time required to compute the fee increases. Fees must be reasonable, related to cost and not provide a barrier to care. In selecting the client fee discount categories, it is important to remember that too few categories may either classify many clients at the lower end, reducing income, or at the upper end, discouraging clients to seek care because of the cost, thereby also reducing income. Too many categories may be difficult to implement and administer. For the purpose of this manual, we will use a six step sliding fee scale. See Attachment G.
Attachment A
EXAMPLES OF ADMINISTRATIVE COSTS
1.
Project Director
2.
Administrative Secretary and Receptionist
3.
Bookkeeper
4.
Administrative supplies
5.
Administrative staff travel and per diem
6.
Vehicle rental or lease expense
7.
Auditing and accounting
8.
Legal fees
9.
Consultants expense
10.
Dues and subscriptions
11.
Advertising
12.
Postage
13.
Printing
14.
Purchased staff training
15.
Fidelity bonding
16.
Photo copy
17.
Equipment depreciation
EXAMPLES OF FACILITY COSTS
1.
Custodian or Janitorial Contractual Services
2.
Building rental
3.
Building depreciation
4.
Building and contents insurance
5.
Building maintenance and repair
6.
Security
7.
Utilities
8.
Telephone
9.
Janitorial supplies
Attachment B
COST OF SERVICE/FEE DETERMINATION WORKSHEET
MEDICAL
COST CENTER
(A)
SERVICE/PROCEDURE
(B)
SERVICE
UTILIZATION
(FREQUENCY)
(C)
RVS
VALUE
(D)
TOTAL
SERVICE
UNITS
(E)
TOTAL
COST/
COST/CENTER
(F)
AVERAGE
COST/SERVICE
UNIT
(G)
COST/
SERVICE
(H)
COST
OF LIVING
ALLOWANCE
(I)
ADJUSTED
COST
(J)
FEE
Minimal Service
11.00
////////////////////////////
Brief/Intermediate Exam
18.00
////////////////////////////
Extended Exam
30.00
////////////////////////////
IUD Insertion
30.00
////////////////////////////
Diaphragm Fit
15.00
////////////////////////////
Sonography/lost IUD
30.00
////////////////////////////
X-ray/lost IUD
24.00
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
////////////////////////////
TOTAL
//////////////////////////
////////////////
//////////////////////////////
///////////////////
/////////////////////////////////
/////////////////////////
///////////////////////////////////
NOTES
1.
D = B x C
5.
G = F x C
REVISED
03-NOV-89
2.
Total Column D
6.
M = Cost of Living Allowance (COLA)
3.
E = Column G, line 1 of BCRR Table 6
7.
I = G x (COLA % + 100%)
4.
F = Column E ÷ Column D Total
8.
J = Fee
Attachment C
COST OF SERVICE/FEE DETERMINATION WORKSHEET
LABORATORY
COST CENTER
(A)
SERVICE/PROCEDURE
(B)
SERVICE
UTILIZATION
(FREQUENCY)
(C)
RVS
VALUE
(D)
TOTAL
SERVICE
UNITS
(E)
ADJUSTED
TOTAL COST/
COST/CENTER
(F)
AVERAGE
COST/SERVICE
UNIT
(G)
COST/
SERVICE
ADJUSTED
(H)
PER UNIT
PURCHASE
EXPENSE
(I)
TOTAL
BASE
COST
(J)
COST OF
LIVING
ALLLOWANCE
(K)
ADJUSTED
COST
(L)
FEE
HGB/HCT
3.00
//////////////////////////
Urinalysis
4.00
///////////////////////////
Pregnancy Test
10.00
////////////////////////////
VDRL/RPR
6.00
///////////////////////////
Pap Smear
8.00
///////////////////////////
Gonorrhea Culture
6.00
///////////////////////////
Miscellaneous Culture
6.00
//////////////////////////
Bacterial Smear/Wet Mount
5.00
//////////////////////////
Sickle Cell
5.00
//////////////////////////
P.P. Blood Glucose
6.00
//////////////////////////
Cholesterol Level
6.00
//////////////////////////
SMA – 12
16.00
//////////////////////////
Colposcopy
30.00
//////////////////////////
Colposcopy and Biopsy
40.00
//////////////////////////
Chlamydia
7.00
//////////////////////////
TOTAL
/////////////////////////
////////////////
////////////////////////
///////////////////
/////////////////////////
//////////////////
////////////////////
////////////////
/////////////////
NOTES:
1.
D = B x C
6.
H = Actual Per Unit Purchase Expense From Outside Laboratory
REVISED
03-NOV-89
2.
Total Column D
7.
I = Total Cost G + H
3.
E = Column G, line 2 of BCRR Table 6,
8.
J = Cost of Living Allowance (COLA)
Minus the Cost of Purchased Outside Laboratory Tests
9.
K = I x (COLA % + 100%)
4.
F = Column E ÷ Column D Total
10.
L = Fee
5.
G = F x C
Attachment D
COST OF SERVICE/FEE DETERMINATION WORKSHEET
PHARMACY
COST CENTER
(A)a
SERVICE/PROCEDURE
(B)
SERVICE
UTILIZATION
(FREQUENCY)
(C)
RVS
VALUE
(D)
TOTAL
SERVICE
UNITS
(E)
ADJUSTED
TOTAL COST/
COST/CENTER
(F)
AVERAGE
COST/SERVICE
UNIT
(G)
COST/
SERVICE
ADJUSTED
(H)
PER UNIT
PURCHASE
EXPENSE
(I)
TOTAL
BASE
COST
(J)
COST OF
LIVING
ALLOWANCE
(K)
ADJUSTED
COST
(L)
FEE
Orals
1.20
//////////////////////
Creams
2.65
//////////////////////
Jellies
2.65
///////////////////////
Suppositories (each)
0.15
///////////////////////
Foams
3.00
///////////////////////
Diaphragms
4.00
///////////////////////
IUDS
50.00
///////////////////////
Basal T & C
10.00
///////////////////////
Sponges (each)
1.50
///////////////////////
Condoms (each)
0.22
///////////////////////
Meds/Vag Inf
5.00
///////////////////////
Meds/STD
5.00
///////////////////////
Contraceptive Film
2.00
///////////////////////
///////////////////////
///////////////////////
TOTAL
/////////////////////////
//////////////
////////////////////////
//////////////////////
////////////////////
////////////////
/////////////////////
////////////////////
//////////////////////
NOTES:
1.
D = B x C
6.
H = Actual Per Unit Purchase Expense
REVISED
2.
Total Column D
7.
I = G + H
03-NOV-89
3.
E = Column G, line 4 of BCRR Table 6
8.
J = Cost of Living Allowance (COLA)
Minus the Cost of Consumed Pharmaceuticals
9.
K x (COLA % + 100%)
4.
F = Column E ÷ Column D Total
10.
L = Fee
5.
G = F x C
Attachment E
COST OF SERVICE/FEE DETERMINATION WORKSHEET
EDUCATION/COUNSELING
COST CENTER
(A)
SERVIC/PROCEDURE
(B)
SERVICE
UTILIZATION
(FREQUENCY)
(C)
RVS
VLAUE
(D)
TOTAL
SERVICE
UNITS
(E)
TOTAL
COST/
COST/CENTER
(F)
AVERAGE
COST/SERVICE
UNIT
(G)
COST/
SERVICE
(
H)
COST OF
LIVING
ALLOWANCE
(I)
ADJUSTED
COST
(J)
FEE
Indepth 1 Hour
11.00
///////////////////
Counseling/15 Min to 1 Hr
7.00
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
///////////////////
TOTAL
////////////////////
///////////////
////////////////////
//////////////
//////////////////
/////////////////
//////////////
NOTES:
1.
D = B x C
5.
G = F x C
REVISED
03-NOV-89
2.
Total Column D
6.
H = Cost of Living Allowance (COLA)
3.
E = Column G, line 7 of BCRR Table 6
7.
I = G x (COLA % + 100%)
4.
F = Column E ÷ Column D Total
8.
J = Fee
Attachment F
EXAMPLE
POVERTY INCOME GUIDELINES
CLIENT FEE DISCOUNT CATEGORIES
03/08/89
Family Planning Services
1989 Revised Guidelines as published in Federal Register, 2/16/89, Vol. 54, No. 31
FAMILY
SIZE
0%
20%
40%
60%
80%
100%
A
B
C
D
E
F
G
H
I
J
K
1
0
–
5980
5981
–
8224
8225
–
10467
10468
–
12711
12712
–
14950
14951
2
0
–
8020
8021
–
11029
11030
–
14037
14038
–
17046
17047
–
20050
20051
3
0
–
10060
10061
–
13834
13835
–
17607
17608
–
21381
21382
–
25150
25151
4
0
–
12100
12101
–
16639
16640
–
21177
21178
–
25716
25717
–
30250
30251
5
0
–
14140
14141
–
19444
19445
–
24747
24748
–
30051
30052
–
35350
35351
6
0
–
16180
16181
–
22249
22250
–
28317
28318
–
34386
34387
–
40450
40451
7
0
–
18220
18221
–
25054
25055
–
31887
31888
–
38721
38722
–
45550
45551
8
0
–
20260
20261
–
27859
27860
–
35457
35458
–
43056
43057
–
50650
50651
*
FOR FAMILY UNITS WITH MORE THAN 8 MEMBERS, FOR EACH ADDITIONAL MEMBER AND ADD TO COLUMN B; $2,040
**
POVERTY LEVEL
$5,980
B
=
Family size = 1 = Poverty Level
B
=
All other Family size = Previous Family size Poverty Level plus $2,040
C
=
(B + 1)
D
(J – B) / 4 + C
E
(D + 1)
F
=
(J–B) / 4 + E
G
=
(F + 1)
H
=
(J–B) / 4 + G
I
=
(H + 1)
J
=
(B x 2.5)
K
=
(J + 1)
Attachment G
SLIDING FEE SCALE
**********************************************************************************************************************
SERVICE/PROCEDURES
(a)
COST/
SERVICES
FEE
0%
20%
40%
60%
80%
100%
Minimal Services
Brief/Intermediate Exam
Extended Exam
IUD Insertion
Diaphragm Fit
Sonography/lost IUD
X-ray/lost IUD
HCT/HBG
Urinalysis
Pregnancy Test
VDRL/RPR
Pap Smear
Gonorrhea Culture
Miscellaneous Culture
Bacterial Smear/Wet Mount
Sickle Cell
PP Blood Glucose
Cholesterol Level
SMA-12
Colposcopy
Colposcopy and Biopsy
Chlamydia
Orals
Creams
Jellies
Suppositories (each)
Foams
Diaphragms
IUDS
Basal T & C
Sponges (each)
Condoms (each)
Meds/Vag Inf
Meds/STD
Contraceptive Film
In-depth 1 Hour
Counseling/15 Min. to 1 Hr.
**********************************************************************************************************************
ALLOCATION OF MONIES FOR BCRR
SALARIES
EQUIPMENT DEPRECIATION
0.5
OB/GYN Physician
50,000
Medical
800
2.0
OB/GYN Nurse Practitioners
52,000
Laboratory
200
1.5
RN’s
24,000
Patient Records
100
0.5
RN (Pharmacy)
8,000
Administration
900
2.0
LPN’s
22,000
0.5
Medical Appt. Secy.
5,750
0.5
Client Records Clerk
5,750
INSURANCE
1.0
Health Educator
16,000
0.5
Laboratory Technician
7,000
Medical Malpractice
5,000
1.0
Project Director
20,000
Fidelity Bonding
100
1.0
Admin. Secy./Recept.
12,000
Facility (fire, flood)
1,000
1.0
Bookkeeper
12,000
0.2
Custodian
1,600
RENT
12,000
UTILITIES
1,800
TELEPHONE
740
FRINGE BENEFITS
27,300
PHOTO COPY
560
POSTAGE
375
ADMIN. TRAVEL
200
CONSULTANT & CONTRACT SERVICES
Nurse Practitioner
17,000
SQUARE FOOTAGE
Outside Laboratory
19,792
Account’s Fee
800
Medical
1,600 sq'
Attorney’s Fee
100
Laboratory
200
Security
2,000
Other Health
300
Administration
400
2,500 sq'
SUPPLIES
Medical
10,000
Laboratory
3,000
Health Education
500
Pharmacy
1,000
Patient Records
200
Administration
500
Housekeeping
100
DONATED MATERIALS
Volunteer R.N.’s
6,000
GC’s done by State lab
1,200
Contraceptives from closing clinic
2,400
Volunteer Counselor
400
Administrator’s time
700
Rent at 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