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.

MAXIMUM MONTHLY FEE BY FAMILY SIZE

Annual Gross IncomeMonthly Gross Income123456789+
11,880990000000000
17,8201,4853700000000
19,8901,6584400000000
21,9601,8305200000000
24,0302,00360370000000
26,1002,17568440000000
28,1702,34877520000000
30,2402,520876037000000
32,3102,693976844000000
34,3802,8651087752000000
36,4503,03812087603700000
38,5203,21013297684400000
40,5903,383144108775200000
42,6603,5551571208760370000
44,7303,7281711329768440000
46,8003,90018514410877520000
48,8704,073200157120876037000
50,9404,245215171132976844000
53,0104,4182311851441087752000
55,0804,59024720015712087603700
57,1504,76326421517113297684400
59,2204,935281231185144108775200
61,2905,1082992472001571208760370
63,3605,2803182642151711329768440
65,4305,45333728123118514410877520
67,5005,625357299247200157120876037
69,5705,798377318264215171132976844
71,6405,9703983372812311851441087752
73,7106,1434193572992472001571208760
75,7806,3154413773182642151711329768
77,8506,48846339833728123118514410877
79,9206,66048641935729924720015712087
81,9906,83351044137731826421517113297
84,0607,005534463398337281231185144108
86,1307,178558486419357299247200157120
88,2007,350584510441377318264215171132
90,2707,523609534463398337281231185144
92,3407,695636558486419357299247200157
94,4107,868662584510441377318264215171
96,4808,040690609534463398337281231185
98,5508,213718636558486419357299247200
100,6208,385746662584510441377318264215
102,6908,558775690609534463398337281231
104,7608,730805718636558486419357299247
106,8308,903835746662584510441377318264
108,9009,075866775690609534463398337281
110,9709,248897805718636558486419357299
113,0409,420929835746662584510441377318
115,1109,593961866775690609534463398337
117,1809,765994897805718636558486419357
119,2509,9381,028929835746662584510441377
121,32010,1101,062961866775690609534463398
123,39010,2831,096994897805718636558486419
125,46010,4551,1311,028929835746662584510441
127,53010,6281,1671,062961866775690609534463
129,60010,8001,2031,096994897805718636558486
131,67010,9731,2401,1311,028929835746662584510
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