ABILITY-TO-PAY FEE SCHEDULE

DEPARTMENT OF STATE HEALTH SERVICES
MONTHLY ABILITY-TO-PAY FEE SCHEDULE

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. Effective March 1, 2022.

MAXIMUM MONTHLY FEE BY FAMILY SIZE

Yearly Income Before TaxesMonthly Income Before Taxes123456789+
13,5901,133000000000
20,3851,6994200000000
22,7451,8955000000000
25,1052,0925900000000
27,4652,28968420000000
29,8252,48578500000000
32,1852,68289590000000
34,5452,8791006842000000
36,9053,0751117850000000
39,2653,2721248959000000
41,6253,469137100684200000
43,9853,665150111785000000
46,3453,862165124895900000
48,7054,05917913710068420000
51,0654,25519515011178500000
53,4254,45221116512489590000
55,7854,6492281791371006842000
58,1454,8452451951501117850000
60,5055,0422632111651248959000
62,8655,239282228179137100684200
65,2255,435301245195150111785000
67,5855,632321263211165124895900
69,9455,82934228222817913710068420
72,3056,02536330124519515011178500
74,6656,22238532126321116512489590
77,0256,4194073422822281791371006842
79,3856,6154303633012451951501117850
81,7456,8124543853212632111651248959
84,1057,00947840734228222817913710068
86,4657,20550343036330124519515011178
88,8257,40252945438532126321116512489
91,1857,599555478407342282228179137100
93,5457,795582503430363301245195150111
95,9057,992609529454385321263211165124
98,2658,189637555478407342282228179137
100,6258,385666582503430363301245195150
102,9858,582695609529454385321263211165
105,3458,779725637555478407342282228179
107,7058,975756666582503430363301245195
110,0659,172787695609529454385321263211
112,4259,369819725637555478407342282228
114,7859,565851756666582503430363301245
117,1459,762884787695609529454385321263
119,5059,959918819725637555478407342282
121,86510,155953851756666582503430363301
124,22510,352988884787695609529454385321
126,58510,5491,023918819725637555478407342
128,94510,7451,059953851756666582503430363
131,30510,9421,096988884787695609529454385
133,66511,1391,1341,023918819725637555478407
136,02511,3351,1721,059953851756666582503430
138,38511,5321,2111,096988884787695609529454
140,74511,7291,2501,1341,023918819725637555478
143,10511,9251,2901,1721,059953851756666582503
145,46512,1221,3311,2111,096988884787695609529
147,82512,3191,3721,2501,1341,023918819725637555
150,18512,5151,4141,2901,1721,059953851756666582
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