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ABILITY-TO-PAY FEE SCHEDULE

DEPARTMENT OF STATE HEALTH SERVICES

MONTHLY ABILITY-TO-PAY FEE SCHEDULE

Austin Travis County Integral Care charges a maximum monthly fee for services based on a client’s income and family size. To determine their maximum monthly fee, Integral Care clients must provide all required documents and complete a Financial Assessment. Failure to complete a Financial Assessment will result in the client being charged the full price of services received. Clients covered by Medicare, Medicaid, CHIP, or any other insurance must authorize payments to Integral Care. Clients covered by private insurance are responsible for paying all co-pays and deductibles. Integral Care clients should be prepared to show proof of insurance upon check-in and pay all fees, co-pays, and deductibles for services at every visit. 

Maximum Monthly Fee By Family Size

Annual Gross Income Monthly Gross Income 1 2 3 4 5 6 7 8 9+
                     
11,880 990 0 0 0 0 0 0 0 0 0
17,820 1,485 37 0 0 0 0 0 0 0 0
19,890 1,658 44 0 0 0 0 0 0 0 0
21,960 1,830 52 0 0 0 0 0 0 0 0
24,030 2,003 60 37 0 0 0 0 0 0 0
26,100 2,175 68 44 0 0 0 0 0 0 0
28,170 2,348 77 52 0 0 0 0 0 0 0
30,240 2,520 87 60 37 0 0 0 0 0 0
32,310 2,693 97 68 44 0 0 0 0 0 0
34,380 2,865 108 77 52 0 0 0 0 0 0
36,450 3,038 120 87 60 37 0 0 0 0 0
38,520 3,210 132 97 68 44 0 0 0 0 0
40,590 3,383 144 108 77 52 0 0 0 0 0
42,660 3,555 157 120 87 60 37 0 0 0 0
44,730 3,728 171 132 97 68 44 0 0 0 0
46,800 3,900 185 144 108 77 52 0 0 0 0
48,870 4,073 200 157 120 87 60 37 0 0 0
50,940 4,245 215 171 132 97 68 44 0 0 0
53,010 4,418 231 185 144 108 77 52 0 0 0
55,080 4,590 247 200 157 120 87 60 37 0 0
57,150 4,763 264 215 171 132 97 68 44 0 0
59,220 4,935 281 231 185 144 108 77 52 0 0
61,290 5,108 299 247 200 157 120 87 60 37 0
63,360 5,280 318 264 215 171 132 97 68 44 0
65,430 5,453 337 281 231 185 144 108 77 52 0
67,500 5,625 357 299 247 200 157 120 87 60 37
69,570 5,798 377 318 264 215 171 132 97 68 44
71,640 5,970 398 337 281 231 185 144 108 77 52
73,710 6,143 419 357 299 247 200 157 120 87 60
75,780 6,315 441 377 318 264 215 171 132 97 68
77,850 6,488 463 398 337 281 231 185 144 108 77
79,920 6,660 486 419 357 299 247 200 157 120 87
81,990 6,833 510 441 377 318 264 215 171 132 97
84,060 7,005 534 463 398 337 281 231 185 144 108
86,130 7,178 558 486 419 357 299 247 200 157 120
88,200 7,350 584 510 441 377 318 264 215 171 132
90,270 7,523 609 534 463 398 337 281 231 185 144
92,340 7,695 636 558 486 419 357 299 247 200 157
94,410 7,868 662 584 510 441 377 318 264 215 171
96,480 8,040 690 609 534 463 398 337 281 231 185
98,550 8,213 718 636 558 486 419 357 299 247 200
100,620 8,385 746 662 584 510 441 377 318 264 215
102,690 8,558 775 690 609 534 463 398 337 281 231
104,760 8,730 805 718 636 558 486 419 357 299 247
106,830 8,903 835 746 662 584 510 441 377 318 264
108,900 9,075 866 775 690 609 534 463 398 337 281
110,970 9,248 897 805 718 636 558 486 419 357 299
113,040 9,420 929 835 746 662 584 510 441 377 318
115,110 9,593 961 866 775 690 609 534 463 398 337
117,180 9,765 994 897 805 718 636 558 486 419 357
119,250 9,938 1,028 929 835 746 662 584 510 441 377
121,320 10,110 1,062 961 866 775 690 609 534 463 398
123,390 10,283 1,096 994 897 805 718 636 558 486 419
125,460 10,455 1,131 1,028 929 835 746 662 584 510 441
127,530 10,628 1,167 1,062 961 866 775 690 609 534 463
129,600 10,800 1,203 1,096 994 897 805 718 636 558 486
131,670 10,973 1,240 1,131 1,028 929 835 746 662 584 510

25 TAC, Chapter 412, Subchapter C

 

Source:  2016 Federal Poverty Guidelines

EFFECTIVE:  April 1, 2016

Joint Comission